7 February 2025. Meeting summary. Lancet Psychiatry Commission Roundtable with Mr Josh MacAlister MP

1. Welcome and introductions.

Present:
Mr Josh MacAlister MP.
Naomi Fineberg (Roundtable Chair), University of Hertfordshire. Chair, Lancet Psychiatry Commission Global Action on Problematic Usage of the Internet (PUI), and Coordinator, BootStRaP – Boosting Societal Adaptation and Mental Health in a Rapidly Digitalizing, Post-Pandemic Europe.
Baroness Beeban Kidron. Member, Lancet Psychiatry Commission Global Action on PUI
Henrietta Bowden Jones, Cambridge University. Member Lancet Psychiatry Commission Global Action on PUI
Joan Marsh, Editor in Chief, Lancet Psychiatry.
Sarah Kline, United for Mental Health and Advisor, Lancet Psychiatry Commission Global Action on PUI.
Karis Eaglestone, The Prudence Trust.
Hans-Juergen Rumpf, University of Lubeck, Workstream Lead BOOTSTRAP.
Andres Roman-Urrestarazu, Cambridge University. Member Lancet Psychiatry Commission Global Action on PUI and Workstream Co-lead BootStRaP.

Apologies: Dan Stein, Marc Potenza, Zsolt Demetrovics.

2. Conflict of interest (COI) disclosure
No parties disclosed a COI

3. Brief introduction to the Lancet Psychiatry Commission Global Action on Problematic Usage of the Internet (Prof Naomi Fineberg)
The Commission [Global action on problematic usage of the internet: announcing a Lancet Psychiatry Commission – The Lancet Psychiatry] is a multidisciplinary international group of authors with expertise in compulsive, impulsive, and addictive behaviours, public health and policy, working in close collaboration with an advisory group including clinicians and policymakers with an interest in this area and people with lived experience of being negatively affected by problematic usage of the Internet (PUI).

Our aim is to deliver evidence-based recommendations to improve health practices and advance health policy globally in the field of PUI, in the form of an evidence-based document for publication in the journal Lancet Psychiatry- expected publication date Autumn 2025.

As a Commission, we recognise the many benefits the internet and digital media have brought society. Our overarching aim is to support and strengthen balanced and resilient internet usage across all age ranges and social groups. However, we recognise that not everyone is able to use the internet safely in all circumstances.

We work in the field of PUI (problematic usage of the Internet)- an umbrella term for a wide range of problematic internet-related behaviours (gambling, gaming, social media use, pornography viewing, shopping, cyberchondria, video-viewing, other forms of information seeking…). These different forms of PUI are not exactly the same, but they do share common features including loss of control of screen use, resulting in compulsive or addictive engagement at various degrees of severity (hazardous versus disordered behaviour).

PUI is common across all age groups (~7% globally, ~25% in young people) with a likely colossal health economic burden, though health economic data in much of the world is limited (in 2018, the gaming industry alone was estimated to cost ~USD 3.5 billion per annum in S Korea1).

Harms linked to PUI involve the individual (direct/indirect via neglect of normative activities, presenteeism etc), families and carers and society. Importantly, gambling disorder, gaming disorder, and compulsive sexual behaviours disorder are already recognised by the WHO as diagnosable conditions and are therefore eligible for treatment, but health services barely exist.

Risk factors for developing PUI seem to fall into 3 domains, each of which may serve as a target for intervention and policy change:
1. The product/provider (Commercial models, availability and low cost, addictive content e.g. gambling elements, design elements to maximise engagement (cues, reminders, scrolling functions, multipliers), persuasive algorithms, AI)
2. The individual (Age, gender, genetics, temperament, cognition, executive function, educational status, mental health)
3. The environment (Family environment and role models, school environment, social and cultural factors, advertising, accessibility, treatments and services)

Our understanding of how these risk factors interact is limited, owing to a scarcity of mechanistic research and lack of longitudinal cohort studies to determine the directions of causality and the wellbeing outcomes with greater certainty.
To answer these important gaps in knowledge, members of the round table are leading the UKRI-Horizon-Europe funded BootStRaP programme [BootStRaP – Boosting Societal Adaptation and Mental Health in a Rapidly Digitalizing, Post-Pandemic Europe]. Bootstrap represents the largest governmentally funded longitudinal study investigating PUI in Europe. Over a 5-year period we will recruit (starting December 2024) >10,000 children aged 12-16y in schools across several centres in UK and continental Europe. Bootstrap aims to determine who is most vulnerable to developing PUI. The project will also develop and validate new tailored age-appropriate digital self-help preventative tools and interventions to protect those most vulnerable from developing PUI at the earliest opportunity, before the addiction takes hold.

As the Bootstrap findings become known, they will be disseminated at a global level to interested parties, including politicians, at future round tables, and other public stakeholders. Looking ahead, Bootstrap representatives in this round table would hope to sustain channels of communication with Mr Macallister and the UK Parliament, to keep them informed of the scientific advances as they develop.

