Adolescent Health, Body Image, Eating Disorders and Media Use | Jason Nagata, MD, MSc

Studies, in order mentioned:

Adolescent Brain Cognitive Development (ABCD) Study SM https://abcdstudy.org/

Nagata, J. M., Cortez, C. A., Cattle, C. J., Ganson, K. T., Iyer, P., Bibbins-Domingo, K., & Baker, F. C. (2022). Screen time use among US adolescents during the COVID-19 pandemic: findings from the adolescent brain cognitive development (ABCD) study. JAMA Pediatrics, 176(1), 94-96.

Nagata, J.M., Al-Shoaibi, A.A., Leong, A.W. et al. (2024). Screen time and mental health: a prospective analysis of the Adolescent Brain Cognitive Development (ABCD) Study. BMC Public Health, 24. https://doi.org/10.1186/s12889-024-20102-x

Nagata, J. M., Iyer, P., Chu, J., Baker, F. C., Pettee Gabriel, K., Garber, A. K., … & Ganson, K. T. (2021). Contemporary screen time modalities among children 9–10 years old and binge‐eating disorder at one‐year follow‐up: A prospective cohort study. International Journal of Eating Disorders, 54(5), 887-892.

Nagata, J. M., Chu, J., Zamora, G., Ganson, K. T., Testa, A., Jackson, D. B., … & Baker, F. C. (2023). Screen Time and Obsessive-Compulsive Disorder Among Children 9–10 Years Old: A Prospective Cohort Study. Journal of Adolescent Health, 72(3), 390-396.

Nagata, J. M., Ganson, K. T., Iyer, P., Chu, J., Baker, F. C., Pettee Gabriel, K., Garber, A. K., Murray, S. B., & Bibbins-Domingo, K. (2022). Sociodemographic Correlates of Contemporary Screen Time Use among 9- and 10-Year-Old Children. The Journal of Pediatrics, 240, 213–220.https://doi.org/10.1016/j.jpeds.2021.08.077

Nagata, J. M., Lee, C. M., Yang, J., Al-Shoaibi, A. A. A., Ganson, K. T., Testa, A., & Jackson, D. B. (2023). Associations between sexual orientation and early adolescent screen use: findings from the Adolescent Brain Cognitive Development (ABCD) Study. Annals of Epidemiology, 82, 54–58. https://doi.org/10.1016/j.annepidem.2023.03.004

Nagata, J. M., Balasubramanian, P., Iyra, P., Ganson, K. T., Testa, A., He, J., … & Baker, F. C. (2024). Screen use in transgender and gender-questioning adolescents: Findings from the Adolescent Brain Cognitive Development (ABCD) Study. Annals of Epidemiology, 95, 6-11.

Nagata, J. M., Singh, G., Sajjad, O. M., Ganson, K. T., Testa, A., Jackson, D. B., … & Baker, F. C. (2022). Social epidemiology of early adolescent problematic screen use in the United States. Pediatric Research, 92(5), 1443-1449.

Nagata, J. M., Singh, G., Yang, J. H., Smith, N., Kiss, O., Ganson, K. T., Testa, A., Jackson, D. B., & Baker, F. C. (2023). Bedtime screen use behaviors and sleep outcomes: Findings from the Adolescent Brain Cognitive Development (ABCD) Study. Sleep Health, 9(4), 497–502. https://doi.org/10.1016/j.sleh.2023.02.005

Nagata, J.M., Weinstein, S., Alsamman, S. et al.  (2024). Association of physical activity and screen time with cardiovascular disease risk in the Adolescent Brain Cognitive Development Study. BMC Public Health, 24, 1346. https://doi.org/10.1186/s12889-024-18790-6

Nagata, J. M., Weinstein, S., Bashir, A., Lee, S., Al-Shoaibi, A. A. A., Shao, I. Y., Ganson, K. T., Testa, A., He, J., & Garber, A. K. (2024). Associations of Contemporary Screen Time Modalities With Early Adolescent Nutrition. Academic Pediatrics, 24(5), 748–754. https://doi.org/10.1016/j.acap.2024.01.023

Gültzow, T., Guidry, J. P. D., Schneider, F., & Hoving, C. (2020). Male Body Image Portrayals on Instagram. Cyberpsychology, behavior and social networking, 23(5), 281–289. https://doi.org/10.1089/cyber.2019.0368

