The Digitally Challenging Child Modifying the Rules for Kids with ADHD, Anxiety, and Depression

Dylan’s mom and I cajole Dylan, a 7-year-old second grader, to come into my office. After reluctantly agreeing, he makes a beeline for my desk and computer. After spinning around on my desk chair a few times, he opens up Minecraft on my computer and shows me the new water slide that he has built. I have a hard time getting him off the computer. He is fidgety and walks over to my Playmobil toy hospital and trashes it in 20 seconds flat. Eventually, his mom and I convince him to sit on the sofa and his mom hands him his 3D DS. He starts playing and is lost to us. He is neither fidgety nor oppositional; he is transfixed by the screen. His mom begins to tell me that he becomes violent with his little sister after watching too much TV. He throws tantrums when she turns off games or the computer. During our discussion, Dylan looks up occasionally and is clearly listening to our exchange. When I tell him that it is time to leave, he doesn’t budge. He doesn’t want to leave.

In my office I observe that children and adolescents have different relationships with technology. Some children can play video games without parental conflict, and other children melt down every day when it is time to unplug. Some teenagers use social media to feel more connected, and others use it to hide from real-life interactions. Knowing your child’s strengths and weaknesses is a key to being a good parent. Digital media has given us another lens through which to view our children and ourselves. The way your child uses digital technology may be a window into his mental health and general well-being.

The way your child uses digital technology may be a window into his mental health and general well-being.

DIGITAL TECHNOLOGY AND ADHD SYMPTOMS

Is every 7-year-old boy addicted to video games? Do all little boys become more revved up after playing games and watching TV?

Most children, who play games in moderation, don’t become violent. “One size does not fit all” is true for digital technology. Children and teens who meet criteria for ADHD or who exhibit symptoms of ADHD are at greater risk of problematic technology use. As a child and adolescent psychiatrist, I am very focused on making accurate diagnoses of ADHD. However, for our purposes, the exact diagnosis is less important than whether your child’s symptoms resemble the overall picture of the syndrome.

Does your child have problems paying attention?

  Does your child frequently forget to bring home what he needs to do his homework (or forget what the assignments are entirely)?

  Does he flit from activity to activity?

  Does he have trouble sticking with chores or other mundane endeavors?

  Does he seem like he’s not listening or is off in the clouds?

  Does he have an eternally messy bedroom and backpack?

  Does he have trouble following instructions?

If you answered “yes” to any of these questions, then your child may be struggling with attention symptoms.

Does your child show signs of being hyperactive? Kids with problems in this area can seem like whirling dervishes—they can’t sit still, they pick up (and drop) everything in stores, they’re chatterboxes, and quiet pursuits rarely keep them entertained.

Is your child impulsive? Children with symptoms of impulsivity are the ones who don’t seem to think before they act or speak. They seem not to learn from their mistakes, they interrupt others’ conversations, and they have trouble learning to take turns when the other kids do.

A diagnosis of ADHD requires a minimum number of certain symptoms that have lasted for an extended period of time (vs. being a brief phase). If you have observed symptoms of hyperactivity, inattention, or impulsivity in your child for several months, then you may want to adjust your tech rules to protect your child and maximize the benefit she gets out of digital media.

Digital Risks for Hyperactive and Impulsive Children

  Inability to turn off games and the Internet

  Difficulty “changing gears”

  Risk of dangerous impulsive behavior (e.g., sexting, oversharing)

  Greater risk of becoming overstimulated by digital technology

  Greater vulnerability to violent and overstimulating games and movies

  Higher risk of Internet addiction

  Higher risk of problematic usage

Digital Risks for Inattentive and Disorganized Children

  Inability to turn off games and the Internet

  Difficulty “changing gears”

  Increased risk for distraction

  Risk that online behavior will lead to greater disorganization

  Higher risk of Internet addiction

  Higher risk of problematic usage

How can I get my son to turn off the games?

