As in traditional media, the depiction of ideas and behaviors on social media can influence viewers to adopt them. Social media may be particularly influential because the platforms are highly engaging, reach a vast audience, and personalize user experience to feature content most likely to affect the individual user. Numerous high-risk adolescent behaviors have been linked to viewing related social media content, but the extent to which they are the cause of and caused by content exposure remains unknown. Pediatric providers are advised to adopt standardized approaches to the prevention and management of social media contagion in clinical practice.
Key points
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Social media’s unique features facilitate the rapid transmission of ideas and behaviors among users, particularly adolescent youth.
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Youth with a history of high-risk behavior may be at particular risk of being influenced by graphic content viewed via social media.
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Pediatric clinicians should regularly assess the social media content viewed by their patients at risk.
Background
Teenagers in the United States spend up to 9 hours per day on screens, and nearly 20% report “constant” use of social media. The increasing amount of time youth are exposed to social media content has led to growing concerns about how these platforms influence adolescent behavior. To date, social media has been implicated in the “spread” of several high-risk behaviors among populations of youth, including substance use, non-suicidal self-injury, disordered eating, suicidal behavior, and violence. The process by which beliefs or behaviors are transmitted via social media is commonly referred to as social media contagion.
Social media contagion is a recent phenomenon, but mass media has long been recognized as a driver of social contagion. Books, television shows, movies, and newspapers can all be held culpable for influencing the actions of large groups of individuals through their storytelling. However, while social media contagion represents a single subtype of media-driven contagion, it distinguishes itself in important ways. Social media platforms are especially efficient vectors for spreading “contagious” ideas and behaviors, and their rapid evolution has made them challenging to study.
Review papers evaluating social media contagion research are often focused on a specific high-risk behavior (eg, non-suicidal self-injury). This approach makes it difficult to appreciate the phenomenon of social media contagion as a whole, and obscures commonalities shared by various forms of social media contagion. The hypothesized mechanisms enabling social media-driven spread of diverse ideas and behaviors are often identical. Furthermore, the same types of media contagion recur with the rise of each new platform, differentiated only by unique risks associated with that new platform’s functionality. For example, one should expect social media content that promotes disordered eating to appear on any new video-sharing platform, and the risks will be similar to those seen with pre-existing video-sharing platforms (eg, YouTube, TikTok).
Here, the authors review existing research on identified forms of social media contagion influencing high-risk behavior among youth, certain traits that may make some youth particularly susceptible to this phenomenon, and limitations to scientific understanding of social media contagion. The authors also provide the reader with a broader conceptualization of social media contagion. By comparing and contrasting social media contagion subtypes, and offering a theoretic framework for how social media specifically facilitates social contagion, this article will help pediatric clinicians adopt a singular, standardized approach to the prevention and management of social media contagion in clinical practice.
Why Is Social Media Such an Effective Vehicle for Social Contagion?
To best understand social media contagion, it is important to appreciate the unique aspects of social media that make these platforms more influential than traditional forms of media. For a contagion to be effective, it needs both access and opportunity; social media platforms not only create an environment optimal for social contagion, they also connect a vast network of susceptible viewers.
An optimal environment for transmission
Several mechanisms have been proposed as drivers of social contagion. Social transmission is perhaps the mechanism most similar to a “real” contagious process, and posits that exposure to specific content in and of itself can influence a person to entertain thoughts or engage in behaviors related to that content (eg, watching a video on YouTube about non-suicidal self-injury triggers a teenager to cut themselves). Social transmission is thought to explain how behaviors like suicidality could spread via news reports or television shows. However, in most instances, content exposure alone is not enough to influence individual behavior; environmental factors that increase host susceptibility are important when considering whether or not a behavior will be imitated.
These other factors include perceived descriptive norms, practices perceived to be “acceptable” or commonplace within one’s community, and injunctive norms, behaviors that an individual believes one “ought” to engage in based on peer expectations. In other words, individuals are more likely to participate in behaviors they believe “everyone else is doing” or that are expected to gain peer approval. Social media platforms offer engaging multimedia content through text, images and videos, and use algorithms identifying and catering to individual viewer preferences, which results in an artificially narrow range of content exposure, insulating the viewer from exposure to multiple, contrasting opinions. Thus, social media can provide unlimited access to multimedia content featuring a particular ideology or behavior, and repeated viewings of like videos or posts reinforces that thought or behavior by giving teens the impression that “everyone else” is thinking and behaving that way.
