Skeletal System

Dr. Steven Wenner, who specializes in hand surgery, and nurse practitioner Jessica Drenga show off a model of the bones beneath the skin.

Rehabilitation is a very broad term in the medical community, encompassing a range of services — ambulatory, cardiac, developmental, the list goes on — with one basic aim: to help patients achieve, or rediscover, the quality of life they desire. This story and the ones that follow demonstrate how area facilities are doing just that.

Thirty years ago, Dr. Joseph Sklar and Dr. Sumner Karas were among a group of physicians who gave birth to a medical practice that was ahead of its time: a place where every orthopedic surgeon had a subspecialty and only saw patients whose problems related to their area of expertise.

New England Orthopedic Surgeons (NEOS) was opened in 1987 by seven doctors and three physician assistants who made the decision to merge Mulberry Orthopedics and Chestnut Orthopedics, which were both in Springfield. The roster of physicians included Sklar and Karas, who met doing their residencies and fellowships at Mass General Hospital, liked the model they saw there that focused on subspecialties, and presented the idea to their partners, which became a central focus as they orchestrated the merger.

Over the past three decades, the practice has been highly successful. It has grown to 18 physicians and 22 physician assistants who see 700 patients a day in their Springfield office and two physical-therapy locations.

“We were a little ahead of the game, but thought this was the best way to deliver optimal patient care,” Sklar told BusinessWest, explaining that the idea stemmed from the belief that, if a doctor focused all of his or her energy on a subspecialty and did the same surgery frequently, their skill would improve, which would result in improved patient care and outcomes.

“We also believed if each doctor specialized in one area, the likelihood would increase that they would be able to recognize unusual problems and know the best way to treat them,” he added.

At the time, no studies had been done to substantiate these beliefs, but over the past several decades, a wide range of benefits from treatment by subspecialists have been documented; they range from accurate diagnoses to a low incidence of post-operative complications.

Today, NEOS is the largest surgical orthopedic practice in the Pioneer Valley. Patients range in age from infants to people in their 90s, although children who need reconstructive surgery for conditions such as congenital hip or spinal disorders or a club foot are usually treated at Shriners Hospitals for Children in Springfield.

Dr. Sumner Karas, Dr. John Corsetti, and Dr. Joseph Sklar say New England Orthopedeic Surgeons has grown to be the largest subspecialty practice of its kind in Western Mass.

But NEOS does provide care for many young people with traumatic injuries that include broken bones, dislocated shoulders, meniscus tears, or other sports-related problems.

Dr. John Corsetti, who specializes in sports medicine, arthroscopy, and shoulder and knee surgery, joined NEOS in 1995. He was impressed by the practice and said the number of surgeries its physicians perform today is significantly higher than orthopedic groups in Boston.

“Orthopedic surgeons in private practice usually do about 300 to 400 surgeries a year, but our doctors can do as many as 1,300 every year,” he said, noting that many of their patients are referred by other doctors for diagnosis refinement and confirmation.

The practice continues to grow, and on June 5 a new location was opened on Benton Drive in East Longmeadow with the goal of making care more convenient for patients who live in that area or in Connecticut. To that end, the NEOS physical-therapy office in the Sixteen Acres area of Springfield also moved to East Longmeadow.

Two new jobs for physician assistants were created, and an aggressive growth plan is in place for the future, but in the meantime, changes have been put into place that have reduced the time it takes to get an appointment.

In the past the wait was often several months, but NEOS has established a waiting list, and as soon as an appointment is cancelled, a receptionist picks up the phone and begins calling people until someone is found to fill the slot. It has led to 80 additional appointments each week, due in part to a ripple effect: when a cancellation slot is filled, the appointment time the person originally scheduled opens up.

In addition, X-rays no longer need to be taken in advance of an appointment. They can be done while the patient is in the office, which makes it easier for people to get the care and treatment they need in an expedited manner.

For this issue and its focus on rehabilitation and sports medicine, BusinessWest examines the growth of NEOS, the types of problems its doctors treat, and its plans for the future.

Storied History

Karas and Sklar moved to Springfield from the Boston area after completing orthopedic fellowships, which requires an extra year of training in a specialized area after a surgeon fulfills his or her residency requirements.

Sklar joined Mulberry Orthopedics, while Karas joined the Chestnut practice, and although they knew each other, they never dreamed they would play a major role in developing the largest orthopedic practice in Western Mass.