Children with ADHD symptoms have more difficulty unplugging. In a study of video game use among 11- to 12-year-old boys and girls, those children with ADHD had more difficulty getting off their video games than the control group.1 ADHD stands for “attention-deficit/hyperactivity disorder.” The name is a bit of a misnomer since people with ADHD have an abundance of attention but don’t regulate it as well as other people. This means that they have trouble shifting attention—a tendency to have “attention deficit” on unpleasant tasks and an overabundance of attention on pleasurable or rewarding tasks. Attention dysregulation is a recipe for disaster when you sprinkle in online games or Internet shopping and surfing. Gaming is particularly problematic for younger children with ADHD.

Neuroscientists have identified the neurotransmitter dopamine as the primary mediator in ADHD. Decreased dopamine in the prefrontal cortex and striatum contribute to inattention, attention dysregulation, and overattention. Decreased levels of dopamine have been linked to both inattention and “overattention” in ADHD. Hyperfocus is a strength when a child matures and can harness it. In children and teenagers, however, it often results in becoming engrossed in TV, games, or the Internet. Normally developing children with moderate technology use do not miss out on other physical and stimulating life activities. But I do find that kids with ADHD can become so engrossed that they “lose time” and miss out on opportunities for real-life play. Their inability to “shut down” and transition creates challenges for parents and caregivers. If only I had a nickel for every parent who has told me that their biggest family conflict was unplugging in the evenings. For parents, it is critical to understand how hard it is for kids who have ADHD to unplug. It is easier for parents to be patient and helpful when they understand that their child is not always being oppositional and defiant but rather struggling to shift gears.

It is critical to understand how hard it is for kids who have ADHD to unplug.

My Recommendations for Managing Technology and ADHD

  Establish clear time limits for game and Internet use.

  Use a big timer that is not embedded in a phone or computer.

  Start giving warnings 15 minutes prior to shutdown.

  Give reminders every 5 minutes prior to shutdown.

  Help with the transition by clarifying the next activity.

  Provide encouragement when your child is able to unplug successfully.

  Recognize that shifting attention and tasks is a learned skill.

Is it possible that my son becomes more hyperactive and violent after playing video games?

Violent video games do not directly cause violence in the real world. People who identify as being “angry” are more likely to become aggressive after playing violent video games. Kids who express anger are more likely to seek out video games with mature (MA) ratings. There is evidence that children use video games to express and work out their anger in a healthy way. Video games can be a good outlet for the safe expression of anger. However, kids who are predisposed to hyperactive and impulsive behavior are at greater risk for becoming agitated or hyperactive after playing highly stimulating or violent games. In my office, parents of elementary- and middle-school-age children with ADHD observe that their children become more agitated or aggressive after extended game use. Fast-paced video games suit the cognitive style of ADHD. They provide an ever-changing, multimodal stimulus and immediate reward with minimal delay.2 Children with ADHD are more likely to be high energy and impulsive, and more likely to hyperfocus on the game and have trouble shifting attention to something else. Therefore, we often see an increase in agitated behavior after extended game or Internet use. Kids with ADHD are often the first ones in their friend group to play Call of Duty or Mortal Combat. Parents of kids with ADHD need to be extra-vigilant in monitoring the content of games and the quality of their child’s online and gaming life.

My Recommendations for Video Games If Your Child Has Symptoms of ADHD

  Do not allow MA-rated games.

  Add 2 years to manufacturer recommendations.

  Understand what types of games your child plays.

  Observe your child’s behavior after he turns off the computer or game.

  Discourage evening play if gaming leads to more agitated behavior.

  Reward kids for successfully unplugging or shifting tasks.

Is it possible that my son is addicted to video and online games?

Yes. Children and teenagers with ADHD are at higher risk for Internet and gaming problems and addictions. Internet addiction is not recognized as a disorder in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), meaning that the American medical community has not recognized it as a formal medical or psychiatric disorder. There has been much debate, and I suspect that it will eventually be officially codified. Currently, pathological gambling is the only behavioral addiction officially recognized by the medical community. There are no standardized criteria, so it’s difficult to determine prevalence accurately. Internet addiction has been broadly defined as:

  A preoccupation with the Internet, electronic communication, or games

  Inability to control usage

  Distress when unable to use technology

If you’re trying to determine whether your child’s technology use is problematic, I recommend keeping these guidelines in mind:

  It is not the duration of usage that matters but the quality of usage.