Chu, J., Ganson, K.T., Testa, A. et al.  (2024).  Screen time, problematic screen use, and eating disorder symptoms among early adolescents: findings from the Adolescent Brain Cognitive Development (ABCD) Study. Eat Weight Disord, 29(57). https://doi.org/10.1007/s40519-024-01685-1 

Nagata, J. M., Shim, J., Low, P., Ganson, K. T., Testa, A., He, J., … & Shao, I. Y. (2024). Prospective Association between Screen Use Modalities and Substance Use Experimentation in Early Adolescents. Drug and Alcohol Dependence, 112504.

Rutherford, B. N., Lim, C. C., Johnson, B., Cheng, B., Chung, J., Huang, S., … & Chan, G. C. (2023). # TurntTrending: a systematic review of substance use portrayals on social media platforms. Addiction, 118(2), 206-217.

Nagata, J. M., Paul, A., Yen, F., Smith-Russack, Z., Shao, I. Y., Al-Shoaibi, A. A., … & Baker, F. C. (2024). Associations between media parenting practices and early adolescent screen use. Pediatric Research, 1-8.

[Kris Perry]: Hello and welcome to the Screen Deep podcast where we go on deep dives with experts in the field to decode young brains and behavior in a digital world. I’m Kris Perry, Executive Director of Children and Screens and the host of Screen Deep. Today’s guest is Dr. Jason Nagata, a pediatrician and researcher specializing in adolescent medicine at the University of California, San Francisco. He researches screen use, body image, and eating disorders among teens of all genders. He edited the book, Eating Disorders in Boys and Men and is senior editor of the Journal of Eating Disorders. He has published over 300 articles in academic journals, and I can’t wait to learn from him today about his research into teens. Welcome, Jason.

[Dr. Jason  Nagata]: Thanks so much for having me.

[Kris Perry]: Jason, you’re not only a prolific researcher, but a trained pediatrician and clinician, which must give you an inside look into what is most affecting adolescents and teens today. Tell us about your clinical experience and how that is connected to your research focus on screen time and adolescent health.

[Dr. Jason Nagata]: I actually first became interested in research on screens and social media through direct patient care with teenagers with eating disorders. And this actually came about during the pandemic when we were experiencing a surge of eating disorders. Unfortunately, our hospital experienced, like, a doubling and even tripling of patients needing to be hospitalized for eating disorders. And during the height of the pandemic and the mental health crisis, I recall that many of our patients would spend countless hours browsing social media sites where they really became lost in disordered-eating content related to weight loss or muscle building. Even in the instances where they were hospitalized and had severe medical complications and – even in that situation, they couldn’t get off of their phones. And that kind of really was a wake-up call for me that, you know, there was some issue going on here that I wanted to explore a little bit more. And so those experiences caring for teenagers with eating disorders during the pandemic and seeing how screens and social media had sort of impacted their illness really got me started in researching more about eating disorders and relations with social media and screen use.

[Kris Perry]: Interesting! And all of us can still remember like it was yesterday the pandemic and the impact that it had particularly on adolescents and younger children–the isolation they experienced and the desire to be connected, probably through screen use, so it’s interesting to hear your clinical experience really validate – verify that anecdotal example. Many of the research publications you’ve authored or co-authored are using data from what’s called the ABCD® study. For our listeners who don’t know what that is, can you describe this giant study and why it’s such a good source of data on adolescents today?

[Dr. Jason Nagata]: Yeah, that’s a great question. And actually during the pandemic, when I was also stuck at home trying to figure out what to do, I looked at all the different data sets that were available and sort-of found that this ABCD study, it stands for the Adolescent Brain Cognitive Development Study℠. It’s the largest longitudinal study of adolescent health and cognitive development in the United States, following over 10,000 9 to 10 year olds every year for a planned over 10 years. So it’s still ongoing. It started back in 2016, so it started before the pandemic, but has continued to have data collection to the present, across 21 different sites in the US. And there’s really rich sources of screen time and social media data based on the teenagers’ report, also their parents’ report. And if teenagers have smartphones, there’s actually an app that they download that tracks their use as well. And then there’s also specific measures – I think, you know, beyond screen time, they have different measures of cyber-bullying or elements of addiction like social media or video game addiction. And also specific contexts like screen use right before bedtime. And also what the parents do in terms of rules and monitoring for screens at home. So there’s just a really rich array of screen measures from all different parties in the household,  and including the phone itself. Which is only one small part of the study actually. It also then has physical health, mental health, and lots of social context data, which makes it like to me, as a researcher, like a playground of lots and lots of data.

