Since the opening of Facebook to the general public in late 2006 social media use has rapidly become nearly universal among adolescents, providing new opportunities for connecting with peers, exploring identity, and expressing creativity. During the same period, rates of depression and suicide among youth have risen. A growing body of evidence highlights a correlation between problematic social media use and depression. Social media does not affect all children and adolescents equally.
Key points
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Adolescent depression rates have risen since 2007, coinciding with an explosive rise in social media engagement.
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A key to addressing depression related to social media use in youth is identifying problematic use and related depression via specific assessment tools.
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The family and home environment play a crucial role in shaping a child’s social media interactions and resulting effect on mental health.
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Pediatricians are encouraged to adopt an approach that takes into account both clinical and developmental aspects in addressing social media use and depression.
Introduction
Ever since the inception of social media, youth have leveraged its capacity for connection with peers. The conceptualization of social media has undergone a significant expansion from its initial manifestation as a tool to share common interests with friends to its present iteration, incorporating greater capacity for user-created content dissemination, interpersonal communication, and community building. , Presently, social media platforms support engagement in diverse communities with complex layers of interaction among users, some using embedded artificial intelligence. This evolution in the capacities of social media platforms reflects a broader, more interactive digital landscape where children and youth are active participants with technology.
As the power and complexity of social media platforms has grown, so has engagement among youth: a staggering 95% of individuals aged 13 to 17 are active on social media, with 35% of them engaging with these platforms “almost constantly”. Notwithstanding the age restrictions imposed by regulations such as Children’s Online Privacy Protection Rule (COPPA), which sets the minimum user age of 13, there is a notable presence of younger children on social media platforms—38% between the ages of 8 and 12 use social media. The deep integration of social media into the daily lives of youth coincides with critical periods of cognitive, socio-emotional learning, and physical development, and emerging data indicate that depression often manifests during these times.
Rates of early-onset depression have climbed since late 2006 and can have lasting effects extending through adulthood, including low self-esteem, substance use, and difficulty maintaining healthy interpersonal relationships. , In the United States, 20.1% youth aged 12 to 17 experienced a major depressive episode in the past year, with 14.7% of those youth experiencing impairment in their ability to perform in school, complete chores at home, get along with others, and socialize. A systematic review and meta-analysis of studies from 2004 to 2019 involving children younger than 13 estimated a far lower prevalence of 1.1% for depressive disorders. Factors such as neuronal maturation and hormonal shifts during puberty and increasing dependency on complex interpersonal relationships may contribute to an increased incidence of depression during adolescence. , Early-onset depression is associated with more severe outcomes than adult depression, including suicide. Twenty five percent of depressed adolescents suffer from severe depression, which is far more likely to be impairing and persist into adulthood.
Pediatricians should understand complexities of the relationship between social media use and depressive symptoms. The current body of research lacks comprehensive longitudinal and experimental studies which would fully explain the manner in which social media affects youth through critical stages of childhood and adolescence. This article provides pediatricians with guidelines for evaluating depression in the setting of social media use including problematic use, identifying important factors that contribute to depression in social media use, and providing appropriate treatment.
The interplay between depression and social media in youth is complex, multifaceted, and not fully understood. Depression rates in adolescents have increased since 2007 correlating with the popularity of social media. Youth who frequently use social media have higher rates of depression, which may be mediated by total entertainment screen time. Conversely, those who spend more time in non-screen related activities, such as doing homework, reading print media, and attending church activities, report fewer mental health problems. Recent increases in depression and suicide rates may be further explained by a generational shift toward screen time and away from engagement in non-screen activities. , Children ages 9 to 10 who use screen media over 2 hours a day are more likely than peers to experience symptoms of depression, engage in self-harm, think of suicide, or attempt suicide. A recent meta-analysis demonstrated a small but significant association between screen time and depression. The small magnitude of association might be indicative of the methods used in statistical analyses that focus on associations as opposed to relative risk, which considers the increased likelihood of depression occurring due to screen time. Other studies have also found a significant association between depression and social media in those younger than 20 years of age but posit that social media use may benefit youth who are depressed (eg, by providing social support).
