505 - Social Media and Youth, Assessing Acute Dizziness, Belonging

From the US Surgeon General, APA, and Jonathan Haidt, PhD

1)  Social Media and Youth Mental Health

Social media use among young people is nearly universal, with up to 95% of teenagers, and even 40% of children aged 8-12, on various social media.  Despite this widespread use among children and adolescents, there is not yet have enough evidence to determine if social media use is sufficiently safe for them—especially during adolescence, a particularly vulnerable period of brain development.

Different children and adolescents are affected by social media in different ways based on their individual strengths and vulnerabilities and based on cultural, historical, and socio-economic factors.  While social media can provide benefits for some children, increasingly, evidence is indicating there is reason to be concerned about the risk of harm social media use poses to them.  Children and adolescents on social media are commonly exposed to extreme, inappropriate, and harmful content, and those who spend more than 3 hours a day on social media face double the risk of poor mental health including experiencing symptoms of depression and anxiety.  This is deeply concerning as a recent survey of teenagers showed that, on average, they spend 3.5 hours a day on these platforms.

As a response to these concerns, in May 2023 the US Surgeon General Vivek Murthy, MD, published an advisory on Social Medial and Youth Mental Health.  The advisory describes the current evidence on the impacts of social media on the mental health of children and adolescents and outlines immediate steps that can be taken to mitigate the risk of harm to them. 

Recommendations include (modified):

·         Patients and caregivers: make plans in their households such as establishing tech-free zones that help protect sleep and better foster in-person relationships ,teach children and adolescents about responsible online behavior, and model that behavior, and report problematic content and activity.

·         Policymakers:  take steps to strengthen safety standards and limit access in ways that make social media safer for children of all ages, better protect children’s privacy, support digital and media literacy, and fund additional research.

·         Researchers:   further prioritize social media and youth mental health research that can support the establishment of standards and evaluation of best practices to support children’s health.

While the Surgeon General’s advisory did not address recommendations for healthcare clinicians, the American Academy of Pediatrics does recommend the following:

·         Work with families and schools to promote understanding of the benefits and risks of all electronic media, including social media.

·         Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

·         Advocate for and promote information and training in media literacy.

·         Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Mark’s Comments:

This concern goes way beyond “screen time.”  Without providing informed consent, all of us who are active on social media platforms are participating in a social experiment of unprecedented scale.  Unfortunately for us, profiteers have developed sophisticated algorithms that readily exploit and take advantage of design weaknesses in the human cognitive and psychological operating system.  While correlation does not indicate causation, the trends regarding emotional health over the past 10 years associated with increased social media exposure/use are startling and disturbing. 

Because to this point social media companies have shown an unwillingness to self-regulate and trying to get consensus in our present political climate is unlikely, it will depend on we as parents, grandparents, community leaders, and healthcare leaders to educate our patients and communities about the dangers of this technology and help to support limitations on use for children and adolescents.  Social psychologist and prolific writer Jonathan Haidt has made the questions surrounding social media a central focus of his research and I have found his work to be quite helpful for me as I try and comprehend the vast impact of this rapidly changing technology.

References:

·         US Surgeon General.  Social Media and Youth Mental Health:  The US Surgeon General’s Advisory.  23 May 2023.  Full Advisory;  Executive Summary

·         American Psychological Association.  Health Advisory on Social Media Use in Adolescents.  May 2023.  Link

·         AAP Council on Communications and Media.  Media Use in School-Aged Children and Adolescents.  Pediatrics (2016); 138(5):e2016-2592.  Link

·         Haidt, Jonathan.  Social Media.  Jonathanhaidt.com. 

From the Society for Academic Emergency Medicine (SAEM)

2)  Assessing Acute Dizziness Complaints

Dizziness is a very common complaint in primary care. Both benign and malignant causes for the complaint exist, and the primary task of the clinician at the initial visit is to efficiently rule out the dangerous causes. The SAEM has put together the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) program to reduce unnecessary testing/workups in the ED for some common complaints.

There was a very comprehensive, organized, and explicit evidence-based process used for this guideline – a full search for evidence, rigorous use of the GRADE framework for assessing evidence and making recommendations, and a robust conflict of interest (COI) process (most COI were about members of the study panel acting as paid expert legal witnesses). This guideline emphasizes use of a strict diagnostic algorithm and training in the physical examination maneuvers discussed. Most of the recommendations listed below had moderate to high certainty of evidence.

The guideline recommends separating dizziness complaints not by symptom characterization (vertigo, pre-syncope, disequilibrium), but instead by the timing of and triggers for the symptom.

·         Acute vestibular syndrome (AVS) is continuously present and persistent dizziness (vestibular neuritis vs. stroke).

·         Spontaneous episodic vestibular syndrome occurs without specific triggers but comes and goes (vestibular migraine vs. transient ischemic attack (TIA)).

·         Triggered episodic vertigo is brought on by specific movements (benign paroxysmal positional vertigo (BPPV) vs. central PPV vs. orthostasis).

·         Patients with obvious stroke or medical causes for their dizziness should be treated for those. Patients with headache, neck pain, other abnormal neurologic findings (dysmetria, dysarthria, weakness, dysphagia, etc.) should be evaluated for stroke.