  Preoccupation with gaming when not on the game can be a red flag.

  Distress when unable to use the computer or games is a red flag.

  Your child’s ability to “hyperfocus” on games does not rule out ADHD as a possible diagnosis.

  Hyperfocus can be a problem if it leads to excessive use or an inability to unplug.

Despite the public debate, we all agree that problematic Internet and video game usage is pervasive. In Asia, they report “addiction” rates as high as 25% in teenagers. There are reports that comorbidity is as high as 30–50%. This means that 30–50% of people with ADHD also suffer from Internet addiction. Attention dysregulation and impulsivity go hand in hand with problematic use of digital technology. In a study of 2,000 adolescents followed over 2 years, the presence of psychiatric symptoms was the strongest predictor for Internet addiction. ADHD topped the list as the single strongest predictor for “Internet addiction.”3 Symptoms associated with ADHD, such as impulsivity, extraversion, disinhibition, and low self-esteem, have also been correlated with problematic Internet use.⁴ Kids with ADHD may have a vulnerability to the immediate feedback and a drive to win more coins or get to the next level. Video games have been found to increase the level of dopamine in the brain, further reinforcing problematic usage.

In 2009, an American and South Korean research team studied Internet video game use and ADHD. They concluded that many children with ADHD use Internet video games as a form of self-medication. Video game use has been shown to increase dopamine levels, and ADHD has been linked to decreased dopamine in the striatum and prefrontal cortex. They also found that treating children with Concerta (a long-acting stimulant used for ADHD) led to a decrease in time spent on the Internet and decreased symptoms of Internet addiction.⁵ It may be that Internet addiction and ADHD share a common etiology. It seems that the symptoms of ADHD make Internet and video game use very attractive, but the Internet and gaming may worsen symptoms of ADHD.

Children who have symptoms of ADHD are at higher risk for problematic use of digital technology.

My Recommendations for Managing Problematic Use of Digital Technology

  Talk to your kids and teenagers about hyperfocusing.

  Help them recognize that they have trouble unplugging.

  Help kids and teenagers set reasonable time limits and use timers.

  Use lots of gentle reminders to prepare them for unplugging. Encourage healthy use.

  Take breaks when use becomes unhealthy.

Is my teenager who has ADHD safe on social media?

Teens and tweens with impulsivity are at risk for problematic use of social media, electronic communication, and the Internet. The anonymity and pace of technology make everyone a little bit more impulsive. For most people, a little bit of impulsivity is not a problem. However, if you are prone to impulsive behavior, you can get into a lot of trouble very quickly. Snapchat and Ask.fm are two of the biggest areas of concern. On Snapchat, you send a picture and set how long it will last, from 0 to 10 seconds, before “disappearing.” However, the recipient can easily save the picture by taking a screenshot. The sender is notified when a screenshot is taken. Ask.fm is an anonymous question-asking platform. It has become a notorious breeding ground for hate speech and bullying. Teens with ADHD are more likely to post an inappropriate picture or make an impulsive comment. Teenagers with ADHD need to be aware of their symptoms. They need to take their time when posting or responding. They should consider getting friends or family to look at comments or pictures prior to posting. If they are mindful of their symptoms, then they can take a thoughtful approach to social media.

Make your teen with ADHD aware of her symptoms so she’ll understand why you encourage her to take her time when posting or responding on social media.

Disorganized Children and Teenagers

Teddy is an 11-year-old sixth grader who was referred to me because he is distracted and getting a C in English. I ask him about his homework, and he says that he does it but forgets to turn it in. I ask him if he checks his backpack at night, and he rolls his eyes at me. He explains that he e-mails the homework to his teacher. If that is the case, I ask, then how does he forget it? He opens his laptop and shows me the 60 folders that are open on his desktop and explains that he knows he did it but can’t find it.

Should my child use traditional organization tools or technology for organization and planning?

