Smartphones, Social Media Use and Youth Mental Health

ANALYSIS MENTAL HEALTH CPD

Smartphones, social media use and youth mental health

Elia Abi-Jaoude MSc MD, Karline Treurnicht Naylor MPH MD, Antonio Pignatiello MD

n Cite as: CMAJ 2020 February 10;192:E136-41. doi: 10.1503/cmaj.190434

CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190434-ana

n the last decade, increasing mental distress and treatment for mental health conditions among youth in North America KEY POINTS has paralleled a steep rise in the use of smartphones and • Evidence from a variety of cross-sectional, longitudinal and Isocial media by children and adolescents. empirical studies implicate smartphone and social media use in In Ontario, the proportion of teenagers reporting moderate to the increase in mental distress, self-injurious behaviour and serious mental distress increased from 24% in 2013, to 34% in 2015 suicidality among youth; there is a dose–response relationship, and to 39% in 2017,1 with parallel increases in health service utiliza- and the effects appear to be greatest among girls. tion. Inpatient hospital admissions of children and adolescents for • Social media can affect adolescents’ self-view and interpersonal relationships through social comparison and negative mental health reasons increased substantially across Canada interactions, including cyberbullying; moreover, social media between 2007 and 2014, while admissions for other medical condi- content often involves normalization and even promotion of tions in this age group decreased by 14%.2 Between 2009 and 2014, self-harm and suicidality among youth. admissions to hospital for intentional self-harm increased by 110% • High proportions of youth engage in heavy smartphone use and in Canadian girls.3 Suicide is now the second leading cause of death media multitasking, with resultant chronic sleep deprivation, for Canadian youth.4 A recent analysis of survey data found the and negative effects on cognitive control, academic performance 12-month prevalence of suicidal ideation, attempts and nonsuicidal and socioemotional functioning. self-injury to be 8.1%, 4.3% and 8.8%, respectively, among adoles- • Clinicians can work collaboratively with youth and their families, using open, nonjudgmental and developmentally cents aged 14 to 17 years, with all rates being higher in girls.5 Simi- appropriate approaches to reduce potential harms from social larly, administrative data in the United States show that presenta- media and smartphone use, including education and practical tions to hospital for suicidal ideation or attempts among children problem-solving. and adolescents almost doubled between 2008 and 2015, with the • There is a need for public awareness campaigns and social highest increase for adolescent girls.6 Self-poisoning rates among policy initiatives that promote nurturing home and school 10- to 18-year-olds, which had declined in the US since the turn of environments that foster resilience as youth navigate the the century, increased substantially from 2011 to 2018, primarily challenges of adolescence in today’s world. among girls.7 Surveys of high school students in the US have shown a similar pattern for self-reported symptoms of depression, major depressive episodes and suicidality over the last 2 decades.8,9 are observational, making causality difficult to establish, findings At the same time, social media use has increased markedly. In from a few longitudinal, randomized and controlled studies suggest the US, the proportion of young people between the ages of 13 that social media and smartphone use may be contributing to the ris- and 17 years who have a smartphone has reached 89%, more ing burden of mental distress among youth. We consider the clinical than doubling over a 6-year period; moreover, 70% of teenagers implications of existing evidence, to help practising clinicians to work use social media multiple times per day, up from a third of teens collaboratively with youth and families to mitigate potential negative in 2012.10 The percentage of Ontario’s teenagers who reported effects of social media and smartphone use on mental health. spending 5 or more hours a day on social media increased from 11% in 2013, to 16% in 2015 and to 20% in 2017.1 An analysis of How has use of social media been shown to Australian longitudinal data found that 86% of students owned affect adolescents’ sense of self? smartphones in grade 8, increasing to 93% by grade 11, with increased use of social media communication with age.11 Two cross-sectional surveys of American and German university We review the evidence that links smartphone and social media students, respectively,12,13 found that students who spent more use with mental distress and suicidality among adolescents. We do time on the social media platform Facebook were more likely to not review evidence for online gaming. Although most existing data endorse feeling envy or sensing that others in their social

