When smartphones take over: a mixed methods study of phubbing in child and adolescent psychiatry

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Little is known about phubbing among child and adolescent psychiatrists (CAPs), a group often called upon to provide direction on how to guide children in their rapidly evolving cybernetic contexts. Methods We conducted a mixed methods study of trainees in CAP (n = 73; 68% women), recruited in the US (6 training programs; n = 35) and Türkiye (5 programs; n = 38). For the quantitative component, we administered two standardized tests: the Generic Scale of Phubbing (GSP), and the Generic Scale of Being Phubbed (GSBP). For the qualitative component, we conducted site-specific focus groups. After transcription, translation, and anonymization of the digitally recorded sessions, we analyzed the data using thematic analysis informed by interpretative phenomenology. Results Younger participants scored higher on the GSP (r = -0.43, 0.05). Through thematic analysis we arrived at a four-domain model: 1) Perceptions : regarding the role of smartphone use in modern society and their social implications); 2) Explanations : respondents’ conceptualization of antecedents to phubbing behaviors; 3) Consequences : specific outcomes, such as normalization or split attention; and 4) Recommendations : strategies to address phubbing and problematic phone use. Conclusions Phubbing is a ubiquitous behavior that can have social and emotional consequences. Through a more nuanced understanding of their own phubbing practices, CAPs can modify maladaptive behaviors of their own, have a more empathetic understanding of phubbing by youths under their care, and provide more realistic guidance regarding smartphone use to patients and their families. Phubbing digital health child and adolescent psychiatry qualitative methods INTRODUCTION Electronic devices and smartphones have become an essential part of modern life, serving multiple purposes in education, business, entertainment, and communication. The use of smartphones has specifically increased in recent years, with usage reaching approximately 70 percent of the global population by 2023. 1 This trend is pronounced among children and teenagers as well: 31% of 8-year-old children, 2 and 95% of teenagers in the United States have a smartphone. 3 Smartphones make life easier in many ways, but they can also cause various problems, including the potential impact on mental health among children and adolescents: problematic smartphone use has been linked to increased likelihood of anxiety, depression, and stress in children and adolescents. 4 These devices can also negatively affect sleep quality and duration in adolescents, impacting their performance and well-being during the day. 5 Further, they can have distracting effects and a negative impact on memory. 6 The impact of smartphones extends beyond mental health, changing the very nature of human interactions. This shift has introduced a new phenomenon into our lives: phubbing. Phubbing, derived from the words ph one and sn ubbing , can be defined as the behavior of interacting with one’s phone at the expense of ignored others around oneself. 7 There are few studies on the prevalence of phubbing, but a study conducted among young people aged 15–29 showed a prevalence of 49%. 8 Another study conducted in Spain among young people aged 12–21 found that 17% of participants reported phone distraction during social interactions. 9 Phubbing is common among young people, an Australian study has confirmed that young individuals exhibit the behavior more often than older people. 10 Research has shown that phubbing is especially directed toward people who are close, rather than more distant ones. 10 Phubbing can negatively affect the quality of communication: 11 its impact spans across friendships, 12 parent-child relationships, 13 work relationships, 14 and romantic partnerships. 15 Being phubbed by others might lead to lower relationship satisfaction, greater disappointment, 15 and depressive symptoms. 16 Antecedents to phubbing have also been studied and include: loneliness, fear of missing out (FoMO), boredom, and multitasking. 17 Additionally, a systematic meta-analytic review examined the predictors of phubbing behavior and showed a strong association between problematic smartphone use with phubbing, and a moderate association with psychopathology and being phubbed by others. 18 Considering the results of phubbing and its close relation with problematic smartphone use, this phenomenon is understandably of concern to parents, educators, health practitioners, and policymakers. And yet, research on phubbing struggles to keep pace with the uptake and evolution of the practice. 19 Despite recommendations from professional organizations about screen use in children and adolescents, specific guidelines for smartphone use remain inadequate, 20 , 21 leaving concerned individuals with limited access to reliable information. Child and adolescent psychiatrists (CAPs) are regularly confronted with needing to provide guidance regarding electronic device and smartphone use among youth. However, they often have to rely on limited empirical information. In an effort to address this gap, we conducted a study through which to better understand the phubbing behaviors of CAPs themselves – both in their professional and their personal capacities. To our knowledge, no study about phubbing in CAP has been published before; our study’s unique premise is that that phubbing is a near-universal phenomenon that involves not only others (such as patients) but ourselves as well. We posit that insights from looking at our own practices can inform how we provide guidance to those under our care. METHODS We conducted a mixed methods study to explore the perceptions of trainees in child and adolescent psychiatry (CAP) about their personal use (and misuse) of smartphones, and of their professional role providing guidance on smartphone use to their patients and their caregivers. Participants and ethics approval Through convenience and snowball sampling, we recruited CAP trainees (n = 73) from 11 programs and two countries: the US (n = 35; 6 programs) and Türkiye (n = 38; 5 programs). We conducted hour-long interviews with each program, using videoconferencing and digital recording with Zoom (San Jose, CA). Each session consisted of a focus group facilitated in English or Turkish and loosely following a previously designed interview guide of sensitizing questions ( Appendix 1 ). Focus groups had a median of 7 participants each (range, 2 – 10). In the last 5 minutes of the allotted hour, participants completed demographic and quantitative measures that they accessed on their phones by scanning a QR code linked securely to Qualtrics (Seattle, WA). We obtained institutional review approval from the Yale Human Investigations Committee (Protocol # 2000039371) and the Pamukkale University Non-Interventional Clinical Research Ethics Board (Protocol # E-60116787-020-643288) prior to starting data collection. The study was deemed of minimal risk and exempted from full review. Participants were provided with study information and informed consent documents in advance of their session, at the outset of which they provided verbal consent, which was recorded. Participants agreed to maintain confidentiality within the group, and were assured that all digital recordings would be destroyed as soon as they were transcribed and anonymized (usually within 24 hours). Moreover, we assured participants all their responses would remain confidential, and that neither their willingness to participate nor their specific responses would have any bearing on their training evaluations. Quantitative component All participants completed a demographic survey and 2 standardized instruments: Generic Scale of Phubbing (GSP): The scale measures phubbing behavior in social interactions. It is a 15-item scale using a 7-point Likert scale (1 = never to 7 = always). The scale includes four factors: problem acknowledgment (PA); self-isolation (SI); interpersonal conflict (IC); and nomophobia (the fear of detachment from one's mobile phone, NP). The total score is calculated as the average of all items. Higher scores reflect more frequent phubbing behavior. The GSP is highly reliable and has a Cronbach α of 0.93. 22 It has been adapted into Turkish. 23 Generic Scale of Being Phubbed (GSBP): The scale measures experiences of being phubbed in social interactions. It consists of 22 items using a 7-point Likert scale (1 = never to 7 = always). It includes 3 factors: interpersonal conflict (IC); feeling ignored (FI); and perceived norms (PN). The total score is obtained by averaging scores across all items. Higher scores indicate a greater experience of being phubbed. The GSBP is highly reliable and has a Cronbach α of 0.96. 22 It has been adapted into Turkish. 23 We first calculated scale and subscale scores for the GSP and GSBP. We then used linear regression to compare scores while accounting for the effects of country and participant age. We dichotomized age into two birth cohorts: Millennial [1981 – 1996] or Generation Z [1997 – 2012]. We performed statistical analyses with SPSS 25.0 (Armonk, NY). Qualitative component We used qualitative methods to learn about phubbing practices the participants’ lives. We opted for small focus groups rather than individual interviews in order to foster rich discussion. The questions that guided this part of the study centered both on the personal relationship between CAPs and their smartphones (e.g., at home, at work, during leisure time), as well as when in their professional roes (e.g., the guidance they provide about smartphone use to patients, families, caregivers, or stakeholders). We transcribed digital recordings in English or Turkish using DeepGram (San Francisco, CA). We translated Turkish transcripts by first using DeepL (Cologne, Germany), then ensuring accuracy through manual verification by a native speaker (AB). We next analyzed transcripts using thematic analysis (TA) 24 informed by descriptive phenomenology (DP), which foregrounds participants’ experiences to identify the structure that is the phenomenon, rather than its personal interpretation of the researcher. 25,26 TA provides theoretical freedom and flexibility to identify commonalities, and where writing and analyzing data can occur recursively alongside one another. Two authors worked independently to identify and compare codes before sharing them with the third investigators for triangulation, 27 further refinement, and finalization into a streamlined codebook and overarching domains, themes, and subthemes. Each key theme was supported by multiple quotes. In keeping with the tenets of participatory research, 28,29 we consider our subjects to be co-investigators, and invited all participants to review and comment on our final codes and conclusions. We followed an inductive approach in which research questions evolved beyond sensitizing questions to explore new or unanticipated themes. We analyzed transcripts iteratively until we reached theoretical sufficiency 30 and followed best practice guidelines for the analysis, drafting, and submission of qualitative studies. 31 Reflexivity and positionality statement TA includes a rich and detailed account of the data and welcomes attention to the investigators’ reflexivity, the ability to examine one’s own influence on the research process. 32 The four authors were keenly aware of their own instances of phubbing, of having been phubbed, and of the challenges in addressing phubbing-related behavioral change in themselves and others. They approached the subject matter as one germane to their everyday lives, rather than as something happening exclusively to others. This perspective, complemented by their ability to conduct focus groups in the participants’ native languages, allowed them to have an “empathic foothold” on the phenomena under study. The authors did not have a supervisory or evaluative role on the subjects they interviewed, thus minimizing biases of power dynamics or social desirability. RESULTS Quantitative Component The Turkish and American groups were comparable in gender composition (consisting of 76% and 60% women, respectively; 2 = 2.24, p = 0.13). Turkish participants were significantly younger than their American counterparts (29 ± 2 vs 34 ± 3 years old, respectively; t = 6.83, p <0.001); 18 of the 38 (47%) Turkish participants belonged to the younger Generation Z cohort, compared to none among the 35 American participants. GSP overall score was inversely correlated with age (r = -0.43, <0.001). There was a significant difference in GSP between the Gen Z and Millennial cohorts (61.4 ± 10.9 vs 52.7 ± 10.5; t = 17.54, p <0.001). An apparent difference in GSP between the Turkish and American groups (59.4 ± 11.2 vs 49.9 ± 8.8; t = 4.01, p <0.001) dissipated after adjusting for age, by conducting a one-way analysis of variance with GSP as dependent variable, country as independent variable, and age as covariate (F = 0.65, df = 1, 70, p = 0.42). GSBP overall scores did not differ between countries or across ages (p > 0.05). Table 1 summarizes total and subscale scores for GSP and GSBP for the overall sample of 72 (one participant did not complete the quantitative questionnaires). In response to the question “How many hours can you go during a typical day [excluding sleep] without engaging with your smartphone?”, participants averaged 3.6 ± 2.3 hours. INSERT TABLE 1 ABOUT HERE Qualitative Component Through thematic analysis, we arrived at a four-domain model through which to approach phubbing in child and adolescent mental health: 1) Perceptions; 2) Explanations; 3) Consequences; and 4) Solutions. We provide brief explanations of these domains and their underlying themes in Table 2 . In the sections that follow, we further explore each of the domains and themes. Consentient with our quantitative findings, we did not find notable differences between the US and Türkiye groups. Still, we go on to indicate attribution of specific quotes using the U or T suffix, respectively. INSERT TABLE 2 ABOUT HERE Domain 1. Perceptions: smartphones and technology in a social context This first domain concerns the connotations with which smartphone use and technology are perceived by members of society. Our respondents frequently discussed the use of smartphones for work, communication, searching on the Internet, leisure, and more — and at every conceivable waking hour of the day. Broadly, we found that these devices can be viewed as active dangers (negative connotations), neutral distractions , or legitimate tools (positive connotations). Because these ideas alter the lens through which phubbing is perceived, we first render explicit this underlying social construct in order to facilitate analysis ( Table 3 ). INSERT TABLE 3 ABOUT HERE Active danger Responses we obtained coalesced around three key subthemes: bullying , exposure to polarizing content or misinformation , and hindrance to social development . Participants were concerned with phones and similar devices opening a doorway to increased dangerous interactions online, with cyberbullying being especially relevant for children and adolescents. Similarly, discussions of the danger of exposure to polarizing content or misinformation often centered on the ways in which online content may introduce naive phone users to trends and communities which shift normative viewpoints towards more fringe perspectives: The echo chamber that happens in a lot of places like Reddit, for example, where you'll have views that aren't extreme in a lot of ways, and people that gravitate towards those views end up repeating the same and become more extreme in a way. (02U) Other concerns included children and adolescents’ potential encounters with age-inappropriate content online and how such encounters may interfere with the usual sequence of social development: I've seen that they become more introverted and develop more social anxiety symptoms. I also think that because they can easily access everything, they encounter sexuality too early, and dark things such as drugs, substances, alcohol (04T) Distraction Phones were regarded in a slightly more neutral manner when discussed as mere distractions, providing little or no value to the user, but at least not functioning as an actively harmful exposure. Most commonly, this perception of phones arose in the context of educational settings or didactics: Sometimes training hours become like a time slot specially crafted for looking at phones. Yes: disengaging training hours may be one of the times we do it most. (10T) Legitimate Tool The previously described associations were occasionally contrasted with specific instances where phone use was considered legitimate and justified. For instance, the purposeful use of phones for research and work to augment productivity and learning was generally regarded positively: I think of an attending telling us the story about how he used to ban cell phones from...rounds and everything, and then people would get yelled at for it. And then he came to realize that what was happening is people are actually, in real time, are looking up medication facts to share. (01U) The judicious use of phones for patient connection was usually regarded similarly. Several CAP fellows recounted utilizing a young patient’s phone as a window through which to gather clinically relevant information about their interests, personality, habits, or online social networks. This connection-promoting capacity of smartphones extended to the participants’ personal lives, helping them maintain connections to community and family when in-person interaction may not be feasible: I also have family that's all over the country, you know, old ones, young ones, and people that are still looking to me to take care of them even though my husband and I are far away. (01U) Lastly, phones were also described as promoters of personal health in their own right, often via the monitoring of health data that can be illuminating for patients and clinicians alike: I've also started having them use a lot of the mood tracking apps, to help them build insight into their moods and states, and then we can look at it together. (02U) Domain 2. Explanations: antecedents to phubbing A second domain characterizes antecedents to phubbing by dissecting the reported thought patterns, emotions, and justifications behind participants’ phubbing of others, or how to react when phubbed by others. We found that many of these factors promoted phubbing, yet some effectively dissuaded respondents. By examining these antecedents, we may generate further ideas for sustainable interventions to modulate young patients’ phone use. Our analysis led to four common themes, which we term person-centered , principle-centered , emotion-centered , and economic or utilitarian frameworks . ( Table 4 ). INSERT TABLE 4 ABOUT HERE Person-centered framework The crux of the person-centered framework hinges on how respondents conceptualize the responsibility of managing their phone use: whether proactively and in control of their habits, or reactively, in response to external factors. Those who endorsed an internal locus of control often appeared comfortable triaging concurrent demands on their attention and exhibited a sense of self-awareness of potential distractors: I like to put my phone on do not disturb a lot because I'm just like, I don't really need like, nothing is really usually that urgent. (05U) In contrast, those who endorsed an external locus of control more readily disavowed agency for controlling their phone use, instead attributing the blame to something other than their intentional selves: It's like a habit, not because I'm uncomfortable with what's being talked about or not very interested, but in that empty moment, suddenly my hand goes to it. (07T) At times, when feeling pulled to their devices, setting external barriers could prove the only plausible way to desist: turning the device off, giving it away for temporary safekeeping, letting its battery run out, or most commonly, relegating it to another physical space. I put my phone in another room from where I'm at. (02U) Principle-centered framework Other times, respondents cited first principles such as ethics, respect, or empathy when presented with a dilemma involving phubbing and phone use. This top-down pattern of thinking assumed the necessity of a particular end goal (e.g., ethical responsibility to patients), and worked backwards to consider whether actions such as using one’s phone were precluded or permissible. For instance, a striking finding among the focus group responses was that CAP fellows almost never phubbed a patient: It would be rude if I did it in front of my professor. You know, they might get angry. Doing it in front of a patient could be one of the worst things possible. It would probably directly damage the therapeutic relationship. (07T) Compared to ethics, respect for authority was less universally espoused among respondents, but just as strongly adhered to among those who did. Frequently, this sense of respect was in deference to attending physicians or professors in the clinical/academic environment and parents or elders in personal life. They're imparting knowledge to us, dedicating their time to us. I mean, if we look at the phone during that time, I think we all feel we're being disrespectful, and we think it might be perceived as if we're not listening. (08T) With regards to considerations of empathy between phubbers and phubbees, perceived similarities fostered a sense of forgiveness and mutual understanding: No. I haven't done anything outright to point them out or anything. You know? I'm not trying to be like a micromanager and because I do the same, I'm guilty of the same thing. (05U) On the other hand, perceived dissimilarities in stature often led to the dissuasion of phubbing: If the same was done to me, I would be very seriously disturbed and probably wouldn't make an appointment at the same place again, or if it was a consultation, I would probably say I want to see another doctor. (07T) I feel like there's much less generous interpretations of phone use by older folks because I feel like their assumption is always that you are up to no good (06U) Emotion-centered framework Yet another pattern of thinking about phubbing revolved around the inciting emotions (e.g. FoMO , social anxiety , boredom , and escapism ) which inclined respondents to phub others. For example, some CAP fellows endorsed a strong drive to be maximally updated on current events or trends, prompting increased device use and phubbing: Am I missing something that's happening? What happened in the country today? I feel like I need to check in. (08T) This worry about not knowing presented itself in clinical contexts as well: That messaging center thing that we have is still on. So, when that dings you are like, oh, what happened there? You know? Was there a crisis that happened? (01U) Social anxiety and boredom each functioned similarly, inclining respondents toward phubbing. Still others reported feeling the occasional need to retreat to technology as a type of withdrawal defense: When I'm in an environment or talking to someone, if I don't want to be fully present there and want to escape from that environment, I worry about how I'll escape if my phone isn't with me. (09T) Young patients can also exhibit similar behaviors, especially in the clinical environment when in-person interaction with a psychiatrist may present as a situation outside of their comfort zone: it may take gentle limit setting to make the therapeutic space a phub-free zone. Phubbing during therapy (a not unheard of occurrence) could be taken as an invitation to discuss not just what is being avoided in the therapy, but what is being sought in the ether. Economic/Utilitarian framework This final framework, more pragmatic than the others, arises when one consciously makes comparisons of value, estimations of risks, and evaluations of what may be gained or lost by deciding to phub in a particular moment. Consistent with the concept of attention economy, CAP fellows occasionally analogize attention to currency — they are astutely cognizant of its limited quantity and the increasing array of concurrent attention demands from clinical notifications, personal communications, and more: Both tasks are important, but since stronger stimuli come from the phone, I devote all my attention there and my selective attention is blocked. (04T) Still others explicitly verbalized how they weigh the risks of phubbing against perceived benefits: If I'm in a lecture and I don't think it's as important as some work I need to get done, I will go on my phone. (01U) Domain 3. Consequences: outcomes of phubbing Our third domain explores the outcomes of phubbing behavior, ranging from the reflexive impacts on the phubber to broader societal impacts. Whether as participant, observer, or victim, many respondents reported firsthand experience with the consequences of phubbing. These shared experiences contribute to the reproduction of altered social norms of in-person interaction among many of our respondents and their young patients. We categorize these outcomes into several themes of feelings , attention span and multi-tasking , socialization , and clinical consequences ( Table 5 ). INSERT TABLE 5 ABOUT HERE Feelings The phubber and phubbee may perceive the act through different social and emotional lenses, resulting in distinct impacts on each party. To phubbers, device use in the moment may bring a sense of utility and joy: In my social life, I feel as if the communication I have on the phone makes me even happier at times than verbal communication...I feel as if I am getting a reward when the message notification sounds. (04T) Conversely, being phubbed is often described in a strongly negative light: I don't want to keep talking badly about my home life, but that's where phubbing usually happens. And I think that's where I feel undervalued and almost lonely...it's you and me in this house, and, obviously, there's something more important going on for you...than me existing here. (01U) Attention span and multitasking Often reporting from personal experience, CAP fellows also recognized deleterious effects on attention span as another major consequence of phone use trends: A person might look at their phone unconsciously too. Actually, independent from whether they like the topic or not, it's happening. Maybe interest and engagement exist, but attention spans have momentarily shortened - I mean, they seem to have shortened for many of us. (11T) Correspondingly, it is no surprise that respondents are observing an increased propensity to multi-task, including across more than one technological device: He's a 13 year old boy with ADHD...and he's playing the game. And then over here, he's watching some other kid playing a video game. Meanwhile, the kid playing the video game is listening to music. (02U) Socialization Some focus group participants described a concern as child psychiatrists about maladaptive replacement of in-person socialization with device use. In some cases, using technological devices in parallel can becomes a social act of sorts, an approximation: I think that younger age groups play e-games together, for example sometimes while waiting in corridors all children are looking at their phones, they don't communicate, they don't actually play together. (10T) Fellows themselves also report experiencing technology use in this manner and perceiving these behaviors as normalized, a new kind of parallel play: My husband and I find us doing that...I've got my laptop on my lap, and I'm playing video games on the PlayStation. And then I find he's doing the same thing on his big screen that's right next to him. And then I'll look over and we're both on our phones with these other two activities. (01U) Clinical consequences The most pertinent consequences of phubbing and maladaptive phone use to child and adolescent psychiatry are the implications for the clinical care of patients. Our participants observed firsthand how phubbing in the clinical environment can be dangerous, including directly interfering with emergent psychiatric care: I actually had a patient yesterday...he's sitting in this psych pod in the ER, on Instagram. And, while we were interviewing him, and multiple redirections to get his attention...to the point of having to be really stern. Because he had his mom's phone. Obviously, he's not allowed to have phones and stuff in the ED, but he's about maybe 12...there was obviously something on Instagram that was far more interesting. How do we compete? (12U) Still, CAP fellows generally have ideas about next steps that would better prepare them to tackle this issue. Some are aware of reputable published guidelines about children’s phone use, but others seek more support and resources about how to effectively address these concerns in their clinics. Nonetheless, ongoing challenges complicate the feasibility of developing, disseminating, and executing the needed guidelines. Many fellows admit their own shortcomings with controlling their own phone use habits, and reasonably exhibit skepticism about children’s adherence to any such guidelines: If we can't regulate ourselves as adults, we can't expect the little ones that we're seeing to regulate themselves. (01U) Others worry about the ability of overwhelmed parents to effectively enforce phone use limitations, and still others worry that the opportunity for psychiatric intervention presents itself at a later age than would be optimal to prevent the initial crystallization of maladaptive phone use habits. Domain 4. Recommendations: strategies to address phubbing Despite the aforementioned challenges, CAP fellows were able to offer various recommendations based upon their personal lives and clinical experience managing young patients’ phone use. We have divided these insights into incremental and categorical strategies ( Table 6 ). INSERT TABLE 6 ABOUT HERE Incremental strategies to address phubbing These strategies aim to modulate the overall quantity of time during which children and adolescents are permitted to engage with technological devices. For instance, some fellows stated that on occasion, advocating for total “detox” from the phone and altogether removing the maladaptive stimulus could be a necessary step: Maybe because of safety concerns and whatever else may be going on we do detox...we recommend monitored time, but at times we need to take the phones away, especially if it's becoming a safety concern, and see how they do. (01U) Others disagreed, preferring to promote a more gradual tapering strategy instead: Some parents I've seen do pretty draconian things, like no phone for Google or, tracking apps on their kids' phones. I agree that we can try to curb excessive use. And depending on your bedtime, we need to go to bed. But cutting off all private accesses, that will just backfire tremendously. (02U) Participants also emphasized the need to support children and adolescents in pursuing non-digital activities to prevent backsliding into ingrained phone use habits, delay the age of their introduction to personal devices and online platforms, and carve out specific hours when phone use is forbidden with the hopes of modelling improved compartmentalization and time management skills. Categorical strategies to address phubbing Complementary to the incremental strategies are qualitative approaches that seek to adjust how children and adolescents engage with technological devices. These categorical strategies include device limitations , active parenting and monitoring , and increasing buy-in from children, adolescents, and families . Providing adolescents with an inherently limited device capable of basic functionality but with fewer opportunities for distraction or unanticipated use, such as an older-style flip phone or wearable smartwatch, was occasionally suggested by the respondents. While potentially time consuming, parents could also reinforce more adaptive habits by actively engaging with opportunities to monitor children and adolescents’ technology use. One easy key action item was for parents to invest the time in fully acquainting themselves with the capabilities of the devices they intend to let their children use, and especially any ready-to-use parental safeguards: I'm always surprised by how underutilized the parental controls are on phones. Parents don't even seem to know about them or how to use them. Because I know, at least on iPhones, which I feel like a lot of kids have iPhones, they have pretty robust time controls. (05U) A sense of investment from the entire family is needed to extend the benefits of psychiatric intervention beyond the short clinic visits. A maximally effective strategy should also move children and adolescents to begin practicing self-management techniques and encourage them to request parental or clinician help as needed. In one respondent’s words: Parents can block these things, but they will outsmart their parents and then figure it out. So I think instead of just blocking, having conversations, more than once. And then ask them, the teenagers...What would be the best way?...And then come up with realistic solutions, together. (01U) DISCUSSION At a time when reliance on phone connectivity is ubiquitous, and when children and adolescents have access to smartphones at ever younger ages, phubbing has become a public health and policy concern. All of our participants acknowledged phubbing and being phubbed as routine occurrences in their daily lives. However, the self-reported average of almost four hours that participants claimed to be able to go without using their smartphone is a likely underestimate, whether due to underreporting, social desirability, or unrealistic perceptions. For example, current estimates suggest that cell phone users look at their phones an average of 144 times a day, 33 and underestimates of personal use can vary as much as 40% different from objective measures. 