4. The Safer Phones Bill’ and matters arising (Mr Josh MacAlister)
Mr MacAlister explained the origins of the Safer Phones Bill in the context of his background as a teacher and working for the previous government on child protection and criminal exploitation. He said his experiences taught him that social media was a prominent factor in the exploitation of children. Since then, he has become concerned by the emerging evidence linking the increasing use of smartphones with a variety of harmful societal trends and the lack of any alternative coherent hypothesis to explain this. While the Online Safety Act provides a useful framework, as a lawmaker, he feels a duty to ensure the legislation remains up to date, by incremental additions, to keep up with emerging societal contingencies.

The goal of the Safer Phones Bill is, through the most modest means, to
• ‘dumb down’ the more compulsive components of smartphone products so as to free up children to have more real-world interaction
• raise the age at which children can provide consent without parental involvement
• empower parents and carers to limit children’s daily smartphone screen time.

This not only involves amendments to the Online Safety Act, but importantly also involves ensuring that the UK regulator, Ofcom, fully and confidently enacts its responsibility for holding the digital companies to account by properly interpreting the powers for statutory regulation that are already enshrined in existing legislation. For example, it has been difficult to persuade Ofcom in their developing code of practice to include the specific measurement of the ‘functionality’ of online systems and products.

Mr McAlister noted that while there remains some reticence among politicians to ‘take on’ the digital industries, the tide was changing as public opinion already seems to be moving in favour of greater regulation to protect children. However, he experiences some resistance from certain groups including some academics who claim that the strength of the evidence of harms related to social media use, upon which his legislative programme is based, is too weak and incomplete to be reliable.
He was interested to know from the Commission our joint opinion about A) the health risks associated with smartphone use and B) the need for greater regulation.

5. Responding to the proposal for the Safer Phones Bill and setting new age limits for accessing social media (Prof H Bowden-Jones, Prof A Roman-Urrestarazu)
Prof Bowden-Jones emphasised the real harms that smartphones cause at a clinical level in terms of addictive behaviour. In her leadership role at both the National Gaming and Gambling Clinics, she sees real world empirical evidence of the direct damage that an unregulated industry is having on vulnerable groups including the young and their families. However, it was not only obviously pathological behaviour (addiction) that caused concern but the prodromal early stages of problematic internet related behaviour- which involves a much broader group of people and who are critically important as intervention in the early stages before the addiction takes hold is much more likely to be effective. She said from her lived experience the providers showed no accountability for these harms, and it was quite clear that the digital industries cannot regulate themselves.

Prof Roman-Urrestarazu emphasised the need to regulate the digital industry based on the precautionary principle that in the face of persuasive evidence of harms related to their products in so many online domains, it was necessary and proportionate to act to protect vulnerable young people from harm. In this respect, children under the age of 16y must be considered a vulnerable group, owing to the immaturity of their decision-making faculties. By default, UK law stipulates that children are not considered competent to enter any kind of commercial or legal contract, consent to sex etc until they are at least 16y, unless special rules apply (considered Gillick competent). Research ethics requires parents to give consent until a child is 16y of age. Considering the known harms associated with smartphone products, it would seem rational for the UK regulator to apply at the very least the same rule/age limit (16y) for entering a social media contract as for any other commercial contract. For adults with full capacity, arguably, a different threshold should apply.

6. Making the Internet Safer by Design (Baroness B Kidron)
Baroness Kidron wished to make 4 key policy-related points that had arisen from the discussion so far:
1. The importance of intervening early – don’t wait for pathological behaviour before seeing harm
2. The functionality of the internet, and not just its content, must be the subject of regulation
3. The issue of (lack of) competency of children
4. We must not rely overly on parents to regulate children’s access to smartphones because a) they may not know what is going on with their child; b) they may have become complicit in the PUI; C) they may not be present.
Hence, the optimal solution is working to a situation where companies engineer products that are safe by default.
Finally, she opined that Ofcom need to ‘step up to the plate’.
7. Broader considerations for safeguarding young people’s digital health (Prof N Fineberg, Prof HJ Rumpf) including public health messaging and interventions, business models, research and health service developments.

Prof Fineberg summarised by saying that even though flaws and inadequacies in the scientific evidence exist, the Commission were nevertheless convinced that there is sufficient evidence of harms related to many aspects of internet use, including social media use in particular, for the precautionary principle to protect children to apply. We recognised that this would need to take place at least in part via governmental regulation, as the commercial companies have not shown any convincing interest in self-regulation. However, the need to regulate ought to be balanced against various drawbacks that setting age limits for social media use might bring. We know for example, that many children, e.g. those from marginalised groups, derive benefit from communicating and building communities via social media, who would lose out if these were unavailable. There is also the concern that ‘banning’ as a policy has never been that successful in analogous situations e.g., for controlling addictive substances or managing mental health issues.