Sklar told BusinessWest he had enjoyed working with children at Boston Children’s Hospital, and one of the things that attracted him to Mulberry Orthopedics was the fact that its doctors provided staffing for Shriners.

It turned out that surgeons from both Mulberry and Chestnut covered for each other on weekends there, and the relationship between Sklar and Karas deepened through their shared work ethics and similar beliefs.

When the decision to merge and form NEOS was made, the two practices had nine doctors between them, but one retired and another moved, leaving seven doctors when the group opened their doors at 300 Carew St. in Springfield.

But forming the new partnership was a complex endeavor. In addition to requiring complete trust and a willingness to send each other patients, there were also financial implications. Since the surgeons agreed to see only patients whose problems fell into their areas of specialized expertise, they had to find a way to share incomes, because limiting their work meant some were no longer doing routine procedures that accounted for a significant percentage of their earnings.

But NEOS quickly became known, and as referrals from other orthopedic surgeons with challenging cases as well as the general public mushroomed, it added a physical-therapy area to its medical office.

“It allowed us to work closely with the therapists, which was particularly important for post-operative patient care,” Karas said, adding that it also enhanced their goal of providing the highest quality of care possible.

Fifteen years ago, NEOS moved to a much larger location at 300 Birnie Ave. in Springfield, and today, it is the only subspecialized comprehensive orthopedic surgical practice in Western Mass. Its physicians are all board-certified and focus on sports medicine, knee and hip replacements, hand and wrist care, foot and ankle surgeries, total joint care, trauma and fracture care, spine care, and orthotic services.

Each surgeon has completed a fellowship in at least one of these areas, but the physician assistants and nurse practitioners are generalists.

“This is important because sometimes it is not clear what the problem is; the neck can cause shoulder pain, while a problem with the spine can result in pain in the hip or knee,” Sklar explained, adding that PAs often determine which doctor the patient should see.

Surgery accounts for only half of the services provided at NEOS because medications, different types of injections, and physical therapy are often the best way to treat muscular-skeletal problems. For example, frozen shoulders can be helped with injections, people with arthritis in their knees or shoulders can experience relief with the help of medication and physical therapy, tendinitis in the hands can improve with splints, and ankle pain can be relieved with a splint or brace, which patients often get before they leave the practice, thanks to the wide array of durable medical equipment that NEOS stocks in its office.

A large number of the surgeries undertaken by NEOS physicians are performed at Baystate Orthopedic Surgery Center, and the results are reviewed by Baystate Medical Center.

“We also keep up with technology,” Karas said, adding that NEOS adopted an electronic medical-records system, has digital X-ray machines, and does casting on site.

Patients also benefit from communication that takes place between the surgeons, especially when a case involves complex injuries. “We come up with a plan and help each other with surgery, which gives everyone a great deal of comfort,” Corsetti said.

Sklar says being able to focus on one aspect of orthopedic medicine gave him the time and experience to create tools and implants that would make a difference in knee surgery, which, coupled with sports medicine, has been his primary focus.

He designed and co-designed two fixation devices that anchor grafts to reconstruct torn ACL ligaments into the bones inside the knee, has developed tools to make arthroscopic surgery more successful, secured a grant from the National Institutes of Health to study the effect of a patient’s outlook on their recovery from ACL surgery, and is an advocate of preventive measures that athletes or anyone engaging in exercise can take to avoid injury.

Changing Landscape

Corsetti said NEOS treats every type of orthopedic problem, and has a large population of patients with degenerative disorders. It continues to specialize and keep current in its respective fields, but thanks to minimally invasive surgical procedures, the length of a hospital stay after surgery has been greatly reduced.

“People used to be in the hospital for five to seven days after a total knee replacement, but now are in for two or three days. In the past, a shoulder surgery could involve a five- to seven-day stay, but today people sometimes return home right after it,” Corsetti told BusinessWest, noting that 60% of the patients they operate on go home the same day and often return to work several days later.

It’s all part of staying ahead of the curve in an ever-changing field, which NEOS has done since its early beginnings when Sklar, Karas, and their partners imagined a new way of delivering orthopedic care in Western Mass. — and made it a reality.

Overcoming the Phobia

Dr. James Dores says patients need to know their dentist will stop a treatment if they experience any pain.

