Ask the Mediatrician

My 16-year-old son is addicted to Internet role-playing games--how can I help him?

Q: Over the past year, my 16-year-old son has become more and more addicted to Internet role playing sites. My son has ADHD and has always had a hyper focusing problem, but not on anything that would prevent him from his school work. He started out playing the games casually, but over time they have become the center of his life. 

We had to take away his cell phone, because he was using it in school. When we checked it, he was going to these RP sites hundreds of times. We downloaded a "self-control" app on the computer to help him resist going on to the sites while doing homework, but he found a work-around. When asked, he constantly lies about what he has been doing, and when he is found out and confronted with the problem, he goes into further lies to cover up, or gets enraged if we tell him he can not get back on the computer. He will not admit that he has a problem, and it is really hurting our entire family.

I don't know what else to do, or where to turn. When he is not wrapped up with one of the RP sites, he is such a nice, engaging young man. Do you have any suggestions how we can help him?
-Consumed by computers, in Pittsburgh, PA

A: Dear Consumed,

Your son’s trouble with limiting himself online is rarely talked about, but, in greater or lesser ways, relatively common—he has difficulty self-regulating his media use, and it is hurting his mental and social health and disrupting his relationships.

Though some people are very highy engaged in (and not addicted to) these games, clinicians diagnose ‘addiction’ based on the following broad criteria:

• Excessive use
• Increasing tolerance and use
• Withdrawal symptoms (such as feeling anxious or ill) when the substance or activity is removed and which resolve when the substance or activity is resumed
• Willingness to take on negative psychosocial consequences (for instance, becoming isolated from peers, getting poor grades, or losing a job) in order to maintain the habit

From what you have described, it sounds like your son is addicted to internet role playing games. There are treatment options available, but because internet and video game addictions are not yet recognized as clinical diagnoses in the United States (as they are in Korea, Taiwan and other Asian countries), treatment options can be difficult to obtain and are usually not covered by medical insurance. As a result, clinicians who have expertise and confidence treating these problems are still fairly rare.

When seeking out treatment, it is important for your son and your family to address the major behavioral issues and relationship rifts that have occurred because of his gaming. Remember that because of the addictive nature of what you son is going through, outright withdrawal from gaming is likely to be ineffective, as he will devise ways to continue playing even when restrictions are put in place.

Instead, treat your son’s gaming habits both delicately and diligently:

1. Find a professional therapist, psychologist, or social worker whom you trust and who can talk to about the issues in your family and with your son, in particular. Ask for her advice and support with staging an intervention.
2. Have a family intervention. Use this as an opportunity for your family to honestly express to your son how much you love him and how his gaming has negatively affected your relationships. Make sure that the intervention is not about blaming and shaming him, but about how you can all consciously work together to help and support him in ending his gaming addiction.
3. Generate a plan of action. Come up with a plan with your therapist to help your son, whether it is weekly therapy sessions as a family and/or on his own or sending him to a specialized rehabilitation center. Make sure that you as a family also have a plan to support your son and not enable his gaming tendencies.

Finally, you may also want to take this time as a family to observe a ‘Digital Sabbath’, one day a week where everyone turns off their electronics for 24 hours. This will help support your son and also help mend and strengthen your relationships as a family. If the experiences of other families are any indication, you will discover a lot more free time, activities that you enjoy together, creativity that has been suppressed by the constant stimulation—and each other.

Enjoy your media and use them wisely,
The Mediatrician®

How can I stop my kids from being 'catfished'?

Q:The Manti Te’o “catfish” story makes me wonder how I can best prepare my teens for future online friendships. My teens say that kids meet through friends-of-friends online and off, but online they just lie about personal information. I’ve always thought that practicing strong communication skills, honesty, integrity, and trust would help my kids grow up to be emotionally healthy adults, but can these traits fully develop if they don’t practice or value them online? How can I help my kids avoid catfish schemes without becoming bottom dwellers themselves? 
-Swimming in murky waters, Chicago, IL

A: Dear Swimming,

To answer your questions about how your teens present themselves online—and how they can avoid catfish schemes—let’s first talk about what’s going on with them developmentally:

1) Adolescents are right in the middle of developing self-awareness and individual identities. Because they are figuring out who they are, they may experiment with different behaviors and personalities—both online and off. Sometimes it seems as if they change personalities as often as they change their clothes.