Technology both solves and creates challenges in organization. People with ADHD struggle with organization and executive planning (the ability to plan ahead). Technology should be used as a tool for organizing and planning ahead. Organization and executive planning must be taught just like algebra and chemistry. Many organizational coaches will recommend paper calendars and assignment books for kids. As a digital immigrant, I understand the appeal of the visual poster board calendar and the easily flippable homework pad. Digital natives are as comfortable on apps as they are with wire-bound notebooks. The goal is to help your child or teen develop a consistent system that helps him organize homework and plan ahead for papers, tests, and social events.

My Recommendations for Helping a Child or Teen Get Organized

  Step 1 is the big calendar. Executive planning isn’t fully developed until college. Even your teenager needs help in planning ahead. He needs a big-picture visual of his week and month. I no longer recommend the wall calendar to tweens. I prefer the apps such as Corkulous, which allows you to make your own corkboard with notes, pictures, lists, and calendars.

  Step 2 is the homework planner. The iHomework app allows you to keep track of assignments. Any system works as long as all homework is in one place and there is a section for long-term assignments. Check with your tween or teen’s school to find out where, when, and whether homework and tests are posted online.

  Step 3 is taking notes. Kids with ADHD are notoriously poor note takers. Evernote is a very popular app that allows you to organize and take class notes. You can record audio notes and insert pictures. Also check with your child’s school to see if teachers hand out or post copies of class notes.

  Step 4 is setting priorities. Priority Matrix helps teenagers assess the short-term and long-term importance of multiple assignments. Teens need a daily and weekly game plan for homework. Teenagers often make the mistake of spending too much time on unimportant assignments and neglecting critical work.

  Step 5 is managing time. I continue to recommend an old-fashioned oven timer. I don’t like the iPhone for timers. It is an excuse to pick up the phone that you don’t need at the moment. Help your tween or teen keep track of the time it takes for each assignment and assess efficiency.

  Step 6 is social life. The goal is to balance work and play. If your teen’s calendar has only academic due dates, then she can’t plan her whole life. If your son has a basketball game the night before a big chemistry test, he needs to study in advance. Your teen or tween’s whole life should be visible on one calendar. Google calendar is the easiest calendar, and parents can send invites to events and appointments that they schedule. Galndr (name rhymes with calendar) is a new calendar app designed for teenage girls. It is pink and allows girls to have private and public events and inner circles for their BFFs. It has stricter privacy settings than Facebook. Kids need to be wary of privacy settings when posting schedules on social media. The entire world does not need to know that your teenage son is on a class trip to Washington, D.C.

SOCIAL ANXIETY AND POOR SOCIAL SKILLS

David is a 17-year-old 12th grader sent to see me because he is “depressed.” His parents report that he rarely leaves his room and is on his computer 24/7. They say he is very bright and attends a gifted high school. However, he is tired all the time and interested only in being online. His parents are concerned that he is depressed and addicted to the Internet. When I meet him, he is a bit disheveled and makes minimal eye contact. He is socially awkward but warms up after a few minutes. I ask him about his life online. I ask him if he knows anything about coding and building games. He looks up and seems a bit intrigued by the question. He goes into a detailed explanation of how to build a game. He tells me that he is building a game with his best friend. This time I perk up and ask him about the “best friend.” He says that she is 20 years old and lives in Seattle (he lives in Connecticut). They are collaborating on his new project. The time change has posed some challenges, but he is excited about the multiplayer game they are building. He tells me that he has two friends at school that he sits with at lunch. They talk about games and technology. He doesn’t see them out of school but is in contact with them through texts and games. He is collaborating with one of them on a robotics project. He admits that he is not that “social” and becomes anxious with real-life interactions. He is irritated with his parents’ nagging. He denies being depressed or having difficulty with sleep.

David’s story represents what is so confusing about adolescent online interactions. David is not social and not that interested in making friends. He might have met criteria for what used to be called Asperger syndrome. Asperger syndrome is no longer officially recognized by the medical and psychiatric community. David is a little bit different from his peers, and his real-life social skills are not fluid. Digital technology is a double-edged sword for him. He uses the Internet to connect with other people worldwide who share his interest in building games. He is a very accomplished coder and gamer. He has “colleagues” and “collaborators” online who respect him and want to work with him. In school he does not have close friends, but he is not depressed. He does avoid real interactions when he spends all day and night online. His family has encouraged him to connect online with classmates with whom he shares interests. Some teenagers like David build self-esteem and confidence from online connections. However, David’s online skills do not always generalize to real-life social interactions. David’s challenge is to safely enjoy and connect online while not abandoning real-life relationships and experiences.

