JOSH FEDER: Hi, I'm your host, Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice, second edition, 2023, and the other book Prescribing Psychotropics.

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California, with a private practice and an avid reader of the Carlat Psychiatry Reports. Today, we tackle the mental health impacts of screen time, the double-edged sword of self-diagnosis on social platforms, and the rise of cyberbullying. We'll discuss sexting online hate and how marginalized youth navigate digital spaces. Most importantly, we focus on solutions. Helping kids, parents, and clinicians foster healthier, safer, supported relationships with technology. What are some of the pros and cons you see with social media use for teens and adolescents?

JOSH FEDER: Well, let's start with the pros. The positive impacts include reduced stigma for mental health treatment and increased awareness. Social media platforms can provide connection and identity validation for marginalized groups. A great example is the Neurodiverse community. Where people find each other and hang out. Also, for the gender-diverse community, it's another place where people find each other and interact in ways that they otherwise don't always find, like at school. But, on the flip side, the negative impacts include exposure to misinformation, cyberbullying, incidents that often mirror school dynamics, but they're much bigger because there's a bigger audience, and viral challenges or glorification of harmful behaviors that can increase self-harm or risky actions.

MARA GOVERMAN: Yes, research shows that increased social media use is moderately associated with poorer mental health outcomes. However, the effects are generally small and vary based on individual experiences. 

JOSH FEDER: Social media does transform how young people interact, how they learn about themselves, and how they access health information. It provides protective benefits for those with strong. Offline social networks, but it can increase mental health risks for those lacking those supports offline.

MARA GOVERMAN: As a result of social media, clinical practice is changing. Youth are increasingly influenced by influencer narratives and diagnostic labels. Posing diagnostic challenges and leading to rises in self-diagnosis. 

JOSH FEDER: Sometimes people will get online; and they'll look up various things. I think I'm autistic is a great one. So they go, they take a test, and they're like, Oh wow. And, you know, what? Sometimes, they actually come to care, and you do elucidate a history where it is accurate. But sometimes that's not true.

MARA GOVERMAN: And so, the nuances...

JOSH FEDER: Yeah, the nuances matter. And so the, the clinical problem that arises is that you end up with people who come in and they're pretty convinced that they're autistic or maybe they have ADHD, or something like that; and if in your discovery you don't find those same things, you have to figure out a way to partner with somebody while at the same time letting them down about that diagnosis, but also hearing the symptoms, and thinking about what you could do about those symptoms with them. Let me give you an example, so you have somebody who comes in, they're like, I've got ADHD, I can't focus, and I'm not doing very well, and it just seems like I probably need medicine for it, and you're like, Okay, well tell me about your life. Well, lo and behold, you find out that they're up late at night. They're not getting a lot of sleep. We know that there's like a crisis of this, people up on screens and things. And if they slept better, they probably would be doing better. And that's the first thing that you need to address. So, you have to figure out how to hear them, that they're not concentrating well, but to tell them that before we give you medicine, let's see if we can get you sleeping enough to see if that might make a difference. But that's one of the reasons we're here, is to educate colleagues, to be looking at the whole person, the differential diagnosis, to be ruling out sleep problems before giving people stimulant medications for ADHD.

MARA GOVERMAN: It also makes more challenging treatment, because sometimes they've planted the seed in their thinking that they have anxiety or attention issues, and it's hard to convince them otherwise.

JOSH FEDER: Hard to convince them otherwise. Here's another example, it's something we've talked about before (we published on this about a year or two ago), and that's plural identity, right? So there's a whole group of people who get online, and they believe that they might have either a dissociative identity disorder, like multiple personalities (that kind of thing), or something that's more benign in a way, is plural identity, meaning they identify with several different versions of themselves, which can be entirely different. These ones are aware of each other in plural identity, and it's almost like actors on a stage where they're allowing one person to take the stage and then another person to take the stage, and so you've got this online community of people who are enamored of this and think of themselves that way, and maybe paradoxically or ironically, there's an entire field of psychotherapy where you're looking for those different personas and getting them to function better as a team. So instead of the treatment that you would do with dissociative identity disorder, where you're trying to integrate everybody into one, with these kinds of disorders, I think it's called Family systems.

MARA GOVERMAN: Mm-hmm. No bad parts.