36 E137 positive tasking. A that found 30,31 Other observational Other observational 33 29 A recent empirical field study A recent empirical field study 35 13,34 ISSUE 6 ISSUE | At the same time, there were also positive elements, At the same time, there were also positive 32 Youth do increasingly interact online rather than in person, and VOLUME 192 VOLUME studies have linked spending more than 2 hours a day on social networking sites and personal electronic devices with high rates of suicidality and depressive symptoms among adolescent girls, although youth who sustained high levels of face-to-face socializ- ing were relatively protected against the negative consequences of too much time online. smartphones can interfere even with face-to-face interactions viaeven with face-to-face interactions smartphones can interfere what has been termed “phubbing”: attending to one’s phone when in the presence of others. including providing a sense of community, suggestions for seekingincluding providing a sense of community, behaviour. treatment and advice on stopping self-harm Do the effects of smartphones on social skills Do the effects of smartphones affect mental health? more than a few An observational study showed that spending correlated negatively hours per week using electronic media and self-esteem, with self-reported happiness, life satisfaction (in-person social whereas time spent on nonscreen activities religious homework, media, print exercise, or sports interactions, services, working at a paid job) correlated positively with psychological well-being, among adolescents. Can social media promote self-harm? Can social media - thoughts of suicidality and self-harm behav Youth communicate sharing images of self-inflicted injuries. iours online, including self-injury — particularly cutting — on socialExplicit depiction of shown by site content studies media is common, as photographs or live videos of self-injurious behaviour, many of of videos of self-injurious behaviour, many photographs or live Of particular con- which had no warnings about graphic content. contained cern were viewers’ comments, which typically experiences, andfeedback or personal disclosures about self-injury of recovery. Such find- rarely offered encouragement or discussion romanticizing and mes- ings show the potential for mental illness Indeed, a system- saging that normalizes self-harm among youth. qualitative, descriptiveatic review that included 26 studies (using social media platformsor cross-sectional methodology) found that discussions aboutincluded normalization of self-harm behaviour, live depictions of self- practical issues regarding suicidality and harm acts. using experience sampling in 304 participants showed that even that showed participants 304 in sampling experience using the mere presence of phones on a table caused participants who were randomly assigned to that condition to feel more distracted and have lower enjoyment during social interactions compared away. phone their putting to randomized were who those with establish causality. Youth with lower impulse control may be may be control impulse with lower Youth causality. establish multi effects of media to deleterious more susceptible have signifi- who did not study of adolescents large longitudinal disorder of attention-deficit/hyperactivity cant symptoms media use high-frequency digital baseline found that (ADHD) at meeting emergence of symptoms associated with was positively Manual of Mental Disorders–4th Edition Diagnostic and Statistical ADHD over a 2-year follow-up period, even (DSM-IV) criteria for confounders. after adjusting for known | Most Most 27,28 Concerns 26 19 FEBRUARY 10, 2020 FEBRUARY | As such, reported As such, reported 18 24,25 Moreover, participants participants Moreover, CMAJ 17 25 17 A recent large prospective study 24 15 and has been associated with increased stress stress increased with associated been has and 14 but there is no standard or agreed-upon definition of but there is no standard or agreed-upon In a randomized study, female participants reported female participants reported In a randomized study, Several cross-sectional studies have shown that high high that shown have studies cross-sectional Several 22,23 16 20,21 Two systematic reviews have shown that media multitasking A systematic review identified Internet addiction as being par- The nature of social media interactions, which are arm’s are arm’s media interactions, which The nature of social A systematic review of 20 studies found that use of social of social found that use review of 20 studies A systematic related to Facebook use. related to Facebook is associated with negative effects on cognitive control, academic performance and socioemotional functioning in youth. ticularly associated with self-harm or suicidal behaviour based on 7 included studies, all of which were cross-sectional school-based surveys that used validated outcome measures and were rated as high or medium to high quality. - commenting both easy and more fre length, makes negative An Ontario survey quent than in-person interactions with peers. odds of sui- showed that the of middle- and high school students all significantly higher cidal ideation, plans and attempts were even after con- among those who had experienced cyberbullying, trolling for a range of potential confounders. media was associated with body image concerns and disordered with body image concerns and disordered media was associated eating. smartphone or Internet addiction; studies have used different used different have addiction; studies smartphone or Internet that rely on behav- definitions and scales, varying from those ioural addiction criteria, to measurement of the extent of func- tional impairment and level of device use. prevalence rates are highly variable. of senior high school adolescent students in Taiwan found that of senior high school adolescent students in Taiwan found that youth classified as experiencing Internet addiction had a significantly increased risk of having newly emerged self-harm or suicidal behaviour or both when re-evaluated 1 year later. have been raised about social media platforms having been having been have been raised about social media platforms ways that use deliberately designed — in highly sophisticated artificial intelligence behavioural psychology, neuroscience and and behavioural addic- — to promote behavioural reinforcement tion. more negative mood after just 10 minutes of browsing their their browsing of minutes 10 just after mood negative more an who browsed with those compared account Facebook website. control appearance-neutral