34 The fact that nomophobia (the fear of detachment from one’s phone) was the highest-rated subscale on the GSP further supports just how reliant participants were on their phones, even if not fully aware of the automatic reliance on their devices. Cultural factors may impact phubbing and related perceptions. For example, in a large study (n = 14,700) in which participants rated vignettes related to the behavior, members from “collectivist” countries scored higher on phubbing scales than “individualist” ones. Moreover, “attribution locus” differed notably, with “individuals from collectivist backgrounds more susceptible to perceiving being phubbed as exclusionary and attributing the cause more internally, to themselves.” 35 By contrast, we found no significant differences between our American and Turkish participants. Although this may have to do with our modest sample size and lack of power, it is notable just how similar our findings were across the two countries, suggesting the global nature of phubbing. Even as we found no differences across country, age-related differences were significant. Younger participants (Generation Z) had higher phubbing scores when compared to older ones (Millennials). This finding is consistent with a small decrease in phubbing behavior with age based on a meta-analytic review of 79 studies. 18 Collectively, these findings suggest that age should be strongly incorporated into efforts to address phubbing. For example, with smartphone engagement and practices likely to differ significantly across age and birth cohort, approaches need to be tailored accordingly, particularly against a backdrop of exponential changes in smartphone technologies. Phubbing has been aptly conceptualized as “a social practice that signals relational disengagement”. 36 It can lead to disruptions in normal social interactions, to fragmented attention, and to replacement or loss of healthier activities. In the clinical environment, smartphone use and phubbing can create funneling of attention and distraction, 37 and supervisors' phubbing behavior can be mirrored by those under their guidance. 38 Because such risks can aggregate over time and result in ingrained behavioral patterns, early intervention and prevention can be critical. Despite the risks involved, smartphones are not inherently negative devices; like any tool, they can be put to the use of who wields them. Smartphones have an important role in prosocial activities, such as fostering connection between adolescents unable to drive or living at a distance from one another. In our effort to reach a more balanced utilization of these devices, we should not rush to draconian, all-or-nothing approaches. Even in the privacy of the consulting room, smartphones can be useful and legitimate tools: viewing a screen together; identifying favorite music, videos, and trends; even texting one another during a session are strategies that can prove helpful in breaking the ice, connecting, fostering rapport – in “getting it.” Heightened self-awareness to the antecedents and consequences of phubbing can help adults take a more understanding and empathetic stance when considering how to deal with the same behavior in their children or patients. We need to find ways for ourselves and for those under our care to better adapt to electronic realities of our times that are here to stay, and to more effectively balance personal and professional/educational smartphone use, cognizant that smartphones can negatively impact work/school-life conflicts. 39 A self-reflective inventory of personal phubbing, along the themes we identified, can inform our guidance regarding electronic technologies for youth under our clinical care. Recognizing emotions such as boredom proneness, loneliness, or FoMO as antecedents, 40 or normalization or splintered attention as consequences of phubbing, can help us better understand both ourselves and our patients. It can also help become more realistic in implementing recommendations to children, adolescents, and their families. All participants expressed the need to have better guidelines to help patients and families navigate the tricky shoals of smartphone and electronic device use. Most of them had some familiarity with one or two such guidelines, but no one felt truly confident incorporating them into practice. The most widely cited report, from the US Surgeon General, 41 provides a valuable framework for appropriate social media use, with recommendations specifically tailored to policy makers, technology companies, parents and caregivers, children and adolescents, and researchers. Most proximal to the clinical domain, parents can establish tech-free zones at home to foster better in-person relationships; they can teach and model responsible online behavior; or they can report problematic content and activity. In turn, children and adolescents can limit time on platforms, block unwanted content, be careful about sharing personal information, and reach out if they need help or see harassment or abuse on the platforms. Another widely cited report from the UK’s College of Psychiatrists provides complementary guidance, including making sure that technology use becomes a core part of clinical assessment and formulation, given that “the online world can be just as important to young people as their offline world.” 20 Helpful as these recommendations are, they were not considered granular or realistic enough. In his trade book The Age of Anxiety , 42 Jonathan Haidt puts forth the premise that as a society we overprotect children in the real world, while we under-protect them in the virtual world – that we have failed to see and address the risks of social media on healthy development. His recommendations are clear, though perhaps aspirational at this juncture: phone-free schools; no smartphones before high school; only basic phones before roughly age 14 (with limited apps and no internet browser); and no social media before 16. He advocates for an embodied here and now, given that “in our lives with smartphones, we are forever elsewhere,” and that smartphones and other digital devices are “experience blockers” that reduce interest in non-screen-based forms of experience. Finally, Haidt makes the important point that we should not assume that disadvantaged children or those from minoritized groups have less access to the internet: they just have less protection from it. For example, families with more limited resources or lower “parental literacy” may resort to “electronic babysitting” to fill up a void or to ease challenging parent-child interactions. Clinicians approaching phubbing and other “e-behaviors” in their young patients may have to straddle the roles of trusted therapist, guideline arbiter, and parental ally. This is no easy feat, nor one for which there is a direct formula. Two final concepts may prove helpful. First, phubbing and related behaviors have a goal to connect (to someone, to something), not just to avoid and disconnect. In some sense, they represent transitional objects or behaviors that are quite similar to or own – how many of us have not felt the “phantom” buzzing of our smartphone? How long can we go without checking our device of choice? Second, the age difference between clinicians and their patients in CAP creates a de facto generation gap between them. This is a reality magnified by technology and its rapid advances. It is up to us to turn this potential occupational hazard into a clinical opportunity. Limitations We acknowledge three main limitations, which could inform next steps: 1) Even though our sample was more than sufficient for a qualitative study, 43 it did not provide sufficient power for the quantitative component. Thus, for example, the lack of difference between the US and Türkiye may represent a Type II error; 2) We did not have an objective measure of smartphone use, which would have provided precision and a standard against which to compare self-reports; 44 and 3) We did not include the perspectives of children, parents, or stakeholders to complement those of our CAP fellow participants. Conclusion Smartphone use increased during and after the COVID-19 pandemic, 45 a time in which the need for virtual connection and timely guidance accelerated reliance on and frequent use of these devices. In the wake of the pandemic, some of the benefits of the technology have diminished, making phubbing and problematic electronics use more conspicuous. As we settle back into a “post-pandemic normal,” and as we continue to be inundated with ever faster and more addictive technologies, we will continue to be sought to provide clinical guidance. In order to face the daunting challenge, we will do well by looking into our own electronic reliance and fragile social interactions. Declarations Acknowledgements For their participation and comments, we thank the trainees and directors from the following programs in the US (University of Kansas at Wichita, Rush, University of Illinois at Chicago, Oregon Health Sciences, Boston Children’s Hospital, and the Yale Child Study Center), and in Türkiye (Izmir City Hospital, Ankara Etlik City Hospital, Afyonkarahisar Health Sciences University, Aydin Adnan M. University, and Pamukkale University). Support Supported by the Riva Ariella Ritvo Endowment at the Yale Child Study Center. AB was supported by the TÜBİTAK 2219-International Postdoctoral Research Fellowship at Yale University. Research reported in this publication was supported by the Yale School of Medicine Fellowship for Medical Student Research to BL. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Yale School of Medicine Fellowship for Medical Student Research. Disclosures The authors have no disclosures to report. Prepared for submission to Child and Adolescent Psychiatry and Mental Health HUMAN ETHICS APPORVAL AND CONSENT TO PARTICIPATE This study was approved by the Yale Human Investigations Committee (Protocol # 2000039371) and the Pamukkale University Non-Interventional Clinical Research Ethics Board (Protocol # E-60116787-020-643288). FUNDING DECLARATION Supported by the Riva Ariella Ritvo Endowment at the Yale Child Study Center. AB was supported by the TÜBİTAK 2219-International Postdoctoral Research Fellowship at Yale University. Research reported in this publication was supported by the Yale School of Medicine Fellowship for Medical Student Research to BL. 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Informatics . 2022;9(4). doi:10.3390/informatics9040098 Tables TABLE 1 GSP, GSBP, and factor scores n = 72 Mean SD GSP total 54.8 11.2 Factors NP = Nomophobia (fear of detachment from one's mobile phone) 17.8 4.7 PA = Problem Acknowledgement 13.2 3.2 SI = Self-isolation 13.0 4.3 IC = Interpersonal Conflict 10.8 4.2 GSBP total 83.2 14.6 Factors PN = Perceived Norms 40.5 7.3 FI = Feeling Ignored 28.1 6.1 IC = Interpersonal Conflict 14.6 5.7 Note: GSP = General Scale of Phubbing; GSBP = General Scale of Being Phubbed. TABLE 2 Phubbing framework: domains, themes, and definitions Domain Theme Definition Perceptions Roles of smartphone use in modern society and their social implications Active danger Negative effects associated with smartphone use (e.g. bullying, echo chambers) Distraction Neutral effects associated with smartphone use Legitimate tool Positive effects associated with smartphone use (e.g. research, community) Explanations Respondents’ conceptualizations of antecedents to phubbing behaviors Person-centered The perception of phubbing behaviors as internally or externally manageable Principle-centered How higher-order concepts (e.g. ethics, empathy) affect phubbing Emotion-centered How specific emotions (FoMO, anxiety, boredom, etc.) affect phubbing Economic/ Utilitarian How perceived utility and risk/benefit analyses influence phubbing decisions Consequences Specific outcomes of phubbing behavior (e.g. normalization, split attention) Feelings Emotional effects of phubbing on phubbers and phubbees Attention span and multitasking Effects on attention span and split attention Socialization Further social effects following the rise of phubbing (e.g. normalization) Clinical Effects of phubbing in the clinical environment Recommendations Strategies to address phubbing and phone use trends as suggested by CAP fellows Incremental Quantitative strategies to reduce exposure of children and adolescents to devices Categorical Qualitative strategies to adjust how children and adolescents are exposed to and use devices TABLE 3 Domain 1. Perceptions: smartphones and technology in a social context Theme Subtheme Representative quotation Active danger Bullying A lot of the chief complaints have to do with bullying and problems that happened on their phone, whether it's social media or text, or whatever platform between their friend groups. (01U) Exposure to polarizing content or misinformation It can be very dangerous, skewing their worldviews in certain ways. (06U) Hindrance to social development It's very much related to regression in young children...For primary school children, it's usually related to a decline in academic success, but for adolescents, it can lead to risky behaviors like alcohol, substance use, or abusive relationships. (07T) Distraction I might miss something that's said, or when I'm saying something to the other person, they might miss it. It creates more problems in the work environment, not so much in the friend environment (07T) Legitimate tool Research and work It will aid in the discussion, that we're having an informed debate about something (12U) The phubbing will at times contribute to this patient's care; it is happening in real time; it can enrich the conversation and imbue it with facts. (01U) Patient connection I think it's complicated because, in therapy, you have to do work and you don't let someone on your phone, but, also, my kids want to show me things. And it helps move them on to the next topic without looking at it so closely. And so, I allow it to a certain point: helpful for rapport and for feeling heard. (06U) Connection to community In the course of two or three hours, my husband is at work trying to get a hold of me. My parents are somewhere else in the country. They need to connect with me. (01U) Personal health Because I have diabetes, I use a sensor. I need to constantly open and check the sensor. So, I don't have the luxury of staying away from the phone. It's always in my pocket or by my bedside when I'm sleeping. It beeps when it falls, so I need to hear it. (07T) TABLE 4 Domain 2. Explanations: antecedents to phubbing Theme Subtheme Representative quotation Person-centered Internal locus of control I turn off notifications for a lot of things. So that it's not popping up other than maybe for work stuff; for everything else, notifications are turned off. (12U) External locus of control I started messaging someone else when my fiancé and I were out for a thing and I’m like, man, I go to stop being on my phone, and then, thankfully, it died . (01U) Principle-centered Responsibility to patients It wouldn't be appropriate if the patient makes an appointment and comes to see us. It's time we've allocated for them. Looking at the phone then, rather than looking at the patient, it just wouldn't be right. (10T) Respect for authority I would definitely phub my very close friends, my brother, my wife, my parents. But I'm more careful around people I respect and communicate with, like fellows or professors. (04T) Empathy I get annoyed when other people do it, so I think I have a fairly conscious effort in terms of not doing it. But if I do end up doing it, I like to think I catch myself. (03U) Emotion-centered FoMO We have a system on our phone from work... If we get a message from there, you are prompted to look at it because something could be happening. Has something happened to my patient? You know, you cannot always ignore it. (01U) Social anxiety When I feel socially anxious, I give myself to my phone, I retreat. (04T) Boredom There isn't just one trigger. In many cases, it can be simple boredom. Especially in a crowded environment, and when the topic being discussed might not interest me. (07T) Escapism If I don't want to talk at that moment, turning to my phone is an avoidant behavior (10T) Economic / Utilitarian Attention economy I think there's also a slight competitive drive to it, in the sense that, like, I know these companies are trying to win my attention, and so trying to defeat them a little bit on their turf, on their wily ways, becomes a bit of a game for me. (05U) Risk/benefit calculations If I've decided that if a lecture, for example, is not engaging or high yield, I am more likely to tune out and may resort to my phone. If the speaker is engaging or is giving high yield information, I'm unlikely to do so