[Kris Perry]: When did the study start, and  what age is the cohort now that may have been included in the early data collection efforts? Tell us a little bit more about why we’re getting adolescent data now as opposed to earlier.

[Dr. Jason Nagata]: The study started what they count as baseline or the start of the study was 2016 to 2018. They started with 9 to 10 year olds. And then they’ve been doing annual data collection ever since. And I will say that there is a little bit of a delay from when the data is collected to when it’s released. So the data that has most recently been released has up to age 14. So we really have data right now mostly on early adolescence or it’s kind of that early period. 13 years old is technically the minimum age requirement for social media. So for many of these adolescents, it captures sort of their pre-social media time into like when they are first starting. And then, you know, in subsequent years we’ll have data from middle to late adolescence and also when they transition to becoming adults.

[Kris Perry]: What is the ABCD study telling us about some of the adolescent health factors that are associated with high amounts of screen time in adolescents?

[Dr. Jason Nagata]: Yeah, I think that we’ve learned a lot from the ABCD study, but I will say that one of the most impactful studies we did was actually looking at pre- versus during pandemic findings. And we actually found that among this cohort, screen time doubled from 4 hours a-day to 8 hours a-day from, you know, 2016 to the beginning of 2020 at the very onset of the COVID-19 pandemic. And then we also found that greater screen use was associated with poorer mental health and greater stress during the pandemic. And paradoxically, even though social media is supposed to promote socialization, adolescents who are using social media and screens more actually felt more isolated and felt less social support during the pandemic. So I think that this finding was actually a big one and received national media coverage and even the Surgeon General cited it in the advisory on youth mental health. So I do think that that was one of the big findings from the study because we had pre-pandemic data and were able to look at trends into the pandemic.

[Kris Perry]: Mental health issues in general seem to be associated with high screen use, but one of your studies detailed specific mental health symptoms most associated with high screen use. Can you describe these?

[Dr. Jason Nagata]: Yeah, so I think one of the rich aspects of the ABCD study is they assess all of these adolescents for almost every single mental health diagnosis every year and also symptoms related to these mental health diagnoses. So we were able to do a study that looked at screen use and screen time at the beginning of the study. And then we followed these adolescents’ mental health symptoms for the next one and two years of follow-up. And we did find that those who spent more time on screens had higher symptoms of depression, anxiety, ADHD, and oppositional defiant symptoms over the next two years. And actually the strongest association was with the depression symptoms. And part of the reason was that depression could – or more time on screens could displace physical activity, sleep, in-person socialization, or other behaviors that could be protective of depression. But one thing that I will note is that while we did find statistically significant findings, these were generally small associations. So it was far from being deterministic. And it’s not to say that everyone who’s on screens is going to become depressed.

[Kris Perry]: Interesting. Are there specific types of screen use that are more associated with these mental health systems or symptoms you’re describing, that you found in your research?

[Dr. Jason Nagata]: Yeah, there were actually two, I think, specific findings that I thought were interesting. One was that when we looked actually at associations with eating disorders, we found that social media was the specific screen type that had the strongest   association with eating disorders and specifically binge eating disorder, which involves overeating and a loss of control eating. And that was the highest. So every additional hour of social media spent was actually associated with a 62% higher risk of binge eating disorder the next year. And then another interesting finding that we found was looking at Obsessive-compulsive disorder. And we actually found that watching YouTube videos was associated with higher risk of OCD symptoms a year later, but not traditional television viewing. And so part of the reasoning behind that is that, you know, on YouTube there are algorithms and you can watch very specific content, like almost obsessively. Like if you were really obsessed with, you know, one type of content, you could watch that video over and over and over again. The algorithm will feed you very very similar content. Whereas if you’re watching traditional television, you know, a certain program is only on once a week at a certain time and you can’t obsessively watch the same way that you can on YouTube.

[Kris Perry]: What about other screen use, like video chat or texting or video games? Are there any findings about those types of screens?