Does social media addiction exist and can it Does social media addiction exist affect mental health? 2014 and 2015 associ- One study of repeat survey data from 2013, with subsequent ated the extent of self-reported use of Facebook satisfaction. poor self-reported mental health and life network were better off than they were. The term “FOMO” — fear “FOMO” were. The term they off than were better network apprehension pervasive “a as defined has been — out missing of from which experiences might be having rewarding that others absent,” is one proportions of youth appear to be addicted to their smart- proportions of youth appear to be addicted phones, existing studies, however, are cross-sectional, and measures are heterogenous across studies with limited attempts to consider individual and contextual differences, making it impossible to who were high in appearance comparison tendency reported an comparison tendency reported who were high in appearance or the appearance of their face, hair increased desire to change time on Facebook, in comparison with those skin after spending website. who browsed the control ANALYSIS based onvariousvalidatedscales. externalizing behavioursanddeclineinself-esteemcoping nighttime mobilephoneuseandsubsequentdepressedmood, lia showedthatpoorsleepmediatedtherelationshipbetween ditioned responseinvolvingincreasedarousal. to check media devices when they are present or owing to a con- sleep andexcessivedaytimesleepiness. bedtime wasassociatedwithdecreaseddurationandqualityof media devices and sleep outcomes found that use ofmedia at ontheassociationbetweenportablescreen-based 20 studies cidality haveincreased amongyoungfemalesin particular. trends indicatingthatdepressive symptoms,self-harmandsui- a dayandoddsofinsufficientdurationsleep. nificant relationship between use of social media beyond 1 hour E138 health effects, cyberbullying andshowtendency toexperiencemoremental more timeonsocialmediathan boysdo,havemoreexposureto of experimentalstudies.Girlsand youngwomentendtospend less susceptibletoharm,asindicatedbyanemergingliterature technologies mayvaryamongindividuals—andsome be media useandmentaldistressamongyouth,theimpactofthese Although population-basedstudiessuggestalinkbetweensocial mental healtheffectsthanothers? Are someindividualsmoresusceptibleto nights in2015. most 2011–2013, withmorethan40%sleepingless7 hours the proportionofadolescentsgettinginsufficientsleepafter An analysisofUSannualsurveydatafoundanabruptincreasein media affectmentalhealth? Does sleep-lossassociatedwithuseofsocial dicted greaterboredomandworseoverallmood. Phone usewasalsofoundtopredictdistraction,whichinturnpre- dated depression,anxietyandstressscale. health on4-monthfollow-upbasedmeasuresfromavali - of sleepfromInternetusehadanotableadverseeffectonmental robust effectscamefromtheconsequences—inparticular,lack in generalhadanegativeimpactonmentalhealth,butthemost involving 2286adolescentsinEurope,magnitudeofInternetuse was showntodisruptsleep, ence ofportablescreen-basedmediadevicesinthebedroom 11–20 years sleptlessthanrecommended, 11–20 years data fromOntariofoundthat63.6%of5242studentsaged more hoursperday,andinsufficientsleep. relationship betweendailyelectronicmediausebeyond2or ness. rapid eyemovementsleep,andreducednext-morningalert- secretion, circadianclockdelay,reducedamountanddelayin fall asleepanddecreasedeveningsleepiness,reducedmelatonin time wasshowntodisruptsleepinmultipleways:longer well-controlled conditions,useofelectronicscreensbeforebed- Data fromalongitudinalstudyof1101adolescentsinAustra- In a14-day,randomized,crossoverexperimentalstudyunder 39 A systematic review and meta-analysis that included 10,34 37 Thestudyalsoshowedanexposure–response whichisconsistentwithrecent epidemiologic 40 possiblyrelatedtothetemptation 11 Inanotherlongitudinalstudy 40 CMAJ Ofnote,themerepres- 37 41 38 Ananalysisofsurvey alsoshowingasig- | FEBRUARY 10, 2020 38 36 5–9 | ship wasnegativelyassociatedwithdepressivesymptoms. tacts withwhomparticipantshadacloseface-to-facerelation- with depressivesymptoms,theproportionofsocialmediacon- tact intheabsenceofaface-to-facerelationshipwasassociated studentsfoundthatwhilesocialmediacon- vey of1124 college accessed online. about suicide and self-harm is readily available and widely ble individualsisthateducationalorevenpromotionalcontent chological well-being. tionship betweenuseofelectronicmediaanddecreaseinpsy- mental healthdifficulties,assuggestedbythebidirectionalrela- especially riskyforyoungpeoplewhoarealreadyexperiencing