because that might offend them. (06U) TABLE 5 Domain 3. Consequences: outcomes of phubbing Theme Subtheme Representative quotation Feelings If I'm on my phone and somebody calls attention to it, I'm not angry, but I feel called out, and then I feel embarrassed or guilty, and it comes out as, defensiveness, even when it's my husband. (01U) I think it makes the other person feel worthless. It inevitably made the other person feel that. (04T) Attention span and multitasking TikTok can be such a time suck. It's just constant scrolling for new information, and it really has affected people's attention span and the need for a quick dopamine hit. (05U) TV and my phone. That's what I'm doing. Can't watch a show anymore without having another screen to scroll through. (02U) I've got literally 10 tabs open right now. I usually have a split screen with whatever it is I'm doing, on video and also whatever else I want to work on, and then I also have my phone. (06U) Socialization Everyone is scrolling on Instagram and having this half presence with everyone else around them. (03U) We lie on separate couches at home, despite being so close togehter, we're just sharing Instagram Reels with each other. (11T) Clinical consequences Effect of phubbing on clinical care I have a ton of adolescent patients...but some walk into my office and their parent hands them the phone, and then I can only talk to the parent...I've had parents try to take work calls during appointments as their kid is telling them about things like trauma. (01U) Hope for resources and guidelines I think I want to look into resources that can help parents with that; structured ways, basically behavioral interventions, that we do to promote phone hygiene. (01U) Role modeling I'm telling the kid, hey, could you put your phone away? But I'm also trying for the parent to do the same. And if the parent doesn't listen, the patient's not going to listen. (12U) I'm saying, ‘you should not be on your phone in bed,’ but know that I do it all the time. (03U) TABLE 6 Domain 4. Recommendations: strategies to address phubbing Theme Subtheme Representative quotation Incremental strategies Detox or tapering I've been sober from Instagram for fifteen months now. (06U) If they're looking at the screen for very long periods, we say they can reduce it gradually, that they can't zero it out all at once (08T) Replacement activities We say it needs to be filled with things like sports, courses, or hobbies, making social connections. Otherwise, they'll cling to the phone again, or there will definitely be tantrums, they'll demand it. (08T) I'm seeing that in some of my patients they are purposefully disconnecting from their phones now, and they're taking up things like cross stitch or painting, and they're doing word searches, you know, in their free time or, getting back into reading (01U) Delayed age of introduction to technology I think the AAP's recommendation is wait till eighth. So, typically, parents should wait until their child is in the eighth grade, so, like, 12, 13. And I'll make that suggestion. (06U) Sanctuary hours I personally don't, use the phone from six to 08:30 every day because that's my kids' special time, and I'm focused on the kids. From 08:30 to 09:30, yes, I'm on my phone, and it goes to the silent from 09:30 onwards. (01U) Categorical strategies Device limitations Then what about a flip phone? And, like, I don't know if they're going do it or not, but the kid was not happy when I suggested that. (03U) Active parenting and monitoring So sometimes I have to, like, remind the parent that they're the parent too. So they may have to do so things differently. It's even hard for the adults to control this. (03U) You can't completely shut it off, they'll be exposed to it from friends in their environment too, but at least let the screens you give be ones where you can control the content, know what they're watching. (09T) Increasing buy-in from children, adolescents, and families I think there's a really good conversation that we can have with teens and adolescents from a motivational interviewing perspective and really helping them understand that the same way that we talk about substance use or smoking cigarettes back in the day; how these corporations spend a lot of money trying to force you to do this and you have to be individual and be free. (01U) I ask them to fill out a diary a bit more like to have the child track their screen times, to help them understand the magnitude of the problem at first. (10T) Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6797579","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466969103,"identity":"4dc2f96f-aefe-456e-8209-1698b7382145","order_by":0,"name":"Ahmet Büber","email":"","orcid":"","institution":"Pamukkale University","correspondingAuthor":false,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"Büber","suffix":""},{"id":466969105,"identity":"4e275b38-ffda-49c8-80aa-8522afad4338","order_by":1,"name":"Brian Lu","email":"","orcid":"","institution":"Yale School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Lu","suffix":""},{"id":466969107,"identity":"4336d5ec-0dc1-456f-85ff-9e1dc6ea4b8f","order_by":2,"name":"Bürge Kabukçu","email":"","orcid":"","institution":"Pamukkale University","correspondingAuthor":false,"prefix":"","firstName":"Bürge","middleName":"","lastName":"Kabukçu","suffix":""},{"id":466969109,"identity":"910fdf6f-d35a-4708-9cef-33250744a9fc","order_by":3,"name":"Andrés Martin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYHACAzjrAEMFAwMfiMVDnBZmoJYzDAxsJGlhYGwjQgv/7OZtHz78YYjmn33+4OHCeYfl2dgbGB+8bcOtReLOseKZM9sYcmecS2Y4PHPbYcM2ngPMhnPxaGG4kWPMzNvAkNtwhpnhMO+2w4xtEgls0rx4tMiDtPz5w5A7H6xlzmH7NvkH7L/xaTEAaQF6OXcDWEvD4cQ2CQY2ZnxaDG+kFTP2tknkbjzDbHCY51h6chtPYrPknHO4tcjdSN7M8OOPTe68M4yPP/PUWNv2sx8++OFNGR7vQ4AEjNEMxIwNBNUjgzqSVI+CUTAKRsHIAACiPlBDEtywzAAAAABJRU5ErkJggg==","orcid":"","institution":"Child Study Center, Yale School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Andrés","middleName":"","lastName":"Martin","suffix":""}],"badges":[],"createdAt":"2025-06-01 20:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6797579/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6797579/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13034-025-00950-0","type":"published","date":"2025-08-22T15:56:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89847226,"identity":"5cacce8e-46fd-4bd2-8601-d536e8f6e7a8","added_by":"auto","created_at":"2025-08-25 16:42:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1242414,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6797579/v1/caa8b836-e8ac-4032-9d1c-6d2bb8a2c3b6.pdf"},{"id":84085588,"identity":"33039570-81b0-466e-a7cd-706c4b07e84e","added_by":"auto","created_at":"2025-06-06 14:55:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20183,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6797579/v1/d3336395e98b8a9bc9b08de2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"When smartphones take over: a mixed methods study of phubbing in child and adolescent psychiatry","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eElectronic devices and smartphones have become an essential part of modern life, serving multiple purposes in education, business, entertainment, and communication. The use of smartphones has specifically increased in recent years, with usage reaching approximately 70 percent of the global population by 2023.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e This trend is pronounced among children and teenagers as well: 31% of 8-year-old children,\u003csup\u003e2\u003c/sup\u003e and 95% of teenagers in the United States have a smartphone.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Smartphones make life easier in many ways, but they can also cause various problems, including the potential impact on mental health among children and adolescents: problematic smartphone use has been linked to increased likelihood of anxiety, depression, and stress in children and adolescents.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e These devices can also negatively affect sleep quality and duration in adolescents, impacting their performance and well-being during the day.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Further, they can have distracting effects and a negative impact on memory.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe impact of smartphones extends beyond mental health, changing the very nature of human interactions. This shift has introduced a new phenomenon into our lives: \u003cem\u003ephubbing.\u003c/em\u003e Phubbing, derived from the words \u003cem\u003eph\u003c/em\u003eone and sn\u003cem\u003eubbing\u003c/em\u003e, can be defined as the behavior of interacting with one\u0026rsquo;s phone at the expense of ignored others around oneself.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e There are few studies on the prevalence of phubbing, but a study conducted among young people aged 15\u0026ndash;29 showed a prevalence of 49%.\u003csup\u003e8\u003c/sup\u003e Another study conducted in Spain among young people aged 12\u0026ndash;21 found that 17% of participants reported phone distraction during social interactions.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Phubbing is common among young people, an Australian study has confirmed that young individuals exhibit the behavior more often than older people.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch has shown that phubbing is especially directed toward people who are close, rather than more distant ones.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Phubbing can negatively affect the quality of communication:\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e its impact spans across friendships,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e parent-child relationships,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e work relationships,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e and romantic partnerships.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Being phubbed by others might lead to lower relationship satisfaction, greater disappointment,\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and depressive symptoms.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Antecedents to phubbing have also been studied and include: loneliness, fear of missing out (FoMO), boredom, and multitasking.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Additionally, a systematic meta-analytic review examined the predictors of phubbing behavior and showed a strong association between problematic smartphone use with phubbing, and a moderate association with psychopathology and being phubbed by others.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConsidering the results of phubbing and its close relation with problematic smartphone use, this phenomenon is understandably of concern to parents, educators, health practitioners, and policymakers. And yet, research on phubbing struggles to keep pace with the uptake and evolution of the practice.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Despite recommendations from professional organizations about screen use in children and adolescents, specific guidelines for smartphone use remain inadequate,\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e leaving concerned individuals with limited access to reliable information.\u003c/p\u003e \u003cp\u003eChild and adolescent psychiatrists (CAPs) are regularly confronted with needing to provide guidance regarding electronic device and smartphone use among youth. However, they often have to rely on limited empirical information. In an effort to address this gap, we conducted a study through which to better understand the phubbing behaviors of CAPs themselves \u0026ndash; both in their professional and their personal capacities. To our knowledge, no study about phubbing in CAP has been published before; our study\u0026rsquo;s unique premise is that that phubbing is a near-universal phenomenon that involves not only others (such as patients) but ourselves as well. We posit that insights from looking at our own practices can inform how we provide guidance to those under our care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe conducted a mixed methods study to explore the perceptions of trainees in child and adolescent psychiatry (CAP) about their personal use (and misuse) of smartphones, and of their professional role providing guidance on smartphone use to their patients and their caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThrough convenience and snowball sampling, we recruited CAP trainees (n = 73) from 11 programs and two countries: the US (n = 35; 6 programs) and T\u0026uuml;rkiye (n = 38; 5 programs). We conducted hour-long interviews with each program, using videoconferencing and digital recording with Zoom (San Jose, CA). Each session consisted of a focus group facilitated in English or Turkish and loosely following a previously designed interview guide of sensitizing questions (\u003cstrong\u003eAppendix 1\u003c/strong\u003e). Focus groups had a median of 7 participants each (range, 2 \u0026ndash; 10). In the last 5 minutes of the allotted hour, participants completed demographic and quantitative measures that they accessed on their phones by scanning a QR code linked securely to Qualtrics (Seattle, WA).\u003c/p\u003e\n\u003cp\u003eWe obtained institutional review approval from the Yale Human Investigations Committee (Protocol # 2000039371) and the Pamukkale University Non-Interventional Clinical Research Ethics Board (Protocol # E-60116787-020-643288) prior to starting data collection. The study was deemed of minimal risk and exempted from full review. Participants were provided with study information and informed consent documents in advance of their session, at the outset of which they provided verbal consent, which was recorded. Participants agreed to maintain confidentiality within the group, and were assured that all digital recordings would be destroyed as soon as they were transcribed and anonymized (usually within 24 hours). Moreover, we assured participants all their responses would remain confidential, and that neither their willingness to participate nor their specific responses would have any bearing on their training evaluations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants completed a demographic survey and 2 standardized instruments:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGeneric Scale of Phubbing (GSP):\u003c/em\u003e The scale measures phubbing behavior in social interactions. It is a 15-item scale using a 7-point Likert scale (1 = never to 7 = always). The scale includes four factors: problem acknowledgment (PA); self-isolation (SI); interpersonal conflict (IC); and nomophobia (the fear of detachment from one\u0026apos;s mobile phone, NP). The total score is calculated as the average of all items. Higher scores reflect more frequent phubbing behavior. The GSP is highly reliable and has a Cronbach \u0026alpha; of 0.93.\u003csup\u003e22\u003c/sup\u003e\u0026nbsp; It has been adapted into Turkish.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGeneric Scale of Being Phubbed (GSBP):\u003c/em\u003e The scale measures experiences of being phubbed in social interactions. It consists of 22 items using a 7-point Likert scale (1 = never to 7 = always). It includes 3 factors: \u0026nbsp;interpersonal conflict (IC); feeling ignored (FI); and perceived norms (PN). The total score is obtained by averaging scores across all items. Higher scores indicate a greater experience of being phubbed. The GSBP is highly reliable and has a Cronbach \u0026alpha; of 0.96.\u003csup\u003e22\u003c/sup\u003e It has been adapted into Turkish.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWe first calculated scale and subscale scores for the GSP and GSBP. We then used linear regression to compare scores while accounting for the effects of country and participant age. We dichotomized age into two birth cohorts: Millennial [1981 \u0026ndash; 1996] or Generation Z [1997 \u0026ndash; 2012]. We performed statistical analyses with SPSS 25.0 (Armonk, NY).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used qualitative methods to learn about phubbing practices the participants\u0026rsquo; lives. We opted for small focus groups rather than individual interviews in order to foster rich discussion. The questions that guided this part of the study centered both on the \u003cem\u003epersonal\u003c/em\u003e relationship between CAPs and their smartphones (e.g., at home, at work, during leisure time), as well as when in their professional roes (e.g., the guidance they provide about smartphone use to patients, families, caregivers, or stakeholders).