With the advent of smartphones and the popularization of social media sites at the beginning of the twenty-first century, children and adolescents have been exposed to a world of virtual interactions in social networking sites that are designed to increase engagement of the user for profit. In this article, we review the epidemiology of use of social media, its addictive features, and potential negative consequences of problematic use, and the research on current interventions known to reduce use. We also give recommendations spanning from the policy to the individual level for children to build a healthier relationship with these sites.
Key points
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The design of social media platforms to keep users engaged creates inherently addictive platforms that can cause problems in younger ages.
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Research on problematic social media use is increasingly showing neurobiological, behavioral, and outcome-based similarities with substance use and other behavioral addictions.
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The evidence base on interventions for social media addiction is still nascent, but there is some promise shown by abstinence and reduction periods, as well as cognitive behavioral therapy.
Introduction
Social media (SM) facilitates social connections, information sharing, and entertainment. However, its use can become problematic. The negative consequences of SM at the population level are significant given its almost universal use. An estimated 4.9 billion people used SM worldwide in 2023, and the number of users is expected to increase to 5.8 billion by 2027. In the United States, SM use grew from 5% of adults using at least one SM platform in 2005 to 50% in 2011%, and 72% in 2021. Most users engage with SM at least once daily, about 39% admit feeling addicted, and 9% completely agree with the statement “I am addicted to social media.”
Over time, SM use has extended to all ages, and the age gap has narrowed. Yet, young people continue to use more than other age groups. There is a growing concern that developmental differences in habit-formation make SM’s addictive power more noticeable among youth. In fact, national surveys show that 36% of adolescents say that they spend “too much” time on SM and 54% would find it hard to give it up, with most girls (58%) finding it especially difficult.
The widespread commercialization of the smartphone in 2007 likely facilitated the reach and constant engagement on SM applications or “apps” to a level difficult to predict when Facebook first launched in 2005. Smartphones and SM apps have been adopted by increasingly younger individuals, with little use regulation. The coronavirus disease 2019 (COVID-19) pandemic was another turning point as shown by surveys of parents revealing an increased use of digital devices such as computers, smartphones, and game consoles, even in children aged younger than 11 years in 2021 compared to 2020. Furthermore, despite age restrictions requiring users to be at least 13 years old, SM use expanded across sites such as Facebook, Snapchat, Instagram, with the largest increase being in “other” SM use (which doubled from 8% to 17%), and TikTok, which became popular during the pandemic and which use doubled from 13% in 2020 to 21% in 2021. Parents’ concerns about children’s screen time also increased.
Social media use as an addiction
SM use that negatively affects personal, interpersonal, academic, and professional aspects of an individual’s life has been described using terms such as “problematic SM use,” “excessive SM use,” or “SM addiction.” While problematic Internet use was suggested as a disorder for the latest version of the Diagnostic and Statistical Manual of Mental Disorders, the only disorder related to Internet use included under “conditions warranting further study” is Internet gaming disorder.
There is controversy about whether behaviors in excess that are not related to the consumption of substances should be considered addictions. These “behavioral addictions” include pathologic behaviors related to gambling, food, sex, exercise, video-game and Internet use, and work. However, mounting biological and clinical evidence shows similarities and a need to address these behaviors, supporting the inclusion of behaviors such as pathologic gambling and Internet addiction in a category of “Addiction and Related Disorders.”
In the seminal article, “A ‘components’ model,” Griffiths advanced that behaviors could be considered addictions regardless of whether they involved the use of substances or not. Griffiths noted that specific common components to these behaviors included (1) Salience or the centrality of the behavior in a person’s life; (2) Mood modification, or a feeling of calm or escape, and shifted mood when in need to cope with negative feelings; (3) Tolerance or the need to increase the frequency or amount of the behavior to achieve the same positive effect; (4) Withdrawal or the unpleasant psychological or physiologic feeling when the activity is discontinued or reduced; (5) Conflict, or the interpersonal and intrapsychic conflict, experienced by a person with addiction due to choosing short-term relief in exchange for long-term negative consequences; and (6) Relapse, or the tendency to repeat earlier behavioral patterns, often with a full reinstitution of the addictive behavior even after a long period of abstinence.
Both substance use and behavioral addictions are likely to have onset in adolescence, a period characterized by heightened risk-taking behaviors that increase vulnerability to the initiation and establishment of addiction patterns. In the case of substance use, earlier onset is associated with more psychosocial problems and substance use in adulthood. While evidence is still lacking for SM addiction, one would expect a similar pattern of worse psychosocial and clinical outcomes in adulthood with earlier onset of use.
