Youth health in a digital world: Approaching screen use in clinical practice

Abstract

New technologies, such as smartphones, have altered our behaviours and cultural structures more dramatically than televisions of our past. The array of today’s electronic devices have pulled our eyes closer to the screens and our focus further into the boxes behind those screens. Screens may serve us; simultaneously, they are increasingly giving rise to health and social challenges that researchers are only beginning to understand. There is a growing dis-ease among parents and health care providers (HCPs) about how screens are affecting youth. As the push for increased screen time continues in both educational and workplace settings, HCPs are not only tasked with helping parents and youth cope, but they must find ways to manage the impact of increased personal and professional screen time on their own wellbeing. This article considers the impact of increased screen time on two groups: youth and the HCPs supporting them. Furthermore, the authors explore the impact of screen use on clinical interactions, and patient care, suggesting a process for addressing screen use and provide specific tools including a reflective query for HCPs to better evaluate the impact of their own screen usage, ‘the Coaching Stance’ and TGROW, a questioning approach derived from coaching theory.

Keywords

Youth screen use health care provider Coaching Stance TGROW adolescent brain development mental health physical health

Introduction

New technologies alter human experience and behaviour, driving cultural change. Historically, when televisions became more accessible, ‘watching television’ became a normative activity and an accepted way to socialize, despite some voiced concerns about its potential impact. Now, television has embedded itself so deeply into our lives that it is often used as a source of comfort and companionship, a culturally sanctioned aspect of life that is rarely questioned or considered by way of its influence on our health.

Today’s omnipresent screens, including, but not limited to personal computers, smartphones, and gaming devices, serve us in myriad ways and shape themselves to meet our conscious and subconscious needs. Their ubiquitous presence in our lives, and our increasing dependence on them, has spawned a broad discourse around their influence from the level of neural circuitry to the level of societal organization. Understanding the health impact of increased screen use is made more urgent by considering that screen use is required in many educational and workplace settings, including health care.

The impact of screen use on the developing brains of children and youth, and the consequences for their emerging social patterns, is of particular concern to parents and health care providers (HCPs) who are often faced with questions for which science has no answer. Embedded in the same cultural context as their patients, HCPs are experiencing increases in personal and professional screen use, with uncertain outcomes. Both patients and providers are experiencing the largely unknown impact of screen use simultaneously; how might this impact their clinical interactions?

This article reflects on the current understanding of the impact of screen time on the health of youth and HCPs. With this influence in mind, the authors provide a process for HCPs to approach the topic of screen use with youth in the clinical setting (Figure 1). Beginning by informing themselves of the available guidelines and information, HCPs are next invited to become aware of the possible impact of screen use on themselves. Beyond personal reflection, a technique called the Coaching Stance as described by Elliott and Jericho (2017), is explored as a means of approaching the topic of screen use in the clinical setting. Employing a clinical vignette, the application of the Coaching Stance and a specific coaching approach, TGROW, is demonstrated (Downey, 2014). The authors are hopeful that the process they suggest will enable HCPs to support youth to develop personal reflection and communication skills, risk and opportunity management skills and autonomous decision-making abilities in the area of screen use.

Figure 1.

Process for approaching screen use in clinical practice.

Screen use and youth health

The health impact of increasing levels of screen use on youth and our broader culture are largely unknown. Some reports, including a 2010 Kaiser Study, show youth spending an estimated 7.5 hours interfacing with screens daily (Davie et al., 2019; Faulkner et al., 2015; Foeher et al., 2010). In this context, questions such as ‘How does the amount of screen use impact the developing brain?’ and ‘Should I be limiting my youth’s screen time?’ are increasingly relevant and frequent.

A primary struggle in addressing screen use impact is in defining what problematic screen use is. A systematic literature review in 2016 looked at ‘Internet Use’, ‘Problematic Internet Use’ and myriad terms used in research to describe this phenomenon (Anderson et al., 2017). To expand this query to include the problematic use of screen for all purposes, and then to identify the effects on youth, is a very complex task.