JOSH FEDER: No bad parts, right? That's right. So, you've got all these different parts of you, and we talk about that all the time, The part of me wants this, the part of me wants that. So Internal Family Systems Therapy has this entire way of looking at people as a combination of a bunch of parts and getting them to work better together, not integrating them so much as just better collaboration and teamwork. So, it gets confusing, but then you get these online communities that love this stuff.

MARA GOVERMAN: Let's talk about another challenge for clinicians to navigate — sexting. Teens may engage in sexting within romantic relationships, feeling more confident or closer to their partner. It's not inherently risky if the relationship is stable and reciprocal. However, sexting can be risky when it occurs outside such relationships, often driven by peer pressure or desire to start relationships. So, how should clinicians approach sexting?

JOSH FEDER: Well, there are legal considerations. Sending nude pictures technically fits the definition of distributing child pornography. But legal consequences are very rare. You can't catch everybody. There are so many kids doing it. So, law enforcement typically focuses on cases involving coercion or exploitation, especially with adults involved. I recommend that clinicians encourage open communication with the teen, ensure they understand the risks involved, and assess the context, whether it's consensual and within a stable relationship, or involves pressure or manipulation situations involving exploitation, need to be reported to the authorities such as Child Protective Services, particularly when there's an adult involved.

MARA GOVERMAN: I also suggest that we bring up these conversations frequently because as you and I have found in our practice, teens and adolescents forget quite frequently.

JOSH FEDER: They do; they do. You put a device in somebody's hands, and it's got a camera. They're going to take pictures, and they're interested in sex—they're going to take pictures. They can send them around—they're going to send them around. How do you get people to delete those pictures, delete them at the end of a relationship? Does anything ever really go away permanently? I don't know, but you kind of need to find ways to try to encourage people to respect their privacy. So, for instance, in clinical practice, I've had people who have been cyberbullied in a way that maybe they were dating, they took a picture of themselves that was, something you wouldn't want everybody to see, they break up, and then the person they broke up with spreads it all across social media. It's, it's humiliating, and there's a Talmudic saying that humiliation is the same as murder. I mean, people really want to die and sometimes hurt themselves when they've been humiliated.

MARA GOVERMAN: Meaning, someone is motivated to send a picture, they have no thought in their minds of how that picture is received or how it goes out in the world and what the consequences are. They're not thinking of the bigger picture. Are there clinical implications for cyberbullying, and how does it differ from other bullying?

JOSH FEDER: Cyberbullying involves intentional repeated cruelty with a power differential where the bully's actions are amplified by an audience on social media, making it more emotionally damaging. If your patient experiences this, you have to help them by documenting the bullying, maybe taking screenshots, encourage kids to reflect on their online interactions, and understand their role in conflicts. In severe cases, limiting screen time may be necessary, though that can cause anxiety, but you need to address this swiftly to prevent escalation.

MARA GOVERMAN: Yes, and other considerations is suicide and threats of violence. Encouraging teens to share suicidal thoughts of violent plans is crucial. Social media has become a platform where teens and adolescents express distress, and while this can sometimes result in help, it often doesn't.

JOSH FEDER: And so, there's no big remedy to that, but a little remedy is to be encouraging adults to be communicating with their kids and trying to hear them, and hear their distress, and to talk with them directly about that and to help them get competent mental healthcare. When I hear about a kid who's posted something online that indicates they're in distress. What I want to have happen is for somebody to help that kid get to somebody who can work through that, understand that, unpack that, figure it out with them so that they can address the distress rather than just sort of leaving it there to fester and maybe grow. It's important to maintain a no-secrets policy when it comes to safety. Risks always intervene if there's a threat to life or well-being. Encourage teens to share distressing thoughts with adults they trust, and to do that offline. It's also important to check in on your patient's self-worth. Many teens link their self-worth to social media metrics like how many likes they're getting and how many followers they have. This can create a very fragile sense of identity, especially when online popularity fluctuates. Encourage teens to develop a healthy self-image independent of online feedback. Discuss the superficial nature of social media metrics and promote activities that foster self-esteem outside digital validation, like hobbies and academic success, or face-to-face relationships.

MARA GOVERMAN: We hope you enjoyed today's podcast. Our discussion today is inspired by our interview with Dr. Paul Weigle from our July/August/September 2024 newsletter.

JOSH FEDER: If this episode resonates with you, share it with colleagues, parents, and anyone invested in supporting the health and wellbeing of young people. Together, we can make a difference. 

MARA GOVERMAN: Our newsletter is independently researched and produced. There's no funding from the pharmaceutical industry.