Social media features contributing to addictive behaviors
SM platforms’ features make them potentially addictive. One aspect is the opportunity for social engagement linked to the behavior. , With SM, the drive to use may originate, or at least be maintained, by the need to sustain offline social connections and/or create new ones on the platform. This phenomenon comes at a time in human history of a certain degree of replacement of in-person interactions by technology. Yet, the innate need for human connection persists.
There may be differences in addictive potential by SM platform. For example, Nextdoor, a platform that facilitates communication with neighbors about events of interest, with geographic centeredness and potential for parallel in-person interactions, is qualitatively different from text-based platforms such as Twitter (X) or video-based platforms like TikTok, where the user interacts with people they may never see in person.
According to a study based on psychological and economic theories by Montag and colleagues, the introduction of the smartphone created an “app” environment difficult to penetrate by scientists without the help of the app designers. The features of the phone apps and not the phone itself may be the culprit of the tendency to use in excess. The business model of Silicon Valley, where the user shares personal data instead of making financial payments, has the goal to keep the user engaged on the app for as long as possible, even to the detriment of other aspects of the user’s life. These authors propose that a series of “app” features contribute to keep users engaged.
One feature with addictive power is the “endless scrolling and streaming” that facilitates the “flow,” a state in which a person is so immersed with the task at hand that the perception of time is distorted. In SM, new videos or images appear without an automatic stop. At unpredictable times, the user sees content of interest or entertainment. This process follows an intermittent reinforcement schedule. As with slot machines, a reward is delivered at irregular intervals, which seem random to users but are designed to keep them engaged. Intermittent reinforcement schedules are more successful than regular and predictable schedules of continuous reinforcement, leading to the strongest type of behavior maintenance. Most SM platforms have endless scrolling and streaming, and the user must make an active decision to disconnect from the “app.” Notable platforms for endless scrolling and streaming include Instagram, YouTube, and TikTok where the next suggested video is selected for the user and previewed before the current video ends. TikTok’s videos are typically 2 minutes or less (also referred to as “reels”). By shortening the length of the videos, the app incorporates yet another feature contributing to addictive behaviors: instant gratification. Soon after TikTok gained popularity during the COVID-19 pandemic, other SM sites, including YouTube and Snapchat adopted the characteristic “reels.” Endless streaming also occurs with TV shows on the platform Netflix, which lead to show “binges,” a behavior unknown to previous consumer generations whose only options were weekly sequenced episodes further interrupted by commercial breaks.
Another feature is the “endowment or mere exposure effect.” This effect explains that the more time exposed to an online gaming world or effort expended building it, the more the user likes it and the harder it is to disengage from it. This feature applies to SM. In the case of Snapchat, for example, young people have “streaks,” which are seemingly of no benefit to the user or the company, other than maintaining the user engaged. When 2 friends text back and forth frequently, they will have a longer “streak” or continuous days of texting. Once the user and a friend reach 100 days, an “emoji” (a digital icon to express an emotion or idea) appears next to the name of the user’s friend. The “app” gives warnings if the streak is about to expire, which is after 24 hours of no engagement. In this process, a small action (eg, messaging a friend), becomes larger than the act itself, promoting daily app use. , This feature uses the exposure effect, along with social pressure. Montag and colleagues highlighted the “double-tick function” in WhatsApp, a worldwide used messaging “app” that allows users to see if a message has been received and read. Younger generations are now adopting colloquial language such as “leaving me on open” to signal when they know someone has read their message but has not responded. Another addictive feature is the “Newsfeed” on Facebook, which shows the user’s preferences and allows the company to track the user’s product preferences and how much time they spend looking at them. TikTok is well-known for its strong algorithms that direct users to topics of their interest, providing endless user-created content.
SM provide many additional features with opportunities for social reward. Some examples include the “like” on Facebook, the “love” on Instagram, and the former Twitter (current X)’s “retweet.” Experimental studies of participants using Instagram have shown that more “likes,” even when artificially controlled, have a stronger effect on brain areas related to reward processing such as the ventral striatum. , Social “apps” like Tinder, an online dating “app,” require little effort to establish new interest relationships. Tinder also connects users geographically to people within their interest range. By swiping right or left depending on the user’s interest, this app allows for immediate access to new social connections.
It is worth noting that not all negative effects of SM have been conceptualized under this model of addiction. Cognitive-behavioral principles can also help explain characteristics of SM problematic use such as the preference for online versus face-to-face social interactions and Internet use for mood regulation.
Epidemiology of problematic social media use
The global pooled prevalence of SM use in the general population nears 18%, with higher rates in the eastern Mediterranean region and in low/lower middle income countries. The increase in prevalence over the past 2 decades was exacerbated during the COVID-19 pandemic.