2) Because their identities are still fluid and forming, adolescents often present, in person or through social media, a mix of who they are and who they aspire to be. So a shy girl may post a picture of herself in a bikini or a boy who doesn’t drink alcohol, but wants to be included in the party crowd, will post a story about getting drunk.

So your adolescents’ online portrayals of themselves do appear dishonest, but it is usually experimental and aspirational - who they think they are or want to be right now - rather than deceitful on their part. “Catfishing”, such as what occurred in Manti Te’o’s case, is more intentional, a deliberate effort to deceive. It may be the work of a shy or insecure person who feels inadequate trying to attract someone they like, so they create a fake online persona. This fictional character can be completely different than the actual person,  and may even use someone elses’ photos, life story and gender (as in Manti Te’o’s case) in hopes of attracting attention. Other  “catfishing” schemes are scams, that try to draw vulnerable people into “relationships” in order to get them to send them money.

It is important that your kids use social media to connect with people they already know, whether through school, the community or through trusted friends and family. They shouldn’t send money or locating information to people whom they do not know – and they shouldn’t arrange to meet those people in person, unless they are in a safe public place and are accompanied by friends or family.

Perhaps the most effective and developmentally optimal way to approach this is not solely as a social media or internet issue, but about how an honest portrayal of themselves can help your kids connect with others in real and substantial ways. Encourage them to think about how they would respond to discoveries that their friends or romantic interests were not who they represented themselves to be. Good relationships are built on honesty and trust. Social media is a great way to connect with people of like interests and a useful venue in which to explore how to communicate and build relationships. Done with foresight and care, it can provide a good foundation for lasting friendships.

Enjoy your media and use them wisely,
The Mediatrician®

Am I limiting my child’s chances of success in today’s economy by trying to limit his screen time?

Q: My 11-year-old son spends every free minute in front of his computer—doing homework (he really does, thank goodness), social networking, playing games, and now creating his own games. Concerned that, one by one, he has dropped sports, playing with friends, getting outdoors, and, frankly, spending time with the family, I have struggled (and been stalemated) for years trying to get him out from behind the screen. He came home from school with a news article provided by his teacher about a 17-year-old boy in England who just sold an app he developed for $30 million. Now I am wondering—are my efforts to get him away from the computer not only futile, but limiting his chances for success in today’s economy? 

Apprehensive about Apps, Ontario, Canada

A: Many parents already believe that their children need media early and often so that they will be prepared to compete in the adult world. That means parents are putting kids in front of screens from an early age, having toddlers and babies use lapware, tablet apps, smartphone games, and other forms of screen-based “edutainment” that often have little real educational value and, in some cases, may be developmentally detrimental.

It is important to remember that the reason a 17-year-old boy developing an app and selling it to a prominent company is news is because it is such a rare event. We need to understand that while there are kids with brilliant ideas and skills, these children have often spent many hours honing and developing these skills, sacrificing other activities in the process. While some may look at this early dedication as a career route, it is similar to becoming a professional athlete or musician: It requires a strict focus, innate skills, hours of practice, and sacrifice of other activities (primarily social). And after all of that, for every child who is able to successfully achieve professional status, there are thousands who will not.

My advice is for you to continue what you are doing—in addition to having some time when he’s on the computer, provide a rich and diverse experiential landscape for your son where he has the choice of many different activities (not just on a computer). Limit his screen time and give him options for other activities. If he isn’t into sports, maybe a book club, art classes, or free time outdoors will interest him. Many children join clubs, sports teams, and other organized activities for the social exposure, not necessarily for the activity itself.

Remember that children are natural generalists, not specialists. It is important for them to be able to sample a broad menu of life and to follow their hearts and minds to find what they are most passionate about. Providing your son with a landscape of diverse experiences and opportunities and seeing where he naturally gravitates will help you raise a child who is as happy, social, and productive as possible—it would be a shame to create a rich but unhappy coder at the cost of losing a brilliant and happy person because he focused his energy so narrowly so early.