addition, thechallengesassociatedwithsocialmediamaybe others, whichinturnwasrelated tolifesatisfaction. showed differentemotionalresponses tobeingcomparedwith based” versus“opinion-based”) foundthatdifferentorientations ized participantsbysocialcomparison orientations(“ability- presenting with emotionalandmentaldistress. findings offersomeinsightsfor theindividualizedcareofyouth to exacerbatenegativeeffectsofsocialmedia. such asthosethatinvolveruminationandbrooding,appeared of “likes”)ontheirself-photographposts. dated scalehadlowersensitivitytofeedback(basedonnumber greater senseofpurposeinlifebasedonmeasuresfromavali - age, aboveaverage and belowaverage); those ratedashavinga to eitherof3conditionswithdifferentnumbers“likes”(aver - lege studentswhowereasked to takeaselfiewere randomized negative consequencesoftoomuchtimeonline. face socializingappeartoberelativelyprotectedagainstthe person interaction;incontrast,youthwithhighlevelsofface-to- appears to be much greater for adolescents with low levels of in- negative impactofsocialmediaondepressivesymptoms support, whichinturnhadapositiveimpactonmood. but activeusehadapositiveimpactonperceivedonlinesocial girls, passiveuseofFacebookhadanegativeimpactonmood vey of910highschoolstudentsinBelgiumfoundthat,among structural equationmodellinganalysisofacross-sectionalsur- social comparisontraits. tions, aneffectnotseenamongstudentswhoscoredlow on acquaintance, relativetothoserandomizedthecontrolcondi - negative affectafterbrowsingtheFacebookprofileof an scale hadpoorerself-perceptions,lowerself-esteemandmore engage insocialcomparisonbasedonmeasuresfromavalidated 120 collegestudents,thosewhoscoredhighlyonthetendencyto teristics andsocialmediaexperiences.Inarandomizedstudyof tal studieshaveshownrelationshipsbetweenindividualcharac- social mediaisatopicofactiveinvestigation.Recentexperimen- interactions andindividualfactors. social connectednessandsupport)dependingonthequalityof actions andsocialcomparison)beneficial(suchasthrough effects couldbe both detrimental (such asfromnegativeinter- related withdepression,anxietyandmeasuresofwell-being, review of70studiesfoundthatwhilesocialmediausewascor- ever, forboysactivesiteusehadanegativeeffect.Asystematic VOLUME 192 The contextofsocialmediausemaymediateitseffects. A The roleofindividualdifferencesintermstheeffects | ISSUE 6 30,31 33 Ofparticularconcernforsuchvulnera- 45 Inanotherempiricalstudy,102col- 43 Certaincognitivestyles, 46 Astudythatcategor 43 34 Moreover,the Arecentsur- 47 Theseearly 42 How- 44 In In ANALYSIS - E139 This This 58 may be helpful in 59 Further, the American Further, the American 56 However, such interventions Enforcement of blanket bans Enforcement of blanket bans Mobile-phone policies at the Mobile-phone policies at the 60 62 61 63,64 ISSUE 6 ISSUE | as well as a Family Media Use Plan that offers struc- a Family Media Use Plan as well as 55 A qualitative study of focus groups involving a total of 24 Other practical strategies to mitigate negative effects effects negative mitigate to strategies practical Other 57 More broadly, public awareness campaigns can provide educa- The American Academy of Pediatrics provides a number of use- provides a number Academy of Pediatrics The American A motivational interviewing approach may be useful to help help to useful be may approach interviewing motivational A At the system level, school and community-based programs At the system level, school and community-based programs VOLUME 192 VOLUME Academy of Pediatrics has partnered with Common Sense MediaAcademy of Pediatrics for Toolkit that has useful information to produce a Family Media parents. tion on the impact of problematic use of digital media and pro and media digital of use problematic of impact on the tion mote healthy behaviours in this regard. Various social media platforms have placed bans and restrictions on content related to self-harm. school and classroom level have been implemented in several school and classroom level have been implemented in several jurisdictions, with mixed results. 