Similarly, exclusive, tight-knit communities with diminished external influence have long been known to be hotspots of social contagion, as demonstrated by the well-documented tendency for non-suicidal self-injury to spread within insular environments like college campuses, prisons, and inpatient psychiatric units. Social media platforms allow for the creation of smaller, independent digital communities, fertile breeding grounds for social contagion.
Widespread access to large social networks
Audience is also a critical component of social contagion, as an early example of suicide contagion demonstrates. The eighteenth century publication of Von Goethe’s novel The Sorrows of the Young Werther, depicting a romanticized protagonist who died by suicide, was followed by a noted increase in suicides among the book’s young audience. “The Werther effect” refers to the potential of suicide portrayal in mass media to inspire real-life suicidal behavior. However, The Sorrows of the Young Werther is by no means the earliest depiction of glamorized suicide in the literature. Shakespeare’s Romeo and Juliet predated Von Goethe’s novel, and culminated in the suicides of its heartbroken protagonists. Romeo and Juliet might also have been expected to inspire suicide contagion, but it reached a much smaller audience because of widespread illiteracy of the era.
Social media platforms have the ability to immediately present a specific idea or behavior to a nearly limitless audience. Social media influencers constantly design content to connect with a wide audience and maintain engagement, and their most engaging material is selected via algorithm to reach the largest audience. Adolescents are intentionally targeted by content producers for profit; it is estimated that major social media platforms make billions of dollars annually through advertising to minors. By refining a user-friendly interface that caters personalized content targeting adolescents’ reward-driven neurocircuitry, social media companies excel at capturing and sustaining the attention of a vast audience of teenaged viewers.
Discussion
Still in the process of identity formation, status-conscious adolescents are susceptible to internalizing and imitating “viral” social media trends. While frustrating for some parents, the majority of these trends are harmless, not appreciably different from prior youth-driven movements championing specific fashion brands, music artists, dance moves, or pastimes. However, even non-viral social media content can still inspire contagion. Adolescents whose online activities center around a singular community with homogenous beliefs will be subject to the same pressures (both perceived and real) compelling them to think or act in accordance. Many of the following high-risk forms of social media contagion are believed to spread via such like-minded online subcommunities.
Suicide
Suicide contagion is among the most well-documented forms of social contagion. A substantial body of evidence supports the Werther Effect and the role of mass media in spreading suicidality. Those most susceptible to suicide contagion appear to be those who identify with the character or individual who espouses or dies by suicide, and “copycat” suicides tend to be most common in the first few weeks following suicide exposure.
Like traditional media (eg, books, newspapers), social media content has been implicated in varying degrees of suicide contagion. For example, exposure to suicide-related content on online forums has been associated with subsequently increased suicidal ideation. Exposure to content concerning a suicide cluster (ie, a series of 3 of more united suicide events in a common space and/or in a contiguous time frame) may confer additional risk. Youth without a history of suicidality who experience exposure to suicide cluster-related social media content during a suicide cluster are significantly more likely to endorse both suicidal ideation and suicide attempts.
To understand why certain types of social media engagement might confer a greater contagion risk, it is helpful to consider additional research exploring the Werther Effect. While most forms of media have the potential to drive suicide contagion, not all suicide-related media content will. Stories that sensationalize or promote simplistic explanations of suicide, or those that depict suicide as a means of accomplishing a goal, seem more likely to inspire suicide contagion. , Based on related research, specific words and phrasing are recommended when reporting on suicides, and adherence to suicide reporting guidelines has been shown to decrease incidence of suicide contagion.