[Dr. Jason Nagata]: Yeah, I will say that one of the challenges of screen research is that there is a lot of overlap. You can use social media for messaging and texting to some extent. You can use a lot of social media for video chatting as well. So there are kind of blurred lines between, some of these modalities. But I think in general, some of the trends that we see most strongly with social media also apply often to more of the kind of “social” types of platforms, like whether it’s texting or video chats. And so some of those, the associations tend to be similar with those types of screen modalities.

[Kris Perry]: Whenever I talk to researchers like you, I always feel like, is this a chicken and the egg situation where there’s a mental health condition that may be emerging? And then around the time that that’s occurring, the child is given more access or finds a way to have more access to screen time. And there’s this, I don’t know, exacerbation of each, that’s happening at this critical developmental stage, adolescence. What do you think about that? Is it – is it chicken and the egg? Is it that if you have this propensity, you’re likely to find this device? It just comes up every time we talk with experts like you and. I want to hear what you think about it.

[Dr. Jason Nagata]: Yes, I think that’s the million dollar question. And I will say that with the study that we had mentioned earlier about mental health, we did design the study so that we really looked at screen time occurring before the onset of the mental health symptoms, and then we controlled for what mental health symptoms they had at the beginning of the study. So we did show, again, like small or weak associations with screen time leading to depression and some of the other mental health symptoms. But I think you’re absolutely right. There can be linkages both ways and certainly you can have sort of negative feedback cycles or get into these cycles where, you know, more screen use can lead to higher depression symptoms. If you’re more depressed, you might not want to see people in real life or in person. And so then you are more stuck on your screen and it kind of goes back and forth. So I do think that it works both ways. Our initial studies have looked at the direction of screens leading to higher risk of depression, but I do think that the opposite is also at play as well. So it’s a little bit hard to parse them apart, but I do think that in reality,  the risks go both ways.

[Kris Perry]: Yeah, and I also recognize that we’re at a point among researchers where you’ve all been doing a huge amount of work and we’re finally gaining these deeper insights into exactly who is most at risk and exactly what types of activities on devices are having maybe the most negative impacts. Whereas years ago, before the pandemic, we were thinking more about screen time and just childhood, bigger buckets. And I see what’s happening is you’re all starting to sort and sort and sort through all the possible interactions. And that’s been really exciting to learn more about. Are there different screen usage patterns and impacts among genders or other demographic breakdowns that you saw in the ABCD study?

[Dr. Jason Nagata]: Yes, that’s a great question. And I do think that to try to give parents individualized guidance, we do need to think about some demographic differences. And so I would say that the main gender differences that we saw, at least at the beginning of the ABCD study, was that boys tend to spend more time actually overall, but particularly this is driven by video games. Whereas girls, although their total screen time at the beginning of the study was less than boys, they still did report higher social media use. But again, again, amongst 9 and 10 year olds, it was not a significant amount of their day. One other kind of interesting finding that we had was that actual sexual and gender minority adolescents, so LGBT youth, also reported much higher screen use than their cisgender or heterosexual peers, respectively. And then also we did find that adolescents from lower socioeconomic backgrounds, so with lower parent-income or lower parent-education, tended to have higher screen use overall as well.

[Kris Perry]: Are there other demographic differences when it comes to the mental health associations with screen time?

[Dr. Jason Nagata]: That’s a really great question. In the main study that we talked about earlier looking at associations between screen time and and all these mental health symptoms, one interesting difference did emerge in that we found that actually the associations were weaker in racial and ethnic minority groups, particularly like Black and Asian adolescents compared to white adolescents. And I do think that there is a little bit more complexity in terms of screen use with minority adolescents. There are certainly risks associated with screen use, but I think there are also particular benefits for minority adolescents. You can imagine that if you know, someone in their actual like in-person community or school is like a minority and isn’t able to connect with people with that same background or experience, they may be able to connect with lots of people on the internet who share that same experience across the country, across the world. And so we did generally find that particularly for minority adolescents, whether it was racial-ethnic minorities or sexual gender minorities, actually the associations with depression and some of the other mental health symptoms were not as strong as they were in sort-of majority group adolescents.

[Kris Perry]: Are there other specific screen uses that are associated with different health outcomes that you found in your research?