A smaller sample of all SM users will experience problematic social media use (PSMU). A recent meta-analysis of SM addiction studies conducted across 32 countries showed heterogeneity in the prevalence, which ranged between 0% and 82%, depending on the threshold used to define PSMU. Studies with more conservative classifications for identifying PSMU had 5% prevalence, while those with the lowest threshold had a 25% prevalence. The authors noted that studies that use a lower threshold to define PSMU may be appropriate to guide prevention state-level and country-level policies, while studies with higher thresholds may be useful to guide clinical decisions about SM addiction. An optimal threshold guide, for which more research is needed, would correspond to functional impairment. Interestingly, there are also cultural differences in SM use; collectivistic societies presented a higher prevalence, likely due to the social pressures to conform to group norms of SM use.
Neurobiology of problematic social media use
Dopamine has been hypothesized as the main monoamine neurotransmitter involved in reward-guided behavior. Primates show greater tissue concentrations of dopamine and a peak of cortical dopaminergic innervation during adolescence. These neurobiological characteristics of adolescence parallel processes of autonomy from the caregiver, but may be associated with a higher risk for addictive behaviors in human adolescents.
In substance use, a substance binds to receptors implicated in addictive behaviors. In behavioral addictions, changes in neurotransmitters are driven by the environment. Yet, both types of behaviors show similarities. Structural and functional brain function changes with problematic SM indicate reductions in the volume of ventral striata, amygdala, and cortical areas, increases in ventral striata and precuneus activity (in response to SM cues), abnormal functional connectivity involving the dorsal attention network, and communication deficits between both hemispheres. These regions recruited with SM use are involved in the mentalizing network (perspective-taking and empathy), self-referential cognition (ability to relate information from the external world to oneself) and salience, reward, and the default mode network, also engaged in substance addictions. However, the small number of studies and heterogeneity of methods limit the strength of the conclusions. Well-powered longitudinal research is needed for a definite affirmation of corresponding processes between SM and substance use addictions.
Problematic social media use and mental health
Most studies on PSMU focus on its relationship to mental health and behavioral problems. Systematic reviews and meta-analyses show SM use to be linked to depression and anxiety, suicidal thoughts and behaviors, poor sleep, body image, more distress, and poorer well-being. There are only weak associations between time spent or intensity of SM use and mental health outcomes such as depression, but the associations between PSMU and depression are moderate. In children, time spent on SM, and especially PSMU, is both associated with depression, most notably in females, and with younger onset age. Adolescents with attention-deficit hyperactivity disorder (ADHD) symptoms also present higher risk of PSMU than their peers without ADHD. Other behavioral addictions such as Internet use, gaming, and gambling are risk factors for PSMU, but no associations with substance use treatment needs have been found.
Limitations of current research
Existing research presents several limitations. First, there is a lack of agreement on the terminology. Many studies use SM addiction , while others use problematic Internet or SM use , with the intent to employ less stigmatizing language and avoid pathologizing the behavior. Second, many studies have used measures focused on one SM site (ie, Bergen Facebook Addiction Scale). , Given the rapid addition of new SM platforms, the development and use of scales that are applicable and sensitive to screen for all or at least some subtypes of SM are important. The new Bergen SM Addiction Scale (6 items, public access) is a good example of this transition. Another public access scale found to be acceptable is the SM Disorder Scale (9 items). , Finally, more research is needed to understand the differences between online and offline relationships.
Current evidence on therapeutic interventions
Universal approaches focused on screening and guidance are needed for all SM users. More targeted interventions for those at risk of presenting SM addictive behavior patterns can borrow from effective for substance use interventions such as motivational interviewing and cognitive behavioral therapy (CBT), assuming a similar model for substance use and SM addiction.
Prevention for the general population
While SM can become an unhealthy habit manifesting addiction patterns and comorbidities that require moderation in its use, it also offers opportunities to increase communication, and access to entertainment and news from around the world. These advantages became vital in the context of the COVID-19 pandemic lockdowns, which limited activities outside the home. Considering the potential for addiction of psychoactive substances and other behaviors (ie,: video gaming and SM use), and the greater chances that these behaviors would be used for “escapism” and to alleviate pandemic-related stress, a group of experts provided guidance for healthy engagement with information and communications technology. Their recommendations still apply after the pandemic and included (1) following daily routines and creating schedules that include work/study, socialization, and leisure time; (2) maintaining healthy sleep, eating, and personal hygiene habits; (3) exercising regularly; (4) using other stress-reduction techniques; (5) maintaining social connections, including with family; and (6) balancing news consumption: staying informed while limiting unnecessary exposure. More specific recommendations included self-monitoring one’s screen time and reducing access to devices to self-regulate use; for parents, monitoring children’s behavior, negotiating rules for use, being a good role model, and sharing some online activities with children to help them regulate their use; using digital well-being apps to limit time spent on SM and balancing it with screen-free time; and using analog tools when possible (ie, alarm clocks).