The smell of freshly baked cookies wafts through the office at Dores Dental in Longmeadow, and a ‘comfort menu’ on the wall of the waiting room offers patients heated spa towels, movies, noise-canceling headphones, hot and cold drinks, and other items designed to help them relax before, during, and after a treatment.

The menu and idea of overcoming the smell associated with a dentist’s office by baking cookies all day are measures that Dr. James Dores and his staff use to help people overcome dental phobia, a severe, debilitating fear of having any type of dental work done.

And indeed, it’s a significant problem: the National Institute for Health reports the majority of people become anxious before getting dental treatment, and 10% to 20% have dental phobia. It tends to affect more women than men and can be detrimental to health as well as appearance.

People with dental phobia have fewer fillings and more decayed and missing teeth than their peers and typically contact a dentist only when they have pain that becomes unbearable, or when a major life event such as a divorce inspires them to do something about the condition of their mouth. However, waiting until that point often results in the need for complicated and traumatic procedures such as a root canal, which can further exacerbate and reinforce fear.

“About 75% of the population has some fear in regard to dental work. But there are definitely different tiers of it,” Dores said, adding that dental phobia can be resolved, but it takes caring and patience as it often stems from a traumatic, painful experience that occurred during childhood.

Health and Dental Plans in the region

Dr. Jane Martone has seen patients whose mouths are in terrible condition because of their fears regarding dentistry. “Some people are so afraid you will hurt them that just walking through the door is a major step,” said the founder of Westfield Dental Associates Inc., who teaches at the Medical College of Georgia School of Dentistry one week each month.

Dr. Vincent Mariano, a board-certified prosthodontist and co-founder of EMA Dental in Northampton and East Longmeadow, has seen patients who need work done on their entire mouth, and may need as many as a dozen crowns.

“If they have neglected their mouth for years, they can have problems with functionality. Some people have worn down their teeth so much that they can’t chew, or they have teeth that are so loose, they’re just moving around in their mouth,” he said.

As a result, people spend hours in his chair, so it is critical for him to develop a relationship with them and make sure they understand exactly what will be done before any work begins.

“I treat patients with very complicated dental needs, so the relationship is of the utmost importance for success,” he said, explaining that, in addition to fearing pain, many people with dental phobia are embarrassed about neglecting their oral health, but once a patient knows he is not judgmental, there is a much greater chance of success of rebuilding their mouth or treating their problem.

Martone concurs, and has talked to people at length on the phone to allay their anxiety before they work up the courage to visit the office. But since most are in pain, the first step is to eliminate it, although it’s equally important to reduce their overall fear, as preventive care can reduce the likelihood of future problems.

Dr. Vincent Mariano says establishing trust with a patient is key to alleviating fear.

“People have died from infections because they didn’t seek dental treatment at the appropriate time,” Dores said, adding that gum disease starts out as gingivitis (inflammation) which can easily be addressed in the early stages, but if it progresses into periodontal disease, it can destroy structures in the jawbone that support the teeth.

Researchers are also finding links between gum disease and heart disease, stroke, premature births, diabetes, and respiratory disease, and Martone has discovered medical problems during an office visit and referred people to their primary-care doctor to treat high blood pressure or other health issues they were not aware of.

In this issue, BusinessWest looks at what local dentists are doing to help people overcome dental phobia and how advances in technology help to alleviate pain.

Treatment Choices

Dentists take different approaches to treating patients with irrational fears. They all believe it’s critical to establish a solid, trusting relationship, but some prescribe drugs to relax patients before a visit, while others offer sedation during procedures.

Dores calls every new patient the night before their first visit to welcome them to the practice, allay any fears they might have, and answer questions, and since he caters to people with dental phobia, the conversations can be lengthy.

“Some people have told me they are terrified and really appreciate the call because it shows that someone cares,” he said, adding that many prospective patients read online reviews that help boost their confidence in his practice.

When they do arrive, they are greeted warmly, then given a tour of the office, and before a treatment plan is drawn up, Dores talks to them about their previous dental experiences, taking note of things they didn’t like.

Many report an instance when they tried to tell a dentist they were experiencing pain, but were ignored. “I have had people tell me they were in tears and the dentist kept going,” Dores said, adding that, since people like to talk about bad experiences, it’s easy to have negative experiences validated and reinforced by friends, family members, or co-workers.