Parents need to help their socially avoidant kids to connect online. There is no reason for kids with pervasive developmental disorders (high-functioning autism spectrum) or simply poor social skills to remain isolated. Isolated children and teenagers may be able to find their voice on the Internet. There are also lots of opportunities to cultivate computer and technology skills. Many young adults with high-functioning pervasive developmental disorders attend school and work in jobs that they can do via the Internet. Of course, you want to maximize your child or teenager’s social skills as he or she is growing up. The key is to help your child find healthy outlets online and to be aware of how your teenager is using the Internet. If you know that your teenager struggles with social interactions, then you need to be wary about and involved in how he spends his time online.

Socially awkward and anxious teenagers often turn to online relationships to avoid real-life interactions.

Is it possible that my daughter prefers social media and texting to real-life interactions?

Most healthy teenagers prefer face-to-face interactions but find electronic communication and social media to be more convenient. Children and teenagers with social anxiety may use digital technology as an escape from their real lives.

Social anxiety disorder involves the extreme fear of being scrutinized and judged by others in social or performance situations. It can wreak havoc on the lives of those who suffer from it. Social anxiety disorder goes beyond shyness. There is a heightened self-consciousness and fear of scrutiny in social situations. The typical age of onset is 13 years. Social anxiety disorder is an official psychiatric disorder with criteria and duration requirements. Once again, I am less concerned with whether your teenager or tween meets specific criteria. I do worry about children and teens who are excessively self-conscious in social situations.

Social anxiety is a risk factor for problematic digital technology use. Teens who are socially anxious often turn to the Internet and social media for social connectedness because of their fear of face-to-face interactions. Socially anxious teenagers prefer online disclosure to offline disclosure.6 It is wonderful when they can connect and build confidence online. A challenge for socially anxious teenagers is to present their real self online. They are often concerned that no one will like their real self, so they present a false or “fake” self. Researchers have found that those who “fake” it online are more likely to suffer from anxiety and poor social skills.⁷ I believe that online connections are more likely to generalize to real-life skills if the teenager is able to present her real self in cyberspace.

Socially anxious teens have much more at stake on the Internet. They are more likely to become overly dependent on online connections and relationships. Socially anxious teens report that Facebook support contributes to their sense of well-being beyond face-to-face support. Nonanxious individuals do not report that social media connections contribute to their well-being.⁸ There is a risk that digital technology will feed avoidance and worsen fears of real-life interactions.⁹ There is concern that teenagers who are overly dependent on the Internet and prefer online disclosure may be more vulnerable to online predators. The pros and cons of digital technology need to be weighed carefully. Parents need to take an active role in helping socially anxious kids find confidence and support online that can be generalized to their real lives.

Social anxiety is a risk factor for problematic Internet usage.

My Recommendations for Digital Technology Use by Socially Anxious Children and Teens

  Help your teenager present his or her real self on social media and the Internet.

  If your teenager is socially awkward, encourage him to use the Internet for self-expression and social connectedness.

  Be wary if your teenager becomes overly involved with one person online.

  Help your socially awkward child cultivate both digital and real-life relationships.

  Encourage your anxious child or teen to connect to real-life friends and classmates via texts and social media.

  Encourage online disclosure in moderation.

  If online interactions are making your child anxious, take a break.

  Be wary of overdependence or excessive reassurance seeking online.

  Be aware of whether online interactions are replacing real-life interactions.

  Be wary of teenagers who are preoccupied with online relationships and who are distressed when they are unable to connect online.

  Help anxious tweens or teens not to disclose personal information or make plans to meet strangers.

DEPRESSION, SUICIDE, AND DIGITAL MEDIA

Nadia, an 18-year-old depressed teenager from Ontario, had three exchanges with “Cami,” a 31-year-old depressed nurse, in a suicide chat room in 2005. “Cami” suggested that Nadia hang herself rather than drown herself. She even suggested what type of rope to use. Cami offered to guide Nadia through the process via a webcam. After her chat with “Cami,” Nadia chose to jump off a bridge. Local authorities found her body 1 month later. “Cami” turned out to be a 45-year-old man named William Melchert-Dinkel, who has been convicted of two counts of assisted suicide and admitted to encouraging dozens of depressed people to commit suicide.