For adolescents, screen use occurs at a particular stage of developmental sensitivity, where youth are primed for social engagement and comparison. Usage among teens diminishes the need for real time, face-to-face dialogue. The opportunities that may have been present in the past to learn interpersonal skills by participating in non-screen-related activities are lessened. Broadly, there are concerns about how youth interacting with screens are learning to communicate and relate with others.

Parents and providers are often left to wonder if behavioural and emotional changes in teens are an expression of typical adolescent individuation or suggest a more concerning change related to screen use. An increasing amount of time spent interacting with screens is paralleling a trend of increasing mood and anxiety disorders in youth. The extent to which these factors are related is still uncertain. Areas of active inquiry include the impact of screen use on brain development, psychosocial health, addiction, body composition and fitness, sleep disruption and cognitive impairment among others (Domingues-Montanari, 2017; Faulkner et al., 2015; Stiglic & Viner, 2019).

A systematic exploration of reviews in the British Medical Journal on the effects of screen time on the health and wellbeing of children and adolescents found the strongest evidence for the association of higher levels of screen time for adiposity, unhealthy diet, depressive symptoms and quality of life but concluded that limited evidence existed to guide policy on safe screen time exposure. (Stiglic & Viner, 2019) The authors point out that many expert groups may be well meaning in their creation of guidelines, despite moderate to weak evidence.

Given the tsunami of questions and concerns, one can see why expert groups have felt the need to create guidelines to help parents surf this inevitable wave (Canadian Paediatric Society [CPS]; Digital Health Task Force, 2019; Chassiakos et al., 2016; Davie et al., 2019). Providers must exercise caution to not ‘throw the baby out with the bathwater’ when research suggests that screen use may be causing harm, despite the lack of absolute certainty. Families and youth benefit from limits and guidelines that reinforce the importance of family time and other health-promoting activities whether the increasing use of screens has a clear correlation with decreasing health and wellbeing.

Screen use and provider health

Screen use among HCPs in the clinical setting has become the norm as technology takes on an ever-increasing role in health care delivery globally. A 2016 survey of 6375 doctors in the United States found that 84.5% of respondents were using electronic health records (EHRs). (Dyrbye et al., 2016).

In addition, an American survey showed that physicians’ use of smartphones for professional purposes had been steadily increasing from 68% in 2012 to 84% in 2015, with little guidance available to best regulate their use in the clinical setting (Rosenberger et al., 2018; Statista Research Department, 2015)

The impact of screen-based tech in health care settings is a vast area of study, with measurable patient health outcomes often being the primary focus. Some research has focused on the experiences of the HCP, clinical interactions and patient care relationships (Antoun et al., 2017).

Results of a recent survey of American primary care providers (PCPs) using EHRs serves to underscore some of the paradoxes and challenges in understanding the impact of increased screen use by HCPs. A total of 60% of PCPs reported that EHRs have led to improved patient care. However, half of the respondents felt the EHRs detracted from their clinical effectiveness, and 70% advocated for a system that would reduce screen time. A total of 70% of respondents also felt that EHRs took time away from patients and ‘contributed greatly to physician burnout’. (‘How doctors feel about electronic health records’, 2018) Despite factors related to EHR implementation and refinement being inseparable from the unique factor of screen time, this survey suggests that screen use may be affecting physician wellness and patient care.

Physicians were found to be gazing at their screens for 30% of each clinical encounter in a recent study (Montague & Onur, 2014). Decreased physician satisfaction is associated with time spent disengaged from patients. As such, it is not improbable that screen use could be an important factor affecting physician wellness and contributing to burnout (McKenna, 2016). Burnout includes feelings of exhaustion, depersonalization and futility and is associated with concerning outcomes ranging from increased perceived errors to increased suicidal ideation. (Durning et al., 2008; Montague & Onur, 2014).

It behoves HCPs to consider if their screen use may be leading to disengagement from patients in the clinical setting and affecting their satisfaction and wellness. This insight can inform how physicians choose to interact with tech in the clinical setting and can alert them to possible personal health sequelae.