Enjoy your media and use them wisely,
The Mediatrician®

 

My 18-year-old son is addicted to video games, what can I do?

Q: Our 18-year-old son started playing video games at age 9 and became addicted gradually. We struggled with him over the years to limit the time he was online. It became the center of his world, especially when he hit puberty and was dealing with insecurity, anxiety, and depression. The games became more and more violent. He withdrew socially and just recently dropped out of college in the first month of his freshman year. He denies having an addiction but has ceased to do anything but play the games all night and sleep all day. His only friends are those who play games with him online. We are trying to get him into a Video Game Addiction Detox program, if there is such a thing, but he is 18 and refuses to go. What do we do?

- Desperate for Detox, in Miami, FL

A: Dear Desperate,

Your story is heartbreaking and, unfortunately, not unique. Without more information and getting to talk to your son directly, I can’t offer anything that can be construed as medical advice. What I can offer is observations on what you have shared and some thoughts about choices you might make. For a definitive plan, seek out the professional advice of someone who knows your son well, a primary care doctor, psychologist, even a former college advisor or school guidance counselor.

You are absolutely right that your son is legally an adult and thus must seek professional help himself. However, as with those addicted to alcohol or other substances, you son may be oblivious to the harm and disability that is obvious to those around him. It’s likely that your son may have begun using video games to distract himself, to “self-medicate” his anxiety and depression. Video games allow users to master environments and can give players a sense of control and self-confidence within these virtual worlds that they may not experience outside of the game. What makes your son’s gaming problematic is that it is consuming his efforts in a way that prevents him from achieving larger life goals. Since your son can’t be admitted to therapeutic care without his consent, the best solution may be to stage an intervention—just as you might if he were addicted to alcohol or drugs.

First, educate and empower yourself with strategies and resources for interventions.  There are professional interventionists who can help you through the process if you decide that’s the best route to take. It sounds as if your goal is for your son to agree to entering treatment, so part of your preparation will be to identify a specialist and/or facility where he can receive treatment for anxiety, depression, self-harming behaviors, and video game addiction. You will need to be prepared to admit your son into care immediately following the intervention, as that is when he will be most willing to go.

The intervention will likely involve gathering some close, trusted family members and friends (maybe even some gaming friends) who care about him and whom he trusts, and then confronting him about the issue in a way that is clear, and, most importantly, from a place of love and concern. Tell him that you all have noticed that his video game play has hurt his physical and mental health and that all of you want him to seek out treatment so that he will be happier, healthier, and more able to pursue his life goals. Please keep me updated about how it goes, I am certain that other parents will benefit from your experience.

Enjoy your media and use them wisely,

The Mediatrician®

 

What should I do when my 8-year-old won't stop asking me for a cellphone and other gadgets?

Q: My 8-year-old son sees a lot of kids around him with iPods, iPads, video games, and phones, and keeps asking us for them. Even though we have explained that he doesn’t need all of these electronics and expose him to lots of other activities, the peer pressure is getting to him. What can I say to my son when he asks for yet another gadget [Video]?!
-ifrustrated, in Pawtucket, RI

 A: Dear ifrustrated,

What you’re describing makes perfect sense. Kids at this age start to really focus on fitting in with their peers, and that’s part of why there’s such a strong pull to have what everyone else has. When it comes to technology, this developmentally normal behavior can make it extra challenging to maintain the boundaries you’ve set—especially when other kids have their own gadgets or are allowed to spend more time using them than you allow your son.

Your son is showing that he needs to be involved in making decisions about when and how he uses media. And as he grows and spends more of his day in school or at other people’s houses, he will have more responsibility for maintaining those boundaries himself. Part of your role as a parent is to help him learn to be responsible for his media use whether you are with him or not.