66 adolescents found that while adolescents valued freedom and duration. These would include avoiding use of electronic screens screens electronic of use avoiding include would These duration. portable, and not having 2 hours before bedtime, within 1 to bedrooms overnight. media devices in screen-based the use of youth regarding and safety tips to support ful health social media, should be developmentally appropriate and aim to respectfully should be developmentally appropriate and aim to respectfully ensure adolescents’ autonomy. approach should involve open, nonjudgmental exploration of all approach should involve open, nonjudgmental positive and negative. aspects of a youth’s digital life, including to address training reversal habit from youth might benefit Some “nonscreen time” that compulsive use, including having daily that a random- can be progressively increased. Sharing evidence assigned to not using ized controlled trial found that participants “life satisfaction” and Facebook reported significantly greater with controls who positive emotions after 1 week, compared were told to continue using the site as usual, is often a challenge; rather, a more productive approach involves negotiation between teacher and students, as developmentally appropriate, in the context of a relationship built on mutual trust and respect for autonomy. from using smartphones and related media are offered by the Cen- and related media are offered by the from using smartphones (http://humanetech.com/),ter for Humane Technology an organ ization developed by former technology industry members out of former technology industry members out ization developed by on deleterious effects of new media concern for the potential psychological states. online of pattern their in changes make to start people young an intervention with behaviour. Motivational interviewing is with substance use, established effectiveness for adolescents to have poor self- which could be useful for youth who appear smartphone. or media social of in their use control effecting change. Youth might be encouraged to inform their to inform their effecting change. Youth might be encouraged or otherwise limiting, friends that they are taking a break from, about alternative ways their social media use. Talking with youth or even talking directly to connect, including meeting in person media gap, the social by phone, could help with strategies to fill in-person interaction reinforced by discussion of evidence that may protect mental health. can institute limits on social media and smartphone use, along posi- a have to shown been recently have that of those lines the tive effect on healthy behaviours. ture to the recommendations related to limiting use and havingture to the recommendations appropriate use. discussions regarding | - Youth Youth 54 50 52 48 Results from a Results from a FEBRUARY 10, 2020 FEBRUARY | 34,38 CMAJ These findings underscore the importance 53 and the benefit on academic outcomes when phones and the benefit on academic outcomes 51 The participants reported that “these characteristics The participants reported that “these characteristics 53 It is also worth reminding parents that they model smart- It is also worth reminding parents that they 49 Sleep hygiene measures specific to social media and smart- A qualitative study that collected data via focus groups with A qualitative study that collected data via focus groups with Encouraging parents to be proactively involved in limiting involved in limiting Encouraging parents to be proactively Clinicians treating youth with mental illness and those at risk with mental illness and those at risk Clinicians treating youth phone use with their own behaviour; a randomized study a randomized study phone use with their own behaviour; associated was use smartphone parental heavy that showed their children. with poorer quality of interactions with phone usage are crucial, as several studies have shown that that shown have studies several as crucial, are usage phone sleep shorten and sleep disrupt can use smartphone increased adolescent girls found that high levels of confidence, high media literacy and sound appreciation of individual differences appeared to mitigate negative effects of social media on body image. children’s and teens’ use of smartphones and social media may children’s and teens’ use of smartphones to become prob- be helpful, given that social media use appears lematic when it surpasses 1 to 2 hours daily. recent meta-analysis suggest that while parental limits may be parental limits may be recent meta-analysis suggest that while use by younger chil- effective at reducing the amount of media engagement and guid- dren, open discussion focused on positive risks for adoles- ance might be best for reducing media-related studies pertained to cents; however, only 5 of the 52 included cross-sectional sur- social media, all of which were based on veys. were nurtured by positive parental influence and a supportive were nurtured by positive parental influence and a supportive school environment.”