The highlights (edited by me) of the guideline:

·         Clinicians who evaluate dizziness should consider training in Head Impulse-Nystagmus-Test of Skew (HINTS) examination as well as therapeutic maneuvers such as the Epley maneuver. Clinicians without such training should not use HINTS testing, due to a risk of false positives.

·         To help distinguish central from peripheral causes in patients with the acute vestibular syndrome (stroke vs. vestibular neuritis):

o   use HINTS (for clinicians trained in its use) in patients with nystagmus (any positive HINTS finding is consistent with central etiology, but should be used only in patients with persistent nystagmus)

o   use finger rub testing in patients with nystagmus to evaluate for concomitant hearing loss, which can indicate stroke

o   use severity of gait unsteadiness can be assessed in patients without nystagmus to assess likelihood of stroke (increased with worsening gait)

o   do not use brain CT – low sensitivity for early posterior circulation strokes

o   do not use routine MRI first-line if a clinician trained in HINTS is available

o   use MRI as a confirmatory test in those with central or equivocal HINTS exam

·         In patients with the spontaneous episodic vestibular syndrome (transient ischemic attack (TIA) vs. vestibular migraine):

o   search for symptoms or signs of cerebral ischemia

o   do not use CT (as above)

o   use CT angiography or MRI angiography if there is concern for TIA

·         In patients with the triggered (positional) episodic vestibular syndrome (BPPV vs. central PPV vs. orthostasis).:

o   use the Dix–Hallpike test to diagnose posterior canal BPPV (pc-BPPV)

o   Other forms of BPPV are diagnosed by different, more difficult to interpret tests – consider specialty referral.

o   do not use CT

o   do not use MRI routinely, unless atypical clinical features are present

·         In patients diagnosed with vestibular neuritis:

o   consider short-term steroids as a treatment option

·         In patients diagnosed with pc-BPPV:

o   treat with the Epley maneuver

John’s Comments:

This is a dense and prescriptive guideline, and its full implementation requires training (see https://www.acep.org/dizzy for a set of training resources). Its primary use to me is to think about the differentials for dizziness in a new way (timing and triggers for symptoms rather than relying on symptom descriptions from the patient). In outpatient primary care, we see dizziness commonly, but probably not as much as we would in the emergency department. So, why discuss this guideline? Because by expanding the scope of care in our offices, we provide more consistent, personalized longitudinal care, avoid over-testing, and reduce costs. The point of this guideline is to use physical examination accompanied by sound, research-based reasoning to reduce over-testing and over-treatment, which sounds to me like good primary care.

References:

·         Edlow JA, Carpenter C, Akhter M, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Academic Emergency Medicine. 2023;30(5):442-486. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  It’s Either Belonging or Be Longing …

“ … belonging is the meaning of life.”  Eric Barker, Author and Blogger

What was the best job you ever had?  While for you the answer might be “being a physician,” that is not the case for me.  Summertime always reminds me that being a summer camp counselor during college continues to be the standard by which I have measured every job since.

Two years ago, I hired a leadership coach to help guide me through a professional crossroads, and she encouraged me to explore this seemingly nostalgic standard, asking “What was it about being a camp counselor that so spoke to your soul?”  While there were many aspects I loved about camp and being a counselor, the quality that sets it apart from my other jobs was the sense of being part of something where I felt I belonged – where all of me felt welcomed and valued, and where others felt the same.  It was truly a “come as you are” and “let’s grow together” time.

In a 2013 study entitled “To Belong is to Matter,” Nathaniel Lambert and colleagues concluded, “Using a diverse set of methods, we found converging evidence that feeling a sense of belongingness is a powerful predictor and cause of finding life meaningful.”  Not only did belonging predict a sense of meaning – it actually caused it.  This identical conclusion was reached by Eric Barker in his 2022 book, Plays Well With Others, where he boldly states, “ … belonging is the meaning of life.”  He goes on, “… the most memorable moments in my life … are always when I was with a group where I felt accepted.  Where I felt I belonged.” 

Belonging has been defined as 'the extent to which an individual perceives being valued, needed, and accepted by people in his or her social environment.”  True belonging is not the same as inheriting (“I belong to my family”), joining (“I belong to my professional society”), being selected (“I belong to this honor society”) or fitting in, selling out, or pretending (“I belong to this social group”).  Belonging does not require you to change yourself, nor others to change themselves.  It is not about adaptation – it is about acceptance, starting with yourself.   

Indeed, what was most impactful for me about those summers working at YMCA camp was the level of acceptance I experienced – the opportunity to both "bring the best of me, and the rest of me."  We encouraged each other to share the hidden parts of ourselves, to take interpersonal risks, and while doing so, to show grace for and laugh with each other.  In the process, “the rest of me” slowly began to transform, to heal, to soften, to grow.  And that is what I have aspired to in every job since then.  Certainly, there are other places outside of work to find this as well, but given the amount of “life energy” one spends at work, I believe if we are not able to find a sense of belonging there, we will continually find ourselves in a place of “be longing.”

It therefore shouldn’t surprise me that as I have become more vulnerable and allowed more of my authentic self to show up in my present job, I’ve experienced a greater sense of belonging … and deeper meaning.  If I keep that up it could become my new “best job ever”!  That is certainly something I’d wish for all of us.  ….

Feel free to forward Take 3 to your colleagues.  Glad to add them to the distribution list.

Mark and John

Carilion Clinic Department of Family and Community Medicine

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org