[Dr. Jason Nagata]: Yeah, I think that a lot of the debate and discussion now is about mental health. But I will say that we’ve also been able to look at physical health in the ABCD study and some really important physical health aspects are, I think, sleep. So we found that overall two-thirds of the participants in this study say that they have a TV or internet-connected device in their bedroom, and having a device in your bedroom is associated with poor sleep and less sleep. We also looked at sort of cardiovascular disease risk factors. So we did, and many of the screen modalities, especially television viewing, are often sedentary. So, you know, that might displace time for being outside, for being physically active. And we did find that overall more screen time was associated with more weight gain over time, as well as actually higher blood pressure and worse sort of cholesterol markers. And then there also are detailed nutrition data that are collected and we also found that generally diet quality was worse among those who had more time on screens. So you may be more likely to snack or overeat while you’re distracted in front of the screen, you might be more sedentary, and also you may be exposed to food advertisements for junk foods.

[Kris Perry]: There’s been a lot of coverage over the last few years on the impacts of photo-centric social media platforms, like Instagram, and female body image disorders. One area of your focus has been on bringing to light male body image disorders and how they may be missed by clinicians looking for a classic female presentation. Can you tell us more about this?

[Dr. Jason Nagata]: Yeah, thank you so much for asking. I think that, you know, a lot of the coverage, as you mentioned, is about thinness and weight loss, which certainly is rampant on social media and is an issue that needs to be addressed. But I think that in general, people don’t realize that there are actually a lot of pressures for boys and men related to body image. And these may not be necessarily for thinness and weight loss. The sort of idealized masculine body ideal is big and muscular and bulky. And so, this may lead to a whole host of behaviors, like anabolic steroid use, excessive exercise, protein overconsumption while restricting carbohydrates and fats, and any other muscle-building or performance-enhancing substances or drugs, that I think people don’t talk about as much as we talk about, like, the weight loss and, sort of, restrictive eating disorder behaviors. And so, some of my research has actually focused particularly on some of the impacts of social media, particularly in boys and men, and how it can sort of exacerbate these feelings of insufficient muscularity or dissatisfaction about being too scrawny – and then, also, associations with performance-enhancing drugs or substance use, particularly for building muscle.

[Kris Perry]: These sound like really high-risk behaviors in young people, and I wondered what your research is showing on how screen media use relates to both female and male body image disorders and disordered eating behaviors.

[Dr. Jason Nagata]: We actually have found some interesting trends in, like, male versus female social media users. And so, we’ve actually found that boys, in general, are more likely to have – allow for public followings than girls. And also, male selfies tend to be more full body photos that show their muscularity as opposed to just like a face selfie. And people who have done content analysis of male body image-related posts have found that a majority depict muscularity and leanness. And then, on the sort of consumer side, we’ve seen that boys who spend more time on Instagram or other image-based social media platforms do have a higher risk of body dissatisfaction, muscle dissatisfaction, and even use of anabolic steroids in the future.

[Kris Perry]: I saw one of your recent studies showed each additional hour of daily screen time to be associated with specific eating disorder-related behaviors two years later, which would be, you know, fear of weight gain or self-worth tied to weight. Can you tell us more about this finding and anything you think people should know?

[Dr. Jason Nagata]: Yeah, I think that one of the reasons why social media is thought to have such a big impact on people’s body image is that we’ve always known that media can impact teenagers’ body image. But, if you think back to past decades, traditional television viewing or movies, even if they depict certain body image types – whether it’s thin or muscular – for the most part, teenagers in the past were kind of living in a read-only environment. You would see these images, but you would never put your own body on display. Like most teenagers never thought they would be, you know, the star of a Hollywood movie or featured on the news. But with social media, that’s not the case. Like now teenagers have this additional pressure to not only consume, but actually to put their own bodies on display almost as a performance – to gain likes, to gain followings, and to even interact with their peers. And so there’s this new pressure to actually put your own body on display. And when that happens, I think people are much more conscious about their body. And there’s also just constant comparisons with other people’s bodies. I mean, peers in particular, but other influencers. And I think one thing that many teenagers don’t realize, necessarily, is that they’re comparing themselves to the idealized version of peers and influencers. So these images can be highly filtered, or even if they’re not filtered, they’re choosing the best photo out of hundreds in a photo shoot. And so, they’re not necessarily a depiction of reality. And I think when you’re constantly comparing your own body to unrealistic, idealized bodies that often makes people feel worse about their own body and their own self-esteem and can lead to some of these eating disorders.