So when your son asks for another gadget, don’t say no right away—instead, involve him in the decision. Have a conversation with him in which you:

• Treat media as ‘tools’—not as playthings. If he’s asking for a smartphone, ask him, “What do you want to use it for?”, and then listen to and discuss his answer. For example, if he wants one because “everyone else has one”, explain that media are tools to be used for a specific purpose. Say that you understand it’s hard not to have what other kids have, especially when it seems like everyone else has it. Let him know that that is not the right reason to get that tool right now, and that you understand if he’s upset.
• Talk about how he sees it fitting into his day. Ask him what he likes to do when he’s not engaging with media [Video], and talk about where those things fit into his day. Then talk about how media can fit in without replacing those other things. By building his schedule around what he does want to include, rather than focusing on limiting media time, you can avoid making media—or this particular gadget—into the ‘forbidden fruit’.
• Address cost. If you would be fine with him having a particular item but feel that the cost is too great, use it as an opportunity to teach him about saving money for something he wants.
• Have him help set rules. If and when you do decide that it’s time to incorporate a new media tool into his life, have him be part of the process of setting rules around how and how often he uses it. Then, as he shows you that he can handle this responsibility, increase his freedom to build his confidence and sense of mastery.
• Remind him that all media—including those he owns—are subject to house rules. Be consistent and up front with the house rules you set around media [Video]. Make sure your son knows that the rules apply to all media, even those his friends bring over and those he buys himself.

Enjoy your media and use them wisely,
The Mediatrician®

My teen loves a role-playing game involving torture, what should I do?

Q: My 16-year-old son loves playing role-play games on the Internet. We recently became concerned, though, when we found out that the plots often involve torture. We are wondering why he is attracted to this kind of play and if there are any long or short term risks we should know about. We wonder if we should totally restrict his Internet access, but realize that this is not truly a realistic option. We do our best to keep the lines of communication open, but we need some guidance as to how to talk about our concerns with him.
-Tongue-tied, in Beverly, MA

A: Dear Tongue-tied,

Seeing your child engaged in this kind of play can certainly be alarming, and your impulse to talk to him about it is right on—but your discussion needs to be driven by reason rather than emotion, or it can backfire. Understanding what might be going on can help.

Kids are often drawn to media violence because it scares, upsets, or alarms them—they are attempting to master the troubling experience. But children who repeatedly engage with it until it doesn’t bother them can become desensitized to not only virtual violence but to real violence as well. This is a big part of the problem with exposure to media violence; it makes violence seem more common than it actually is and changes our beliefs about what’s normal.  

Another contributing factor may be your teen's “big” feelings, which may include a good deal of anger. His interest in these games may be driven partly by a need to explore those feelings. However, engaging in simulated torture is not a therapeutic way to do that. Short-term effects could include signs that he is more on edge, such as increased anxiety, sleep disturbances, and irritability. In the long term, he may see violence as a more acceptable way of addressing conflict.

It sounds like you’ve already set the groundwork for open communication about media messages, and talking about the issue of torture need not be very different. Still, there are some particular approaches that may be helpful in addressing this issue:

• Help him find a way to explore the “big” feelings. Restricting internet access won't make the feelings go away. That's why it can be helpful to have him work with a therapist to find a different, more therapeutic outlet for them, like sports or martial arts.
• Keep computer in public space, like the dining room table. That way he can play in areas where you can see what he’s doing and discuss it with him.
• Open a conversation about this game by playing with him, or sitting beside him while he plays. Ask him to teach you about the game and to explain what’s going on in it, how he feels playing it, and what he finds enjoyable about it. Listening to him can help you learn what needs this game is filling, and can open the door to brainstorming other ways to meet those needs.
• Set limits on content. It may be difficult to be reasonable rather than emotional at this point, but try saying something like, “As your parent, just like I can’t feed you junk food, I can’t let you practice hurting others. I see that you find it exciting, and I know that your rational mind understands it’s only make-believe, but getting used to even simulated torture changes you. I don’t want you to change that way.” Then work with him to find games that excite him but don’t include torture.

Remember that his media interests can offer a window into what he's processing internally, so a combination of setting limits on the content and helping him find another way to explore and process the feelings should serve the whole family well.

Enjoy your media and use them wisely,
The Mediatrician®

How can I help my son limit computer time when he says he can't resist?

