Latest / Mind & Medicine - A Behavioral Health Podcast by Sentara / Screen Addiction (PIMU) with Dr. Bushra Rizwan - Episode 2

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Screen Addiction (PIMU) with Dr. Bushra Rizwan - Episode 2 · Mind & Medicine - A Behavioral Health Podcast by Sentara

• 0:00
  Speaker 1: Hello and welcome to Mind and Medicine, a Sentara podcast. I'm Tommy Bateman, your host, and today we will be meeting with Dr Bushra Rizwan to talk about PIMU or screen addiction. But before we begin, some important CME announcements. This episode is accredited for AMA PRA Category 1 credits. For full accreditation, designation, and disclosure information, please refer to the show notes and now the show. Welcome back, Dr.
• 0:28
  Speaker 1: Rizwan.
• 0:29
  Speaker 1: So in part one, we really talked about what screen addiction really is.
• 0:34
  Speaker 1: And now we have an opportunity to kind of talk about what we do about it.
• 0:38
  Speaker 1: So let's start from the beginning.
• 0:40
  Speaker 1: Someone walks into your office.
• 0:41
  Speaker 1: What are we doing to screen it?
• 0:43
  Speaker: Sure.
• 0:43
  Speaker: So I think any clinician, any anyone who has a touch point with an adolescent, I think it's important to touch on screen use questions as part of the history taking.
• 0:55
  Speaker: Primary care physicians providers are the first line of defense, I would say.
• 1:00
  Speaker: So integrating or getting used to just asking about screen use is part of the interview.
• 1:05
  Speaker: Things to ask, maybe how, you know, how much time the team is spending online, on their games, on their devices, habits around phone use is another favorite question of mine.
• 1:17
  Speaker: So, you know, where do you use the phone?
• 1:19
  Speaker: Do you use it in bed?
• 1:20
  Speaker: Are you using it in the bathroom?
• 1:22
  Speaker: Are you using it on the dinner table?
• 1:23
  Speaker: So just to get a sense of what kind of behaviors, habits are in place.
• 1:29
  Speaker: I think the other things to kind of think about when interviewing a teen, they might not want to open up about this specific topic in front of a parent.
• 1:40
  Speaker: So if you, as part of your usual intake or touch point are screening for substance use in adolescents, this might be a nice place to kind of put this question in as well.
• 1:55
  Speaker: Um and maybe doing it without the parent in the room.
• 1:58
  Speaker: And that way you can get some honest feedback.
• 2:00
  Speaker: The other way, if you can't get the parent out of the room, what I usually say my blanket statement is this is not to get you in trouble.
• 2:08
  Speaker: You're not in trouble in here, we're here to help.
• 2:10
  Speaker: Um and that usually tends to uh bring the guard down a bit.
• 2:14
  Speaker: And sometimes I joke around and say, you know, we all do it.
• 2:17
  Speaker: You know, parents do it, we as clinicians do it as well.
• 2:20
  Speaker: Which when I when I say do it, I'm talking about the screen use.
• 2:23
  Speaker: Um so just kind of normalizing the behavior and so that then helps um, you know, obtain some useful information um from the from the patient.
• 2:33
  Speaker 1: What role does parent self-report play?
• 2:35
  Speaker: Yeah, so I think um asking uh the parent for some feedback so you can um collaborate here and just kind of get some feedback.
• 2:43
  Speaker: A lot of times the teenagers will underestimate um how much time they're using on their screens.
• 2:49
  Speaker: Uh, one way of being able to get some objective data, uh, you know, when the parent and the child are conflicting and not providing the, you know, uh providing conflicting information on screen use.
• 3:01
  Speaker: I sometimes I'll ask for permission and I'll say, hey, would you feel comfortable looking at your screen usage?
• 3:10
  Speaker: Because every phone, um, if it is a smartphone, will have uh the ability to send a C screen usage over a week, over a day, what apps they're using.
• 3:21
  Speaker: So if you're a patient and you you have that therapeutic rapport and the patient is comfortable kind of, you know, uh showing you that or disclosing that information to you, you can ask them to pull up that data in real time in the session and kind of share that with you.
• 3:36
  Speaker: So that is another way to kind of figure out um or pinpoint how much screen use is actually happening.
• 3:43
  Speaker 1: And how do we differentiate when there are other complicating factors like ADHD or even autism?