Approaching screen use in clinical practice

Youth and HCPs are finding themselves in a developmental parallel, as each is learning to incorporate screen use at a time when there is much speculation on impact and risks, but limited conclusive evidence. Limits and boundaries around excessive use have been suggested. How then do HCPs acknowledge warnings about screen use in themselves and in their patients, reflecting their knowledge directly and indirectly through their own choices and behaviours in the clinical setting?

Before advising others, HCPs may consider the impact of screens on their own health, wellness and interpersonal behaviour. Table 1 provides a query approach and invites the HCP to pay attention to the signs that screen use may be having a negative impact. As the table suggests, a similar approach can be effective for both members of the clinical dyad.

Table 1.

An approach to considering screen use in the patient and the provider.

Who (user)	Patient	Provider
What (pattern of use)	● Is the patient aware of their screen use patterns? ● Is the patient considering their health and wellness in the context of screen use?	● Are you aware of your screen use patterns? ● Are you considering your health and wellness in the context of screen use?
Why (reason for use)	● In considering the patients screen use patterns, be curious about the reasons for screen use. ● Invite them to consider why they are using their screens.	● In considering your own screen use patterns, be curious about the reasons for your screen use. ● Is it essential for your job or is it being used excessively or for other purposes?
How (impact on function and wellness)	● How does screen use impact daily functioning? ● Is use becoming problematic for sleep, socializing, mood or other important areas of health and functioning?	● How does screen use impact your daily functioning? ● Are there any mood or personality changes? ● Are there changes to your practice style, which concern you?
When (to set limits)	● Does the patient have a plan to establish when they will and when they will not access their screens? ● Consider a family SAP (Figure 2)	● Do you have boundaries for screen use in your own clinical environment (e.g. checking personal messages, checking work emails after hours and on holidays and using your smartphone in the clinic)?

SAP: screen use action plan.

Figure 2.

Family screen use action plan (SAP).

By developing insight into their screen use, HCPs are better equipped to offer authentic support to their patients, which will enable the use of the Coaching Stance described in Table 2 (Elliott & Jericho, 2017). The Coaching Stance employs the use of the five factors: non-judgement, curiosity, empathy, openness and flexibility.

Table 2.

Coaching Stance: the five factors.

Factors	Example questions
Non-judgement	‘If there were no right or wrong explanation, how would you describe this situation to your best friend?’
Curiosity	‘How do you think things are going?’
Empathy	‘It seems like a difficult situation’.
Openness	‘What other factors do you think we should consider?’
Flexibility	‘What else do you think is important here?’

The Coaching Stance is suggested by the authors as an approach for supporting youth in decision-making in areas of ambiguity, such as screen use. The clinical case and encounter, which follow, provide an example of this approach in practice.

Clinical case

GB is a 13-year-old boy who has been brought into your clinic by his father for concerns related to his mood. GB’s father, RB, wonders if his son’s screen use may be causing the ‘changes’ he is seeing in his son.

In the history, you hear that GB’s mood started to decline following some online bullying. He is currently engaged in social media use for 5 hours a day and is also using a laptop for school work and finds it difficult to ‘wind down’ and sleep without checking his smartphone repeatedly. While conducting your interview, he twice reaches for his phone and casually glances at the incoming messages. He appears mildly distracted but apologizes and proceeds with the interview.

You are a General Practitioner working in a family practice setting. You have recently been connected to a broader EHR system in your district. Despite the training requirements, you have found that there are some appealing features to this system, which allows you to gather information about patients efficiently and also flags potential patient risks. While meeting with GB, you are entering his history into your laptop. There are some struggles with formatting because your system does not have fields that work ideally with psychosocial histories yet. You repeatedly find yourself looking down to the screen and then back at the patient. Also, in the office are your personal computer and smartphone, which is silenced and charging.

Following this encounter, you return to the waiting room to find GB’s father on his smartphone; ‘It’s great that I can work while I’m out of the office’, he comments, while you return to the office for your wrap up discussion about GB’s mood.