Q: My 10-year-old son plays mostly role-playing games, and has a 90-minute screen time limit per day. Overall he's a great kid—does well in school, is active in sports, has plenty of friends—but we have limited his screen time as a consequence for poor behavior, which is mostly related to abusing screen time limits. He contends that he is trying to resist but can’t help himself, tearfully complaining that we just don’t understand how hard it is. He wakes up as early as 3 am to use the computer surreptitiously. I don't know whether we are being unrealistic in our expectations and if we are inadvertently incentivizing him to sneak time on the computer. He acts like he is addicted. What should we do?
-World of Worry, Berkeley, CA

A: Dear World,

Many parents are struggling with variations of their kids getting “stuck” on screen media like computers, but fortunately, there are ways that you can help. Start by reframing screen time as part of your son’s everyday life, to be used in focused ways and managed in coordination with his other daily activities. This way he won’t view the computer as a reward (or, through its removal, a punishment), but as a tool he will be using, hopefully productively, for the rest of his life.

Work with him to find a solution that is both healthy and his own:

• Talk with him when there is not an immediate conflict to resolve, plenty of time, and few distractions (I recommend car rides).
• Lay out his 24-hour day and work with him to build a time management plan from the ground up: Include at least 8 hours of sleep (remind him that that’s when he grows taller…), school time, snack, physical activity (preferably outside), a sit-down meal with family, and homework.
• Plan how to use the remaining time, whether with focused, mindful media use or with other activities that have a planned end time. To help him stick to the plan, you can offer to use timers to remind him or even, if he really feels he can’t control it, to ‘lock off’ electronics at certain times—not as punishment but as a regular part of the routine.

Then, gently inquire why he is on the computer at 3 AM:

• Is he using it to do things he wouldn’t do if you were there? If so, perhaps moving the computer to a public space such as the dining room will help.
• Is he waking up and unable to get himself back to sleep? Or does he feel that he needs to be on the computer and wakes up at all hours to fulfill that desire? If either of these is the case, seek out the help of a pediatrician or child psychologist – he may be struggling with anxiety, depression, or even problematic, addiction-like computer use.

If you can discuss this in a respectful and nurturing way, you’ll learn a lot about what’s going on with him. He is trying to figure out how to manage the world and how he should behave in it and deserves a lot of credit for acknowledging that he is struggling. Now you can offer to work with him toward a solution.

Enjoy your media and use them wisely,
The Mediatrician®

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How can I cut out TV time from my two-year-old's dinnertime routine?

Q: My husband and I were having difficulties preparing dinner with our two-year-old daughter in the kitchen, so we began letting her watch Curious George to keep her occupied. Initially this worked well; the show seems to have primarily positive content, and the two 15-minute segments entertained her while we cooked. We’ve been trying not to use the TV that way so much anymore, but when we leave it off, my little girl stands in front of the screen and cries, saying, “George! George!” Her crying often causes me to give in and let her watch the show, but I’m worried that this has become an unhealthy obsession…how can I effectively wean her off of the TV?
-Curious about George, in Boston, MA

A: Dear Curious,

First, don’t worry—your daughter’s behavior doesn’t mean that she is obsessed with Curious George or with TV. It just means that watching that show has become part of her transitioning-to-dinnertime routine. Having routines to help move from activity to activity can be very helpful for toddlers, who don’t have a clear sense of time and can’t quickly shift their attention, especially when they’re right in the middle of something.

This is a great opportunity to create a new pre-dinner routine that doesn’t center on TV. Try giving her books to read, or some different shapes of raw noodles to sort into bowls. Through a bit of trial and error, you can discover activities that will both allow you to cook dinner and meet your daughter’s developmental needs.

Although making this shift in her routine will be hard at first, be consistent with it, even when she cries for George. Let her know you understand that she’s upset, that that’s okay, and that we’re having reading or noodle time now. Eventually, she will settle into the new routine.

For some ideas on activities young children can do with minimal supervision, check out:

• http://www.pbs.org/parents/child-development/baby-and-toddler/

Enjoy your media and use them wisely,
The Mediatrician®

What can I do for my 15-year-old son, who has Asperger's and ADHD and seems addicted to video games?