• 3:48
  Speaker 1: Um, yeah, how do we flesh that apart and say, okay, screen addiction or PMU is is a uh significant factor here?
• 3:55
  Speaker: That's a great question.
• 3:56
  Speaker: So um as my role, so I former form uh primarily screen for psychiatric uh disorders.
• 4:05
  Speaker: Um screening for depression, anxiety, ADHD.
• 4:08
  Speaker: Now, a lot of these disorders co-occur in individuals with screen use, and there's a lot of overlap.
• 4:15
  Speaker: Um, and so what I see is um as a clinician kind of being careful to not over-diagnose whether it's depression or ADHD.
• 4:25
  Speaker: So if someone's coming in and saying they have difficulty paying attention in class, they have a hard time sleeping, um, while you're screening and while you're going through the questions for depression for ADHD, reminding yourself to ask those questions about screen use.
• 4:42
  Speaker: And I'll give an example.
• 4:43
  Speaker: Um, if someone comes in and says they have a hard time focusing in class, my follow-up questions after asking some of those ADHD questions is are screens involved?
• 4:53
  Speaker: Do you are, you know, do you use your cell phone in class?
• 4:56
  Speaker: Because if they are and they're distracted by their phone, then it's less likely truly ADHD and it's actually the phone that's the issue.
• 5:05
  Speaker: Um, similarly with sleep.
• 5:06
  Speaker: So if they're telling me they're not sleeping at night, um, and and I'm screening for depression, I'm screening for anxiety, and they're you know answering yes to those questions, but there is sleep disturbance, taking that extra step and asking about screen use, asking um whether they're using their phones in bed, those kind of questions, I think helps kind of differentiate um between you know uh true sort of clinical depression versus um versus this being an issue that started with a phone.
• 5:38
  Speaker: Now, both can be present at the same time and they could be cyclical, which means one is affecting the other and it's resulting in a spiral.
• 5:46
  Speaker: Um, so I think diving deeper and making screen use questions as part of the assessment is very important.
• 5:54
  Speaker 1: So also I wonder, you know, what if the screen use is just simply a symptom of the larger problem?
• 6:01
  Speaker 1: You know, a lonely depressed teen, um only friend is the screen in front of them.
• 6:08
  Speaker 1: Um, do you diagnose the primary diagnosis and and just call the screen use a symptom of it?
• 6:16
  Speaker 1: Or do you diagnose both at the same time?
• 6:18
  Speaker: I would say both at the same time.
• 6:19
  Speaker: I think it's bi-directional relationship, right?
• 6:22
  Speaker: So one is making the other worse and is kind of spiraling.
• 6:25
  Speaker: So I think you brought up a good point, right?
• 6:27
  Speaker: What purpose does the device serve, right?
• 6:29
  Speaker: Is it connection with friends?
• 6:31
  Speaker: Um, if so, um do they, is it a balance?
• 6:35
  Speaker: Are they do they have real life friends?
• 6:38
  Speaker: And my you know, my patients will say IRL in real life.
• 6:42
  Speaker: So do you have do you have real life friends?
• 6:44
  Speaker: And I think encouraging those connections.
• 6:46
  Speaker: So they're using the devices for connection, um, reminding them about balance, about um, you know, uh having some some real life uh interactions as well.
• 6:57
  Speaker 1: Okay, and and then in screening this, do you need like a you know a formal screening tool like the Cage Questionnaire, or is this better handled just using open-ended interview questions?
• 7:09
  Speaker: Yeah, so you can do a formalized screen.
• 7:12
  Speaker: Um, there are some resources available for that.
• 7:15
  Speaker: So the American Academy of Pediatrics um has uh two forms that can be used.
• 7:20
  Speaker: They're called Prius.
• 7:21
  Speaker: Um, there's a Prius 3, which stands for problematic and risky internet use screening, which is a brief scale.
• 7:28
  Speaker: Um that's a quick screener.
• 7:30
  Speaker: Um, it's for adolescents age 11 and above.
• 7:33
  Speaker: Um, and then if they screen positive, then there is um another screener, um, which is Prius 18.
• 7:41
  Speaker: Um, so those are the formalized ways of kind of testing.
• 7:44
  Speaker: Um, if anyone's interested, kind of going to those websites and pulling those forms is one way.