Prof Rumpf followed on by saying that while applying age restrictions is a good way to start, there are many other promising policy opportunities for making the internet a safer place for children, based on emerging scientific evidence, that should be considered. These include
1. Interventions in school settings – to strengthen skills of children in the domains of emotional regulation (how to manage emotions without immediately resorting to the internet) and inhibitory control (how to control when and how long it is used for).
2. Preventative interventions aimed at identifying at-risk’ children and teaching them better control of their experiences online. These interventions go beyond simple ‘digital literacy’, which has been shown not to be enough to counteract PUI. The interventions need to focus on vulnerable groups and target their specific vulnerabilities. They have to be selective and indicative. Those who are at risk should be detected and then offered help.
3. Behavioural change. What and how to help effectively? – That is a challenge and an important area for research. How to get the children to reflect and change their behaviour?
4. Challenging Stigma. We know that only a minority of people with addictions or PUI (<10%) make use of the interventions available, and stigma is often the underlying reason.

In sum, in this area we need to combine a broad approach involving targeting at-risk groups, with a low threshold i.e., not just those who are disabled by addiction, AND applying specific interventions that we know will work.

Finally, Prof Rumpf stated that systematic reviews show there is enough evidence to say that social media and other internet-related functions are having a negative impact on young children. However, we need more studies to look at the effects of age restrictions and other regulations to see if it really works i.e., We need more research grounded in intervention to fill this knowledge gap.

Prof Bowden-Jones added that we need to work out a process for enforcement of age restrictions and that there are various mechanisms under development for doing this effectively (e.g. face recognition software for children) that need to be considered. She also said that any regulation should be based on the principle of the public collectively ‘opting in’ and not ‘opting out’.

Mr MacAlister added that he was suspicious of expecting parents to ‘figure it all out’ and bear the burden of policing their children’s internet activities and habits without the support of regulation.

Prof Fineberg said that while regulation of age limits for PUI makes sense, it could sit in a broad policy model that also supports public health education, preventative and therapeutic intervention, and service development.

Mr MacAlister said that some academics he has conversed with have suggested that the evidence of social media-related harms is not sufficient to support policy change. They are moving toward taking a neutral stance on risk, but that is not helpful as it still blocks action.

Prof Rumpf said that there is enough evidence to say categorically that a substantial minority of young people are adversely affected by the internet/social media.

Prof Roman-Urrestarazu repeated that children are recognised as a vulnerable group and need the protection of the law. He has argued with those academics at his university, but it is hard to change their views.

Prof Rumpf added that some vocal UK scientists claiming there is no risk are in the minority in the scientific community. Of course, in science there are always people who think differently- for example, when working with the WHO he found some researchers tried to prevent gaming disorder becoming a diagnosis, but there is an overwhelming amount of evidence in so many areas – the adverse effects and the mechanisms are clear.

Specifically, we see such a broad range of individual PUI-related harms (harmful use, cyberbullying, suicidality, eating disorder) that, although a specific piece of research might not find a positive correlation, taken together the picture is clear that harms exist. What is less clear is the effect of internet use on brain development and on normal developmental trajectories.

Baroness Kidron said that a neutral stance toward harms is not only unhelpful but blocks progress.

Prof Bowden-Jones added that there is a constellation of research demonstrating harms, from powerful anecdotal testimony to epidemiology to neurological studies.
The issue of conflict of interest affecting research was raised. Baroness Kidron said that the House of Lords is debating the importance of getting technology companies to make available access to their behavioural data for independent research, which so far has held everyone back.

Joan Marsh (Lancet Psychiatry) said we cannot wait for academic trials to produce results- it takes too long. The data we need are there in the possession of the technology companies and researchers need to access it – that is the way forward. If we can, there are ways in which we can analyse it and work out the behavioural effects of social media and other forms of PUI including how people are getting addicted.

Sarah Kline (United for Global Mental Health) commented that it was important for politicians to hear the voice of those who are not usually able to speak – the public, who are often overlooked. It is so important to bring ordinary people’s voice to the table. What happens in the UK Parliament will be noticed around the world and her organisation will support dissemination.

Karis Eaglestone (Prudence Trust) added that this is such an important area in field of youth mental health and her organisation is often pressed for a view. She was aware of a recent UK-based report that had seemingly not fully endorsed the harms associated with internet use in children and so her organisation had not promoted it strongly. She was encouraged by the roundtable discussion and the work of the Commission and wanted to be kept abreast of developments to promote it more widely when it is published.

8. Concluding remarks and next steps (Mr J MacAlister)
Mr Macallister concluded the meeting at 2pm, thanking everyone for their contribution, which said he had found extremely helpful and encouraged the Commission to continue their work.
It was agreed that Prof Fineberg would produce a meeting summary for circulation.

Second draft N Fineberg 30/1/2025

References
1. Cho DJ, Kim HT, Lee J, Park SH. Economic cost–benefit analysis of the addictive digital game industry. Applied Economics Letters. 2018 May 21;25(9):638–42.