At one San Francisco hospital, it's not uncommon for teens hospitalized with an eating disorder to surreptitiously use their phones to find weight-loss tips on social media. A psychologist who treats children in an Ohio primary care office hears from anxious or depressed patients who go online for fun only to encounter harmful content, like racial slurs in the public chat of the video game they play with friends. Suicidal teens receiving outpatient treatment at a Dallas hospital say their time spent on screens has included experiences like feeling left out or bullied, or being exposed to violence and self-harming behaviors.
Interviewed by Mashable, these doctors on the frontlines of the teen mental health crisis are quick to say that social media and screen use aren't universally bad for their patients. Indeed, they can connect teens to friends and fulfilling activities.
But even if the research on screen time and youth mental health is inconsistent, the worst-case scenarios illustrate how digital technology can help push teens into a downward spiral. Excessive or harmful screen time may act like an accelerant when combined with other risk factors for anxiety, depression, and suicide, which include chronic stress and trauma, drug or alcohol use, bullying violence, discrimination, and economic insecurity.
A recent report from the Centers for Disease Control and Prevention (CDC) revealed that, in 2021, teen girls experienced record levels of sexual violence and sadness, and that three quarters of LGBQ+ teens expressed persistent feelings of sadness or hopelessness, with nearly one in four LGBQ+ teens reporting a suicide attempt. Some argued that these trends, particularly amongst girls, could be partly traced back to the advent of smartphones and the sophistication of social media algorithms.
As political and consumer pressure mounts on social media companies like TikTok, YouTube, and Instagram to better protect youth from negative online experiences, parents are desperately searching for ways to let their teens enjoy the internet without becoming ensnared in the dark side of digital life. This week, TikTok announced that it would begin rolling out a 60-minute daily screen time limit for accounts belonging to users younger than 18. Once they reach that limit, they must enter a passcode to continue, a loophole that teens could easily exploit.
While the policy change was welcomed by the doctors Mashable interviewed, they also emphasized that parents can't count solely on these measures and trust that their children will be OK online. Instead, they need to better understand what content is being recommended to their teens by social media algorithms, what potentially unhealthy "norms" they're being exposed to online, and what they can do to boost their own family's connectedness as a bulwark against negative online experiences.
Dr. Ariana Hoet, a pediatric psychologist at Nationwide Children’s Hospital in Columbus, Ohio, knows that parents come to this challenge with their own strengths, whether that's clear values, deep ties to their community, or strong family relationships. But she also understands the tremendous pressure they're under to meet their kids' basic needs and deal with other problems. Sometimes, it's easier to let a teen have free rein of their screens in the midst of that chaos, but Hoet cautions against that approach.
"Adults have a hard time" managing their own screen time, she points out. "Kids with a developing frontal lobe going against these machines and algorithms that are meant to hook you in, they're going to lose."
"You're always on, you're being watched"
Hoet, clinical director for On Our Sleeves, a national movement for children's mental health, typically sees Latino and Somali youth in her primary care clinic. Though youth mental health had declined nationwide prior to the pandemic, like other psychologists Hoet saw an increase in mood disorders amongst children 8 and older, beginning in 2020.
During the pandemic, screen time surged for youth. One study found that 12- to 13-year-old youth spent twice the amount of minutes on non-school-related screen time, or 7.7 hours per day, than prior to the pandemic, with Black, Latino, and low-income youth reporting higher usage than their white, wealthier peers.
For many of Hoet's patients, digital connectivity is like a metronome in their heads. Even if their screen time is often positive, they've developed hyper-awareness of how they're perceived online.
"You are always on, you're being watched," says Hoet, describing how patients talk about their online lives. "A lot of kids view themselves as a brand, and they focus on that brand and how they're presenting themselves to others. That's a lot of pressure. That's a lot of stress 24/7."
This pressure may not be obvious to parents, who see their children texting with friends, posting funny TikToks, and exploring their interests on YouTube. But feeling like they can never turn off could be eroding their teens' confidence or overwhelming their developing brain. These same teens might also be dealing with violence in their community or economic insecurity at home, and relying on their phones to provide an escape — a coping strategy that can become problematic.
Once teens start to feel something is amiss with their mental health, they might search the internet for symptoms and a diagnosis, which only leads to more stress and anxiety. Hoet says she frequently talks to patients who've decided they have bipolar disorder or obsessive-compulsive disorder based on information they found online. Hoet can help debunk misinformation or clarify their diagnosis, but she knows there are plenty of teens who are convinced they have severe mental illness but never talk to a therapist or mental health professional.
Hoet says that parents can help relieve some of these pressures for teens by looking for ways to strengthen their child's relationship with peers as well as their own family bonds, particularly by doing offline activities together. Positive and fulfilling relationships are protective against a number of harmful experiences, including bullying and trauma. But Hoet knows that parents may encounter challenges as they try to boost their children's connectedness, like being unavailable after school because they work long, demanding hours.
Parents shouldn't blame themselves, says Hoet, but instead hold technology companies accountable and also look to policymakers who could address pressing social and economic issues that burden caregivers.
"We cannot expect parents to be at their best if they're battling the systems around them," she says.