• 7:49
  Speaker: I do it as part of my intake, so it's a little bit more kind of conversational, doesn't feel like um, you know, that I'm asking.
• 7:58
  Speaker: Um, but I do include some of those questions, and those are some points that I do hit on as part of my intake.
• 8:04
  Speaker 1: And you're finding sufficient information through these interview questions.
• 8:08
  Speaker: I think so.
• 8:09
  Speaker: Um I I usually do kind of that objective, you know, if I find the parent and the child are disagreeing on, you know, what the actual use is happening, um then I ask them to kind of, you know, I can I can view or they can tell me what their phone says about their actual use.
• 8:25
  Speaker: Um sometimes I've had uh colleagues, I've done this myself too, is kind of co-viewing content, especially with adolescents, you know, if they're um comfortable just kind of sharing what they're viewing, um just to get an idea of, you know, are they uh the ideas that they're having, the the um the symptoms that they're reporting, um, is that showing up on their feed?
• 8:47
  Speaker: And we are seeing some of that too, you know, people coming in saying they have ticks and and um there was a phenomenon and still is uh tick tock ticks is what it was called.
• 8:58
  Speaker: So people thinking they have a symptom based on you know what they're seeing online.
• 9:04
  Speaker: So that's a that's a whole different um yeah, that's a whole different can of words.
• 9:10
  Speaker 1: And so, you know, with the cage questionnaire, there is a certain number of drinks that lead to a determination of problematic use.
• 9:17
  Speaker 1: Is there something similar here?
• 9:19
  Speaker 1: Is there a uh a level of uh screen use, if you were to quantify it, that bridges over into problematic use?
• 9:28
  Speaker: Yeah, so I think for problematic use, I go back to we talked about this in the first segment a little bit.
• 9:33
  Speaker: Um so compulsive behaviors, obsessive behaviors, impairment in functioning is the biggest one.
• 9:39
  Speaker: So your grades are slipping, they're struggling at home, they're struggling in relationships, all those are red flags that there is a problem.
• 9:47
  Speaker: Um the Prius III and the Prius 18 do have some cutoffs, and forms have those specific numbers.
• 9:54
  Speaker: Um, in terms of clinical, clinically, what I'm seeing though, I think going back to those red flags that we talked about, so behavior is compulsive, they're obsessing, um, they're built, they've built tolerance, so they're spending more and more time on the device, and then withdrawal.
• 10:10
  Speaker: So we're seeing tantrums, we're we're hearing um, you know, when they don't have the device, uh, they're feeling worse.
• 10:16
  Speaker: So they're having mood states, and the device is not present.
• 10:20
  Speaker: So those kind of things are all, I would say, red flags for me that there is a problem.
• 10:25
  Speaker 1: Excellent.
• 10:26
  Speaker 1: So we have the diagnosis.
• 10:29
  Speaker 1: Um person's come in, we screen them, we've gotten to the point where now we're developing the treatment plan.
• 10:34
  Speaker 1: So let's go on to that.
• 10:35
  Speaker 1: What is the treatment plan and what's the prognosis?
• 10:38
  Speaker 1: How long does it take to uh overcome this?
• 10:41
  Speaker: So um therapy would be considered first line.
• 10:44
  Speaker: So we don't have medications, right?
• 10:45
  Speaker: Unless there is a co-occurring condition, then there are medications to treat the depression, the anxiety, the ADHD.
• 10:53
  Speaker: Um, but first line, I would say cognitive behavioral therapy, um, that's the most supported intervention for problematic screen use in children and adolescents.
• 11:04
  Speaker: Um, the other thing I would say is a family-based intervention.
• 11:08
  Speaker: So involving the family makes the outcome better.
• 11:12
  Speaker: Um, so if the parent is saying, don't use your phones, and then they themselves are going and using their phones at the dinner table, using their phones in their bedroom, they're sending mixed messaging to their kids.
• 11:24
  Speaker: And I think having the family involved and strengthening the family unit and functioning of the family unit and improving those relationships, the parent and the child, then directly instead of directly targeting and calling it addictive behavior, I think changing the dynamics in the entire house, I think that approach is the best and usually leads to the best outcomes.
• 11:48
  Speaker: Um the American Academy of Pediatrics actually has a family media plan that comes with kind of just general rules for the entire family, and that tends to work really well.
