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Electronic Screen Syndrome (ESS)
Is It Real?

Is Electronic Screen Syndrome (ESS) real? Is it a disease? An addiction? Do violent video games cause aggression? Can playing video games have positive effects? In this column from Skeptic magazine 25.2 (2020), Harriet Hall, M.D. examines ESS and shares the science.

You may have noticed that children seem to spend a lot of time interacting with screens: cell phones, tablets, computers, television, and video games. They do, and a great many people— from parents to pundits—are wondering if this is bad for them or good for them. The answer is “it depends.”

In 2012, Victoria L. Dunckley M.D. was the first to describe what is now called Electronic Screen Syndrome. She wrote an article in Psychology Today arguing that there was an unrecognized disorder that explained many psychiatric symptoms in children. She listed complaints that many parents can relate to:

  • “He’s revved up all the time.”
  • “He can’t focus at all and is totally defiant. Getting ready for school or bedtime is a daily nightmare.”
  • “She’s exhausted and has meltdowns even when she’s slept enough.”
  • “He flies into a rage over the slightest thing. The other kids don’t want to play with him anymore.”
  • “Her grades have gone downhill this year and we don’t know why.”

These are common complaints that can have many causes and can lead to faulty diagnoses. Dunckley said the two most over-diagnosed conditions she sees in the pediatric population are bipolar disorder and attention deficit/hyperactivity disorder (ADHD or ADD). Overdiagnosis leads to inappropriate treatment with psychotropic drugs that have side effects. She wondered if the true cause of these misdiagnosed symptoms might be environmental. Seek and ye shall find. Sure enough, Dunckley found one: “the unnaturally stimulating nature of an electronic screen, irrespective of the content it brings.” She called it “Electronic Screen Syndrome” or ESS, alleging that too much screen time could cause mental health issues or exacerbate pre-existing ones.

Characteristics of ESS in Children

Dunckley says ESS is a disorder of dysregulation, the inability to modulate one’s mood, attention, or level of arousal. She says interacting with screen devices over-stimulates the child and shifts the nervous system into fight-or-flight mode. The response can be immediate, as with action games, or more subtle, as in repeated texting.

A child diagnosed with ESS exhibits symptoms such as irritability, depression, tantrums, low frustration tolerance, poor sportsmanship, poor eye contact, insomnia, poor short-term memory, and learning difficulties. Dunckley claims that ESS can mimic virtually any mental health disorder.

She claims that these symptoms markedly improve or resolve with strict removal of electronic media and may or may not recur when the media are re-introduced. Boys with ADHD and autism are particularly vulnerable. She claims to have treated over 500 patients with “electronic fasting,” with good results. Keep in mind that she is a psychiatrist and her patients are not representative of the general population of children. She has not published any scientific studies; she has only written books for popular consumption.

Who is Dunckley? An “integrative” child and adult psychiatrist in Los Angeles, she is on the advisory board of Physicians for Safe Technology, which endorses fears of wi-fi and cell phone towers. According to their website, Dunckley is “currently involved in research looking at the impact of screentime on the development and severity of autism.” Early electronic screen exposure has been linked not to autism, but to “autistic-like symptoms,” and only in a study that had no control group and is therefore meaningless.

ESS is not accepted by most other psychiatrists. The American Academy of Pediatrics has issued guidelines for limiting media use in children, but only because they are concerned that children may not have adequate time to play, study, talk, or sleep. They don’t even mention the term ESS. Shouldn’t we ask how that screen time is being used and what is happening in the rest of their lives that might influence their development? The World Health Organization recommended limited or no screen time for children under 5. The published guidelines are based on opinion rather than on scientific data. I’d like to see a controlled study that compares children who are allowed unlimited screen time to children who are subjected to the guidelines. No such study exists.

Addiction?

The World Health Organization (WHO) does not accept ESS, but it does call “gaming disorder” an addiction. The word addiction is overused and applied to what might be more accurately called habits. To apply it to screen time, sex, food, gambling, and other habits is to trivialize the meaning of true addiction for alcoholics and drug addicts. I like coffee and drink a lot of it, but I’m not “addicted” to coffee. If it were a true addiction like heroin addiction, I would have intense cravings, I would become tolerant and have to increase my dosage to get the same effect, I would suffer withdrawal symptoms when I stopped using it, and it would create serious problems with my health, family, and occupation. It would take over my life. Just as none of that is true for coffee, it is also not true for many other things that have been called “addictive.” I think spending time with screens is a habit, not an addiction. We don’t even know for sure that increased screen time correlates with psychiatric symptoms. There have been no studies of what happens when people are suddenly deprived of their screens. And when correlation of screen time with psychiatric symptoms hasn’t been established, it’s premature to speculate about causation.

