Texting and Teens

1. Mark Henin PGY-1 5/23/2012 Texting and Teens

2. Goals Discuss prevalence of texting among adolescents Discuss impact of texting on adolescent development and health Discuss issues regarding safety Discuss anticipatory guidance

3. Case 1 You are seeing a 14 yo female in your clinic for a new patient visit. While gathering a history you notice the patient is glued to her phone despite pleas from her mom to “put the phone away!” Clearly frazzled, mom looks over and states that her daughter is “on her phone all the time.” Occasionally she hears from teachers about texting in classes. Patient states “whatever, my grades are fine, not a big deal.” Continues to text through dinner and into the night as parents are trying to get two words in with her. Mom wants to know if she should blow this off as “normal teenage behavior?”

4. Survey Says • Princeton Research Survey (2009) • 800 teens surveyed • 75% teens have cell phones (45% 2004) • Equivalent across ethnicities • Socioeconomic divide

5. Survey Says • 77% Teens text • 50%: 50 texts/day • 33%: 100 • 15%: 200 • Texting: primary form of communication with peers • More likely to call parents

7. Survey Says • Nielsen Company (2010) • Average Adolescent 3339 texts per month • Females: 4065 • Males: 2539 • 8% increase from 2009

8. Survey Says • 2,089 adolescents surveyed • 42% reported that they can “text blindfolded” • 47% indicated that “without texting their social life would deteriorate or simply end.”

9. Reasons • Unlimited message plans • Major carriers • “Text only plans” • Convenience • Efficiency • “Privacy”

11. Parental Involvement • Phone use common source of conflict • Digital Divide • 64% parents check children’s messages • More common with younger teens (12-14) • Alters teens phone usage • Girls more likely to have phone taken away as punishment

12. So What? • Texting relatively new technology + • BIG part of majority of adolescent’s lives = • Many effects (proven and presumed) on health and development

13. Sleep Disturbances • Common for teens to send and respond to texts through night • “Ringing,” “Bombing,” and Chain Mail • “Texting After Lights Out” • Prospective Cohort Study w/ 1 Year Follow Up (2007)

14. Sleep Disturbances Teens: Require avg 8-10 hrs Irregular Sleep Schedules Circadian Shift vs School Delayed Sleep Phase Syndrome

15. Sleep Deprivation Profound Effects on Teens Decreased academic scores Increased behavioral issues Increased mood disorders Increased risk of motor vehicle accidents

16. Case 2 A 14-year-old female visits your clinic with “throbbing right thumb pain” that gradually worsened over the past week. There is no history of trauma, participation in sports, or joint problems. She has no fever or other associated symptoms. She is a healthy high school freshman doing well academically and reports having many friends that she enjoys keeping in touch with.

17. Case 2 Being an astute 21st century pediatrician, you ask the patient about her cell phone and computer habits. She admits to being on the phone “all the time” and estimates that she probably texts about 4 hours every day.

18. Case 2 PE: tenderness of the right thumb is noted on the lateral aspect of the first proximal phalanx, the first interphalangeal joint, and the first metacarpal. Local soft tissue swelling and mild erythema are noted. No nodularity is present. Thumb abduction aggravates the pain, which is against resistance. There is no tenderness to palpation in the anatomical snuffbox. Finkelstein's test, Phalen's test, and Tinel's sign are negative. Studies: X-ray negative.

19. Case 2 What's the most appropriate next step? A. MRI B. Orthopedics Referral C. Steroid Injection D. NSAID's E. EMG

20. Texting Tendinitis • Repetitive use injury • Extensor Policis Longus and Brevis • Action: thumb extension • Abductor Policis Longus • Action: thumb abduction • Conservative Mgmt • Thumb Spica Splint • NSAIDs • Rest!

21. Texting and Driving Motor Vehicle Collisions Leading cause of death in teens (36%) Most caused by inexperience + NO seatbelt + distracted driving National Young Driver Survey (2008) 1. Drinking 4. Marijuana 2. Texting 5. Road Rage 3. Racing 6. Passengers

23. Texting and Driving • Three Types of Distraction • Visual • Manual • Cognitive • Texting incorporates all three! • CDC: 9% of US drivers admit to texting regularly while driving • 33% drivers feel less safe on road compared to 5 yrs ago

24. NC Driving Law Limited Provisional License Teenagers prohibited from all cell phone use while driving. Can drive from 5a-9p unsupervised Exceptions: Work, Volunteer Emergency Services Teens limited to 1 passenger <21 yo when driving unsupervised Unlimited Provisional License Can apply after 6 mos if no moving violations Can drive at any time No passenger restrictions Cell phone prohibition remains After 18: full license Can talk on cell phone Texting illegal for all drivers

25. National Safe Driving Month May Safe Driving Pledge

26. Public Health • San Francisico • Increase Gonorrhea rates among 15-19yo • African American Women • 12x greater than Caucasian women • SEXINFO (2006) • Sexual Health Text Message Service • Opt in program • Basic STI info • no diagnoses made • Targeted to high risk youth

27. Public Health April-October 4500 inquiries; 2500 referrals Top 3 Texts “What 2 do if ur condom broke?” “2 find out about STDs” “if u think ur pregnant” 44% Teens Surveyed saw Ads 93% African American

28. Public Health Australia Survey: What makes a text effective? Attention Grabbing Short Rhyming, Funny Colloquial, Not “preachy” “get lucky” > “intercourse” Appropriate Timing Feel more Personal Results: Mixed Increased knowledge of STIs No direct change sexual behavior Indirect: Teens more likely to get STI testing Conclusion Texting: effective method to educate teens Doesn’t replace good primary care

29. Adolescent Development (per presentation by Dr. Matkins and Dr. Rager) Identity = “Who am I?” Autonomy = “How am I going to use my independence as a self-governing individual?” Achievement = “What am I good at and how can I make a contribution?” Sexuality = “What are sexual feelings and how am I going to express them?” Intimacy = “How am I going to establish close relationships with others?” Morality

30. Recent research indicates that there are frequent online expressions of offline behaviors, such as bullying, clique-forming, and sexual experimentation, that have introduced problems such as cyberbullying, privacy issues, and “sexting.”