Jessica Laney was a 16-year-old girl who hung herself after being bullied on the question-and-answer social media site Ask.fm. She was called “fat” and a “slut,” and one person posted, “Can you kill yourself already?” According to her Ask.fm posts, she struggled with family issues, school conflict, and concerns about her body image. She sought support on social media and found abuse instead.

Admittedly, I have chosen two extreme examples of teenage suicide that are linked to digital technology. The statistics on suicide and depression make this a group that we must address as we carve out our digital blueprint.

  Suicide is the third leading cause of death for 15- to 24-year-olds.

  11% of young people suffer from depression by the age of 18.

  Depression is the leading cause of disability worldwide for 15- to 44-year-olds.10

Digital technology does not cause or worsen depression. In fact, there may be ways for technology to be a tool for screening and prevention. As a parent, you need to be on guard for depression. Your teenager’s technology use may offer you a way to identify depression and intervene. I am not so concerned that technology causes depression. Adolescent depression existed well before the first computer was invented. Teenagers who are depressed are certainly more vulnerable to online predators and cyberbullying. If your teenager is depressed, then you should be monitoring for cyberbullying, online predators, and visits to dangerous pro-suicide websites.

The Invisible-Risk Group

My big concern is that most parents don’t recognize when their adolescents become depressed. It can be hard to tease out normal teenager irritability and oppositionality from depression. Parents have a tendency to blame gaming and social media when technology use is usually a symptom, not the cause. In a European study by the Saving and Empowering Young Lives in Europe (SEYLE) organization, 12,000 adolescents were divided into three groups:

  High-risk group (13%): higher rates of alcohol, drug, and cigarette use and truancy

  Low-risk group (58%): low rates of alcohol, drug, and cigarette use; low rates of truancy and Internet use; more time spent sleeping and exercising

  Invisible-risk group (27%): higher rates of Internet use and less time sleeping and exercising

No one is surprised that the teens who exhibited risky behaviors fell into the “high-risk” group for mental health problems. We didn’t need a 12,000-person study to give us that finding. What might surprise you is that the “invisible-risk” group’s rates of depression, anxiety, and suicidal thoughts were similar to those of the “high-risk” group.11

Depressed teenagers and adults have different patterns of Internet usage. Teens who play games and use the Internet for more than 5 hours per day may be at higher risk for sadness, suicidal ideation, and suicidal planning but not for suicide attempts, according to a survey done in 2007 and 2009.¹² The online activities of 216 participating undergraduates at Missouri University of Science and Technology were monitored, and the findings showed consistent patterns of use.

Depressed college students were found to be more likely to:

  Spend more time on the Internet.

  Send more e-mail messages.

  Use the Internet in a random way with lots of switching between games, video, and communication.

  Spend more time watching videos, playing games, and chatting.13

Sriram Chellappan, the lead researcher, explained, “We believe that your pattern of Internet use says something about you. Specifically, our research suggests it can offer clues to your mental well-being.” The social media world is becoming increasingly aware of how people may turn to social media when they are feeling depressed and suicidal. Facebook has launched an antisuicide initiative. It has partnered with the National Suicide Prevention Lifeline and SAVE, a national suicide prevention organization. Facebook friends can report people they are concerned about. Suicide counselors will contact flagged people. Facebook is also working on an initiative to identify high-risk users by looking for problematic patterns and keywords. In 2012, researchers looked at 1.7 million tweets by 1.2 million users from May to August. They compared rates of suicide comments on Twitter with actual rates of suicide in a particular state. The suicide tweets correlated with the rates of suicide. Midwestern states, western states, and Alaska had a higher proportion of suicide-related tweeters. Twitter has the potential to serve as a tool for real-time monitoring of suicide risk factors and a platform for intervention. Right now, parents can monitor their teenagers’ social media and texts for depression and suicide content.

Can the Internet serve as support for my depressed teen?