Generational research confirms a closely-matching concomitant rise of social media and depression in the lives of American youth. Studies of college students found that indices of mental health dropped at individual schools following the introduction of Facebook onto campus. A wealth of correlational data confirms a modest link between time spent on social media and poor mental health among adolescents. Longitudinal studies indicate that greater time spent on social media leads to a greater likelihood of new-onset depression 6 months later. Combined, this evidence points to a strong link between social media use and depression. Randomized double-blind controlled trials of social media use would provide the best possible evidence but are impossible for 2 reasons: subjects cannot be blinded with regard to whether they are using social media and youth would not submit to instructions to use or refrain from social media on a daily basis for the extended periods needed for such studies to be useful. However, it seems improbable to imagine social media has an equal depressogenic effect on all users.
Research confirms that certain characteristics of the user and specific social media habits and experiences moderate this effect. Youth who tend toward social comparison, those with low social status, or are more likely to experience FOMO (fear of missing out) may be particularly likely to suffer depression with more time spent on social media. Similarly, engaging with social media in a passive manner (looking at the posts of others without commenting or contributing themselves), those who multitasking with social media (eg, checking posts intermittently during schoolwork), have a problematic habit (compulsively checking social media excessively to the detriment of other activities), and those who use late at nighttime may be most subject to this effect. , Finally, youth involved in cyberbullying, as a bully or especially as a victim, may be most prone to depression. Conversely, for youth enjoying high offline social support, using social media more may have a protective effect against depression. The displacement of in-person socializing, disruption of healthy sleep patterns, and decreased physical exercise due to excessive social media use could predispose individuals to depression. As we strive for a more nuanced understanding, it becomes imperative to consider the multifaceted interplay between specific online experiences, individual user characteristics, and the broader lifestyle implications of social media engagement in youth.
General assessment of social media use
An important step in managing depression in the context of social media use in children and adolescents is the identification of maladaptive, or problematic social media use and the underlying depressive state. Problematic social media use can be defined as an excessive habit which impairs functioning and is accompanied by symptoms associated with addiction (eg, withdrawal, tolerance, and dependence). Problematic use is associated with low self-esteem, low life satisfaction, depression, and loneliness, and may partially mediate the relationship between social media and depression. Available screening tools may help assess problematic internet and social media use in clinical practice. It is important to take a holistic approach to assessment and screening, including an understanding of online habits and experiences.
A number of screening tools may assist in both the identification of problems and subsequently for assessment of treatment response. Several instruments have demonstrated validity in assessing problematic social media use in adolescents and young adults. The Bergen Social Media Addiction Scale (BSMAS), the Social Media Addiction Scale (SMAS), and the Social Media Disorders Scale (SMDS) are adapted from the Diagnostic and Statistical Manual (DSM) of Mental Disorders proposed criteria for internet gaming disorder, which are in turn modified criteria for substance use disorders and gambling disorder. Broadly, these scales assess preoccupation, withdrawal, tolerance, displacement of other activities, inability to reduce use, excessive use, deception, and family conflict as a consequence of social media use. All are short-form self-reports (6 to 10 items, answered yes/no or Likert scales), which take approximately 5 minutes to complete in a clinic. All were developed and tested internationally, demonstrating convergent validity to one another in a diverse group of age 13-19-year old American adolescents. Among the scales, the BSMAS was shown to demonstrate better reliability in older adolescents.
Problematic social media use, typically conceptualized as a behavioral addiction, may be accompanied by poor insight into problems associated with social media use. Patients and their families may object to the term problematic social media use due to implications of addiction. Therefore, assessing parental endorsement of symptoms is warranted, which can be evaluated via the Problematic Media Use Measure Short Form (PMUM-SF). This instrument is not specific to social media, but rather overall screen engagement.
Pediatricians may benefit from incorporating an assessment and discussion of social media use into initial patient encounters and follow-ups. Social media use is a major part of the lives of most adolescents, as a significant portion of an average teenager’s day is spent on social media: connecting with peers, learning, and being entertained. Inquiry about this significant part of a child’s life, which often has high consequences for self-esteem and well-being, is warranted. Helpful comprehensive guides to media assessment can be used to frame questions for assessment. Many pediatricians currently incorporate the HEEADSSS (Home, Education, Eating, Activities, Drugs, Sexuality, Suicidal Ideation, and Safety) assessment model into adolescent wellness checks. Incorporating a fourth S for Social Media is a helpful mnemonic. See article 8-“Cracking the Algorithm: How to ask the right questions about social media during the interview” by Sood, Chapman, and Hadamati in this issue for more details about assessment of social media habits and experiences.