31. Identity Formation • Lack of face to face contact • Allows for identity experimentation • impulsivity • easier to be bolder, flirtier, more confident • “Jekyll and Hyde”

32. Identity Formation Traditional “Offline” Issues How many friends do I have? Are my friends… Cool? Hip? Swag-tastic? Nerdy? Outcasts? Where am I on the “social ladder?” Am I desirable to members of the opposite sex? Am I dressed in the latest fashions? Self-Esteem? Online Issues How many contacts do I have? Who are my contacts? Contacts of the opposite sex? How many texts do I send/receive? Do my peers want to keep in touch with me? Are members of the opposite sex actively trying to contact me? Do I have the latest phone? Self-Esteem?

33. Autonomy Development of independence Cognitive vs. Behavioral vs. Emotional Importance varies across cultures Eastern vs. Western Culture Constant “Connectedness” “If you're constantly looking for validation from other people -- getting that message out, needing an immediate response -- teens move from 'I have a feeling, I want to send a text' to 'I want to have a feeling, I need to send a text.” Dr. Turkle- MIT Social Studies and Technology Prolonged Adolescence

34. Achievement RM, a 13 yo female, racks up 14,000 texts in one month. Appalled, her father, a local journalist, decides to punish her by writing an article about her texting in the local paper. Much to his chagrin, instead of shaming his daughter, his article elevates RM to celebrity status. In the months that follow, her texts explode to 24,000/month.

35. Achievement Unfortunately, not even our testing-extraordinaire can balance the demands of her new-found fame with the demands of “ordinary” tasks such as schoolwork. Her grades suffer dramatically. Backed by their well trained and appropriately concerned PCP, her parents finally take bold action and confiscate her phone. Almost instantly, her grades return to their normal lofty levels. Her phone is returned under the condition that she keep her grades up AND stay within the modest confines of 5000 texts/month. “My Daughter’s Texting Story Goes Global” Orange County Register. Jan 14, 2009

36. Intimacy • Communication Skills • Decreased face to face contact • Eliminates nonverbal cues • Miscommunication • “Apology vs Confession”

37. Case 3 A 12 yo female presents for her annual physical exam. Currently has no acute issues. Thorough HEADSS exam reveals she has no major stressors at home, A/B grades, loves Twilight (Team Jacob), shopping, hanging with her best friend, denies tobacco/alcohol/drug use, no SI, and no sex. After complimenting her smart, healthy decisions, you ask her if she has any questions. After hesitating for a few moments, she responds, “Well yea, uhm, well, a, a couple of days ago I sent a picture of my breasts to this guy at school.” Noting your look of surprise, she quickly adds, “Well my bra was on and my face was cut out. That’s not so bad right?” You respond…

38. Sexuality • Sexting: the sending of sexually explicit photos, images, text messages, or e-mails by using a cell phone or other mobile device. • Extension of adolescent sexual exploration to modern technology.

39. Prevalence National Campaign to Prevent Teen and Unplanned Pregnancy: 2008 20% teens sent/posted nude/semi nude images of themselves Problems with Study Internet sample Included 18-19 yo

40. Prevalence Pediatrics: Dec 2011 Surveyed 1560 youth (10-17yo) Screening Questions Anyone ever sent you nude/nearly nude images of kids under 18? Have you ever forwarded said images? Have you ever taken such pics of yourself? Has someone else taken these pics of you? Have you taken these pics of someone else?

41. Results • Sent Image: 2.5% • 61% Girls • 72% 16-17yo • 54% sexually explicit • Received Image: 7.1% • 55% Girls • 56% 16-17yo • 84% sexually explicit

43. Summary Prevalence varies based on definition Sexually Explicit Images Send: 1.3% (CI: 0.7-1.9) Send & Receive: 5.9% (CI: 4.1-7.1) Nearly Nude Images Send: 2.5% (CI: 1.7-3.3) Send & Receive: 7.1% (CI: 5.8-8.4)

44. Dangers Today Show: Jesse Logan 18 yo Ohio female who texted nude images of herself to her boyfriend. After they broke up, the boyfriend forwarded images to hundreds of classmates. Jesse reported being teased and harassed for months by fellow classmates. Spiraling into depression, she began skipping school and ultimately committed suicide, mere weeks after successfully graduating high school. She was due to start at the University of Cincinnati that fall.

45. Legal Ramifications • NC State Law: Child Pornography • Creating, possessing or distributing sexually explicit images of a minor • Felony offense +/- sex offender status • Similar laws across the country • Federal Legislation • NY Lawyer petitioning for standard fed law making it a misdemeanor

46. Anticipatory Guidance Parents and Teens Encourage parents to regulate child’s cell phone use. Discourage use of cell phone after bedtime “Electronics Free Zone” Never safe to text and drive. Teens Rest those thumbs! Sexting can have serious ramifications Legally Socially Psychologically

47. “There's an App for That” Safe Texting AR Mobile Media Guard My Mobile Watchdog

50. Acknowledgments Thanks to Dr. Preeti Matkins, Dr. Kasey Scannell, Dr. Dan Neuspiel, and the staff of Teen Health Connection for their help in editing and providing valuable resources.