[Kris Perry]: I have so much empathy for these kids today with that kind of pressure. I can remember back to middle school and high school long before there was social media, and just the exposure to print media – certain magazines, certain commercials – had a very significant impact on me. And I learned early what was considered beautiful or not. And to think that now the – that children are being inundated with imagery that, in many cases, is probably altered or maybe not even real – much less feeling compelled to put their own body out there – makes me, you know, really concerned for them. And I’m glad we’re talking about it, because I think parents listening are deeply concerned about their children’s well-being and their mental health and the strength of their ego. Are there specific features on social media or other platforms beyond social comparison that you think are specifically contributing more to body image disorders in youth?

[Dr. Jason Nagata]: Well, I do think that – other than this pressure to put one’s body on display – I do think that, actually studies have shown that over the past several decades, actually the body pressures have exacerbated. And so, if I go back to sort of the idealized masculine body ideal, studies have actually shown that boys’ action figures over the last 30 years have become increasingly muscular. So if you actually measure the biceps and triceps and every muscle group of Batman, Superman action figures, they’re much more muscular now than they were 30 years ago. And I think that this is a trend that is not only for action figures – which young children are playing with – but with Hollywood stars. If you think about the actors that portrayed, you know – Adam West, as the original Batman, was kind of like a normal looking body. Whereas if we think about the Marvel superheroes now, they’re really big, they’re really bulky and almost, like, unattainable. Like, you know, people have professional trainers that they’re working out with to get these roles. And they’re, you know, likely taking muscle-building supplements to get to that. And so, I do think that across the different types of media – whether it’s

magazines, television, movies, or social media – we have just seen an increasing trend in muscularity in sort of the extremes over the last few decades. So, I do think that that is a trend across all media that we have sort of been observing.

[Kris Perry]: I think most health professionals agree that exercise is healthy, yet over-exercising is a common symptom for young people with body image disorders. What should a parent watch for to make sure their teen’s focus on health and exercise isn’t veering into unhealthy territory?

[Dr. Jason Nagata]: Yeah, I think that’s a really important question, and I will note that I think it’s very complex. Actually, most teenagers don’t get enough physical activity. You know, the recommendation is 60 minutes a day of moderate to vigorous physical activity. And for a lot of teens, especially those who are on screens a lot of their day, actually don’t get enough physical activity. But, I will say that there is a subset who sort of takes it to the extreme. And, for some of the patients that I care for with eating disorders or a condition we call “muscle dysmorphia” – which is characterized by, like, feeling scrawny or insufficiently muscular – I will have young people who, you know, spend all of their free time exercising to a point that it can really take over their lives. And so I think, to me the sort of tipping point when something becomes a disorder or might be a warning sign for a parent is when that exercise or food choices lead to preoccupations or obsessions with appearance, body size, weight, or exercise in a way that really worsens someone’s quality of life. And they may withdraw from usual activities or friends because of concerns about exercise or body size. And so, some of the young men that I take care of with muscle dysmorphia, they no longer eat with friends or family, because they think the food that they’re going to get is not high enough in protein content or it’s too fatty. And if they spend any time not in the gym, they feel guilty about it. So, I do think that at the point that it becomes a preoccupation or obsession and really worsens someone’s quality of life, that’s when you might need to get help.

[Kris Perry]: Well, for youth themselves, what advice would you give to young men and women who want to be strong and athletic, but may be getting mixed, and sometimes dangerous, messages online about how to safely do that?

[Dr. Jason Nagata]: I think, in general, exercise and physical activity is supposed to bring you joy and protect from depression. So, if there’s a certain point when you’re exercising and it’s not bringing you joy – like, it’s making you feel worse about yourself, you’re feeling guilty, or it’s like just becoming a nagging obsession – those might be reasons to think about, “Is this really gonna be benefiting me?” And potentially getting help, if needed. And, I think one other important point for teenagers on social media is, you know – people post all kinds of stuff about, you know, weight, –or like lots of different advice that people give on social media about gaining muscle or eating certain types of foods. And just to say that, while some of it may be okay, some of it may just be wrong or incorrect. And I think you should just take it with a grain of salt and think about who is actually posting this – you know, if potentially they’re getting advertising deals, you know, from like muscle-building supplement companies. Because I think there’s a lot of sort of surreptitious advertising – it doesn’t look like an advertisement, but it actually is. So, I would just be wary of what you see on social media and think a little bit more critically about the advice you’re getting before fully on taking it.