Certified dental assistant Diane Harvey, who works with Dores, assesses each patient’s body language before and during treatments, and says talking about their family or pets and using humor helps alleviate anxiety.

“It only takes one bad experience for a person to become scarred for life, and I have seen people shaking and crying before the dentist even comes into the room,” she recalled, explaining that she tries not to leave phobic patients alone in the room and reassures them if they tell her the the work will result in pain.

“I tell them that dentistry has come a long way, and in this day and age there should be no discomfort,” she said.

Mariano says patients need to know that if they raise their hand, the dentist will stop working on their mouth, which is critical, as fear of loss of control is almost as great as the fear of pain. To that end, he not only explains procedures in advance, but gives patients all of their treatment options and lets them choose what they want to have done.

“If a patient is going to lose a tooth, treatment could be a removable replacement or extend to a dental implant. But the patient needs to help make the decision,” he said, adding that he tells people not to focus on the procedure, but to think about the outcome, and since he is doing restorative work, that often means a beautiful smile.

Dores and Mariano sometimes prescribe mild sedatives for patients with dental phobia, which can be taken the night before a procedure and an hour before they arrive at the office. It means they need someone to drive them to and from the appointment, but Dores said their visits are always booked early in the morning so they don’t have time to upset themselves.

Martone said she is the only general dentist in the area who is board-certified in implant surgery, and is also trained and certified in intravenous sedation. She told BusinessWest that many patients with dental phobia seek her services because they want to be sedated even for simple treatments, such as filling a cavity.

Surveys show that IV sedation eliminates embarrassment about the condition of teeth, as well as the fears of gagging, injections, not becoming numb when injected with a local anesthetic, pain, and drills.

However, before it can be administered, the person’s medical history is taken to make sure there are no contraindications, and while they are under sedation, their vital signs are tracked, and they are put on a cardiac monitor.

Since they are not under general anesthesia, Martone noted, people are able to talk and follow commands while they are sedated, but feel no pain and have no memory of what took place when the procedure is finished.

She believes IV sedation is safer than oral medications, as the onset is very rapid, and the dose and level of sedation can be tailored to meet individual needs.

“This is a huge advantage compared to oral sedation, where the effects can be very unreliable,” she told HCN.

Technological Advances

State-of-the-art equipment also helps eliminate pain or discomfort that might occur during a diagnosis or treatment.

Martone uses a DEXIS CariVu device that uses near infrared light to detect cavities. “It allows the dentist to see decay without having to take an X-ray,” she said, explaining that some people can’t tolerate having to hold film in their mouth, and the device eliminates that problem.

Martone and Mariano also have CT-scan machines in their office that allow them to take X-rays without having to put anything in the person’s mouth, and Martone adds that small things can make a difference. For example, she uses a numbing topical anesthetic before giving an injection so there is no pain from the needle. And since rapid injections can also be painful, she makes sure she administers local anesthetics slowly.

Dores employs a DentalVibe Oral Injection System to administer local anesthetics. The handheld device was created by a dentist and sends soothing vibrations to the brain that block any sensations of pain.

He also uses laser therapy to fill cavities and says he is the only dentist in the area with the machine to do so. The device he employs never touches the tooth and delivers anesthesia, eliminating the need for numbing injections, along with wavelengths of light that evaporate the tooth enamel. A drill still may be needed for refinements, but Dores said the majority of the work is done with the laser.

Still, dentists agree that one of the most critical factors in treating fearful patients is a good relationship. “Technology helps, but it is secondary to the main component,” Mariano said. “Pain control begins outside of the office.”

Things like sleep matter: if a patient does not get a good night’s sleep before a treatment, it has an enormous affect on their pain threshold.

Mariano recalled a patient he had worked on before without a problem, but during a visit where she had had three sleepless nights in a row, “she was such a wreck I couldn’t do the procedure. Many times the anxiety and pain patients feel in a dentist’s office is not related to the significance of the treatment,” he told BusinessWest. “The patient’s state of mind is of the utmost importance in successful treatment.”

Which means if the person is going through a divorce, has lost their job, or has another major problem in their personal life, the anxiety they feel will be exacerbated, so they need to be comfortable talking to their dentist about anything that is affecting their state of mind.

Slow but Steady Progress

Dentists say they do their best to have their staff go above and beyond and take extra time with people with dental phobia.