Specific interventions targeting problematic social media use
While the literature regarding the associations between PSMU and poor psychosocial outcomes is extensive, the research on SM-specific interventions is still scant.
In the general population, research following a model of addiction has examined SM use abstinence and reduction interventions with conflicting results. Some studies have found no benefits of SM abstinence. For example, a study examining loneliness, quality of life, and well-being found no differences between groups based on abstinence time (from 0 to 4 weeks). Another study found differences based on type of use, with changes in affect among passive SM users (those who scroll and read other people’s posts), but lower positive affect among active users (those who post and comment) after a 1 week abstinence period. Other studies have found benefits of SM use abstinence and reduction. One study saw reductions in loneliness and depression in undergraduate students who limited SM use to 10 minutes per platform, per day, compared to a group using SM as usual. Female adolescent dancers who abstained for 3 days showed reductions in body surveillance and body shame, and more positive mental states. A group taking a week-long SM break presented improvements in well-being, depression, and anxiety compared to the group using SM as usual. Another week-long trial found a 50% versus a 10% reduction in time spent on mobile SM to be beneficial to attentional performance and well-being, with decreased negative emotions in all participants, but no differences in outcome measures between groups. Abstaining from Facebook for 5 days was also associated with lower levels of cortisol and life satisfaction than continuing to use as usual. However, participants may be substituting SM with other forms of technology (ie, video games). Future research will need to explore differences between all-technology abstinence and SM-only abstinence.
Beyond abstinence and reduction studies, there is potential for improved affect with interventions on cognitive mechanisms related to social comparisons. Experimental studies with Romanian high schoolers who were asked to compare downwards (with others who are worse off) showed increased gratitude. In college students, a self-help intervention (combined CBT with cognitive reconstruction about SM use) reduced PSMU and improved mental health and academic outcomes. The intervention included daily diaries with reflections and reminder cards about a reflection on the advantages of reducing SM use and the disadvantages of excessive use as a phone lock screen. Finally, therapy-based interventions appear to be more effective in improving mental well-being than abstinence-based and use reduction interventions, the latter of which are the least effective.
Combining approaches may also be beneficial. Integrating CBT, short abstinence periods, and daily dairies over a 2 week period showed improved life satisfaction compared to daily diaries and SM use as usual. The support for CBT interventions for SM is drawn mostly from literature on Internet addiction. There is certain overlap between Internet and SM addiction. Half of US teens spend 4.8 hours daily on SM on average, suggesting that much of the time spent on screens is used to navigate SM sites. However, SM-specific interventions are understudied. Parental restrictions may be beneficial in decreasing time spent on SM, suggesting a role of family therapy, which has proven effective for Internet addiction. ,
What can we learn from other behavioral addictive disorders interventions?
Adapted interventions common in substance use disorders may have a role in technology addictions. Research on addictive behaviors on digital technologies (ie, Internet, smartphones, and computers), such as on-line games, pornography, and shopping addictions, is advanced , and includes adolescents and young adults. Notably, activities such as Internet-based massive multiplayer gaming with built-in chat features are becoming increasingly social, and more difficult to distinguish from SM.
The literature supports CBT, Acceptance and Cognitive Restructuring, and Craving Behavioral Interventions as promising interventions for gaming disorder. However, the studies conducted on CBT did not include PSMU scales. Other propitious treatments include motivational interviewing, mindfulness, exercise, and family-based interventions. Regarding medications, one open label study suggested antidepressants as potentially useful in treating Internet addiction. A recent review on psychopharmacological interventions for all technological addictions showed supporting evidence for the use of stimulants (ie, methylphenidate), antidepressants (ie, escitalopram and bupropion) and CBT for Internet gaming disorder, and CBT as a valid treatment for SM addiction, online porn, and shopping addictions. Bupropion, an antidepressant medication with dopaminergic and noradrenergic properties, is effective for Internet gaming disorder treatment independently of the presence of comorbid depression. As with other disorders of addiction and mental health, combined psychosocial and pharmacologic interventions seem to be more effective for Internet use disorders than either approach alone.
Discussion
Based on existing research, addressing PSMU requires multilevel interventions.