Despite the limitations of the evidence base at this time, clin evidence base at this limitations of the Despite the in their available knowledge be able to use currently icians may behavioural on effecting combined with evidence practice, change in youth. families and their adolescents with discuss mental distress can of mental to use smartphone and media social of risks known the choose to advocate for a harm reduction health. Clinicians may - reduced use of social media and the Inter approach, suggesting - for youth, given evidence that sug net rather than abstinence A is associated with poorer mental health. gests prolonged use with communication that found review systematic large recent alli- effective in the context of a therapeutic adolescents is most nonjudgmental, elicits trust and emotional ance that is open and autonomy. safety, and offers a sense of inclusion and How might physicians use this evidence to to this evidence use physicians might How practice? inform their are put away when studying, preferably in another room. sures as using social media only for set times, and preferably onlysures as using social media only for set times, motivator may be toin common living areas in the home. A further of smartphones ondiscuss evidence showing an adverse impact learning, and their families can be encouraged to set boundaries for to set boundaries for and their families can be encouraged mea such include could smartphone and social media These use. of a nurturing home and school environment in fostering resilience as youth navigate the challenges of adolescence. An empir just in affect on browsing Instagram of effect the of study ical more than 500 adolescents found that randomization to conditions that provided greater contextual awareness regarding posts by others mitigated against postbrowsing negative affect in teens who reported higher levels of negative social comparison. ANALYSIS steps tomitigatethis. tive impactofsocialmediaontheirlivesandstartingtotake E140 References development. gests thatonlinerelationshipsarepartoftypicaladolescent counterproductive. TheAmericanAcademyofPediatricssug- harms fromsocialmedia,aprohibitionistapproachwouldbe Given theimportanceofengagingyouthinmitigatingpotential Conclusion their control. favour ofautomaticmonitoringinsituationsthatwerebeyond privacy, theyrecognizedaneedforprotectionandmostwerein reported cuttingbackonthetimetheyspendit. felt theyspendtoomuchtimeontheircellphone,andabouthalf addiction, deliberately designed to promote behavioural reinforcement and extent towhichsocialmediacompaniescanusefeaturesthatare youth resilience. economic factorsthatunderpinfamilywell-beingandnurture initiatives aimedataddressingthesocial,environmentaland safeguards theirmentalhealth,againstabackgroundofpolicy themselves fromharmandusesocialmediainamannerthat brought aboutbyuseofsmartphonesandsocialmedia,protect and systemicinterventionstohelpthemnavigatethechallenges based talkingtherapiescannotbediscounted. well aslowbarrierstoresourcessuchcrisislinesandInternet- self-expression, senseofbelongingandcivicengagement—as mental healthinformation—includingmedialiteracy,creativity, norm, andthepotentialbenefitsofonlineaccesstoproductive known aworldwithoutsocialmedia,digitalinteractionsarethe

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J Adolesc Child

ANALYSIS

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