Treating screen dependence in adolescents: a therapist's manual

1. The programme at a glance

Indication. Screen use that has become uncontrollable and disabling in adolescents aged 12 to 18: video games, social media, short video, pornography, messaging. The programme suits gaming disorder as defined by the eleventh revision of the World Health Organization's International Classification of Diseases, ICD-11 (section 7), and the neighbouring presentations linked to the other uses, which are not diagnoses.

Three warnings, which are not stylistic precautions.

"Screen dependence" does not exist as a diagnosis. Only one presentation is recognised, gaming disorder. For social media, video or the phone, there are neither consensus criteria nor solid instruments, and the prevalence figures in circulation are heavily inflated.

In adolescents even more than in adults, the screen is often the symptom of something else: an undiagnosed attention disorder, an anxious school refusal, bullying, a depression, a social anxiety, a delayed sleep phase — falling asleep and waking up shifted later — that is physiological at this age (section 3). Section 9, devoted to differential diagnosis, is for that reason the most important in the manual.

And you have to look for what is happening on those screens before looking at how long they are switched on. Bullying, dangerous content, grooming by adults, gambling, purchases. Section 10 is devoted to that screening, and it comes before everything else.

Reference models. An individual cognitive behavioural therapy articulated with family work. The data specific to adolescents are thin; the best concern family and multi-family interventions — several families brought together in a group — which justifies the space given to the six sessions with the parents. The individual protocol rests on the most rigorous of the controlled trials in the field, conducted in adults (Wölfling et al., 2019), complemented by motivational interviewing (Miller & Rollnick, 2013), which is used to work on ambivalence in session 4, by behavioural activation, which rebuilds off-screen activities in session 8, and by stimulus control, that is, modifying the environment that triggers the use (sessions 6 and P4).

Format. Fourteen individual sessions of 45 minutes with the adolescent, and six sessions with the parents, interleaved. About four months, plus two booster sessions. The family sessions are not an extra: in a minor, it is the parents who control the environment, and their omission is a major cause of failure.

Session	Focus	What the session produces
1	Welcome, alliance, confidentiality	What they say about it, in their own words
2	Safety, differential, real measurement	Screening done, record in hand
3	What it is for	Diagram made with them
4	What they want	Three goals of their own
5	Nights and rhythm	Times written down
6	The environment, device in hand	Five settings changed
7	What triggers it in them	Three states, one gesture each
8	Replacing, and being good at something	Two activities begun
9	School	Return or adjustment plan
10	Friends, online and outside	One real contact taken up
11	The sentences beforehand, and anger at the rules	Permissions tested
12	Boredom and attention	Two exercises kept up
13	Risky moments, and the slip	A plan for three of them
14	Stocktake, plan, what comes next	Summary sheet made by them

Parent session	Placement	Focus
P1	Before session 1	Assessment, information, frame, confidentiality
P2	After session 2	What the screening found, the decision to treat; rules or surveillance
P3	After session 4	The family plan: negotiated rules
P4	After session 6	The household environment, and the parents' screens
P5	After session 9	School, sleep, consistency between adults, conflict at home, what the activities need
P6	After session 13	Stocktake, family plan, what comes next

The "What the session produces" column shows what must exist by the end of each session. The terms in it that are specific to the programme — the diagram in session 3, the states and gestures in session 7, the permissions in session 11 — are explained in the session concerned.

What the adolescent takes away. Seven printable worksheets, listed in section 35 and downloadable from this page: my real use, what it does for me, what I want, my nights, what I do instead, what I tell myself, my plan.

What sets this programme apart from parental controls. The aim is not to obtain obedience to a quota of hours. An adolescent whose wifi has been cut off and who has gone back to lessons while lying about everything has not been treated. An adolescent who sleeps, goes to school, has taken up a sport again and plays three hours on a Saturday is doing well. That difference governs the whole treatment — and it is difficult to get parents to accept, which is the business of session P3.

2. Before you start

The prior question: what are we talking about?

It is settled in sessions 1 and 2, and it involves three decisions.