• 12:00
  Speaker: Um so I highly encourage, you know, for providers to kind of pull that and have that as part of their toolkit when they're working with families on this specific issue.
• 12:12
  Speaker 1: As a therapist, I'm all about some CBT, but I I also wonder, you know, how about parental controls?
• 12:18
  Speaker 1: Is sometimes the uh less clinical intervention may be the best.
• 12:25
  Speaker: I have.
• 12:25
  Speaker: So I think parental controls are very, very good.
• 12:28
  Speaker: Um, and it's nice that they see that countdown and they get that visual feedback that this is the time I have, and this is, you know, this is um how much time I'm gonna have on the device.
• 12:38
  Speaker: Um so I think that feedback for kids is very helpful.
• 12:41
  Speaker: Um, I was also gonna touch on um, I think the having consistency is key, um, as cliche as that sounds.
• 12:51
  Speaker: Um when a kid expects and knows what to expect and what outcome they're gonna get, then you can reinforce that behavior.
• 12:59
  Speaker: So if the parent is consistently saying this, these are the rules, these you know, you get your screens if you do this, um, I think that tends to keep the behavior going.
• 13:09
  Speaker: When I say that, you know, um, all the positives that you get from CBT, if you're consistent with it and the parent has established some rules and keeps those rules consistent, then you know, those positive gains that you get with with restricting screen usually stay.
• 13:26
  Speaker 1: Now I know everybody's different, but what what is the typical turnaround for this sort of issue?
• 13:31
  Speaker: So I usually say four to eight weeks as long as you're consistent.
• 13:34
  Speaker: So if you are if you have parental controls in place, um, limiting notifications is another one that's actually I've tried myself and works really well.
• 13:43
  Speaker: Um, so you can turn off notifications from apps so it's not constantly going off and you're um not picking up your phone and checking to see if someone messaged you, you got a new email.
• 13:54
  Speaker: So I think turning off those notifications is super helpful.
• 13:57
  Speaker: Putting things into folders is another thing that I've tried myself and I think is very helpful.
• 14:01
  Speaker: And I encourage um kids to do the same.
• 14:04
  Speaker: Teenagers who come through through my door, I always encourage, you know, if there is an app you keep going for, whether it's Snapchat, put it into a folder.
• 14:12
  Speaker: You can even label it, do not touch, or whatever you want to label it, um, and put it on a different um page on your on your um phone.
• 14:19
  Speaker: And that tends to work as well.
• 14:21
  Speaker: You're just trying to break those cycles almost like a detox uh from those those um those apps.
• 14:28
  Speaker 1: And you know, as a parent, I I look at my own screen usage and I use my phone for work, for personal life.
• 14:34
  Speaker 1: Um, I looked at my you know, screen usage because it keeps track and it was a little scary.
• 14:38
  Speaker 1: So I don't think I'm setting up a good uh uh example for my children.
• 14:44
  Speaker 1: So it kind of behooves us parents to really set the tone.
• 14:48
  Speaker: Absolutely.
• 14:48
  Speaker: I think modeling those healthy behaviors are are what's gonna keep the change going.
• 14:54
  Speaker: So yeah, I I 100% agree with that statement.
• 14:57
  Speaker: Um, Dr.
• 14:58
  Speaker 1: Iswan, we've reached our time.
• 15:00
  Speaker 1: Do you have any parting words?
• 15:02
  Speaker: I would just say um remembering balance is key.
• 15:05
  Speaker: Um so just encouraging uh children to go outside, especially now with uh you know summer months coming along, um, going outside.
• 15:13
  Speaker: If it's winter, finding indoor activities to do, um, substituting that screen use uh for some exercise and some in-person um interactions is what I would say is gonna be the key.
• 15:27
  Speaker 1: Touch grass, in other words.
• 15:28
  Speaker 1: Yes.
• 15:29
  Speaker: So smell the grass, touch the grass, roll around in the grass.
• 15:33
  Speaker: Yes.
• 15:36
  Speaker 1: You've been listening to Mind and Medicine, a Sentera podcast.
• 15:39
  Speaker 1: As a reminder, please check the show notes for details on how to claim your continuing education credits, as well as any resources mentioned in the episode.
• 15:46
  Speaker 1: That's it for now, but keep an eye out for another episode and more evidence based education for healthcare providers on the go.
• 15:52
  Speaker 1: You wel.