Yes. The Internet, social media, and some online games can provide support. Suicides have been prevented and depressions treated when an online friend reaches out and gets real-life support. There is plenty of good information about depression online that can lead teenagers to hotlines and help. Unfortunately, teenagers who go looking for help can easily find themselves on pro-suicide or pro-self-harm sites. You can order suicide kits and copies of Final Exit, the pro-suicide movement’s bible. Researchers have found that watching suicide videos and going to suicide sites increased the risk of actual suicide. Most teenagers who have attempted suicide admit to looking online for ideas and information.¹⁴

The biggest mistake that a parent can make is to take away the phone and the computer of a depressed adolescent. You may further your teenager’s isolation and take away his or her only supports. Recently, I worked with a high school student who was being bullied at school. At home, she was irritable, argumentative, and always on her phone. Her parents were worried that she was depressed and were annoyed by her stubborn and argumentative behavior. They felt that there should be “consequences” for her bad behavior. So they took away her phone. When we explored it further, it turned out that her phone was a lifeline and critical support for her. She texted her mother from school when she was lonely. She called or messaged her friends outside of school to find reassurance and support. Without her phone, she was stuck with the “mean girls” at school and felt unsupported. The family and I recognized that she was depressed, and we initiated family and individual therapy. She kept the phone, and her parents used other “consequences” to deal with her oppositional behavior. Over time the depression and bullying improved. Her attachment to her phone became more reasonable and less frantic. Sometimes it is appropriate and necessary to not take away the phone.

Parents need to understand how their teenagers use the phone and the Internet before they take either away.

The take-home point is to look for red flags for depression and recognize when technology use is problematic. Digital technology in moderation is an integral and positive component of high school. However, children who are depressed or anxious join the “invisible-risk” group.

As noted above, it’s not always easy to know when a teen is depressed. Children and teens with depression often don’t fit the classic picture of acting down and dejected but may be more likely to act irritated and angry. If your child is often sad, expresses hopelessness, seems oversensitive to criticism, or feels guilty, talk to your pediatrician. A depressed child or teen may also seem bored and uninterested in former hobbies, or complain of being tired or having a lot of stomachaches or headaches. Depression can cause problems with sleeping and changes in eating habits. Relationships may become difficult, the child may avoid school, and grades might fall. Ask your teenager if he has thoughts about killing himself or dying. Teenagers rarely offer this information but may answer you honestly if asked directly. If your child expresses any suicidal thoughts or exhibits any of the symptoms above for longer than a week, then definitely seek help from your pediatrician or a mental health professional.

WORRISOME TECHNOLOGY PATTERNS

•  Abrupt change in how the child uses the Internet, social media, and games

•  Erratic use of the Internet with lots of switching

•  Dramatic increase in electronic communication

•  Overdependence on a single online relationship

•  Avoidance of school or friends to stay online

•  Significant sleep impairment from online activities

•  Browser history that shows visits to suicide or self-harm sites

•  Worrisome posts or pictures on social media sites

•  Cyberbullying

What to Do If You’re Worried about Depression and Problematic Technology Usage

  Talk to your child or teenager.

  Ask directly about hopelessness, self-harm, and suicide.

  If he won’t talk to you, then find someone he will talk to.

  Inquire in a noncritical way about what the child or teen is doing online.

  Take an interest in the child’s online activities.

  Find out how technology is supportive and helpful for your teen or child.

  Inquire about cyberbullying.

  Check the browser history.

  Check the phone.

  Check the child or teen’s social media posts.

  Google your teenager.

  Set limits around sleep and technology.

  Inquire about drugs and alcohol.

  Get professional help if symptoms don’t improve.

Digital technology can be a powerful tool to help increase efficiency for those with ADHD and provide critical support and intervention for anxious and depressed kids. It’s important to understand your children’s challenges with attention, distractibility, and anxiety, and look for changes in behavior that might signal depression. If you are concerned about your child or teenager, then you must be accommodating, flexible, and vigilant as you customize your family technology rules in the next chapter.

Parents who have lost a child to suicide regret “respecting” their child’s privacy. Monitoring your child’s digital life could save his real life.