central issue. But a child’s diminished ability to self-soothe or regulate mood due to of ESS will prolong and worsen the episode, all while creating a hair-trigger response to stress. Then, when the usual treatments don’t improve symptoms, parents become even more exhausted — and almost invariably children are allowed even more screen-time. This creates a vicious cycle of stress and dysfunction that can further overshadow the role of electronics. The bottom line is that ESS needs to be both ruled out and addressed before tackling whatever lies underneath.
Lily: When a Smartphone Isn’t Smart
A bright young girl, Lily was sixteen when I met her. By then, Lily had already been kicked out of school because of her rages and emotional instability, and she was being homeschooled. She had also been diagnosed with bipolar disorder, and because of the prescribed medications she was taking, she’d gained nearly thirty pounds. Her mother initially brought her to me for a second opinion on her medication regimen. Instead, as I discovered the amount of computer time Lily devoted to gaming and chatting on anime sites, I suggest that they do the Reset Program.
After much convincing, Lily’s mother agreed, but Lily was furious. During the first few days of the fast, Lily screamed and cried, pleaded, slammed doors, threw things, and generally gave her mother hell. “It was like taking someone off heroin,” her mother told me. “She swore up and down and cursed you and me both.” I told her mother that this behavior was expected, and I encouraged her to hang tight and continue the fast. When Lily and her mother returned to my office several weeks later, Lily was smiling and admitted her mood was better since the fast, even though she was initially “mad as hell” at me. Her mom described Lily as “more even-keeled” and noticed she was sleeping a lot better. Eventually Lily returned to school, and we were able to greatly reduce her medication doses — which in turn helped her lose weight. Because Lily was a lot more pleasant to be around, she began making friends.
Lily continued to improve over the next several months, and we were able to wean her off all her medications with the exception of a mild mood stabilizer that didn’t cause weight gain. During this time, she and her mother decided Lily would try attending a very strict and structured boarding school, which emphasized fitness and developmentally based learning. The school did not allow any electronic screen devices — no cell phones, no television, no computers — and it had a psychiatrist on site who would monitor Lily closely. For the next year and a half, Lily did wonderfully: not only did she lose the thirty pounds she’d gained, but she lost ten more; her mood was relaxed and happy; and her self-esteem and social skills greatly improved.
In April of her second year at school, however, I received a frantic call from her mother stating that Lily’s mood swings had suddenly returned and that she was suicidal and had to be brought home. When Lily came in, I tried to find out what stressors may have triggered a mood episode, but could find none. Lily claimed she hadn’t used any computers, even when she had been home over that recent spring break. On the surface, it looked like Lily was “cycling,” or experiencing a bipolar episode, perhaps because of her reduced medication regimen. But I kept digging — and eventually I uncovered that when Lily had turned eighteen in March, she’d been allowed phone privileges, and her parents had given her a new smartphone.
Lily admitted to texting incessantly, playing electronic games, and accessing the Internet on her phone throughout the day. She also admitted to using her phone at night, texting while in bed, and sleeping with the phone under her pillow. Thus, despite the fact that she was still restricted from television and computer use at school, she had ramped up her interactive screen-time over a very short time period and was exposing herself to light-at-night, which, as mentioned earlier, has been linked to depression and suicidal thinking. Lily’s sleep was disturbed, her mood had become dysregulated, and her grades had fallen.
To me, this was a no-brainer: the culprit was the phone. Although neither she nor her mother agreed that the phone could possibly be the trigger, they agreed to a fresh electronic fast — which included handing over the phone — since they were both reluctant to increase or add medication. Lily quickly stabilized.
As with Dan, Lily was now a legal adult, and some might argue that she had the “right” to own a phone. This may be true, but if excessive smartphone use could put her in the hospital, did we really want her have one? Did she really need it? In the end, her mother bought Lily a simple flip phone with no texting, games, or Internet capabilities, and Lily was able to return to school successfully. My opinion is that Lily was indeed somewhere on the bipolar spectrum, but screen-time clearly dysregulated her already vulnerable brain and made it nearly impossible for her to succeed in life.
Cognitive Concerns
As opposed to mood or behavior, cognition relates to thoughts and thinking. Cognitive problems associated with ESS run the gamut, from trouble concentrating and diminished creativity all the way to paranoia and even hearing voices. The influence of interactive screen-time on cognition is thought to be due to dopamine imbalance, blood flow shifting from higher to lower centers of the brain, mood disturbance, and stress chemicals and hormones associated with hyperarousal (see figure 5). Furthermore, cognitive effects are compounded by screen-time’s effects on sleep. Light-at-night studies confirm that children suffer immediate and lasting impairment of cognition and sleep quality from any amount of interactive screen-time after bedtime.14
Figure 5. How screen-time effects translate to cognitive symptoms
Attention, Executive Functioning, and Learning
Children with attention problems generally have difficulty sustaining and shifting attention, and they have trouble initiating and completing goal-oriented activities — particularly if the activity is experienced as difficult or tedious. Inseparable from the ability to pay attention are two other abilities: executive function — that is, the ability to “get things done,” which includes planning, prioritizing, organizing, revising, strategizing, attending to details, and managing time and space — and working memory, that is, “seeing in the mind’s eye,” or the ability to hold and manipulate incoming information in the mind. Difficulties with attention and executive functioning, which are largely governed by the brain’s frontal lobe, have a profound impact on quality of life — affecting everything from academic and career achievement to the success of relationships.
Attention and executive functioning are largely dependent on dopamine and another brain chemical (or neurotransmitter), norepinephrine. These two neurotransmitters are the same chemicals that attention-deficit drugs seek to increase. Our brains need not just an adequate supply of these chemicals, but they also require them to 1) be active in the appropriate areas, 2) bind to adequately sensitive receptors, and 3) strike a balance with other brain chemicals, such as serotonin. These functions are sensitive to stress of any kind and can also be impacted by lack of proper sleep.
Whether related to ESS or not, what do attention difficulties look like? The child or teen with poor executive functioning …
• has difficulty with multistep directions and executing tasks that require planning and prioritizing, like school projects or applying for college or a job.
• loses homework even when completed or forgets to turn it in.
• has trouble keeping track of things, including time and personal belongings.
• is easily overwhelmed and becomes frustrated by small demands.
• exhibits paralyzing procrastination and avoidance of chores, and will have a “hard time getting started” on homework (especially “busy work”) and paperwork in general.