Is there a danger? Bullying, self-harm or suicide content, sexual solicitation by an adult, intimate images shared or extorted, gambling, substantial purchases. That comes before everything, and section 10 says how to look for it and what to do.

Is there another disorder in the foreground? That is the most frequent case. See section 9.

Is there any disorder at all? An adolescent who plays fifteen hours a week, who sleeps, who goes to school and who has friends does not have a disorder, whatever their parents' concern. It is a very common reason for consulting, and the right answer is to say so — and then to work on what is really worrying the parents, which is often something else. That is the purpose of the brief pathway described under session P2.

The frame, to be laid down before the first session

Two points specific to minors, and they must be settled at the outset.

Consent. Treating a minor requires the agreement of those with parental responsibility, and the adolescent's own buy-in is what decides the outcome. Those two things are not the same: you can have one without the other, and the second is built in session 4.

Confidentiality. It must be stated in front of the adolescent and in front of the parents, in the same terms, at the first meeting. A formulation that works, to be said in session 1 with the parents present: "what you tell me stays between us. I will tell your parents what we are doing, not what you say. There are two exceptions: if you are in danger, or if someone is hurting you — and in that case I will tell you before I talk about it."

Hold to it. An adolescent who suspects a full report will tell you nothing that matters — and what matters, at this age, is precisely what the parents do not know.

How to use it

Read the whole thing before session P1, and in particular sections 9 and 10: the differential and the safety screen. Those are the two places where the essential thing gets missed.

Every session is described on the same frame: the objective, a step-by-step run-through, what to say, the common mistakes, and the criterion for moving on.

One warning specific to this age. You are the third adult to talk to them about their screens, after their parents and their teacher, and they expect the same conversation. The first five minutes of session 1 decide everything that follows: if you begin with screen time, you have lost. Begin with them.

3. What is normal in adolescence

This section is as much for you as for what you will say to the parents in session P1. Many consultations are not disorders.

What is normal, and widespread

Heavy use. Several hours a day is the norm in this age group, not the exception. A high figure is not in itself a sign.

Screens as the main social place. That is where adolescents see each other, talk, fall out and make up. Taking the screen away from an adolescent without building anything is cutting them off from their social life. It has to be said to parents, because most think the opposite.

Team gaming with obligations. An adolescent committed to a group has appointments and responsibilities towards other people. That is not an excuse: it is a fact to be dealt with.

Late bedtimes. They are partly physiological: in adolescence the internal clock naturally shifts later, spontaneous sleep onset happens later, and the need for sleep stays high — eight to ten hours. An adolescent who does not fall asleep before midnight is not necessarily doing something wrong; their phase is delayed, and the screen worsens a shift that already existed. The practical consequence is important: do not put down to screens what belongs to development, and treat both.

Irritation at being interrupted. It is very widespread, and it is not in itself a withdrawal symptom.

The need for a space of their own, out of their parents' sight. That is a task of this age, and the screen stands in for it.

What should cause concern

Lastingly, and by comparison with what the adolescent used to do:

sleep collapsed, with nights of less than six hours on school days;

school: absences, dropping out, marks falling, refusing to go;

withdrawal from real friends and the stopping of all activity;

giving up sport, music, what they used to love;

meals skipped, hygiene neglected, weight changing;

major rages when interrupted, sometimes with violence towards objects or people;

organised lying about durations, and workarounds — a second device, at night;

reversed rhythm: in bed at five, up at three in the afternoon;

thoughts of death, or use that visibly serves to stop thinking.

What does not help parents, and what they have already heard

The alarming figures about screen time. The analogies with cocaine. The duration recommendations by age, which have no solid basis beyond childhood.

One useful piece of information to give them, because it soothes without denying: at population level, the link between screen time and adolescent wellbeing is very weak (Orben & Przybylski, 2019). That says nothing about their child, who is a case and not an average. But it allows the conversation to shift from the figure to what matters: does he sleep, does he go to school, has he got friends, does he still do anything?

4. The clinical picture

What the adolescent describes

Nothing, at first. They come under duress, they know it, and they expect a lecture. Their first sentence is often "I do not see the problem", and it should be received rather than corrected.