Policy
Broad-level interventions involve federal-level and state-level restrictions on youth’s access to SM platforms and their addictive features. While important, the ubiquitous presence, use, and constant evolution of SM make regulation challenging. Public health campaigns explaining the risks for addiction at a young age and the ways to manage SM use could be used for public education. Guidance by the medical and educational communities on the appropriate age for smartphone acquisition and exposure to SM is needed. However, individual differences among children should be considered. The US Congress and some states have already enacted laws to protect children and prevent excessive or early SM access. Clinicians should continue to be part of these conversations.
School/Community
Some schools across the country have enacted policies to limit cell phone use in the building or during class. School interventions to limit screen-based entertainment have potential for positive effects on student academic and behavioral outcomes. Support by parents (ie, to restricting smartphone use in school) should be addressed educating communities about the risks of SM use.
Schools also have a role in educating children about SM’s potential negative effects, including its addictive nature. Teaching good habit formation and healthy use of SM could provide students with the skills necessary to self-regulate their use. Schools can also promote digital media citizenship, teaching students safe and responsible ways to interact with each other online.
The trend in schools to heavily rely on technology in the classroom needs to be discussed in the context of screen addictions. Appropriate use of technology can optimize educational outcomes, , but there are risks such as distraction, technology misuse during school hours, and disruption of efforts to regulate healthy screen use at home with school-issued technology and digital assignments. Technology use to complement and not substitute traditional teaching methods may be most beneficial. Options for individual accommodations for those struggling with PSMU, such as paper-based assignments and additional monitoring of technology use during class time can be helpful.
Clinicians
Professional associations should update guidelines on screen time limits to include SM use, given the changing environment that has left previous guidelines outdated. Clinicians working with children should consider including Internet-related behavior (including SM use) as part of their assessments. Helping families set screen limits and understand the risks of problematic SM, and brief interventions with aspects of healthy-habit building, motivational interviewing, and CBT can be beneficial and feasible in pediatrician’s offices. If screening questions identify that SM is negatively impacting overall health (ie, displacing sleep, exercise, and nutrition) or mental health (ie, impaired self-esteem, depression, and anxiety), referral to a psychiatrist and/or psychotherapist may be helpful. In cases with severe symptoms such as school avoidance or suicidality, placement in a psychiatric hospital, residential center, or other specialized program may be warranted.
Families
As consensus on what is healthy SM use and regulation remains challenging, much of the burden for safely navigating a world overrun with SM falls to the home environment. Families can help shape behaviors by instilling healthy routines, off-screen activities, and better placement of cues (ie, keeping digital devices in a different location from schoolwork and sleep areas). Parents or guardians may also add structure, such as programming of outdoor activities and regular exercise, helping children navigate unstructured time with time-limited blocks of SM use, and delaying the age of acquiring smartphones. Parents can model by moderating their own use, eliminating smartphone use at mealtimes, and scheduling in-person social activities, which can positively affect the entire family’s SM use habits. Family media plans can be created with online resources. Parents should seek professional help when their children show signs of addiction. Future research should focus on the effectiveness of periods of brief abstinence from digital devices as a family intervention.
Individuals
Children can learn to schedule their SM use, avoiding use at night or early in the morning, and prioritizing other activities, such as school work, sports, and face-to-face time with friends and family. Young adults may need support after leaving home onto more unstructured or unsupervised environments.
Summary
The current universal use of SM among children places them at risk for SM addictive behaviors. Pediatricians already provide guidance for healthy-behavior formation and can incorporate SM use screening and guidance in their practices. While the research on effective interventions specific to SM use is still growing, brief periods of abstinence, family media plans, and an overall mindful use of technology that promotes other health-related behaviors such as sleep and in-person socialization may benefit children’s development. More severe addictive behaviors or other mental health comorbidities may require referral to mental health specialists.
Clinics care points
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SM use is now almost universal among youth, and a proportion of children will develop addictive use patterns on these platforms.
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Children can learn to schedule their SM use, avoiding use at night or early in the morning, and prioritizing activities such as school work, sports and in-person interactions.
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Pediatricians can involve families and provide anticipatory guidance, promoting healthy behaviors, screening for PSMU, providing brief interventions, and referring to specialists as needed.
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Brief interventions with aspects of healthy-habit building, motivational interviewing, and CBT can be beneficial. Brief abstinence, use reduction and periods of self-monitoring show promise.
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For children with acute dysfunction related to SM use, additional interventions and referral to a psychiatrist and/or psychotherapist should be considered.
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In case of severe symptoms such as school avoidance or suicidality, psychiatric placement may be warranted.
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