was gaunt and pale, and his muscles had literally atrophied from sitting and lying down so much.
To see this in a young male was shocking. Dan complained of fatigue, joint pain, back pain, shortness of breath, depressed mood, trouble sleeping, and feeling “flat.” His mother had made the rounds to numerous medical specialists and therapists — for both physical and psychiatric complaints — but to no avail. By the time I consulted with him, Dan was taking three psychotropic medications plus a pain medication, and he had been tried on numerous other “psych meds” but found them all ineffective. Not one person ever suggested he remove the computer and other devices from his bedroom, despite this being a standard-of-care intervention for sleep disturbance.
Naturally, when I suggested an electronic fast, Dan resisted. As is often the case with youths over eighteen, his treatment providers and his parents had been reluctant to force any screen-time rules upon him, which only escalated the problem. I, however, viewed his situation as an emergency; his behavior was showing us he wasn’t able to care for himself. Fortunately, his mother — who had been suspecting that the computer was part of the problem — readily agreed that imposing the fast was warranted, and she removed all the electronics in the home that same day.
Initially, Dan became even more isolated. Most days, he stayed in bed and didn’t speak much at all. Because he was so depressed, we decided to extend the fast for at least six weeks, and this proved to be prudent. Right around the six-week mark, Dan started coming alive again. He got out of bed each day, made spontaneous conversation with his mom, and began going to class. His interest in physics and history revived, and he joined some academic clubs. Initially, we maintained the fast except for school-related work, but as time went on, his mother and I established strict rules for personal use and continued to actively moderate his usage, in part by requiring his schedule be structured. Dan got a part-time job, made friends, and started getting As and Bs in school. Slowly, Dan put on some weight and started walking and stretching regularly with a family friend. As he regained his strength and energy, it became clear that all Dan’s physical ailments stemmed from deconditioning (being out of shape), depression, and stagnant blood flow — not some mysterious medical disease.
Dan’s case underscores the seriousness of electronics’ role in mood disorders, highlights the risk that social anxiety can bring, and demonstrates some of the physical effects that can occur with electronics overuse. Other individuals at high risk for screen-related depression are those with autism spectrum disorders, particularly after graduating from high school (for more on autism and ESS, see page 99). Suffice it to say, it is not enough to address depression in young people solely with conventional psychotherapy and perhaps an antidepressant. Even if screen-time is not the primary cause, it is virtually always a contributing factor.
Bipolar Disorder
Bipolar illness is a mood disorder characterized by severe high and low mood states. While “low” refers to a depressed mood, “high” can refer to a state of either euphoria or irritability. In adults these swings tend to be relatively discrete episodes, but in children, bipolar episodes are less distinct, and both the “highs” and “lows” can be associated with irritability — making the disease mimic a lot of other mental disorders. Thus, the diagnosis can be missed in those who truly have it, but it also tends to be overdiagnosed in children with other difficulties.
When I first began my “Mental Wealth” blog for Psychology Today a few years ago, I wrote a post entitled “Misdiagnosed? Bipolar Disorder Is All the Rage!” in which I proposed that the large increase in pediatric bipolar disorder diagnosis was due (in part) to children who were overstimulated from video games and other screen-time who raged, and thus “looked” bipolar.13 I received emails from mothers all over the world — including the United States, Europe, Canada, South America, and the Middle East — telling me their child had been diagnosed as “bipolar” because he or she was exhibiting rages. Typically, the email would reveal that the mother had long suspected video games were the real culprit, but that the notion had always been shot down by whoever was evaluating the child. When these mothers read my article, however, the sense of validation they felt prompted them to follow their instincts — and out went the electronics. Story after story poured in about how a child’s rages had resolved or at least become manageable when they followed this simple intervention. Although I’d seen this in my practice hundreds of times, it was validating for me to hear that mothers around the world were using the intervention effectively.
However, behind the satisfaction loomed something more ominous. How many children were receiving psychotropic medication unnecessarily? How many were labeled as “bipolar” when they were simply overstimulated and unable to regulate themselves? As I mention in the introduction, the diagnosis of childhood bipolar disorder has increased dramatically in recent decades, and a new diagnosis was created in 2013 — Disruptive Mood Dysregulation Disorder — precisely out of concern that children are being inappropriately diagnosed with bipolar disorder and receiving unnecessary medication. In my experience, disruptive children are sometimes given a “bipolar” diagnosis by a pediatrician during a routine ten- to fifteen-minute visit, while in other cases a teacher or therapist suggests to parents that their child “might be bipolar” and “might need medication,” or worse, “can’t come back until he’s medicated.” Often, a child need only exhibit aggression or explosive rage to get this label slapped on by a well-meaning but misinformed clinician. In some instances, a mother will read a description of pediatric bipolar disorder, feel her child fits the description, and then convince herself and others that bipolar disorder is the correct diagnosis. Of course, childhood bipolar disorder can and does exist (with or without ESS), and it’s not a diagnosis you want to miss — early treatment improves prognosis. But it is relatively rare, especially if there is no family history of the disease (or no genetic predisposition).
So, what is it about ESS symptoms that prompt this mistake and create what seems to be a bipolar “picture”? In addition to rages and mood swings, ESS symptoms can include severe insomnia, impulsivity, distractibility, and, in certain vulnerable individuals, hallucinations or vague paranoia. Especially together, these symptoms can take on a very convincing bipolar persona. The misdiagnosis of bipolar disorder is even more common in children for whom ESS amplifies other difficulties, such as existing learning disorders, intellectual delays, ADHD, attachment disorder, sensory integration issues, and autism spectrum disorders. These children’s nervous systems are already more vulnerable to environmental assaults of all kinds, and they are more likely to become impulsive or aggressive under stress. For instance, say an eight-year-old boy has learning difficulties and ADHD. Both of these disorders will affect functioning of the brain’s frontal lobe, which governs planning, judgment, prioritizing, and emotional regulation. Now, if this boy is repeatedly overstimulated from electronics, this will further reduce frontal lobe activity, disrupt sleep, shorten attention span, and worsen mood. Now the boy will have even more trouble processing his environment, and very minor frustrations will be experienced as uncomfortable. You can see how a child like this might become explosive and have mood swings, or how he could be calm and loving after getting a good night’s sleep but be a wreck again the following day. His hyperarousal and poor processing might also mean he barely remembers his outbursts, and so he acts as though they never happened. These are all patterns that can occur when ESS compounds or mimics other disorders, and they are the same patterns that contribute to misdiagnosis.
Finally, of course, ESS can and does occur alongside true childhood bipolar disorder. ESS can easily make things worse for such a child, since bipolar illness is exquisitely sensitive to lack of sleep: staying up all night can induce mania, while inducing sleep is an important part of managing acute mania. If a child truly does have a serious mental illness like bipolar disorder, an electronic fast can help clarify the diagnosis, and it may help manage symptoms, both directly (by helping to regulate mood) and indirectly (by improving sleep). Either way, it may help reduce the need for medication.
For parents witnessing serious mood disturbances and dysregulation that appear to take on a life of their own, it may be hard