[Kris Perry]: Has your research found differential impacts or considerations for LGBTQ youth vis-a-vis screen use?

[Dr. Jason Nagata]: We did find that in the ABCD study, lesbian, gay, and bisexual adolescents actually reported four more hours a day of total screen time than their heterosexual peers, which actually is quite a lot. And even transgender adolescents had almost five hours more of daily screen time than their cisgender peers. So, I do think that overall, sexual and gender minorities spend a lot more time on screens than their heterosexual or cisgender peers. And as I mentioned earlier, you know, this may be in support of fostering virtual connections and communication, particularly if they’re more isolated in their home or school communities, you know, to try to find support online. So it’s not all bad, but we did also find that there were higher rates of social media addiction or problematic sort of social media use even among LGBT adolescents. So I do think that there are risks associated with that much more screen time a day.

[Kris Perry]: I’m shocked, I’m absolutely shocked by that increase in time per day among LGBTQ youth, given how many hours youth are spending online already. It’s a shocking increase. Are there any specific examples of screen use and body image disorders among LGBTQ youth?

[Dr. Jason Nagata]: You know, I will say that we are continuing to do research on this in the ABCD study. Right now, as I mentioned, the data are only available for – like the most recent data is like for 13- to 14-year-olds. And so, I will say that my guess is that some of the early adolescents who may be LGBT are not actually fully “out” yet. You know, they’re still in a sort of an exploratory, developmental phase. And so right now, the sample, I think, of LGBT youth is a little bit too small to look at specific eating disorder associations. But I do think that, potentially, if there are more out LGBT youth in the study, especially as they get a little bit older, we may be able to parse apart some of those more specific risk factors in the future. But, one thing that we did actually look at was cyberbullying and sexual orientation discrimination. So, we did see that LGBT youth are more than three times more likely to experience cyberbullying online, and cyberbullying is linked with eating disorder risk. So, that is one potential sort of mechanism. We know that LGBT youth experience in-person bullying at higher rates as well, but we have also seen this trend online, unfortunately.

[Kris Perry]: Has your research shown a relationship between adolescent screen use and substance abuse behaviors?

[Dr. Jason Nagata]: Yes, we looked mainly at substance experimentation, again, because these are younger adolescents. But, we did actually find that screen time and particularly social media use, texting, video chatting – so these are like the more social modes of screens – were associated with more experimentation with alcohol, cannabis, and nicotine. And as I had mentioned, we do have some measures of social media addiction. And we did find that social media addiction sort of explained some of the association with substance use. And obviously addiction is an issue with substance use as well. So, I do think that it’s sort of a common pathway that, you know, there could be social media addiction and then substance use addiction. And overall, I do think that youth who are on social media could be exposed to advertising, even though technically they’re not supposed to target youth. You know, a lot of the ads are very enticing to young people. And also, you know, people who have looked at actually people’s posts of substance use online have found that over 90 % of content on social media that depicts substance use, depicts it in a very positive light. You know, it’s like at a party with cool college students having fun while drinking alcohol – it’s very rarely in a negative light. So I do think that, you know, there’s sort of peer norms that are formed on social media that may entice underage people to start trying substances.

[Kris Perry]: Your research has shown wide ranging impacts on health outcomes for adolescents from screen use. Do you think pediatricians and physicians, in general, should play a larger role in helping families understand these potential health risks, or are parents just out there on their own?

[Dr. Jason Nagata]: I think that hopefully parents are not out there on their own. I think that screens are not something that’s going to go away. And I will say that, you know, it’s not just parents for their kids, but you know, all adults are facing these same decisions. And so, I do think that there is a role for pediatricians. I also think there’s a larger role for policy makers, and tech companies, as well. But since I’m a pediatrician, just talking specifically about the role of pediatricians, I will say that the American Academy of Pediatrics does advocate for developing a Family Media Use Plan – which is like having a pediatrician help families, or help parents, to start conversations about potential rules that are practical for one’s household. And so, some things that could be considered in this Family Media Use Plan can include just having regular discussions with family and potentially talking about screen-free time – so, like we know that right before bedtime is a key time, or also during meals. Also, potentially having screen-free zones. So especially with younger adolescents, if you don’t want them getting into dangerous content, potentially restricting screen use to public spaces like family room, kitchen, living room, and restricting use in bathrooms and bedrooms. And then, also just having discussions about digital privacy and safety and balancing media use with other activities.