There exists no single agency responsible for monitoring the wording of suicide-related social media content, and the sheer amount of available media content makes effective monitoring challenging. Social media accounts affiliated with reputable news outlets are more likely to follow suicide reporting guidelines than the social media accounts of individuals. Social media users, typically motivated by the prospect of obtaining “likes” and “shares,” may be incentivized to post suicide-related content in violation of suicide reporting guidelines. Unfortunately, the tendency for social media platforms to reward the posting of content more likely to inspire harmful contagion is not limited to suicidal behavior.
Non-Suicidal Self-Injury
Multiple studies have reviewed non-suicidal self-injury (NSSI)-related content on social media platforms and found hundreds of message boards and videos concerning NSSI which are unrestricted and easily accessible to teenagers , NSSI-related content exists on most social media platforms to varying degrees, as some platforms tolerate or feature more posts portraying NSSI graphically or in a positive manner. , Graphic images of self-injury may be especially likely to provoke copycat behavior.
Adolescent and young adult females appear more likely to view and post NSSI-related social media content, for various reasons. Some youth seek peer validation or support in abstaining, while others use these forums to facilitate their self-injurious behavior (eg, by learning new methods of NSSI or ways to conceal it) , Despite its theoretical benefits, youth access to NSSI-related social media content should be monitored carefully. Engagement with this contentmay as easily trigger as quell self-injurious urges, depending upon characteristics of the viewer and content viewed. Social media platforms may actually incentivize continued self-injury. A systematic review of studies on NSSI-related Instagram content determined that posts featuring graphic NSSI imagery were more likely to receive online attention. If this finding applies to other social media platforms, even youth who turn to these forums to avoid self-injury may as a consequence feel compelled to self-injure and post about it to obtain online peer support.
Violence and Extremist Ideology
Exposure to media violence, particularly exposure to actual interpersonal violence, has been associated with youth engagement in violent behavior. While many factors predispose an individual to engage in violent behavior, increasing evidence has found social media may be among them. In-person social networks are capable of “spreading” violence locally (eg, shootings within a city), but epidemiologic modeling shows that online social networks may do so faster and to a larger geographic distribution. Organizations studying extremist groups have emphasized the growing role of social media platforms in extremist recruitment and organization.
Research linking exposure to violent social media content and real-life violence is often unable to confirm the directionality of this relationship. Youth harboring extremist or violent ideology are inherently more likely to seek out online content that reaffirms their beliefs. However, engagement with violent content may indeed lead to acts of violence. Online forums dedicated to extremist ideology create insular echo chambers, spaces in which group members “echo” one another’s opinions, reinforcing violent ideology and sheltering members from exposure to alternative viewpoints. Such echo chambers effectively synthesize moral outrage, a factor in the development of extremism that has been linked to social media. , Perceived limits in accountability for online behavior also contributes to greater invisibility and dissociative anonymity and imagination, resulting in an “online disinhibition effect,” the tendency for individuals to act out more aggressively in a digital setting.
Research linking the adoption of extremist ideology to social media forums further supports a contagion effect. Engagement with extremist forums, and having one’s posts positively reinforced by other group members, predicts further radicalization. For example, the individual who perpetrated the 2022 mass shooting in Buffalo, New York, cited platforms 4chan and reddit as formative to his racist beliefs.
Substance Use
Youth exposure to depictions of drug or alcohol use via television, movies, and video games correlates consistently with increased substance use. This effect has led to video game and movie rating systems designed specifically to flag substance-related content. However, social media platforms are not subject to such content warnings, and drug and alcohol companies have found creative ways to circumvent restrictions on advertising substances to youth. For example, product placement for drugs or alcohol can occur within music videos, and young adults exposed to e-cigarette product placement within music videos are more likely to report e-cigarette use. Music videos featuring such product placement can be shared easily via social media platforms without flagging as an advertisement.
Substance-related social media content frequently portrays drug use in a humorous or entertaining light. In their review of 73 studies, Rutherford and colleagues found that over 75% of substance-related content on social media depicts substance use positively. Social media platforms also give youth a means to visualize the drug and alcohol use of their peers. Many youth report seeing videos of peers intoxicated online, and admired celebrities and influencers sharing about their substance use. The relationship between youth exposure to cannabis and alcohol-related social media content and offline substance use is mediated through perceived descriptive and injunctive norms. Youth whose peers appear engaged in substance use on Snapchat or Instagram are likely to consider drug use to be normal or even expected. The degree to which substance-related social media content causes youth substance use remains debatable, as youth already engaged in drug use are more likely to seek out substance-related content. However, as peer influence is a well-established factor driving adolescent substance use, the potential influence of online peers is likely considerable.