Asked without reproach, they describe three things. That they do not think it is that serious. That their parents are exaggerating. And — later, at the third or fourth session — that they cannot stop in the evening, that they are tired all the time, and that school has become impossible.

That gap between the first and fourth session is the rule. Do not build anything on what you hear at the first appointment.

What the parents describe

A daily conflict, rages, a child they no longer recognise, and a list of things tried: cutting off the wifi, confiscating, negotiating, threatening, taking the bedroom door off. Often a disagreement between them about what to do, which will have to be dealt with.

And frequently a broader worry they do not voice at first: they have lost contact with their child, and the screen is what they can name.

What keeps the use going at this age

Function, as in adults, but with answers specific to adolescence: being with mates, being good at something, escaping a humiliating day, not thinking, existing somewhere other than at home, not being alone in the evening.

Avoidance of a specific situation. This is the most important particular feature. In many of these adolescents, the heavy use dates from the moment something became unbearable: bullying, an academic failure, a change of school, a parental separation, a humiliation. The screen is then a refuge — what research describes as compensatory use (Kardefelt-Winther, 2014) — and taking it away without dealing with the situation is cruel and ineffective.

Delayed phase, made worse. Described in section 3, it keeps itself going in a circle: the adolescent goes to bed late, cannot manage to get up and misses their school day; that day with no obligations puts no constraint on their evening, and they go to bed later still.

The environment. The device stays in the bedroom, at night, with no limit. In a minor, that environment does not depend on them: it depends on the parents, and it is the business of session P4.

Family conflict. It becomes both consequence and cause: the reproaches increase the withdrawal, the withdrawal increases the reproaches, and the screen is the only place where the adolescent is not criticised. In adolescents who have gaming disorder, family conflict is more frequent and family relationships are poorer (Bonnaire & Phan, 2017).

The loss of everything else. Eventually they have no other competence, no other social place, no other activity — and they know it. That is what makes session 8 decisive.

Epidemiology, in two useful reference points

The prevalence of gaming disorder in adolescents is estimated at between under one and a few per cent, with wide variation by instrument and country. The highest estimates come from the least demanding questionnaires (Stevens et al., 2021).

For social media and phones, there is no usable prevalence, for want of a definition. Do not quote the figures in circulation.

5. The uses, and what they change

Identify the dominant use in session 2; it determines half the programme.

Video games

It is the only presentation that corresponds to a diagnosis, and the most frequent in boys. It has three particular features at this age.

Obligations to the team. They are real and they carry social weight. An adolescent who "drops" their group loses standing.

Gaming as the only place of competence. Decisive in an adolescent failing at school: it is the only place where they are good, recognised, and sometimes responsible for a group. Taking that away without building elsewhere is a net loss, and that is why session 8 comes before any significant reduction.

Purchases. Games with randomised rewards — paid "crates" or "chests" whose contents are drawn at random — affect minors, with sometimes considerable and often hidden amounts. Ask the question, and check the payment methods with the parents in session P2.

Social media and short video

More frequent in girls, and the mechanism is different: social comparison, waiting for a signal, fear of being excluded from what is happening. Short video adds a total absence of any stopping point.

These uses have three targets of their own: comparison, body image — to be assessed, along with eating behaviour — and the fear of missing what is happening, which organises the evenings (section 32).

Pornography

To be raised, without making it a scandal or a moral question. Three points.

Exposure is frequent and often early, including unintentionally. That does not in itself constitute a disorder.

What warrants work: compulsive use, discomfort the adolescent reports themselves, worry about their own sexuality, or representations of sexuality and of consent built solely from that source.

Do not take sides on pornography. And never talk about it to the parents without the adolescent's agreement, unless safety is at stake.

Messaging and group chats

It is underestimated. It is often the real night-time use: it is not the game keeping them awake, it is the class group chat that runs until two in the morning. And it is also where bullying happens.

Online gambling

To be screened for in every adolescent, despite the legal prohibition: sports betting, poker, loot boxes. See section 10.

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