[Kris Perry]: Is there any one finding or piece of research you’ve been involved with that particularly surprised you?

[Dr. Jason Nagata]: One of the biggest findings that we had from the parent screen use questionnaires was actually that even though parents don’t think that their teenagers are listening or following to them, that actually one of the single biggest predictors of adolescent screen use was their parents’ screen use. And so, it’s really important for parents to act as a role model for their children. And so, if you’re going to make household rules, like for instance, “No texting at meal time,” it’s really important that parents follow those rules, too. Because, if they make a rule, but they break them, it’s not likely that their teenager will follow suit. But, I also think that it’s a good opportunity to have some of these discussions. Because, as I mentioned, we all live in these very screen-heavy environments, and we all have to balance, you know – we’re using these devices often for work as well as recreation. And so, they’re always around. I think also being open with our kids about when we struggle with putting down our phone or logging off, that, I think, helps kids to start to think through their own processing. And, you know, teenagers, eventually, will become adults and will be able to make these decisions on their own. So, I think helping them think through some of the pros and cons for when they’re adults can be helpful.

[Kris Perry]: In your opinion, what’s the next most important thing to study or look at regarding adolescent health and media use?

[Dr. Jason Nagata]: You know social media and screen use isn’t inherently good or bad. There are potential health risks, but there are also potential benefits. And I do think that, to me, trying to really understand what is– how we can best optimize all the benefits – like connection, communication – while mitigating the risks, like, related to poor sleep or sedentary behavior or mental health. Just trying to figure out how we can guide teens and their parents to sort of find that nice balance and sweet spot. Because it’s, I don’t think it’s a one-size-fits-all, and I don’t think that it’s all inherently good or bad. But, trying to figure out like, you know, for specific households with specific devices and kids in specific ages, what are like a little bit more of the nuances that we can help to guide families.

[Kris Perry]: Has your work impacted how you and your family use media?

[Dr. Jason Nagata]: That is a great question. I will say that there were some specific questions about screen use during bedtime in the ABCD study. And some of the findings from that were that two-thirds of teenagers have screens in their bedroom, but those who didn’t overall had longer sleep and better quality sleep. And then, in terms of if you did have the phone or device in your room, actually turning it completely off – not just on silent or vibrate – was actually more effective, or was associated with better sleep and longer sleep. So, I think in the past had had my phone, you know, as my phone alarm – so I had it on silent overnight. But I think even if it’s on, you know, if you wake up in the middle of the night to go to the bathroom, and you just check it, then all of sudden your brain is activated. And you’re like, thinking – you see all the emails that came in, and you’re like, “Uh.” Your brain is wired. So, I have now, because of this study, I turned the phone completely off, and I put it in another room. And, I think that actually has helped my sleep quality as well.

[Kris Perry]: I’m so glad you brought up sleep health. We have a podcast with Dr. Lauren Hale, who takes a deep dive into the research around sleep and its impact on child development. So listeners, please tune into that podcast. Jason, based on all of your work, what would be the single most important advice you would give to parents today who want to help their child thrive in a digital world?

[Dr. Jason Nagata]: I think that screen use is not inherently bad or good. There are some risks related to poor sleep, sedentary behavior, or mental health that we really want to minimize. But, I do think that we want to enjoy screens for connection, communication, and education. And so, I do think that not thinking of it as all bad or all good, but trying to really embrace the benefits while minimizing the risks is sort of a way that I’ve tried to balance media use in my own practice and in my household.

[Kris Perry]: Jason, thank you so much for taking the time today to share your experience and research with us. Gaining a better understanding of how adolescents’ immersion in digital worlds impacts their health and wellbeing is truly vital and potentially transformative work for today’s teens. Thank you, too, to our listeners for tuning in today. For a transcript of this episode, visit childrenandscreens.org, where you’ll  find a wealth of resources on parenting, child development, and healthy digital media use. Until next time, keep exploring and learning with us.