“You have to gain their confidence, as somewhere along the way someone has hurt them,” Martone said, recalling a time when a patient traveled from Orange to see her and started crying as soon as she walked into the office. Another came from Sunderland, and although they had a long discussion about her dental fears, she was afraid to even sit in the chair.

“It takes time to get a person to trust you, and sometimes all you can do is treat their emergency. My goal is to win them over, but it’s not always possible,” she continued. “Their fear never really leaves them, but it is reduced each time they come in.”

Still, the goal is to develop a relationship where the patient feels safe and secure.

“The relationship is a life-long investment,” Mariano said. “It’s all about changing the quality of their life.”

See Change

Drs. David Momnie and Camille Guzek-Latka say scleral lenses are giving hope to a subset of patients who have tried other remedies unsuccessfully.

Since Bradley Sweet was diagnosed with keratotonus, he’s had to choose between poor vision and constant discomfort. Until now.

Keratoconus, also known as ectatic corneal dystrophy, is a progressive, debilitating eye disease in which degenerative thinning results in irregular bulging of the normally spherical cornea, the clear covering in front of the eye. The condition results in grossly distorted vision, causing glare similar to looking through a windshield while driving in a rainstorm without using wipers.

Eyeglasses don’t help with this particular condition, leaving contact lenses as the only non-surgical path to functional vision. Unfortunately, said Dr. David Momnie, Sweet’s eye doctor and owner of Chicopee Eyecare, soft contact lenses have trouble conforming to the irregular cornea, while rigid, gas-permeable lenses that rest on the cornea can cause discomfort to that area.

In Sweet’s case, his corneal lenses fit poorly and ‘rocked’ on the surface, causing moderate pain. “On top of that, there was chafing; he had a scar from it,” said Dr. Camille Guzek-Latka, who has worked with Momnie since 1990.

But the team at Chicopee Eyecare was able to offer something different from most optometrists — scleral lenses, which contact the sclera, or the white part of the eye, and vault the entire cornea. If they fit properly, they offer both improved vision and comfort, Momnie told BusinessWest. For Sweet, they worked — and the rubbing and chafing was a thing of the past.

“No one else around here is fitting these,” Momnie said, adding that he knows of optometrists in Lowell and Boston who fit them.

Another patient came to the practice with similar issues. In 1994, she had undergone radial keratotomy, a procedure that involves making incisions in the cornea, and one that is mostly out of favor in the vision world. In her case, the procedure didn’t heal properly, and she ended up with distorted corneas, which causes blurred vision.

“We tried all kinds of things on her,” said Momnie, including soft lenses, corneal lenses, and hybrid lenses, which are hard in the middle but have a soft edge.

“We never got a good outcome with any of those,” Guzek-Latka said. “She was motivated, too — she would always say, ‘what do you have? What do you have?’”

When he decided to start fitting scleral lenses last year, Momnie called her up. “She’s the first one who came to mind. I said, ‘would you be interested in coming down sometime?’ She said, ‘I’ll be there in 10 minutes.’”

The fact that she finally found relief is immensely gratifying to Momnie and his team. Keratoconus affects somewhere between one in 500 and one in 2,000 people, and for those suffering with it, it can be debilitating.

“They can’t function; a lot of them can’t drive, can’t get licenses, can’t work,” Guzek-Latka said. “I’ve had people crying because they were so happy once they can see. That’s why we do it. To give someone their sight back is the best feeling in the world. People are so appreciative.”

Forward Looking

Chicopee Eyecare has a long history in the region. In 1974, Momnie took the reins of the practice from his father, Dr. Paul Momnie, who opened the office in 1950. After Guzek-Latka came on board in 1990, Dr. Julianne Rapalus, a part-time associate, joined soon after, and the three have been working together to solve vision issues ever since.

Scleral lenses gave Bradley Sweet the ability to see without constant discomfort.

Specialty contact lenses have long been among the practice’s niches, Momnie said. Until about 10 years ago, his team fit infants as young as eight weeks old with special contact lenses after they underwent cataract surgery. Fortunately, today, children born with congenital cataracts are now able to undergo intraocular lens-implantation surgery, eliminating the need for such specialty contacts.

Scleral lenses are a continuation of that mission to provide widely unavailable solutions for specialty eye issues — in this case, keratoconus.