In brief, clinicians can initiate an open-ended discussion with patients about social media use. Such a discussion is most relevant to assessment of social history when discussing hobbies, peer relationships, and sexual history. Consider inquiring what platforms patients are most active on, an estimation of their time spent on social media, what they like and do not like about social media, the content of their social media feed, and household rules and expectations of social media use.
Assessment of depression
Screening and assessment of depression is a topic familiar to most pediatricians. Useful practice guidelines for assessing and managing depression are available from professional organizations, such as the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP). Both documents were developed from a combination of expert consensus and evidence-based literature reviews. Most applicable to the practicing pediatrician is AAP’s Guidelines for Adolescent Depression in Primary CARE (GLAD-PC), which focuses ages 10 to 21. , AACAP’s Practice Parameters for depression are particularly beneficial, when considering best practices for assessment and management of younger children.
GLAD-PC guidelines recommend annual screening for all adolescents aged 12 and older at annual visits, as well as screening children who have significant risk factors (eg, family history of mood disorder, childhood trauma or abuse, prior depression). , Clinicians are encouraged to consider evidence-based screening tools that are easy to administer and include self-report. , A good choice is the Patient Health Questionnaire-9 modified for adolescents (PHQ-9A), which assesses recent DSM criteria using a Likert scale and rates the severity of symptoms.
AACAP practice guidelines also suggest universal screening in primary care for adolescents but not younger children. When risk factors or symptoms suggest childhood depression, an appropriate screening tool is the Mood and Feelings Questionnaire (MFQ) offers both short and long-form versions for parents or children to complete.
Screening for social media use in children and adolescents is a new clinical need and complicated by important limitations. Social media is rapidly evolving, and new and younger users may gravitate toward newer social media platforms. Consequently, screens normed in the past on an older social media platform like Facebook may not fully translate to the latest version of Facebook, much less to newer platforms (eg, TikTok). Many studies assessing screening measures focused on adolescents and young adults, and may not apply to children. Most screening measures attempt to detect problematic or addictive social media use, and may fail to capture the full impact of social media on young people’s lives (eg, a teen who does not have addictive social media patterns but is significantly affected by cyberbullying). Future research should focus on updated screening of social media use across the lifespan, with measures for both parents and children.
Mediating factors
The links between problematic social media use and depression are multi-factorial, with variation based on the individual’s maturity and cognitive development, the nature of their social media habits and behaviors, the home environment, and social status. These may provide risks or protective factors to the individual child. Psychiatric co-morbidities influence the likelihood of problematic social media use and related depression. Some of the most important mediating factors follow.
Family and Friends
The family and home environment significantly shape if and how children engage with social media. Parents of children struggling with depression or other stressors often feel unable to limit their child’s social media use or protect them from harm done by social media. These parents are most likely to express inability to supervise whom their child communicates with, what they talk about, and when they do it.
When treating adolescent depression, providers should empower parents to help children manage social media use. Parenting strategies broadly fall into categories of restriction (placing limits on use), active mediation (supporting the child’s critical thinking about their use), and co-use (enjoying screen experiences together). Parents use different styles and approaches, and vary in permissiveness, expectations, warmth, and consistency with rules. A recent meta-analysis shows that positive parenting styles, such as authoritative style characterized by high warmth and involvement, may best prevent and address problematic internet use. Beyens and colleagues found that restrictive approaches balanced to support adolescent autonomy may help reduce anxiety and depression, particularly when exacerbated by cyberbullying. Parents who are open to adolescent input and discuss issues around media tend to have more success in helping children achieve healthy boundaries.
Peers influence tends to grow as children move into adolescence. Adolescents enjoy greater autonomy in their social media use and engagement with peers. Social support can be protective against depression. For youth with high social status at school (who typically also have high social and support online) social media use may be protective against depression. Social support gained via social media may be protective, but cannot replace offline relationships. One study found that youth high in offline social support were less likely to experience depressive symptoms than those with high online support or neither. An adolescent’s approach to social media can also affect risk for depression. Passive social media use, in which an adolescent monitors others’ social media feeds without contributing (eg, no posting, ‘liking’ or commenting), has been associated with greater risk for depression, although inconsistently. The nature of peer interactions on social media can greatly impact mood. Cyberbullying (ie, intentional, repeated, online harassment) is strongly associated with depression, as confirmed in a recent meta-analysis, especially for girls and older adolescents at highest risk.