Q: My son is 15 and displays symptoms of video game addiction, including lying and sneaking to try to gain access. He has Asperger’s and ADHD, and regardless of what medication regimen we try, the gaming obsession remains. I recently asked the psychiatrist to hospitalize him and treat him as they would other addicts, but they just changed his meds. Anyway, even if he were treated, he needs the computer for school. Do you have any advice for me?
-Dealing with Addiction, Orlando, FL

A: Dear Dealing with Addiction,

Unfortunately, more and more families share your story. Whether through sleep deprivation, anxiety, or social isolation, teens struggling with problematic video game or internet use are suffering, and their families are disrupted. And research shows that young people with ADHD may actually be more susceptible to problematic video game or internet use.

Part of why it’s so hard to find good treatment is that these symptoms have yet to be recognized as a formal psychiatric diagnosis in the U.S. (unlike in South Korea and China, where clinics, hospitals, and “detox” centers treat Internet Addiction Disorder). Still, there are steps you can take to help your son:

1. Keep working with mental health professionals. Make sure that his providers recognize and respect these particular problems.
2. Optimize his treatment. Just as youth with ADHD learn more effectively in the controlled computer environment than in the chaos of a classroom, they are also at higher risk for problematic internet behaviors. Similarly, the social awkwardness of Asperger’s syndrome feels more manageable online. That may be why there’s some evidence that problematic behaviors may decrease or disappear underlying issues are addressed in therapy and any medication is optimized.
3. Move his computer and internet access into common space. Your presence will help you help him regulate his computer behaviors. Be aware that smartphones and many portable digital players are wireless internet-capable, so treat them similarly.
4. Find diverse activities that fill his needs. Look for pursuits that have clear rules, and achievable goals, and that allow him to move at his own pace. Rock climbing or a martial art like tae kwan do or karate would build his mindfulness and self-discipline, while also providing exercise and positive social interaction.
5. Get him outside. Being immersed in nature has a calming and focusing effect. It can also be an effective context for treatment—wilderness therapy has worked wonders for some of my patients and could be a good option for your son.

Remember, too, that when used in moderation, computers and video games can help young people with ADHD and Asperger’s learn, grow, and thrive in ways that they cannot in more traditional educational and social contexts. For more information and resources, take a look at this website.

Enjoy your media and use them wisely,
The Mediatrician®

With video games, how can I help my kids know when enough is enough?

Q: I'm a pediatric nurse practitioner, and we have three boys ages 5, 7, and 9. Several parents/patients have told me that they have the same problem as I do enforcing video game time limits. Certain kids just seem “addicted” and can’t wait until they get more. Do you have any visual time charts, contracts, or other concrete examples of how to work with your kids on knowing when enough is enough? 
-PNP Parent in Bozeman, MT

A: Dear PNP Parent,

Try approaching this issue with a positive rather than restrictive approach. Instead of limiting video game time, focus on creating a daily schedule with your sons where there is enough time to do everything that is important to them.

Search online for “hourly calendars,” and print a copy for each child. Then, ask them to think about all the things they need to do in a day—like eating meals as a family, school, homework, active play (outside, if at all possible), spending time with friends, and getting enough sleep—and help them remember others that they forget. For each task, have them choose a color, think through how long it will take, and color in the time blocks needed.

They will see their time filling up with important activities, and they will see what time is still left. Talk about what they can do in that time. Perhaps they can spend some of it playing video games, but offer them attractive alternatives as well, like organized sports or hobbies. In this way, they will have some ownership of mindful, directed “down time” rather than simply sliding into video gaming.

By focusing on what they do want and need to do in their limited time, you can avoid making video games a forbidden fruit. Whatever choices they make, remember that they will learn from what they experience, so exercise your judgment about the content of any media they use.

• For information on video game addiction, take a look at this post: My 10-year-old son is miserable since I took away Call of Duty--what do I do?
• For ideas on creating a family media agreement, click here.

Enjoy your media and use them wisely,
The Mediatrician®