This clinical case highlights several realities which may affect the HCP’s engagement with youth. A primary issue here is that there is insufficient clarity regarding the connection between mental health conditions and screen use. Beyond our limited understanding of screen use impact, the case illustrates the ubiquity, utility and normativity of screens in clinical settings. Clearly, this vignette would require the HCP to perform a full clinical assessment, for which the SSHADESS approach would be an essential component (Ginsburg, 2014), and provided there is no acuity identified, a conversation about screen use could become the focus of your clinical intervention.

Engaging youth and families in the context of ambiguity presents a challenge and opportunity for the provider. In the following example, we demonstrate the use of TGROW (Table 3), an approach utilized in coaching (Downey, 2014) and previously described in an earlier paper (Elliott & Jericho, 2017). This approach invites the youth to establish their own priorities and generates solutions in the problem area.

Table 3.

TGROW – a structured approach to problem-solving.

Steps	Intended outcome
T: Topic	Establish what the patient wants to talk about
G: Goal	Decide what will be achieved by the end of the encounter
R: Reality	Generate the clearest possible picture of the situation
O: Options	Establish a sense of all the possibilities for achieving the goal
W: Wrap-up	Select the most appropriate option and agree on next steps

The clinical encounter, using the TGROW approach

HCP:

‘Sounds like your dad is concerned about your screen use’.

GB:

‘Yup, he blames everything on screen use, he’s totally obsessed with it’.

HCP:

‘So . . . that’s annoying at times?’

GB:

‘Totally’.

HCP:

‘OK, do you want to change anything about your screen use?’

GB:

‘Nope. I just want him to stop bugging me about it and taking my phone away’.

HCP:

‘OK. How about we work on that issue then?’

GB:

‘Fine. But I doubt it will work’.

HCP:

‘Tell me more about what he’s doing that’s so annoying for you?’

GB:

‘He’s always telling me to stop and put my phone away. He totally doesn’t get it. This is how I know what’s going on with my friends. If I’m not on my phone I don’t know what’s going on and I’m out of it. It sucks because I miss stuff’.

HCP:

‘What’s it like to miss stuff?’

GB:

‘It sucks. I get totally stressed because I don’t know what’s going on, you know?’

HCP:

‘OK. So when your dad takes your phone away he doesn’t get that it disconnects you and makes you nervous’.

GB:

‘Exactly. If he was worried about my mood, he would stop trying to separate me from my friends. And also, he’s on his phone all the time, he’s being a total hypocrite’.

HCP:

‘OK. Anything else about this issue that’s bugging you?’

GB:

‘My dad totally exaggerates. He thinks I’m always on my phone. I’m not, I still do other stuff too’.

HCP:

‘OK. Anything else about your dad bugging you?’

GB:

‘Not really. Oh, he thinks I shouldn’t use it too late because he read that it wrecks your sleep. That’s also really annoying’.

HCP:

‘OK, so your dad doesn’t understand the importance of the phone for you and how it helps you to feel calmer by keeping you connected to your friends. He also doesn’t appreciate that you aren’t always on the phone . . . that you have limits. He also bothers you when he brings up using your phone late at night. Is that right?’

GB:

‘Something like that’.

HCP:

‘OK. What are the barriers to changing this situation?’

GB:

‘Well, for starters he needs to calm down. It’s not like I never put my phone down. And also, he needs to chill a bit – he seriously thinks screens are like, the worst thing ever! Which is weird because he’s on his computer all day, and his phone!’

HCP:

‘OK, so the situation might change if your dad actually understood that you have limits and also was aware of the real risks of screen use? I’m also hearing that his behaviour is a bit confusing and that he seems stressed?’

GB:

‘For sure’.

HCP:

‘OK. So what can you do to make your father see things a little differently, if that’s the barrier?’

GB:

‘I’m not sure, I could tell him, again. But he probably won’t believe me. Maybe you could tell him that there’s no problem using my phone. He’d listen to you’.

HCP:

‘I can’t tell him something that isn’t entirely true, but I am happy to try to talk to you and your dad about what we know about screen use. Then I could help you explain your perspectives about why screen use is helpful for you. Do you think this might help your dad to see things a bit differently?’

GB:

‘I don’t know but we could try’.

HCP:

‘OK, I’ll go and ask your father to join us’.

RB:

‘So have you two figured everything out?’