Glasses can’t help because the lenses are too far away from the surface of the cornea to create the smooth, refractive surface necessary to translate the image clearly to the back of the eye and therefore to the brain. And primitive scleral contact lenses were made of low-breathability materials (the same as in Plexiglas, actually), resulting in severe swelling of the cornea.

However, today’s scleral lenses are manufactured with highly oxygen-permeable materials and are a viable treatment for irregular, diseased, or severely dry corneas, Momnie said. “These lenses require an exact alignment as they rest entirely on the damaged cornea. Fortunately, for some people, newer designs and materials have made scleral contact lenses more compatible with the eye and more comfortable to wear.”

Despite these advances, he added, the eye-care community has been slow to embrace these lenses, probably because they require an entirely new fitting philosophy, Momnie noted. “The lenses must be aligned with the exact amount of clearance to achieve adequate comfort and oxygen transmission to the cornea.”

He’s not surprised their use isn’t widespread. “They’re very time-consuming to fit and require a large investment in fitting sets. However, the more we looked into the advances in scleral-lens technology in the last few years, the more we realized this was a service that we needed to offer.”

The only other therapeutic option for improving vision in keratoconus patients is called penetrating keratoplasty, also known as a corneal graft or corneal transplant.

“In some cases, the eyes are too distorted. If it doesn’t work, sometimes the next step is corneal grafts, but these can have inherent problems too,” Guzek-Latka said. Because of the inherent risks and high cost of surgery, this option is typically reserved only for patients who cannot receive treatment from contact lenses.

Also, “while many transplants are successful,” Momnie said, “the eye is permanently weakened, and often a complex contact-lens fitting is still required to restore vision.”

Progressive View

Keratoconus isn’t the only condition that can benefit from scleral lenses. Others include corneal scarring or irregularity due to trauma or prior surgery, as in the case of the patient with a past radial keratotomy; severe ocular surface disease associated with surface defects like erosions and ulcers; and a number of other conditions, including severe dry eye, radiation injury, chemical or thermal injury, or certain congenital disorders.

In the case of keratoconus especially, Momnie said, there are few options beyond scleral lenses.

“Very often, for keratoconus, we are the last stop before the operating table,” he told BusinessWest, noting that some patients’ corneas are too damaged to avoid surgery. “But if we can keep them off the operating table and fit them with one of these, they’re in good shape.”

Only a handful of laboratories in the country manufacture scleral contact lenses, he noted. Often, the fitting requires two or three attempts before a proper fit is achieved. Advanced, computerized instruments like a topographer and an optical coherent tomographer — which maps the corneal irregularity much like a landscape topographic map, but much more precisely — are used to improve the chances of success.

When a patient does find success with scleral lenses and avoids surgery, which is most of the time, it can be life-changing, Guzek-Latka said.

“To be able to get someone to see, these younger guys trying to raise a family … if you can do that for them, that’s the best feeling in the world for me,” she added. “Anybody can give you a pair of glasses, and we love doing that for people. But when you take someone who can’t see, can’t function, and get them back to work and a normal life, when they look at you and say, ‘I can see, I can see,’ that’s what I love.

“We help more than we can’t, and they’re often pretty desperate by the time they see us; they’ve tried everything,” she went on. “So if we get someone like that seeing and doing their thing, that’s priceless. It’s very rewarding.”

Joseph Bednar can be reached at [email protected]

Share Scare

Elizabeth Morgan says young people interacting online are “experimenting with their public persona.”

Worried parents have all kinds of reasons why their kids shouldn’t participate in social media, Elizabeth Morgan said. But perhaps it might be helpful for them to consider why they want to.

“Researchers have asked teenagers this, and the typical reason is to connect with other people. Their primary motivation is to maintain connections, and establish new connections, with other people,” said the assistant professor of Psychology at Springfield College.

Teens with niche interests or unique challenges also benefit from social media, she said, because they might not find similar support locally.

“A lot of times, they’re using it to get information and learn about some experience they’re going through from people online who may not be in their immediate social network,” Morgan said. “That’s one of the positives. Think about a teenager with a chronic illness in Western Mass., where not many people experience that chronic illness. They can connect with people in Missouri, California, or Florida who are going through the same thing, to get information about what they’re going through.”

Still, whatever the reason, young people are also doing something developmentally important when they interact online — they’re experimenting with their public persona. And that can present social and emotional pitfalls.