Sleep
Co-morbid issues explored thoroughly in this journal’s companion articles (see article 1-“Social Media and Sleep Health” by Hale and colleagues, article 13-“Youth Digital Dilemmas: Exploring the Intersection Between Social Media and Anxiety” by Ariefdjohan and colleagues, and article 4-“The Impact of Social Media Use On the Development of Eating Disorders” by Gerwin and colleagues). However, it is worthwhile to briefly discuss the importance of insomnia, anxiety, and eating disorders in the relationship between depression and social media use. The impact of screen media on sleep is well documented, as inadequate sleep’s capacity to predispose to and worsen depression. Screen media’s impairment on sleep may be mediated by the physiologic impact of blue light from screens on melatonin release, interruption of sleep by notifications, arousal caused by engaging media content, and displacement of sleep time to engage with screen media. Many depressed youths retreat to their bedrooms after school, isolating and scrolling social media in bed in a “depressogenic” habit which runs contrary to their need for behavioral activation. Depression, social media use, and insomnia may evolve into a toxic feedback loop, in which depressed mood feeds into excessive social media engagement, worsening sleep, and consequently exacerbating depression.
Anxiety
Anxiety and depression are common comorbidities. Depression can predispose toward anxiety and vice versa. Psychological stress related to social media experiences may in certain cases cause depression. Given the centrality of peer relationships to adolescents’ self-esteem and well-being, adolescents who experience FOMO tend to increase engagement with social media, in doing so exacerbating their distress. Similarly, adolescents may also fear they are being negatively judged and stress over management of their social media presence. The combination of FOMO and stress over curation of a social media presence may lead to compulsive social media use which is correlated with depression.
Eating Disorders and Body Image
Social media has been shown to exacerbate negative body image via unfair comparisons with idealized images of peers, influencers, and celebrities. Poor self-image negatively impacts well-being and can predispose to depression as well as eating disorders. Depression frequently accompanies eating disorders, a relationship mediated in part by the depressive effect of caloric restrictions. Social media posts encouraging eating disordered behaviors trace back some of the earliest internet discussion boards and remain all too common today.
Treatment
Treatment guidelines for depression are outlined by the AAP and the AACAP. , In mild cases, monitoring, psychoeducation, and recommendations involving behavioral activation. In moderate to severe cases of depression, evidence-based interventions include psychotherapies based on Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy (IPT). Evidence-based pharmacologic strategies include the Selective Serotonin Reuptake Inhibitors, especially fluoxetine and escitalopram which are Food and Drug Administration-approved for treatment of depression in teens. , Familiarity with community resources for intensive therapeutic interventions and psychiatric care may be required for effective referrals of severe or refractory cases.
For youth at risk for problematic social media use, parental management of their online activity is warranted. Primary care providers must support children and families to sustain healthy and safe online habits. Means of doing so can be found online at the AAP’s Center of Excellence on Social Media and Youth Mental Health and AACAP’s Screen Media Resource Center. AAP’s Family Media Plan, accessible through the Center of Excellence portal and at healthychildren.org , can be an excellent place to start in setting and maintaining health screen media habits which are personalized to the family’s unique needs. Setting up this plan enables families to clearly define about rules and expectations around media use, although a recent study found limited lasting changes after use. Families may be most likely to benefit when a clinician initiates the media plan during an office visit, and subsequently follows up on its progress.
Parents typically have greater influence over a child’s access and interaction with social media than that of a teenager. Consequently, clinicians should encourage families to establish a media plan when children are young, and modify their parenting approach as a child matures, affording increasing agency to older children and teens in negotiating rules about media. Parental control over time spent on social media in preadolescence is associated with reduced social media engagement, social comparisons, and depressive symptoms. Parents should support appropriate adolescent autonomy by coming to agreement regarding limits on social media time and content. Authoritarian, permissive, and uninvolved approaches should be avoided when possible.