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe transcribed digital recordings in English or Turkish using DeepGram (San Francisco, CA). We translated Turkish transcripts by first using DeepL (Cologne, Germany), then ensuring accuracy through manual verification by a native speaker (AB). We next analyzed transcripts using thematic analysis (TA)\u003csup\u003e24\u003c/sup\u003e informed by descriptive \u0026nbsp;phenomenology (DP), which foregrounds\u0026nbsp;participants\u0026rsquo; experiences to identify the structure that is the phenomenon, rather than its personal interpretation of the researcher.\u003csup\u003e25,26\u003c/sup\u003e TA provides theoretical freedom and flexibility to identify commonalities, and where writing and analyzing data can occur recursively alongside one another. Two authors worked independently to identify and compare codes before sharing them with the third investigators for triangulation,\u003csup\u003e27\u003c/sup\u003e further refinement, and finalization into a streamlined codebook and overarching domains, themes, and subthemes. Each key theme was supported by multiple quotes. In keeping with the tenets of participatory research,\u003csup\u003e28,29\u003c/sup\u003e we consider our subjects to be co-investigators, and invited all participants to review and comment on our final codes and conclusions. We followed an inductive approach in which research questions evolved beyond sensitizing questions to explore new or unanticipated themes. We analyzed transcripts iteratively until we reached theoretical sufficiency\u003csup\u003e30\u003c/sup\u003e and followed best practice guidelines for the analysis, drafting, and submission of qualitative studies.\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReflexivity and positionality statement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTA includes a rich and detailed account of the data and welcomes attention to the investigators\u0026rsquo; reflexivity, the ability to examine one\u0026rsquo;s own influence on the research process.\u003csup\u003e32\u003c/sup\u003e The four authors were keenly aware of their own instances of phubbing, of having been phubbed, and of the challenges in addressing phubbing-related behavioral change in themselves and others. They approached the subject matter as one germane to their everyday lives, rather than as something happening exclusively to others. This perspective, complemented by their ability to conduct focus groups in the participants\u0026rsquo; native languages, allowed them to have an \u0026ldquo;empathic foothold\u0026rdquo; on the phenomena under study. The authors did not have a supervisory or evaluative role on the subjects they interviewed, thus minimizing biases of power dynamics or social desirability.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eQuantitative Component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Turkish and American groups were comparable in gender composition (consisting of 76% and 60% women, respectively;\u0026nbsp;\u003cimg width=\"9\" height=\"19\" src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAAkAAAATCAMAAAB1AtffAAAAAXNSR0IArs4c6QAAAFdQTFRFAAAAAAAAAABmADpmADqQAGa2OgAAOgA6OjqQOma2OpDbZjoAZjpmZrb/kDoAkGY6kLbbkNv/tmYAtmY6tv//25A627Zm29uQ2////7Zm/9uQ//+2///bNIIWLAAAAAF0Uk5TAEDm2GYAAAAJcEhZcwAADsQAAA7EAZUrDhsAAAAZdEVYdFNvZnR3YXJlAE1pY3Jvc29mdCBPZmZpY2V/7TVxAAAAU0lEQVQYV2NgoDoQZeRikOFjZmCQEhBjkRBlEgHZIMUhzi4Itkqah5sXYqcMHxfUcmGIIgYGURZ+iCpJJhEhsDIpNl4GIS4pAQYGNlagMCMnsnsBuIQC6s1BBA8AAAAASUVORK5CYII=\" alt=\"image\"\u003e\u003cem\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e = 2.24, p = 0.13). Turkish participants were significantly younger than their American counterparts (29 \u0026plusmn; 2 vs 34 \u0026plusmn; 3 years old, respectively; t = 6.83, p \u0026lt;0.001); 18 of the 38 (47%) Turkish participants belonged to the younger Generation Z cohort, compared to none among the 35 American participants. GSP overall score was inversely correlated with age (r = -0.43, \u0026lt;0.001). There was a significant difference in GSP between the Gen Z and Millennial cohorts (61.4\u0026nbsp;\u0026plusmn;\u0026nbsp;10.9 vs 52.7\u0026nbsp;\u0026plusmn;\u0026nbsp;10.5; t = 17.54, p \u0026lt;0.001). An apparent difference in GSP between the Turkish and American groups (59.4\u0026nbsp;\u0026plusmn;\u0026nbsp;11.2 vs 49.9\u0026nbsp;\u0026plusmn;\u0026nbsp;8.8; t = 4.01, p \u0026lt;0.001) dissipated after adjusting for age, by conducting a one-way analysis of variance with GSP as dependent variable, country as independent variable, and age as covariate (F = 0.65, df = 1, 70, p = 0.42). GSBP overall scores did not differ between countries or across ages (p \u0026gt; 0.05). \u003cstrong\u003eTable 1\u003c/strong\u003e summarizes total and subscale scores for GSP and GSBP for the overall sample of 72 (one participant did not complete the quantitative questionnaires). In response to the question \u0026ldquo;How many hours can you go during a typical day [excluding sleep] without engaging with your smartphone?\u0026rdquo;, participants averaged 3.6\u0026nbsp;\u0026plusmn;\u0026nbsp;2.3 hours.\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 1 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThrough thematic analysis, we arrived at a four-domain model through which to approach phubbing in child and adolescent mental health: 1) Perceptions; 2) Explanations; 3) Consequences; and 4) Solutions. We provide brief explanations of these domains and their underlying themes in \u003cstrong\u003eTable 2\u003c/strong\u003e. In the sections that follow, we further explore each of the domains and themes. Consentient with our quantitative findings, we did not find notable differences between the US and T\u0026uuml;rkiye groups. Still, we go on to indicate attribution of specific quotes using the U or T suffix, respectively.\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 2 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 1. Perceptions: smartphones and technology in a social context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis first domain concerns the connotations with which smartphone use and technology are perceived by members of society. Our respondents frequently discussed the use of smartphones for work, communication, searching on the Internet, leisure, and more \u0026mdash; and at every conceivable waking hour of the day. Broadly, we found that these devices can be viewed as \u003cem\u003eactive dangers\u003c/em\u003e (negative connotations), neutral \u003cem\u003edistractions\u003c/em\u003e, or\u003cem\u003e\u0026nbsp;legitimate tools\u003c/em\u003e (positive connotations). Because these ideas alter the lens through which phubbing is perceived, we first render explicit this underlying social construct in order to facilitate analysis (\u003cstrong\u003eTable 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 3 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eActive danger\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResponses we obtained coalesced around three key subthemes: \u003cem\u003ebullying\u003c/em\u003e, \u003cem\u003eexposure to polarizing content or misinformation\u003c/em\u003e, and \u003cem\u003ehindrance to social development\u003c/em\u003e. Participants were concerned with phones and similar devices opening a doorway to increased dangerous interactions online, with cyberbullying being especially relevant for children and adolescents. Similarly, discussions of the danger of exposure to polarizing content or misinformation often centered on the ways in which online content may introduce naive phone users to trends and communities which shift normative viewpoints towards more fringe perspectives:\u003c/p\u003e\n\u003cp\u003eThe echo chamber that happens in a lot of places like Reddit, for example, where you\u0026apos;ll have views that aren\u0026apos;t extreme in a lot of ways, and people that gravitate towards those views end up repeating the same and become more extreme in a way. (02U)\u003c/p\u003e\n\u003cp\u003eOther concerns included children and adolescents\u0026rsquo; potential encounters with age-inappropriate content online and how such encounters may interfere with the usual sequence of social development:\u003c/p\u003e\n\u003cp\u003eI\u0026apos;ve seen that they become more introverted and develop more social anxiety symptoms. I also think that because they can easily access everything, they encounter sexuality too early, and dark things such as drugs, substances, alcohol (04T) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhones were regarded in a slightly more neutral manner when discussed as mere distractions, providing little or no value to the user, but at least not functioning as an actively harmful exposure. Most commonly, this perception of phones arose in the context of educational settings or didactics:\u003c/p\u003e\n\u003cp\u003eSometimes training hours become like a time slot specially crafted for looking at phones. Yes: disengaging training hours may be one of the times we do it most. (10T)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegitimate Tool\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe previously described associations were occasionally contrasted with specific instances where phone use was considered legitimate and justified. For instance, the purposeful use of phones for research and work to augment productivity and learning was generally regarded positively:\u003c/p\u003e\n\u003cp\u003eI think of an attending telling us the story about how he used to ban cell phones from...rounds and everything, and then people would get yelled at for it. And then he came to realize that what was happening is people are actually, in real time, are looking up medication facts to share. (01U)\u003c/p\u003e\n\u003cp\u003eThe judicious use of phones for patient connection was usually regarded similarly. Several CAP fellows recounted utilizing a young patient\u0026rsquo;s phone as a window through which to gather clinically relevant information about their interests, personality, habits, or online social networks. This connection-promoting capacity of smartphones extended to the participants\u0026rsquo; personal lives, helping them maintain connections to community and family when in-person interaction may not be feasible:\u003c/p\u003e\n\u003cp\u003eI also have family that\u0026apos;s all over the country, you know, old ones, young ones, and people that are still looking to me to take care of them even though my husband and I are far away. \u0026nbsp; (01U)\u003c/p\u003e\n\u003cp\u003eLastly, phones were also described as promoters of personal health in their own right, often via the monitoring of health data that can be illuminating for patients and clinicians alike:\u003c/p\u003e\n\u003cp\u003eI\u0026apos;ve also started having them use a lot of the mood tracking apps, to help them build insight into their moods and states, and then we can look at it together. (02U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 2. Explanations: antecedents to phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA second domain characterizes antecedents to phubbing by dissecting the reported thought patterns, emotions, and justifications behind participants\u0026rsquo; phubbing of others, or how to react when phubbed by others. We found that many of these factors promoted phubbing, yet some effectively dissuaded respondents. By examining these antecedents, we may generate further ideas for sustainable interventions to modulate young patients\u0026rsquo; phone use. Our analysis led to four common themes, which we term \u003cem\u003eperson-centered\u003c/em\u003e, \u003cem\u003eprinciple-centered\u003c/em\u003e, \u003cem\u003eemotion-centered\u003c/em\u003e, and \u003cem\u003eeconomic or utilitarian frameworks\u003c/em\u003e. (\u003cstrong\u003eTable 4\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 4 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerson-centered framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe crux of the person-centered framework hinges on how respondents conceptualize the responsibility of managing their phone use: whether proactively and in control of their habits, or reactively, in response to external factors. Those who endorsed an internal locus of control often appeared comfortable triaging concurrent demands on their attention and exhibited a sense of self-awareness of potential distractors:\u003c/p\u003e\n\u003cp\u003eI like to put my phone on do not disturb a lot because I\u0026apos;m just like, I don\u0026apos;t really need like, nothing is really usually that urgent. (05U)\u003c/p\u003e\n\u003cp\u003eIn contrast, those who endorsed an external locus of control more readily disavowed agency for controlling their phone use, instead attributing the blame to something other than their intentional selves:\u003c/p\u003e\n\u003cp\u003eIt\u0026apos;s like a habit, not because I\u0026apos;m uncomfortable with what\u0026apos;s being talked about or not very interested, but in that empty moment, suddenly my hand goes to it. (07T)\u003c/p\u003e\n\u003cp\u003eAt times, when feeling pulled to their devices, setting external barriers could prove the only plausible way to desist: turning the device off, giving it away for temporary safekeeping, letting its battery run out, or most commonly, relegating it to another physical space.\u003c/p\u003e\n\u003cp\u003eI put my phone in another room from where I\u0026apos;m at. (02U)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrinciple-centered framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOther times, respondents cited first principles such as ethics, respect, or empathy when presented with a dilemma involving phubbing and phone use. This top-down pattern of thinking assumed the necessity of a particular end goal (e.g., ethical responsibility to patients), and worked backwards to consider whether actions such as using one\u0026rsquo;s phone were precluded or permissible. For instance, a striking finding among the focus group responses was that CAP fellows almost never phubbed a patient:\u003c/p\u003e\n\u003cp\u003eIt would be rude if I did it in front of my professor. You know, they might get angry. Doing it in front of a patient could be one of the worst things possible. \u0026nbsp;It would probably directly damage the therapeutic relationship. (07T)\u003c/p\u003e\n\u003cp\u003eCompared to ethics, respect for authority was less universally espoused among respondents, but just as strongly adhered to among those who did. Frequently, this sense of respect was in deference to attending physicians or professors in the clinical/academic environment and parents or elders in personal life.\u003c/p\u003e\n\u003cp\u003eThey\u0026apos;re imparting knowledge to us, dedicating their time to us. I mean, if we look at the phone during that time, I think we all feel we\u0026apos;re being disrespectful, and we think it might be perceived as if we\u0026apos;re not listening. (08T) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith regards to considerations of empathy between phubbers and phubbees, perceived similarities fostered a sense of forgiveness and mutual understanding:\u003c/p\u003e\n\u003cp\u003eNo. I haven\u0026apos;t done anything outright to point them out or anything. You know? I\u0026apos;m not trying to be like a micromanager and because I do the same, I\u0026apos;m guilty of the same thing. (05U) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, perceived dissimilarities in stature often led to the dissuasion of phubbing:\u003c/p\u003e\n\u003cp\u003eIf the same was done to me, I would be very seriously disturbed and probably wouldn\u0026apos;t make an appointment at the same place again, or if it was a consultation, I would probably say I want to see another doctor. (07T)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI feel like there\u0026apos;s much less generous interpretations of phone use by older folks because I feel like their assumption is always that you are up to no good (06U)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmotion-centered framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYet another pattern of thinking about phubbing revolved around the inciting emotions (e.g. \u003cem\u003eFoMO\u003c/em\u003e, \u003cem\u003esocial anxiety\u003c/em\u003e, \u003cem\u003eboredom\u003c/em\u003e, and \u003cem\u003eescapism\u003c/em\u003e) which inclined respondents to phub others. For example, some CAP fellows endorsed a strong drive to be maximally updated on current events or trends, prompting increased device use and phubbing:\u003c/p\u003e\n\u003cp\u003eAm I missing something that\u0026apos;s happening? What happened in the country today? I feel like I need to check in. (08T) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis worry about not knowing presented itself in clinical contexts as well:\u003c/p\u003e\n\u003cp\u003eThat messaging center thing that we have is still on. So, when that dings you are like, oh, what happened there? You know? Was there a crisis that happened? (01U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSocial anxiety and boredom each functioned similarly, inclining respondents toward phubbing. Still others reported feeling the occasional need to retreat to technology as a type of withdrawal defense:\u003c/p\u003e\n\u003cp\u003eWhen I\u0026apos;m in an environment or talking to someone, if I don\u0026apos;t want to be fully present there and want to escape from that environment, I worry about how I\u0026apos;ll escape if my phone isn\u0026apos;t with me. (09T)\u003c/p\u003e\n\u003cp\u003eYoung patients can also exhibit similar behaviors, especially in the clinical environment when in-person interaction with a psychiatrist may present as a situation outside of their comfort zone: it may take gentle limit setting to make the therapeutic space a phub-free zone. Phubbing during therapy (a not unheard of occurrence) could be taken as an invitation to discuss not just what is being avoided in the therapy, but what is being sought in the ether.