“For some teens and tweens, social media is the primary way they interact socially, rather than at the mall or a friend’s house,” said Dr. Gwenn O’Keeffe, co-author of a clinical report issued by the American Academy of Pediatrics (AAP), called “The Impact of Social Media Use on Children, Adolescents, and Families.”

“A large part of this generation’s social and emotional development is occurring while on the Internet and on cellphones,” O’Keeffe added. “Parents need to understand these technologies so they can relate to their children’s online world — and comfortably parent in that world.”

Morgan said the idea of self-presentation in social media, on sites like Facebook, Instagram, and many lesser-known outlets, represent a developmental task. “Teenagers are always testing different identities, different personas face to face, and social media provides a way to do it in a safe place where they can manage their presence.”

But how safe is it, really?

“There are all kinds of risks, in the different choices kids make, in how they’re going to be seen and categorized by their peers,” said Dr. Barry Sarvet, chair of Psychiatry at Baystate Medical Center. “Kids have to deal with that anyway, but the online factor makes it quantitatively different; their choices potentially have bigger, broader consequences because of how viral things can get online. Misunderstandings happen more easily online; things are misconstrued.”

The preteen and teen years come with an array of hazards that aren’t exclusive to the Internet age, he went on, from character disparagement and low self-esteem to being stalked or threatened by truly dangerous people.

“Parents need to be aware of and help kids understand the dangers, but they’re not brand-new dangers; there have always been risks of kids being exploited, stressed, and depressed because they’re being stigmatized and misunderstood. And there have always been social networks, circles of friends, cliques. Social media is just another expression of that — but it’s got higher stakes in some ways, because of the permanence and irrevocability of what happens online.”

The solution, Sarvet says, isn’t necessarily to block teenagers’ access to the online world, but to become partners with them and help them manage it. Because social media, while a potentially valuable tool, poses some complex issues at a particularly vulnerable age.

Pursuit of Happiness

Morgan cited a study indicating that some people who use Facebook are happier than those who don’t — or, perhaps, happy people are more willing to share their lives on social networks — but, interestingly, excessive Facebook use may be linked with depression.

“Facebook can be a great experience that leads to connection, but it can also lead to depression, partly because of social comparison to other people who are presenting their best side,” she said, adding that those effects are not pronounced when people compare themselves to immediate friends and family, but spike when making comparisons to casual acquaintances, perhaps because that ‘best side’ seems more like reality.

When teens make the same comparisons to their peers, it’s even worse, she said, because social comparison is already a big issue in adolescence, so it makes them feel worse about themselves. “They might say, ‘look, he has 200 likes; I only have 100,’ or ‘she has 600 friends; I only have 550.’”

That said, it’s difficult to define exactly when young people should enter the social-media world because there’s such a broad range of personal development.

Dr. Barry Sarvet says the choices young people have when it comes to social media come with “bigger, broader consequences” than ever before.

“Some are late bloomers, some early bloomers,” Sarvet told BusinessWest. “Kids will say, ‘all my friends are on it, so I should be allowed.’ But parents have to consider how mature their child is and how vulnerable they might be and their level of judgment. One 13-year-old can have really good judgment and be very safe and be able to follow guidelines and understand why they’re important, and another 13-year-old may be completely unready to have that freedom and power.”

It’s natural, he went on, for kids to desire more freedom than they’re ready to have. “Parents have to constantly make those difficult decisions, how much freedom to give them. A lot of times, kids have to earn the trust. Parents may say to their kids, ‘I want to trust you, but you haven’t earned it because you haven’t been responsible or careful about things, so I don’t feel you’re ready right now.’

“We live in a world where a lot of personal sharing is going on, and kids don’t always understand the impact of what they put online or even just messaging with each other, not realizing things can be forwarded; even those Snapchat images can be captured and saved,” Sarvet added. “The complexity of people’s privacy, understanding the importance of privacy, is something that takes a lot of judgment, which kids don’t always have.”

Lapses in judgment can wreak havoc on young lives, O’Keeffe said, adding that young people can harm their reputations and safety by posting personal and inappropriate information. Meanwhile, information about sites they visit may be captured and used to target them with advertising.

“Cyberbullying happens as well. That’s the dark side of the situation,” Morgan told BusinessWest. “Really, it’s on the parents to try to help manage their children’s experience and be aware of what’s going on, so if there do happen to be instances of cyberbullying, the parents can help the child deal with it.”