Pediatricians can help prevent problematic use and depression by discussing healthy social media practices with patients and families. As a child begins to use social media, parents should have regular oversight and clearly define expectations around appropriate use while establishing firm limits on time and access. Parents should describe what behaviors on social media are unacceptable (eg, cruelty, sharing personal information, or sending sexually explicit pictures). Parents should explain to children that health information gained via social media is often unreliable, and discourage children from following social media posts focused on unhealthy behaviors such as drug use, self-harm, or eating disorders. Helping parents understand risks associated with social media use and encouraging them to consider limiting social media access may preclude subsequent impairment. Removing screen media from the bedroom entirely can prevent insomnia and enable better supervision. Teenagers typically respond better to a collaborative approach, balancing greater autonomy with appropriate limit setting, which should gradually fade as the teen demonstrates responsible use. , ,
Ethical concerns
Pediatricians should be aware of the ethical considerations regarding social media use in youth with depression and their potential implications for parental supervision. Such considerations include balancing the child’s needs for autonomy, peer engagement, self-expression, and privacy with the need to maintain healthy, safe social media habits. Research shows that depressed youth are more likely to overshare personal information via social media. This may explain in part the higher risk depressed youth have of suffering cyberbullying, peer victimization, and exploitation via online contact with strangers. , , Studies indicate that youth consider the most harmful uses of social media to be online risk taking, cyberbullying, negative social comparison, oversharing, posting negative updates, and encountering triggering material.
The negative impacts of social media on psychological health raise ethical concerns about anonymity. Offered in varying degrees by social media platforms, anonymity may enable destructive interactions such as cyberbullying and online discrimination (ie, racially motivated bias enacted on social media). , Black youth are at a heightened risk of encountering online discrimination, which may involve hate imagery, derogatory comments, or harmful acts. , Research findings indicate personal experiences of discrimination are directly associated with depression, even when controlling for racial identity, gender, discrimination encountered offline, and perceived stress levels.
Pediatricians may also find that young patients who acknowledge the risks associated with sharing self-harm behaviors on social media still partake in such actions for the sake of validation and connection. Children and adolescents frequently falsify their age to gain access to social media sites, which parents should discourage. The American Academy of Pediatrics encourages the minimum user age of 13 set by COPPA. , Pediatricians should encourage parents to be aware of their children’s social media use, limit and supervise internet access, offer guidance on social media safety, and convey the importance of a healthy balance between online interactions and real-world relationships.
Social media and help-seeking in depression
Social media offers opportunity for support for those struggling with depression. It offers a unique means for connecting struggling individuals with supportive peers. Social media platforms have made limited efforts to de-platform or censor content that graphically depicts self-harm or suicide, and promote messages of hope and recovery support. Critical crisis intervention resources area available for those flagged as in need by those concerned about their social media posts. Youth with depression often report finding helpful self-expression, community, and inspiration via social media.
Youth use social media as a tool to obtain health information and support. In a systematic study of young people aged 12 to 25, many reported finding value to gathering health-related information from social media hence considering these platforms beneficial. Social media can facilitate social inclusion, especially for youth who identify as Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual and are at risk for depression due to social isolation. Finding acceptance and validation in like-minded communities on social media can help restore self-esteem and psychological well-being.
Summary
Pediatricians should understand how various aspects of social media engagement affect depression. Providers should evaluate the social media habits and experience of their patients, especially those who suffer depression. Pediatricians can provide guidance to parents and children on navigating the challenges posed by social media, moderating use, and minimizing its potential negative effects. Further longitudinal research is needed to assess how social media influences depression in adolescents. Pediatricians should stay abreast with evolving evidence-based practices to identify and address social media use, depression, and their interactions in young patients. Social media companies should work with pediatricians and child psychiatrists to produce features that maximize healthy use and experiences and eliminate harmful elements. Pediatricians should support efforts to hold social media companies liable for mental health damage done by their platforms, in order to incentivize such changes. A comprehensive and collaborative effort is essential to help children and adolescents circumvent depression and thrive during the mental health crisis of our digital age.
Clinics care points
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Recommend a family screen media plan which is regularly revisited and revised.
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Advise parents to strongly consider banning screen media from the dinner table and from the bedrooms of children and teens, especially at night.
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Encourage parents of children and less mature teens who use social media to consider regular checks of social media content.
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Clinicians should increase their knowledge of social media functions and material popular with children to better evaluate patients’ use and guide families.
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Clinicians should advise parents of depressed youth to encourage behavioral activation by scheduling healthy activities such as in-person socialization, outings, active hobbies, and exercise, while minimizing inactivity and screen time.
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