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEconomic/Utilitarian framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis final framework, more pragmatic than the others, arises when one consciously makes comparisons of value, estimations of risks, and evaluations of what may be gained or lost by deciding to phub in a particular moment. Consistent with the concept of attention economy, CAP fellows occasionally analogize attention to currency \u0026mdash; they are astutely cognizant of its limited quantity and the increasing array of concurrent attention demands from clinical notifications, personal communications, and more:\u003c/p\u003e\n\u003cp\u003eBoth tasks are important, but since stronger stimuli come from the phone, I devote all my attention there and my selective attention is blocked. (04T) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStill others explicitly verbalized how they weigh the risks of phubbing against perceived benefits:\u003c/p\u003e\n\u003cp\u003eIf I\u0026apos;m in a lecture and I don\u0026apos;t think it\u0026apos;s as important as some work I need to get done, I will go on my phone. \u0026nbsp;(01U)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 3. Consequences: outcomes of phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur third domain explores the outcomes of phubbing behavior, ranging from the reflexive impacts on the phubber to broader societal impacts. Whether as participant, observer, or victim, many respondents reported firsthand experience with the consequences of phubbing. These shared experiences contribute to the reproduction of altered social norms of in-person interaction among many of our respondents and their young patients. We categorize these outcomes into several themes of \u003cem\u003efeelings\u003c/em\u003e, \u003cem\u003eattention span and\u003c/em\u003e \u003cem\u003emulti-tasking\u003c/em\u003e, \u003cem\u003esocialization\u003c/em\u003e, and \u003cem\u003eclinical consequences\u003c/em\u003e (\u003cstrong\u003eTable 5\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 5 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeelings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe phubber and phubbee may perceive the act through different social and emotional lenses, resulting in distinct impacts on each party. To phubbers, device use in the moment may bring a sense of utility and joy:\u003c/p\u003e\n\u003cp\u003eIn my social life, I feel as if the communication I have on the phone makes me even happier at times than verbal communication...I feel as if I am getting a reward when the message notification sounds. (04T) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConversely, being phubbed is often described in a strongly negative light:\u003c/p\u003e\n\u003cp\u003eI don\u0026apos;t want to keep talking badly about my home life, but that\u0026apos;s where phubbing usually happens. And I think that\u0026apos;s where I feel undervalued and almost lonely...it\u0026apos;s you and me in this house, and, obviously, there\u0026apos;s something more important going on for you...than me existing here. (01U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttention span and multitasking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOften reporting from personal experience, CAP fellows also recognized deleterious effects on attention span as another major consequence of phone use trends:\u003c/p\u003e\n\u003cp\u003eA person might look at their phone unconsciously too. Actually, independent from whether they like the topic or not, it\u0026apos;s happening. Maybe interest and engagement exist, but attention spans have momentarily shortened - I mean, they seem to have shortened for many of us. (11T)\u003c/p\u003e\n\u003cp\u003eCorrespondingly, it is no surprise that respondents are observing an increased propensity to multi-task, including across more than one technological device:\u003c/p\u003e\n\u003cp\u003eHe\u0026apos;s a 13 year old boy with ADHD...and he\u0026apos;s playing the game. And then over here, he\u0026apos;s watching some other kid playing a video game. Meanwhile, the kid playing the video game is listening to music. (02U)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocialization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome focus group participants described a concern as child psychiatrists about maladaptive replacement of in-person socialization with device use. In some cases, using technological devices in parallel can becomes a social act of sorts, an approximation:\u003c/p\u003e\n\u003cp\u003eI think that younger age groups play e-games together, for example sometimes while waiting in corridors all children are looking at their phones, they don\u0026apos;t communicate, they don\u0026apos;t actually play together. (10T)\u003c/p\u003e\n\u003cp\u003eFellows themselves also report experiencing technology use in this manner and perceiving these behaviors as normalized, a new kind of parallel play:\u003c/p\u003e\n\u003cp\u003eMy husband and I find us doing that...I\u0026apos;ve got my laptop on my lap, and I\u0026apos;m playing video games on the PlayStation. And then I find he\u0026apos;s doing the same thing on his big screen that\u0026apos;s right next to him. And then I\u0026apos;ll look over and we\u0026apos;re both on our phones with these other two activities. (01U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical consequences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most pertinent consequences of phubbing and maladaptive phone use to child and adolescent psychiatry are the implications for the clinical care of patients. Our participants observed firsthand how phubbing in the clinical environment can be dangerous, including directly interfering with emergent psychiatric care:\u003c/p\u003e\n\u003cp\u003eI actually had a patient yesterday...he\u0026apos;s sitting in this psych pod in the ER, on Instagram. And, while we were interviewing him, and multiple redirections to get his attention...to the point of having to be really stern. Because he had his mom\u0026apos;s phone. Obviously, he\u0026apos;s not allowed to have phones and stuff in the ED, but he\u0026apos;s about maybe 12...there was obviously something on Instagram that was far more interesting. How do we compete? (12U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStill, CAP fellows generally have ideas about next steps that would better prepare them to tackle this issue. Some are aware of reputable published guidelines about children\u0026rsquo;s phone use, but others seek more support and resources about how to effectively address these concerns in their clinics.\u003c/p\u003e\n\u003cp\u003eNonetheless, ongoing challenges complicate the feasibility of developing, disseminating, and executing the needed guidelines. Many fellows admit their own shortcomings with controlling their own phone use habits, and reasonably exhibit skepticism about children\u0026rsquo;s adherence to any such guidelines:\u003c/p\u003e\n\u003cp\u003eIf we can\u0026apos;t regulate ourselves as adults, we can\u0026apos;t expect the little ones that we\u0026apos;re seeing to regulate themselves. (01U)\u003c/p\u003e\n\u003cp\u003eOthers worry about the ability of overwhelmed parents to effectively enforce phone use limitations, and still others worry that the opportunity for psychiatric intervention presents itself at a later age than would be optimal to prevent the initial crystallization of maladaptive phone use habits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 4. Recommendations: strategies to address phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the aforementioned challenges, CAP fellows were able to offer various recommendations based upon their personal lives and clinical experience managing young patients\u0026rsquo; phone use. We have divided these insights into \u003cem\u003eincremental\u003c/em\u003e and \u003cem\u003ecategorical\u003c/em\u003e strategies (\u003cstrong\u003eTable 6\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 6 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncremental strategies to address phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese strategies aim to modulate the overall quantity of time during which children and adolescents are permitted to engage with technological devices. For instance, some fellows stated that on occasion, advocating for total \u0026ldquo;detox\u0026rdquo; from the phone and altogether removing the maladaptive stimulus could be a necessary step:\u003c/p\u003e\n\u003cp\u003eMaybe because of safety concerns and whatever else may be going on we do detox...we recommend monitored time, but at times we need to take the phones away, especially if it\u0026apos;s becoming a safety concern, and see how they do. (01U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOthers disagreed, preferring to promote a more gradual tapering strategy instead:\u003c/p\u003e\n\u003cp\u003eSome parents I\u0026apos;ve seen do pretty draconian things, like no phone for Google or, tracking apps on their kids\u0026apos; phones. I agree that we can try to curb excessive use. And depending on your bedtime, we need to go to bed. But cutting off all private accesses, that will just backfire tremendously. (02U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants also emphasized the need to support children and adolescents in pursuing non-digital activities to prevent backsliding into ingrained phone use habits, delay the age of their introduction to personal devices and online platforms, and carve out specific hours when phone use is forbidden with the hopes of modelling improved compartmentalization and time management skills.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategorical strategies to address phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplementary to the incremental strategies are qualitative approaches that seek to adjust how children and adolescents engage with technological devices. These categorical strategies include \u003cem\u003edevice limitations\u003c/em\u003e, \u003cem\u003eactive parenting and monitoring\u003c/em\u003e, and \u003cem\u003eincreasing buy-in from children, adolescents, and families\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eProviding adolescents with an inherently limited device capable of basic functionality but with fewer opportunities for distraction or unanticipated use, such as an older-style flip phone or wearable smartwatch, was occasionally suggested by the respondents. While potentially time consuming, parents could also reinforce more adaptive habits by actively engaging with opportunities to monitor children and adolescents\u0026rsquo; technology use. One easy key action item was for parents to invest the time in fully acquainting themselves with the capabilities of the devices they intend to let their children use, and especially any ready-to-use parental safeguards:\u003c/p\u003e\n\u003cp\u003eI\u0026apos;m always surprised by how underutilized the parental controls are on phones. Parents don\u0026apos;t even seem to know about them or how to use them. Because I know, at least on iPhones, which I feel like a lot of kids have iPhones, they have pretty robust time controls. (05U) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA sense of investment from the entire family is needed to extend the benefits of psychiatric intervention beyond the short clinic visits. A maximally effective strategy should also move children and adolescents to begin practicing self-management techniques and encourage them to request parental or clinician help as needed. In one respondent\u0026rsquo;s words:\u003c/p\u003e\n\u003cp\u003eParents can block these things, but they will outsmart their parents and then figure it out. So I think instead of just blocking, having conversations, more than once. And then ask them, the teenagers...What would be the best way?...And then come up with realistic solutions, together. (01U) \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAt a time when reliance on phone connectivity is ubiquitous, and when children and adolescents have access to smartphones at ever younger ages, phubbing has become a public health and policy concern. All of our participants acknowledged phubbing and being phubbed as routine occurrences in their daily lives. However, the self-reported average of almost four hours that participants claimed to be able to go without using their smartphone is a likely underestimate, whether due to underreporting, social desirability, or unrealistic perceptions. For example, current estimates suggest that cell phone users look at their phones an average of\u0026nbsp;144 times a day,\u003csup\u003e33\u003c/sup\u003e and underestimates of personal use can vary as much as 40% different from objective measures.\u003csup\u003e34\u003c/sup\u003e The fact that nomophobia (the fear of detachment from one\u0026rsquo;s phone) was the highest-rated subscale on the GSP further supports just how reliant participants were on their phones, even if not fully aware of the automatic reliance on their devices.\u003c/p\u003e\n\u003cp\u003eCultural factors may impact phubbing and related perceptions. For example, in a large study (n = 14,700) in which participants rated vignettes related to the behavior, members from \u0026ldquo;collectivist\u0026rdquo; countries scored higher on phubbing scales than \u0026ldquo;individualist\u0026rdquo; ones. Moreover, \u0026ldquo;attribution locus\u0026rdquo; differed notably, with \u0026ldquo;individuals from collectivist backgrounds more susceptible to perceiving being phubbed as exclusionary and attributing the cause more internally, to themselves.\u0026rdquo;\u003csup\u003e35\u003c/sup\u003e By contrast, we found no significant differences between our American and Turkish participants. Although this may have to do with our modest sample size and lack of power, it is notable just how \u003cem\u003esimilar\u003c/em\u003e our findings were across the two countries, suggesting the global nature of phubbing. Even as we found no differences across country, age-related differences were significant. Younger participants (Generation Z) had higher phubbing scores when compared to older ones (Millennials). This finding is consistent with a small decrease in phubbing behavior with age based on a meta-analytic review of 79 studies.\u003csup\u003e18\u003c/sup\u003e Collectively, these findings suggest that age should be strongly incorporated into efforts to address phubbing. For example, with smartphone engagement and practices likely to differ significantly across age and birth cohort, approaches need to be tailored accordingly, particularly against a backdrop of exponential changes in smartphone technologies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhubbing has been aptly conceptualized as \u0026ldquo;a social practice that signals relational disengagement\u0026rdquo;.\u003csup\u003e36\u003c/sup\u003e It can lead to disruptions in normal social interactions, to fragmented attention, and to replacement or loss of healthier activities. In the clinical environment, smartphone use and phubbing can create funneling of attention and distraction,\u003csup\u003e37\u003c/sup\u003e and\u0026nbsp;supervisors\u0026apos; phubbing behavior can be mirrored by those under their guidance.\u003csup\u003e38\u003c/sup\u003e Because such risks can aggregate over time and result in ingrained behavioral patterns, early intervention and prevention can be critical. Despite the risks involved, smartphones are not inherently negative devices; like any tool, they can be put to the use of who wields them. Smartphones have an important role in prosocial activities, such as fostering connection between adolescents unable to drive or living at a distance from one another. In our effort to reach a more balanced utilization of these devices, we should not rush to draconian, all-or-nothing approaches. Even in the privacy of the consulting room, smartphones can be useful and legitimate tools: viewing a screen together; identifying favorite music, videos, and trends; even texting one another during a session are strategies that can prove helpful in breaking the ice, connecting, fostering rapport \u0026ndash; in \u0026ldquo;getting it.