When her youngest daughter, Naomi, was in middle school, Ellen watched the teen disappear behind a screen. Her once bubbly daughter went from hanging out with a few close friends after school to isolating herself in her room for hours at a time. (NPR has agreed to use only the pair's middle names, to protect the teen's medical privacy.)
"She started just lying there, not moving and just being on the phone," says Ellen. "I was at a loss about what to do."
Ellen didn't realize it then, but her daughter was sinking into a pattern of behavior that some psychiatrists recognize from their patients who abuse drugs or alcohol. It's a problem, they say, that's akin to an eating disorder or gambling disorder — some consider it a kind of Internet addiction. Estimates of how many people are affected vary widely, researchers say, and the problem isn't restricted to kids and teens, though some — especially those who have depression or anxiety disorder — may be particularly vulnerable.
Naomi had always been kind of a nerd — a straight-A student who also sang in a competitive choir. But she desperately wanted to be popular, and the cool kids talked a lot about their latest YouTube favorites.
"I started trying to watch as many videos as I could so, like, I knew as much as they did," says Naomi. "The second I got out of school, I was checking my phone." That's not unusual behavior for many teens and adults these days.
But in her hillside home across the bay from San Francisco, Naomi would dart to her room after school, curling up until after dark, watching video after video after video. When she finally emerged, she says, she was often bleary-eyed, and felt hazy and extremely agitated.
Ellen soon found herself walking on eggshells around her daughter; Naomi was often in a foul mood and quick to anger after staring at her small screen for hours. The anger and gloom were unusual for Naomi, and it went beyond typical teen moodiness, Ellen says. Her parents didn't realize it yet, but Naomi was falling into clinical depression, and her compulsive use of the Internet was speeding the descent.
The videos turned from comedy to violence
Over time, Naomi started watching videos of girls fighting each other. They'd pull each other's hair, scratch violently and sometimes knock each other out. Naomi and her friends rooted for certain fighters.
"I think it was just fun to watch because they would make me laugh," Naomi recalls. "And at that time I was having a pretty hard time dealing with depression and anxiety."
Naomi's parents were arguing a lot and she wasn't connecting with her dad at all. Then her grandmother died. For the first time in her life, it was tough to keep up with school.
"She woke up one morning really depressed, and I brought her to the hospital," Ellen says quietly. Naomi had received a poor grade on a test and told her mom she wanted to hang herself — she spent nearly a week at a psychiatric hospital under a suicide watch.
After she was released, Naomi turned back to her phone for comfort and companionship. She'd stopped going outside or visiting friends after school. She started clicking on how-to videos about ways to commit suicide. "I got the idea to overdose online," says Naomi. "I was researching how many pills I had to take to die."
Three weeks later, she ended up in the hospital again, after downing a bottle of Tylenol.
"She was home alone and we had been told to lock it up, but we just didn't think this would ever happen," says Ellen, who is now in tears.
Naomi's parents were shattered, and desperate to find a way to help their daughter.
The road to recovery
When Naomi was released from her second hospital stay, her family checked her into an addiction recovery center for teens called Paradigm. The high-end facility is a converted mansion at the end of a winding road in San Rafael, Calif. The family is tapping their retirement accounts to pay the $60,000 fee for Naomi's six-week, in-patient stay.
Jeff Nalin, head psychologist and co-founder of Paradigm, has been treating teens for substance abuse for more than 20 years. In the last few, he says, he's seen an increasing number of cases similar to Naomi's. She was diagnosed with a depression that led to what Nalin sees as an addiction disorder.
"I describe a lot of the kids that we see as having just stuck a cork in the volcano," says Nalin. "Underneath there's this rumbling going on, but it just rumbles and rumbles until it blows. And it blows with the emergence of a depression, or it emerges with a suicide attempt."
These teens are using smartphones and tablets, he says, for the same reasons others turn to hard drugs — to numb themselves from what's really going on inside.
Most teens with this compulsion come to Paradigm because they've hit bottom in the same way someone addicted to drugs or alcohol does, Nalin says. But the treatment for compulsive Internet use is trickier, he says, because you can't really function in today's society without interacting with the digital world.
"The best analogy is when you have something like an eating disorder," says Nalin. "You cannot be clean and sober from food. So, you have to learn the skills to deal with it."
When does obsession become addiction?
"Digital addictions," whether to social media, video games, texting, shopping or pornography, are not official mental disorders listed in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), and there's a debate among psychologists about whether that should change.
Dr. Anna Lembke, a Stanford University psychiatrist and assistant professor in addiction medicine, says she is seeing a classic addictive pattern of behavior in many of her clients who compulsively use the Internet.
"Addiction begins with intermittent to recreational use, then progresses into daily use, and then progresses into consequential use, which in some cases will progress to life-threatening use," Lembke says.