HCP:

‘Not quite, but we had an interesting talk about screen use. It sounds like you are both open to the idea that screen use may have some pros and cons’.

RB:

‘Well, I’m especially worried about him, because he’s still young. He should be out there talking to real people, it would probably be better for his brain’.

GB:

‘You’re one to talk! You’re always on your phone or your computer! Why is it so different when it’s about me? Why don’t you stop using your phone for a while – see how you like it?’

RB:

‘I need my phone for work’.

GB:

‘And I need my phone to have friends! Don’t you think I’d be more depressed if I couldn’t talk to my friends!?’

HCP:

‘You’re both bringing up some good points here. You both have reasons to use your screens; they obviously are an important tool in all our lives’. (HCP gestures to the computer in the room)

RB:

‘I can see that you need to connect with your friends, I do know that’s important, but as a parent I’m supposed to be looking out for your health. I can’t let you do something that’s bad for you’.

HCP:

‘There are certainly many reasons why we all need to be aware of how much screen time we are having. There are connections between screen use and some health problems, and there is also a lot we don’t know about how screens are impacting us, and that includes everyone – including me’.

GB:

‘See dad! It’s no big deal’.

HCP:

‘What I’m saying is that it might be a big deal, but right now there is a lot that we don’t know about screen use. What we do know for sure, is that when people spend a lot of time on screens, they are spending less time on other things that we know are important’.

RB:

‘Like what?’

HCP:

‘Things like having conversations that aren’t interrupted by texts, family meals without interruptions, and the ability to wind down without always feeling your work is with you. Those kind of things’.

RB:

‘That’s true, I can see myself in that’.

HCP:

‘GB, earlier you told me that you felt that you were able to put your phone down sometimes, and that you weren’t always on it, right?’

GB:

‘Yes, because I’m not’.

HCP:

‘Well, I wonder if you and your dad might want to think about when you can both put your phones down, maybe come up with a strategy which recognizes you both feel the phone is important, but that limits might also be important too – especially given the uncertain health risks?’

GB:

‘I doubt my dad could do it’.

RB:

‘Try me’.

HCP:

‘Here’s a copy of the “Family Screen Use Action Plan”. We can look at it together and see if we can come up with a plan everyone can live we; we can also talk a little more about some concerns around screen use, sound ok?’

Way forward

This viewpoint article highlights the need for ongoing surveillance and study in the area of screen utilization, while acknowledging the current reality of screen use in our culture, for better or for worse. We have suggested a process by which HCPs can consider screen use in the clinical setting, which encourages acquiring knowledge, the development of personal insight and the use of a flexible interpersonal style and coaching technique. Through the application of the process presented, insight may be promoted for both the HCP and for the youth into how screen use is affecting their interactions and health. By engaging in this process, both provider and patient can consider how they would like to balance the possible risks and benefits of screen use and may be motivated to set boundaries and limits around screen time. Another tool, such as the Family Screen Use Action Plan (SAP) developed by the American Academy of Pediatrics, may also support autonomous decision making (American Academy of Pediatrics, 2016).

This article has not explored the complex nuances around type of screen use. We feel it is important to acknowledge that some types of screen use may be more harmful or helpful than others (i.e. Internet research, social media participation and online movie viewing). In addition, caution must be exercised in this area, as screen use patterns do not imply a causal relationship in presentations of social or emotional distress. Screen use must be considered as an important potential contributor to clinical presentations in the same way that it may also be contributing to life enhancement and be a potent coping strategy. Screen use remains a single factor to consider in the complex evolution of psychopathology to be evaluated in the context of each, unique clinical encounter.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

April Elliott

Author biographies

Monique Jericho is a Child and Adolescent psychiatrist working in Calgary, Canada. She is the Medical Director of the Calgary Eating Disorder Program and enjoys working with interdisciplinary teams to support youth and families with complex mental health concerns.

April Elliott is a paediatrician and adolescent medicine specialist and clinical associate professor of Paediatrics. For 19 years she has been instrumental in developing Adolescent Health as a sub-specialty and building youth centered programs in Calgary, Canada.

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