Is It a Disease?

Is it possible that the symptoms listed by Dunckley occur just as frequently in people who don’t use electronic devices? Comparison studies have never been done. The same symptoms certainly occur in people given other diagnoses.

It’s dangerous to jump to conclusions. For years, parents were told that sugar in the diet makes children hyperactive. Today we know that’s a myth. Children were indeed “bouncing off the walls” at birthday parties, but not because of the sweets they consumed. It was because parties caused excitement and stimulation, and because parents were observing what they expected to observe. Confirmation bias can be very powerful. Double blind studies have demonstrated that sugar in the diet does not affect children’s behavior.

For years, children were denied sweet treats for no good reason. It would be a shame if children were similarly denied enjoyment of screen time on the basis of little or no evidence. It might deprive them of a valuable experience and might just make them rebellious and angry with their parents.

An article in The Telegraph says children face social problems such as loneliness, depression, anxiety, low selfesteem and heightened aggression as a result of overusing computers. It claims that those who sit behind a screen for more than four hours a day are particularly at risk, although very low levels of use can cause issues. Their information comes from Public Health England, but it is based on self-reports rather than controlled scientific studies.

Video Games & Aggression

Studies have found that “violent video games increase aggression and aggression-related variables and decrease prosocial outcomes, while prosocial video games have the opposite effects.” But they were wrong. The studies didn’t show that; they only showed correlation, not causation. They didn’t rule out other possible confounders. These findings are debatable and many opposing studies exist. It has been claimed that violent video games lead to mass shootings and school shootings; but studies have shown there is no link.

Positive Effects

As sales of violent video games go up, the rate of violent crimes goes down. Could it be that people are attracted to playing violent or prosocial games because they already have those tendencies? Could a violent game serve as a safety valve? It might keep potential aggressors off the streets and provide a safe way to act out fantasies. If we rushed to treatment and made users stop playing video games, would they be less or more aggressive? We simply don’t know.

A large study in 2016 found that time spent playing video games was associated with mental health, cognitive and social skills in young children. They had higher intellectual functioning and better school performance. But that doesn’t mean that video games make you smarter; maybe smarter people are more likely to play video games. A Japanese study, for example, found that kindergarteners who played video games had more friends and were more willing to talk to others.

Video games can improve fine motor skills, eye-hand coordination, visual attention, depth perception, and computer competency. Doctors who have played commercial video games have better surgical skills, are faster, and make fewer surgical errors; and video games have been proposed as a practical teaching tool to help train surgeons, particularly for laparoscopic surgery. Frequent phone texters have improved reaction times. And more agile thumbs!

Other Factors

I can’t help but wonder if Dr. Dunckley started with the preconception that screen time must be harmful. If so, it is easy to understand how she could find a diagnosis and treatment to support her belief. She looked for examples and found them. She didn’t look for disconfirming evidence. Confirmation bias did the rest.

It is simplistic to look at a single factor like screen time. There are lots of other factors that can influence behavior. Is there an underlying psychiatric disorder? Is the family supportive or dysfunctional? What is the socioeconomic environment? What other activities are available to the child? What is the child’s reason for using the electronic device? In some cases, interaction with electronic screens might cause stress, but for others it might relieve stress.

I don’t think ESS is a useful diagnosis. Interaction with screens may have good or bad consequences. It makes sense to look at the whole picture; it doesn’t make sense to measure one thing and enforce arbitrary rules before the evidence is in. END

About the Author

Dr. Harriet Hall, MD, the SkepDoc, is a retired family physician and Air Force Colonel living in Puyallup, WA. She writes about alternative medicine, pseudoscience, quackery, and critical thinking. She is a contributing editor to both Skeptic and Skeptical Inquirer, an advisor to the Quackwatch website, and an editor of sciencebasedmedicine.org, where she writes an article every Tuesday. She is author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon. Her website is SkepDoc.info.

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