The effects of social media
Dr. Jason Nagata, a pediatrician who cares for teens hospitalized with an eating disorder at UCSF Benioff Children's Hospital in San Francisco, sees perhaps the most extreme examples of how digital technology can erode youth mental health.
His patients require medical care because of the negative physical health effects associated with an eating disorder, which can include heart and kidney complications. From their hospital beds, some secretly try to consult social media for tips on how to continue disordered eating behaviors despite receiving in-patient medical treatment for them.
"To a certain extent, it's not something within their own control," says Nagata. "We do see people who are so entrenched in their illness, and how social media really enables that."
Nagata says the rise in eating disorders, particularly during the pandemic, partly reflects the changing dynamics of social media. While media and peer influences have long been risk factors for disordered eating, teens are no longer in "read-only mode," picking up ideals about body shape and size from movies, magazines, and commercials. Instead, they can create their own content, using their bodies as an example. This pressure can really "drive them over the edge," says Nagata.
Teens in heavier bodies are especially at risk of self-shaming and bullying related to social media content depicting idealized, often unhealthy, body aesthetics, and developing an eating disorder as a result, Nagata says. And while eating disorders are typically considered conditions that affect girls and women, he notes that boys and men are at risk, too. Instead of pursuing thinness, they're more likely to attempt to increase their muscle mass or tone in potentially dangerous ways. Yet Nagata says that social media companies haven't put as much emphasis on flagging and removing harmful content for boys as they have for girls.
Nagata says that social media use is just one risk factor for developing an eating disorder. Others include genetics, childhood trauma, and food insecurity. But he also studies the effect of screen time on children, and has consistently found a negative association with certain types of screen use and youth mental health. A recent study that he co-authored analyzed screen time data from more than 11,000 children between 9 and 11 years old and found that excessive use was associated with increased suicidal behaviors two years later.
Nagata can't say whether the screen use actually caused suicidal feelings amongst the children, but he emphasizes that the relationship between the two things should be better understood.
"These exposures are very complex," says Nagata, "...but [screen time] is an exposure we should pay attention to because it is modifiable."
What's happening on your teen's TikTik For You Page?
Dr. Betsy Kennard, a pediatric psychologist at Children’s Health in Dallas, Texas, treats teens who've been experiencing suicidal thoughts or have made a suicide attempt.
Most patients in the outpatient Suicide Prevention and Resilience at Children’s Program (SPARC) report some form of social media use that is known to be problematic, whether that's being on their phones well past bedtime, experiencing bullying, practicing extreme social comparison, or discovering content that promotes disordered eating.
In each case, the staff psychologists work with the patient to understand all the factors that went into suicidal feelings or an attempt. Then they develop a safety plan to address those specific issues, which vary from teen to teen. Among other skills, the program emphasizes media literacy, helping patients better understand what to share, how to compare themselves to others, and how to remember that their peers may not be posting the full truth about their lives.
But Kennard thinks the most powerful component of the program is helping teens realize that they're not alone, and that they can help each other recover.
Like Hoet, she strongly believes that tech companies need to create safer environments for teens, but also sees an opportunity for parents to protect their children using connection-based strategies.
"We find that a lot of times some of these behaviors we consider to be resilience-building have dropped out," says Kennard, noting how families may have prioritized extracurricular activities or honors-level classes for their children instead of one-on-one or family time. Parents can also talk openly about mental health with their children and model healthy screen use.
Dr. Lisa Damour, a psychologist in private practice, in Ohio, says that parents should learn as much as possible about the "norms in the digital environments" where their children spend time. They can make ideas like unhealthy thinness, bullying, and white supremacy seem conventional, and Damour says that teens are "very vulnerable to the norms" in spaces they seek out. (It's important to remember that their FYP or Instagram feed one week might look much different a month later depending on their viewing habits.)
If their TikTok For You Page is filled with goofy dance videos, that'd be less cause for worry. But if it's dominated by "dark and despairing content," that would concern Damour, author of the new book The Emotional Lives of Teenagers: Raising Connected, Capable, and Compassionate Adolescents.
In general, Damour believes that young people are trying to metabolize a lot of content from the internet while also being constantly aware of what their friends and peers are doing.
"It's a lot to ask of a developing brain," says Damour. "Teenagers deserve time away from the swirl of their broader social network."
If you feel like you’d like to talk to someone about your eating behavior, call the National Eating Disorder Association’s helpline at 800-931-2237. You can also text "NEDA" to 741-741 to be connected with a trained volunteer at the Crisis Text Line or visit the nonprofit’s website for more information. If you're feeling suicidal or experiencing a mental health crisis, please talk to somebody. You can reach the 988 Suicide and Crisis Lifeline at 988; the Trans Lifeline at 877-565-8860; or the Trevor Project at 866-488-7386. Text "START" to Crisis Text Line at 741-741. Contact the NAMI HelpLine at 1-800-950-NAMI, Monday through Friday from 10:00 a.m. – 10:00 p.m. ET, or email info@nami.org. If you don't like the phone, consider using the 988 Suicide and Crisis Lifeline Chat at crisischat.org. Here is a list of international resources.
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