Monthly Archives: January 2019

The cost of persuasive design: digital media use and ADHD

This longitudinal study of American teenagers by Ra and colleagues, sought to explore the association between digital media use and symptoms of Attention Deficit Hyperactivity Disorder (ADHD), as well as explore the relationship between high frequency digital media use and ADHD symptom severity.

The study is topical as all parents worry about the relative amount of screen time versus green time that their children engage in, however on the basis of this study should we be concerned about the relationship between digital media use and an enhanced risk of later ADHD?


All parents worry about the relative amount of screen time versus green time.

Ra and colleagues study highlights the urgent need to ensure that the design of digital services and products is appropriate for children and young people. Their longitudinal study shows a significant (but modest) association between higher frequency of digital media use and subsequent symptoms of ADHD when measured with Self-Report Form DSM-IV.

The study seems to indicate that the likelihood of developing ADHD symptoms among a longitudinal (24 months) cohort of 15 and 16 years olds (that showed no significant ADHD symptoms at baseline) can increase as a result of high frequency social media activities. While more evidence is needed to understand the impact of persuasive design strategies on children and young peoples’ social, mental and physical development, studies such as this illustrate the potential negative outcomes of excessive use.


This longitudinal study shows a significant (but modest) association between higher frequency of digital media use and subsequent symptoms of ADHD.

Pervasive design

Pervasive design, a term coined by psychologist BJ Fogg, combines the theory of behavioural design with computer technology (Fogg, 2002). Behavioural design uses a system of rewards and punishments to determine human behaviour patterns. Both persuasive and behavioural designs can be used to manipulate human behaviour so that users act in the commercial interest of others (Kidron et al, 2018). Persuasive design strategies are deployed for commercial purposes to keep users online.

It is neither ethical or reasonable to design services to be compulsive and then worry about the impact that persuasive design may have on children and young people’s mental health due to smart device overuse. Internet Matters (2015) revealed that in the UK, 40% of secondary school-aged children and 34% primary school-aged children “feel worried that they are addicted to the internet” (Clark et al, 2015).

Often British children and young people display absolute devotion to their devices, on the one hand saying they “could not do without their mobile phone for a day” (Murgia, 2017), that they are “best friends” with their phone or don’t feel “right without it”. At the same time, they report being “addicted”, “attached”, “distracted”, “obliged”, “always consuming”, having “no control” and feeling “panicked” (Coleman et al, 2017).

Common Sense Media (2016) found that one third of American children aged between 12 and 18-year-old struggled to cut down time spent on devices; half said they felt “addicted to their mobile devices”.


Persuasive design strategies are deployed for commercial purposes to keep users online.

Persuasive strategies

The tension between being governed by and devoted to their devices is, in part, a result of the persuasive strategies baked into the digital services that children and young people use. These include:

  • Excessive notifications such as buzzes, pings and all other non-specific alerts
  • Lack of save buttons (so users are forced to stay online to complete a task)
  • Software upgrades that automatically enhance or switch persuasive design features back on
  • Personalised services design to extend use among many others
  • Reward features that release dopamine
  • The need to use social media in order to be social or popular
  • Highly emotive content

All of the above create a digital environment that does not meet the needs of children and young people.


Digital technology is designed to persuade young people to use it as much as possible.

Monitoring and addressing problems with digital media

Whilst acknowledging the great potential of the digital world, and recognising the value of responsive usage, the technology sector should monitor and address the effects of their products on children and young people and recognise that the options provided to parents and teachers to address digital media overuse are inadequate an ineffective. These include:

  • Over simplistic rules
  • Misconceptions
  • Exaggerated claims
  • Widespread uncertainty that may limit opportunities and creativity.

We need better ways to monitor and address overuse of digital technology.

Digital media use in young people with ADHD

Digital media use for children with ADHD presents a unique threat that non-ADHD children do not face to the same extent. It is clear that sustained attention is poorer in children with ADHD compared to typically developing children and reinforcement improves sustained attention (Bubnik et al, 2015).

Taken together these findings suggest that children with ADHD may be even more likely to seek out the immediate and intense reinforcement opportunities available via digital media, because they are less likely to find the reinforcement opportunities in their offline life.


Young people with ADHD are likely to be more susceptible to the intense reinforcement opportunities available via digital media.


In addition to the three study limitations already identified by the Ra and colleagues (i.e., ADHD symptom scale, media use measure validity, and sampling), other issues need addressing:

  • The authors do not reflect on the high attrition rate (almost 50%) or the large proportion of participants (48.2%) eligible for subsidised lunch, its impact on sample representativeness and overall results
  • In addition, the authors do not display data regarding the 13th digital media use index score (i.e., Online shopping or browsing).

While we welcome longitudinal studies that explore the impact of digital social media use on children and young people’s mental health and wellbeing, we need to remain vigilant as to the complexity of multiple confounding influences that may be contributing to the Ra and colleagues’ study results.


Longitudinal studies suffer from problems with confounding, so better evidence is needed before we can be sure of the links between digital media and ADHD.


Primary paper

Ra CK, Cho J, Stone MD, et al. (2018) Association of Digital Media Use With Subsequent Symptoms of Attention-Deficit/Hyperactivity Disorder Among AdolescentsJAMA. 2018;320(3):255–263. doi:10.1001/jama.2018.8931

Other references

Fogg BJ (2002). Persuasive Technology: Using Computers to Change What We Think and DoUbiquity, Volume 2002 December, Article 5.

Kidron B, Evans A, Afia J (2018) Disrupted Childhood. The Cost of Persuasive Design (PDF).

Clarke B, Atkinson R, Svanaes S (2015) How Children Use Mobile Devices at School and at Home (PDF). London: Techknowledge for Schools. September 2015, p4.

Murgia M. (2017) Secret lives of children and their phonesFinancial Times, 6 October 2017.

Coleman S, Pothong K, Perez Vallejos E, Koene, A (2017). The Internet on Our Own Terms: How Children and Young People Deliberate about their Digital Rights (PDF).

Technology Addiction: Concern, Controversy and Finding a Balance. Common Sense Media. Research Brief, May 2016.

Bubnik, M.G., Hawk, L.W., Pelham, W.E., Waxmonsky, J.G.Rosch, K.S. (2015) Reinforcment enhances vigilant among children with ADHD: Comparisons to typically developing children and to the effects of Methylphenidate. Journal of Abnormal Child Psychology, 43, 149 – 161.

Photo credits


This post first appeared on the National elf service.

It was written by:

Dr Elvira Perez Vallejos is an Associate Professor of Digital Technology for Mental Health and Digital Technologies at Nottingham Biomedical Research Centre (Division of Psychiatry and Applied Psychology, Faculty of Medicine).

Dr David Daley is Professor of Psychological Intervention and Behaviour Change in the Faculty of Medicine & Health Sciences at the University of Nottingham.

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