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHeightened self-awareness to the antecedents and consequences of phubbing can help adults take a more understanding and empathetic stance when considering how to deal with the same behavior in their children or patients. We need to find ways for ourselves and for those under our care to better adapt to electronic realities of our times that are here to stay, and to more effectively balance personal and professional/educational smartphone use, cognizant that smartphones can negatively impact work/school-life conflicts.\u003csup\u003e39\u003c/sup\u003e A self-reflective inventory of personal phubbing, along the themes we identified, can inform our guidance regarding electronic technologies for youth under our clinical care. Recognizing emotions such as boredom proneness, loneliness, or FoMO as antecedents,\u003csup\u003e40\u003c/sup\u003e or normalization or splintered attention as consequences of phubbing, can help us better understand both ourselves and our patients. It can also help become more realistic in implementing recommendations to children, adolescents, and their families.\u003c/p\u003e\n\u003cp\u003eAll participants expressed the need to have better guidelines to help patients and families navigate the tricky shoals of smartphone and electronic device use. Most of them had some familiarity with one or two such guidelines, but no one felt truly confident incorporating them into practice. The most widely cited report, from the US Surgeon General,\u003csup\u003e41\u003c/sup\u003e provides a valuable framework for appropriate social media use, with recommendations specifically tailored to policy makers, technology companies, parents and caregivers, children and adolescents, and researchers. Most proximal to the clinical domain, parents can establish tech-free zones at home to foster better in-person relationships; they can teach and model responsible online behavior; or they can report problematic content and activity. In turn, children and adolescents can limit time on platforms, block unwanted content, be careful about sharing personal information, and reach out if they need help or see harassment or abuse on the platforms. Another widely cited report from the UK\u0026rsquo;s College of Psychiatrists provides complementary guidance, including\u0026nbsp;making sure that technology use becomes a core part of clinical assessment and formulation, given that \u0026ldquo;the online world can be just as important to young people as their offline world.\u0026rdquo;\u003csup\u003e20\u003c/sup\u003e Helpful as these recommendations are, they were not considered granular or realistic enough.\u003c/p\u003e\n\u003cp\u003eIn his trade book \u003cem\u003eThe Age of Anxiety\u003c/em\u003e,\u003csup\u003e42\u003c/sup\u003e Jonathan Haidt puts forth the premise that as a society we overprotect children in the real world, while we under-protect them in the virtual world \u0026ndash; that we have failed to see and address the risks of social media on healthy development. His recommendations are clear, though perhaps aspirational at this juncture: phone-free schools; no smartphones before high school; only basic phones before roughly age 14 (with limited apps and no internet browser); and no social media before 16. He advocates for an embodied here and now, given that \u0026ldquo;in our lives with smartphones, we are forever elsewhere,\u0026rdquo; and that smartphones and other digital devices are \u0026ldquo;experience blockers\u0026rdquo; that reduce interest in non-screen-based forms of experience. Finally, Haidt makes the important point that we should not assume that disadvantaged children or those from minoritized groups have less access to the internet: they just have less protection from it. For example, families with more limited resources or lower \u0026ldquo;parental literacy\u0026rdquo; may resort to \u0026ldquo;electronic babysitting\u0026rdquo; to fill up a void or to ease challenging parent-child interactions.\u003c/p\u003e\n\u003cp\u003eClinicians approaching phubbing and other \u0026ldquo;e-behaviors\u0026rdquo; in their young patients may have to straddle the roles of trusted therapist, guideline arbiter, and parental ally. This is no easy feat, nor one for which there is a direct formula. Two final concepts may prove helpful. First, phubbing and related behaviors have a goal to connect (to someone, to something), not just to avoid and disconnect. In some sense, they represent transitional objects or behaviors that are quite similar to or own \u0026ndash; how many of us have not felt the \u0026ldquo;phantom\u0026rdquo; buzzing of our smartphone? How long can we go without checking our device of choice? Second, the age difference between clinicians and their patients in CAP creates a de facto generation gap between them. This is a reality magnified by technology and its rapid advances. It is up to us to turn this potential occupational hazard into a clinical opportunity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge three main limitations, which could inform next steps: 1) Even though our sample was more than sufficient for a qualitative study,\u003csup\u003e43\u003c/sup\u003e it did not provide sufficient power for the quantitative component. Thus, for example, the lack of difference between the US and T\u0026uuml;rkiye may represent a Type II error; 2) We did not have an objective measure of smartphone use, which would have provided precision and a standard against which to compare self-reports;\u003csup\u003e44\u003c/sup\u003e and 3) We did not include the perspectives of children, parents, or stakeholders to complement those of our CAP fellow participants.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSmartphone use increased during and after the COVID-19 pandemic,\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e a time in which the need for virtual connection and timely guidance accelerated reliance on and frequent use of these devices. In the wake of the pandemic, some of the benefits of the technology have diminished, making phubbing and problematic electronics use more conspicuous. As we settle back into a \u0026ldquo;post-pandemic normal,\u0026rdquo; and as we continue to be inundated with ever faster and more addictive technologies, we will continue to be sought to provide clinical guidance. In order to face the daunting challenge, we will do well by looking into our own electronic reliance and fragile social interactions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor their participation and comments, we thank the trainees and directors from the following programs in the US (University of Kansas at Wichita, Rush, University of Illinois at Chicago, Oregon Health Sciences, Boston Children\u0026rsquo;s Hospital, and the Yale Child Study Center), and in T\u0026uuml;rkiye (Izmir City Hospital, Ankara Etlik City Hospital, Afyonkarahisar Health Sciences University, Aydin Adnan M. University, and Pamukkale University).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupport\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupported by the Riva Ariella Ritvo Endowment at the Yale Child Study Center.\u003c/p\u003e\n\u003cp\u003eAB was supported by the T\u0026Uuml;BİTAK 2219-International Postdoctoral Research Fellowship at Yale University.\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the Yale School of Medicine Fellowship for Medical Student Research to BL. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Yale School of Medicine Fellowship for Medical Student Research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no disclosures to report.\u003c/p\u003e\n\u003cp\u003ePrepared for submission to \u003cem\u003eChild and Adolescent Psychiatry and Mental Health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHUMAN ETHICS APPORVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Yale Human Investigations Committee (Protocol # 2000039371) and the Pamukkale University Non-Interventional Clinical Research Ethics Board (Protocol # E-60116787-020-643288).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupported by the Riva Ariella Ritvo Endowment at the Yale Child Study Center.\u003c/p\u003e\n\u003cp\u003eAB was supported by the T\u0026Uuml;BİTAK 2219-International Postdoctoral Research Fellowship at Yale University.\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the Yale School of Medicine Fellowship for Medical Student Research to BL. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Yale School of Medicine Fellowship for Medical Student Research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor their participation and comments, we thank the trainees and directors from the following programs in the US (University of Kansas at Wichita, Rush, University of Illinois at Chicago, Oregon Health Sciences, Boston Children\u0026rsquo;s Hospital, and the Yale Child Study Center), and in T\u0026uuml;rkiye (Izmir City Hospital, Ankara Etlik City Hospital, Afyonkarahisar Health Sciences University, Aydin Adnan M. University, and Pamukkale University).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSmartphones - statistics \u0026amp; facts | Statista. https://www.statista.com/topics/840/smartphones/#topicOverview.\u003c/li\u003e\n\u003cli\u003eU.S. children owning a smartphone by age 2015-2021| Statista. https://www.statista.com/statistics/1324262/children-owning-a-smartphone-by-age-us/.\u003c/li\u003e\n\u003cli\u003eTeens, Social Media and Technology 2024 | Pew Research Center. https://www.pewresearch.org/internet/2024/12/12/teens-social-media-and-technology-2024/.\u003c/li\u003e\n\u003cli\u003eSohn S, Rees P, Wildridge B, Kalk NJ, Carter B. 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Sample sizes for saturation in qualitative research: A systematic review of empirical tests. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2022;292:114523. doi:10.1016/j.socscimed.2021.114523\u003c/li\u003e\n\u003cli\u003eWenz A, Keusch F, Bach RL. Measuring smartphone use: survey versus digital behavioral data. \u003cem\u003eSoc Sci Comput Rev\u003c/em\u003e. 2024;0(0):1-20. doi:10.1177/08944393231224540\u003c/li\u003e\n\u003cli\u003eChemnad K, Alshakhsi S, Almourad MB, Altuwairiqi M, Phalp K, Ali R. Smartphone usage before and during COVID-19: a comparative study based on objective recording of usage data. \u003cem\u003eInformatics\u003c/em\u003e. 2022;9(4). doi:10.3390/informatics9040098\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99.8667%;\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTABLE 1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eGSP, GSBP, and factor scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en = 72\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGSP total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e54.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; NP = Nomophobia (fear of detachment from one\u0026apos;s mobile phone)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; PA = Problem Acknowledgement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; SI = Self-isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; IC = Interpersonal Conflict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGSBP total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e83.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; PN = Perceived Norms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e40.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; FI = Feeling Ignored\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; IC = Interpersonal Conflict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 596px;\"\u003e\n \u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eGSP = General Scale of Phubbing; GSBP = General Scale of Being Phubbed.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 2 \u0026nbsp;Phubbing framework: domains, themes, and definitions\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"702\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceptions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eRoles of smartphone use in modern society and their social implications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eActive danger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eNegative effects associated with smartphone use (e.g. bullying, echo chambers)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDistraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eNeutral effects associated with smartphone use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eLegitimate tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003ePositive effects associated with smartphone use (e.g. research, community)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExplanations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eRespondents\u0026rsquo; conceptualizations of antecedents to phubbing behaviors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePerson-centered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eThe perception of phubbing behaviors as internally or externally manageable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePrinciple-centered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eHow higher-order concepts (e.g. ethics, empathy) affect phubbing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eEmotion-centered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eHow specific emotions (FoMO, anxiety, boredom, etc.) affect phubbing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eEconomic/\u003cbr\u003e\u0026nbsp;Utilitarian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eHow perceived utility and risk/benefit analyses influence phubbing decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsequences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eSpecific outcomes of phubbing behavior (e.g. normalization, split attention)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eFeelings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eEmotional effects of phubbing on phubbers and phubbees\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAttention span and multitasking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eEffects on attention span and split attention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eSocialization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eFurther social effects following the rise of phubbing (e.g. normalization)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eClinical\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eEffects of phubbing in the clinical environment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eStrategies to address phubbing and phone use trends as suggested by CAP fellows\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eIncremental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eQuantitative strategies to reduce exposure of children and adolescents to devices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eCategorical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003eQualitative strategies to adjust how children and adolescents are exposed to and use devices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 3\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDomain 1. Perceptions: smartphones and technology in a social context\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative quotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eActive danger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eBullying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eA lot of the chief complaints have to do with bullying and problems that happened on their phone, whether it\u0026apos;s social media or text, or whatever platform between their friend groups. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eExposure to polarizing content or misinformation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eIt can be very dangerous, skewing their worldviews in certain ways. (06U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eHindrance to social development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eIt\u0026apos;s very much related to regression in young children...For primary school children, it\u0026apos;s usually related to a decline in academic success, but for adolescents, it can lead to risky behaviors like alcohol, substance use, or abusive relationships. (07T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eDistraction\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eI might miss something that\u0026apos;s said, or when I\u0026apos;m saying something to the other person, they might miss it. It creates more problems in the work environment, not so much in the friend environment (07T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eLegitimate tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eResearch and work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eIt will aid in the discussion, that we\u0026apos;re having an informed debate about something (12U)\u003c/p\u003e\n \u003cp\u003eThe phubbing will at times contribute to this patient\u0026apos;s care; it is happening in real time; it can enrich the conversation and imbue it with facts. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003ePatient connection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eI think it\u0026apos;s complicated because, in therapy, you have to do work and you don\u0026apos;t let someone on your phone, but, also, my kids want to show me things. And it helps move them on to the next topic without looking at it so closely. And so, I allow it to a certain point: helpful for rapport and for feeling heard. (06U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eConnection to community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eIn the course of two or three hours, my husband is at work trying to get a hold of me. My parents are somewhere else in the country. They need to connect with me. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003ePersonal health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eBecause I have diabetes, I use a sensor. I need to constantly open and check the sensor. So, I don\u0026apos;t have the luxury of staying away from the phone. It\u0026apos;s always in my pocket or by my bedside when I\u0026apos;m sleeping. It beeps when it falls, so I need to hear it. (07T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 4\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDomain 2. Explanations: antecedents to phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative quotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePerson-centered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInternal locus of control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eI turn off notifications for a lot of things. So that it\u0026apos;s not popping up other than maybe for work stuff; for everything else, notifications are turned off. (12U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eExternal locus of control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eI started messaging someone else when my fianc\u0026eacute; and I were out for a thing and I\u0026rsquo;m like, man, I go to stop being on my phone, and then, \u003cem\u003ethankfully, it died\u003c/em\u003e. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePrinciple-centered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eResponsibility to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eIt wouldn\u0026apos;t be appropriate if the patient makes an appointment and comes to see us. It\u0026apos;s time we\u0026apos;ve allocated for them. Looking at the phone then, rather than looking at the patient, it just wouldn\u0026apos;t be right. (10T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eRespect for authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eI would definitely phub my very close friends, my brother, my wife, my parents. But I\u0026apos;m more careful around people I respect and communicate with, like fellows or professors. (04T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEmpathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eI get annoyed when other people do it, so I think I have a fairly conscious effort in terms of not doing it. But if I do end up doing it, I like to think I catch myself. (03U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eEmotion-centered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eFoMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eWe have a system on our phone from work... If we get a message from there, you are prompted to look at it because something could be happening. Has something happened to my patient? You know, you cannot always ignore it. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSocial anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eWhen I feel socially anxious, I give myself to my phone, I retreat. (04T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBoredom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eThere isn\u0026apos;t just one trigger. In many cases, it can be simple boredom. Especially in a crowded environment, and when the topic being discussed might not interest me. (07T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEscapism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eIf I don\u0026apos;t want to talk at that moment, turning to my phone is an avoidant behavior (10T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eEconomic / Utilitarian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAttention economy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eI think there\u0026apos;s also a slight competitive drive to it, in the sense that, like, I know these companies are trying to win my attention, and so trying to defeat them a little bit on their turf, on their wily ways, becomes a bit of a game for me. (05U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eRisk/benefit calculations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eIf I\u0026apos;ve decided that if a lecture, for example, is not engaging or high yield, I am more likely to tune out and may resort to my phone. If the speaker is engaging or is giving high yield information, I\u0026apos;m unlikely to do so because that might offend them. (06U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 5\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDomain 3. Consequences: outcomes of phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative quotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFeelings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eIf I\u0026apos;m on my phone and somebody calls attention to it, I\u0026apos;m not angry, but I feel called out, and then I feel embarrassed or guilty, and it comes out as, defensiveness, even when it\u0026apos;s my husband. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eI think it makes the other person feel worthless. It inevitably made the other person feel that. (04T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eAttention span\u0026nbsp;\u003cbr\u003e\u0026nbsp;and multitasking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eTikTok can be such a time suck. It\u0026apos;s just constant scrolling for new information, and it really has affected people\u0026apos;s attention span and the need for a quick dopamine hit. (05U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eTV and my phone. That\u0026apos;s what I\u0026apos;m doing. Can\u0026apos;t watch a show anymore without having another screen to scroll through. (02U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eI\u0026apos;ve got literally 10 tabs open right now. I usually have a split screen with whatever it is I\u0026apos;m doing, on video and also whatever else I want to work on, and then I also have my phone. (06U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eSocialization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eEveryone is scrolling on Instagram and having this half presence with everyone else around them. (03U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eWe lie on separate couches at home, despite being so close togehter, we\u0026apos;re just sharing Instagram Reels with each other. (11T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eClinical consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eEffect of phubbing on clinical care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eI have a ton of adolescent patients...but some walk into my office and their parent hands them the phone, and then I can only talk to the parent...I\u0026apos;ve had parents try to take work calls during appointments as their kid is telling them about things like trauma. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eHope for resources and guidelines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eI think I want to look into resources that can help parents with that; structured ways, basically behavioral interventions, that we do to promote phone hygiene. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eRole modeling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eI\u0026apos;m telling the kid, hey, could you put your phone away? But I\u0026apos;m also trying for the parent to do the same. And if the parent doesn\u0026apos;t listen, the patient\u0026apos;s not going to listen. (12U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eI\u0026apos;m saying, \u0026lsquo;you should not be on your phone in bed,\u0026rsquo; but know that I do it all the time. (03U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 6\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDomain 4. Recommendations: strategies to address phubbing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative quotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eIncremental strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDetox or tapering\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eI\u0026apos;ve been sober from Instagram for fifteen months now. (06U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eIf they\u0026apos;re looking at the screen for very long periods, we say they can reduce it gradually, that they can\u0026apos;t zero it out all at once (08T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eReplacement activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eWe say it needs to be filled with things like sports, courses, or hobbies, making social connections. Otherwise, they\u0026apos;ll cling to the phone again, or there will definitely be tantrums, they\u0026apos;ll demand it. (08T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eI\u0026apos;m seeing that in some of my patients they are purposefully disconnecting from their phones now, and they\u0026apos;re taking up things like cross stitch or painting, and they\u0026apos;re doing word searches, you know, in their free time or, getting back into reading (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDelayed age of introduction to technology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eI think the AAP\u0026apos;s recommendation is wait till eighth. So, typically, parents should wait until their child is in the eighth grade, so, like, 12, 13. And I\u0026apos;ll make that suggestion. (06U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSanctuary hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eI personally don\u0026apos;t, use the phone from six to 08:30 every day because that\u0026apos;s my kids\u0026apos; special time, and I\u0026apos;m focused on the kids. From 08:30 to 09:30, yes, I\u0026apos;m on my phone, and it goes to the silent from 09:30 onwards. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eCategorical\u003cbr\u003e\u0026nbsp;strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDevice limitations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eThen what about a flip phone? And, like, I don\u0026apos;t know if they\u0026apos;re going do it or not, but the kid was not happy when I suggested that. (03U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eActive parenting and monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eSo sometimes I have to, like, remind the parent that they\u0026apos;re the parent too. So they may have to do so things differently. It\u0026apos;s even hard for the adults to control this. (03U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eYou can\u0026apos;t completely shut it off, they\u0026apos;ll be exposed to it from friends in their environment too, but at least let the screens you give be ones where you can control the content, know what they\u0026apos;re watching. (09T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eIncreasing buy-in from children, adolescents, and families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eI think there\u0026apos;s a really good conversation that we can have with teens and adolescents from a motivational interviewing perspective and really helping them understand that the same way that we talk about substance use or smoking cigarettes back in the day; how these corporations spend a lot of money trying to force you to do this and you have to be individual and be free. (01U)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eI ask them to fill out a diary a bit more like to have the child track their screen times, to help them understand the magnitude of the problem at first. (10T)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Phubbing, digital health, child and adolescent psychiatry, qualitative methods","lastPublishedDoi":"10.21203/rs.3.rs-6797579/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6797579/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recent term \u003cem\u003ephubbing\u003c/em\u003e is the amalgamation of the words \u003cem\u003eph\u003c/em\u003eone and sn\u003cem\u003eubbing\u003c/em\u003e, and refers to those phone-related behaviors through which we ignore, dismiss, or otherwise eschew social interactions. Little is known about phubbing among child and adolescent psychiatrists (CAPs), a group often called upon to provide direction on how to guide children in their rapidly evolving cybernetic contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a mixed methods study of trainees in CAP (n = 73; 68% women), recruited in the US (6 training programs; n = 35) and Türkiye (5 programs; n = 38). For the quantitative component, we administered two standardized tests: the \u003cem\u003eGeneric Scale of Phubbing (GSP), \u003c/em\u003eand the\u003cem\u003eGeneric Scale of Being Phubbed (GSBP). \u003c/em\u003eFor the qualitative component, we conducted site-specific focus groups. After transcription, translation, and anonymization of the digitally recorded sessions, we analyzed the data using thematic analysis informed by interpretative phenomenology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYounger participants scored higher on the GSP (r = -0.43, \u0026lt;0.001), but ratings did not differ between countries (F = 0.65, df = 1, 70, p = 0.42). GSBP scores did not differ across age or country (p \u0026gt; 0.05). Through thematic analysis we arrived at a four-domain model: 1) \u003cem\u003ePerceptions\u003c/em\u003e: regarding the role of smartphone use in modern society and their social implications); 2) \u003cem\u003eExplanations\u003c/em\u003e: respondents’ conceptualization of antecedents to phubbing behaviors; 3) \u003cem\u003eConsequences\u003c/em\u003e: specific outcomes, such as normalization or split attention; and 4) \u003cem\u003eRecommendations\u003c/em\u003e: strategies to address phubbing and problematic phone use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhubbing is a ubiquitous behavior that can have social and emotional consequences. Through a more nuanced understanding of their own phubbing practices, CAPs can modify maladaptive behaviors of their own, have a more empathetic understanding of phubbing by youths under their care, and provide more realistic guidance regarding smartphone use to patients and their families.\u003c/p\u003e","manuscriptTitle":"When smartphones take over: a mixed methods study of phubbing in child and adolescent psychiatry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-06 14:55:18","doi":"10.21203/rs.3.rs-6797579/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-07T06:55:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T05:30:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312851953172739581817694103234950602577","date":"2025-06-23T23:31:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-12T12:18:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139485633722534331304871317846926718200","date":"2025-06-05T10:57:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-04T05:39:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-04T05:36:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T04:13:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child and Adolescent Psychiatry and Mental Health","date":"2025-06-01T20:36:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a045e5b-e314-4d94-bbf9-1b71a665947b","owner":[],"postedDate":"June 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:33:20+00:00","versionOfRecord":{"articleIdentity":"rs-6797579","link":"https://doi.org/10.1186/s13034-025-00950-0","journal":{"identity":"child-and-adolescent-psychiatry-and-mental-health","isVorOnly":false,"title":"Child and Adolescent Psychiatry and Mental Health"},"publishedOn":"2025-08-22 15:56:55","publishedOnDateReadable":"August 22nd, 2025"},"versionCreatedAt":"2025-06-06 14:55:18","video":"","vorDoi":"10.1186/s13034-025-00950-0","vorDoiUrl":"https://doi.org/10.1186/s13034-025-00950-0","workflowStages":[]},"version":"v1","identity":"rs-6797579","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6797579","identity":"rs-6797579","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}