Self-Diagnosis
Over the last several years, social media has increasingly become a means for adolescents to learn about and self-diagnose medical and psychiatric conditions. Social media platforms provide answers to the health concerns of youth without the perceived inconveniences of professional appointments, and allow teenagers to connect with peers who have similar concerns and experiences, which can promise validation and a sense of belonging.
Unfortunately, mental health information posted on social media is typically unreliable. Research indicates that more than half of TikTok videos about attention deficit hyperactivity disorder contain inaccurate information. Social media depictions of tic disorders not infrequently misrepresent these disorders by displaying rare aspects of these conditions (eg, coprophenomena) at a disproportionately high rate. Medical professionals are also increasingly seeing young patients reporting symptoms which appear influenced by social media, as well as unreliable self-diagnoses ranging from dissociative identity disorder and autism spectrum disorder, to functional tic-like behaviors. Self-identification of such rare diagnoses appears more common in female-identifying youth, and youth with uncomfortable internalizing symptoms like anxiety and depression may prefer to identify with these rarer neuropsychiatric diagnoses. While these self-diagnoses may help some youth make sense of distressing experiences andgrant access to peer approval, attention, or affiliation, they could also enable avoidant behavior due to perceived disability from a self-diagnosed illness.
Body Image and Disordered Eating
Social comparison, the process by which a person determines their own self-worth by comparing themselves to others, is an everyday psychological process. What differentiates social media-related social comparison is the ability to carefully curate self-portrayal. On social media, youth risk unfairly comparing themselves to unrealistic, idealized images of peers. This is especially true as it relates to body image, because photo filters and artificial intelligence allow for flawless seemingly-real renderings of one’s physical appearance online. Aggregate findings from 26 studies confirm a correlation between social media content exposure and body dissatisfaction. Research suggests that adolescent females may be more susceptible to body image-related social comparison, and the degree to which a teen engages either with appearance-related online content or related self-comparison may predict negative body image. , Resulting negative body image or low self-esteem may even mediate the relationship between social media exposures and dietary changes, including disordered eating. Extensive use of image-based (as opposed to text based) social media platforms, popular among teens, has also been linked to eating disorders (ED).
Adolescents may struggle to differentiate online advice promoting “healthy dieting” from content promoting ED behavior, especially those already engaged in such behavior. For youth with disordered eating, pro-ED social media content has been implicated in maintaining the behavior and delaying recovery. Like NSSI-promoting social media groups, pro-ED online communities allow individuals to share information on ways to continue disordered eating, and reports shared by individuals striving to achieve specific metrics of thinness can create a sense of competition among community members. Social media companies’ efforts to ban pro-ED content have been largely unsuccessful. Content creators evade censorship by using coded language for community names and/or hashtags associated with pro-ED messaging. Similar to other forms of social media contagion, the extent to which to pro-ED social media content causes disordered eating is still unknown. Again, the relationship is likely bidirectional; youth already struggling with disordered eating are more likely seek out social media content related to dieting or body image, which further reinforces the maladaptive behavior.
Forms of Adaptive Social Media Contagion
If social media can inspire youth engagement in harmful behaviors like self-injury or disordered eating, it might also be used to promote protective ideas and behaviors. Few studies document beneficial social media contagion or the leveraging of social networks to spread certain healthy behaviors, but examples do exist.
A small body of research evidence supports the use of “social media contagion” to spread accurate health information, particularly in the field of sexual health. Sexual practices, substance use, and eating habits are thought to be most susceptible to influence by social networks. Public health-oriented social media campaigns could theoretically counteract negative effects of social media. Visually-appealing social media campaigns featuring adolescent influencers may be most likely to influence a wide youth audience.