"That's followed by a pattern of consequences like insomnia, dysfunctional relationships and absent days at work or school," she says. "That's the natural narrative arc of any addiction, and the same is true with an Internet addiction."
China has labeled Internet addiction as a mental disorder, she notes, and that's surprising — historically the Chinese have considered addiction a moral failing rather than a clinical disorder.
Some experts attribute China's change in attitude to the widespread involvement of middle- and upper-class Chinese adolescents in what looks like addictive online behavior.
"A little like our opioid addiction here," says Lembke. "People say no one cared about the opioid epidemic until it affected white suburban kids."
Lembke predicts Internet addiction will become a validated clinical diagnosis in the U.S. as more and more cases mirror Naomi's.
Dr. Elias Aboujaoude, a psychiatrist and the director of Stanford's Obsessive Compulsive Disorder Clinic, says there's also increasing physiological evidence that the use of the Internet can become addictive for some people. Some studies using scanning technology have looked at people's brains while they're online, he says, and compared them to scans of the activated reward pathways in the brains of people who have a substance abuse disorder. "Similar pathways seem activated," he says.
He also says tolerance builds in people who compulsively use the Internet, just as it does with the use of hard drugs. He sees "people needing more and more time on a particular online video game, for example," he says, "to get the same kind of euphoric feeling."
Psychologists are still studying whether it is the overall use of the Internet that becomes pathologically compelling, or specific behaviors that people engage in while online — like shopping, gambling, playing video games or viewing pornography.
"My view is that it is both," says Aboujaoude. "These behaviors have long been known to be addictive, but the Internet, in part by making them so easily accessible, changes the equation and increases the likelihood that they will become addictive."
Some people studying the condition compare the development of an Internet addiction to that of a gambling disorder (sometimes called gambling addiction), which is included in the DSM-V. With gambling, even though most of the time when you're sitting in front of a slot machine you don't win, every once in a while you do. And that intermittent reward is what hooks people.
Think about your own use of personal electronic devices. Most of the time when your phone dings, the notification is about something trivial. But, every once in a while, it's something meaningful to you — like, perhaps, a notification that someone has tagged you in a Facebook photo. Researchers studying Internet use say that kind of message is irresistible.
Still, not everyone is convinced that "addiction" is the right way to think about this compulsion. Chris Ferguson, a psychologist at Stetson University, believes moral panic is fueling the rush to label the problem an addiction. "Sometimes with new technology you see these heightened claims of harm, these exaggerated focuses on the detriment of the new media."
Patrick Markey, a psychologist at Villanova University, agrees that society should go slow in using the "addiction" label. He worries some researchers are casting an age bias on younger generations.
"If we see kids playing video games or watching YouTube videos, in our eyes it's as if they're wasting their time and not being productive," Markey says. "We might want them to be outside playing baseball or something, but for that generation that's their pixelated playground. It might not be a sign of a pathological behavior."
Markey acknowledges it's possible to spend too much time interacting with a screen. But both he and Ferguson believe that spending long hours on the Internet falls into the same category as other behaviors that healthy people can overindulge in — like sex, food, exercise, religion and work.
"There's no agreement about whether these pathological behavioral disorders are really the same things as substance abuse addictions," says Ferguson. "But in my opinion they're not comparable to, say, methamphetamine addiction or heroin addiction."
A crusade for change
Even as researchers debate whether the Internet is clinically addictive, many if not most of us feel tethered to our devices. That's not a coincidence. Tech companies are invested in hooking people into spending more and more time online, and they're getting better and better at it, says Tristan Harris, a former design ethicist at Google. His job, he says, was to help the company create products that weren't inherently manipulative.
"When you look at the Facebook news feed, it's not just some neutral thing," Harris says. "That's powered by massive farms of computers who are calculating, with Ph.D.s and large data sets: 'How I can get you to scroll?' "
Harris eventually quit his gig at Google to form a nonprofit called Time Well Spent, because, he says, he was disgusted by the tech industry's race for our attention. He says Google had good intentions, but it was too difficult to turn the tides at the tech giant.
"Never before in history have a handful of technology designers working at three tech companies influenced how a billion people spend their attention," Harris says.
He's now on a crusade to inspire Facebook, Google and Apple to design products that don't deliberately hook kids like Naomi.
Back at Paradigm, Naomi is getting ready for a session with her therapist, who is helping her integrate her devices back into her life. She is now in a month-long outpatient program four days a week after school. She says she doesn't plan to isolate herself again. In fact, she's asked her mom to restrict her phone use, so that she can't use the phone when she's alone.
"I've realized what it's done to me in some ways," Naomi says, "and I've seen what it has done to some of my friends."
Recently some of Naomi's friends were suspended from school for posting inappropriate videos to YouTube. Naomi doesn't want to follow in their footsteps. She hopes she can resist the allure of the digital world and return to the activities she used to love.
This story was produced by KQED's health and technology blog, Future of You.