Straight Talk

The AAP has issued a series of guidelines pediatricians can use to help families navigate the social-media landscape, including:

• Advise parents to talk to children and adolescents about their online use and the specific issues that today’s online kids face, such as cyberbullying, sexting, and difficulty managing their time;

• Advise parents to work on their own ‘participation gap’ in their homes by becoming better-educated about the many technologies their children are using;

• Discuss with families the need for a family online-use plan, with an emphasis on citizenship and healthy behavior; and

• Discuss with parents the importance of supervising online activities via active participation and communication, not just via monitoring software.

Some house rules can be as simple as using the Internet only in a common room of the house, or not logging on past a certain hour at night, as not to disrupt sleep, Morgan added. “There are so many ways to manage these experiences beyond saying, ‘no social media at all.’”

She added, however, that it’s just as important for parents to develop trust and strong communication with their children, so they feel comfortable approaching the adults with problems that arise.

“Be sure your child knows what can happen and, if it does, that you’re available to help them deal with it, whether that involves blocking a person from your network or pressing charges, if stalking is going on, or just learning how to respond to, or ignore, negative statements and emotionally cope with them. Parents can be a good resource for all of that.”

Sreedhar Potarazu, an ophthalmologist and CEO of VitalSpring Technologies Inc., recently wrote at CNN.com that young people are growing up to expect immediate response, gratification, and notification, all hallmarks of social media, and their brains no longer have time to evolve; instead, they must adapt to change in an instant.

“The results are distressing. The difficulties of growing up have never been so public,” he wrote. “Social technology provides a platform where things can run wild. Imagine the stress of high school — the competition for popularity, the pressure to fit in, the judgmental nature of social activities — at an accelerated pace.”

He suggests a number of steps parents can take to help their children navigate this world, such as:

• Create more structured forms of social media that prevent children from diving into, say, Snapchat right from the start;

• Provide a way for parents and administrators to get feedback on their kids’ online use without intruding on privacy and alert them to impending dangers;

• Add courses on social technology and responsibility to school curricula, teaching adolescents that what they do online exposes them to the whole world — sometimes forever, and perhaps affecting their job searches and choice of a mate; and

• Ease up on the pressure, and persuade teens that that they don’t have to market themselves constantly, and that social media can be a mechanism for fostering collaborative relationships, rather than competition, aggression, and irresponsible behavior that contributes to anxiety and depression.

A Question of Trust

Sarvet stressed, however, that the online world is not an intrinsically bad place.

“I think there’s still a lot of richness,” he said. “I tend to encourage parents to be open-minded about this stuff because I think a lot of parents are very suspicious and skeptical of it and focus more on the horrible things that can happen, and they’re also very unrealistic about their ability to control it.”

To wit, a recent Pew Research Center study found that 92% of teens go online daily, and 24% say they are online “constantly.” Common Sense Media reports that 90% of teens have used social media, and 75% of them have profiles on social-networking sites. In another study, CNN found that some 13-year-olds check their social-media feeds 100 times a day.

“I think it’s important for parents to recognize that their kids are in school, out in the world, and they should assume — even if they have a rule that their kids are not allowed to be on Facebook — that their kids might be on Facebook,” Sarvet said. “They should accept that they’re not in charge all the time of their kids’ use of social media, and they can’t be. If you accept that, the focus becomes less on having rules and more on helping them understand the complexity of what they’re doing online.”

Barring teens outright from social media, he suggested, only manages to destroy the lines of communication that might come in handy someday, whether dealing with serious issues like cyberbullying and sexting or simply learning more from one’s teens about the online world, which sites are popular, and what kids today are doing there.

“If they have a nice, respectful relationship with their kid, it allows the parent to have a guiding influence and an opportunity to learn what kids are doing and have an open dialogue about it,” Sarvet went on. “When parents are overly nervous and, in response to this nervousness, start making these strict rules, it just invites kids to find ways to get around the rules, and they no longer talk to their parents about it, knowing you’ll be mad at them.”

In short, he told BusinessWest, “control what you can control,” and the rest is building trust.  No one said it would be easy, in a culture where positive connections and lurking dangers are both just a few clicks away.

Joseph Bednar can be reached at [email protected]