Additionally, many adolescents credit social media platforms for helping them understand and engage with issues important to them. This is evident in youth-driven social justice movements like “Black Lives Matter” or “March for Our Lives.” By compelling viewers to adopt and espouse the ideology behind these moments, exposure to social media activism could influence youth mobilization and engagement with social causes. This form of social contagion can assist in valuable connections with like-minded peers and even identity development for some teenagers.
Adaptive social media contagion could also encourage help-seeking behavior. The character Papageno in Mozart’s opera “The Magic Flute” considers suicide, but decides against it after being offered alternatives. Storylines in which characters choose an alternative to suicide, or news outlets that offer helpful resources (eg, the suicide hotline number) alongside reports of suicide are thought to drive this protective “Papageno Effect,” making exposed viewers less likely to attempt suicide. A contemporary example of the Papageno Effect is the 2017 song “1-800-273-8255” by the artist Logic, which takes its title from the U.S. suicide hotline number. The song’s popularity appears to have resulted in increased calls to the suicide hotline, potentially saving lives.
Given their accessibility and influence, social media platforms could similarly disseminate information about alternatives to suicide and normalize the process of accessing psychiatric help for suicidal ideation and depression. Strategic social media content featuring adolescents who overcame depression and/or suicidal ideation might help to counter the plethora of social media content perpetuating suicide contagion. Such campaigns could prove especially critical for youth living in communities where mental health disorders and care are still highly stigmatized.
Future considerations
The research methodologies most commonly used to study adolescent social media contagion have inherent limitations. Studies performing comprehensive content analyses of social media platforms are unable to confirm whether visualization of certain social media content directly results in high-risk behavior; survey studies depend on accurate recollection of what social media content was encountered prior to engaging in a high-risk behavior. Longitudinal studies that capture both existing social media content and mental health impacts of content exposure would yield study results that are more clinically meaningful. Additionally, use of technologies like smartphone-based ecological momentary assessment has demonstrated promise in furthering scientific understanding of adolescent problematic internet use. , Similar studies using smartphone applications to passively capture data on social media use in conjunction with repeated surveys regarding high-risk behavior could clarify the mechanisms by which social media contagion occurs and identify which youth are most susceptible.
Unfortunately, the lack of robust clinical studies on social media contagion leaves unresolved challenges for pediatric clinicians. Without validated and standardized screening tools to assess for social media contagion, many clinicians remain unaware of its possible contribution to their patients’ symptoms or behaviors. Furthermore, it is not yet clear which patients require regular screening, nor what management strategies are most effective in managing this process. Collection of high-quality data on social media contagion would also help to guide development of these important clinical tools.
For those young patients suffering from mental health symptoms who spend a significant amount of time on social media, clinicians should ask what they have learned about their conditions via social media, and whether they have online peers who deal with similar problems or diagnoses. Adolescent patients may even be willing to share their social media feeds with their clinicians, which can reveal a great deal about what type of content the youth engages in and whether it may be problematic from a mental health standpoint. Patients who are triggered to engage in risky behavior after viewing related social media posts should be encouraged to make changes in platform application or phone settings to eliminate such content from their feeds. If a clinician is able to determine that a high-risk behavior or affiliation with a psychiatric condition addresses the unmet needs of a teenage patient (eg, for affiliation or peer approval), they should help the patient and family to brainstorm healthier alternatives that could also address those needs (eg, afterschool activities, religious involvement).
Summary
Based on our existing knowledge on social contagion and mounting observational studies combined with anecdotal reports, social media platforms are capable of powerfully influencing adolescent behavior. Results from multiple studies support a significant relationship between related social media content exposure and adolescent suicidality, non-suicidal self-injurious behavior, disordered eating, violence, substance use, and self-diagnosis. However, convincing research evidence that social media exposures cause these behaviors is not yet available. As researchers continue to improve upon scientific understanding of this phenomenon, all pediatric clinicians should be aware of the potential of social media contagion to perpetuate or maintain maladaptive high-risk behaviors. Psychoeducation on social media contagion should be provided to pediatric patients and their guardians prior to the child’s first independent social media use ( Box 1 ). Most forms of high-risk social media contagion spread via similar mechanisms, and exist on multiple platforms, so a common standardized approach to clinical management of social media contagion is recommended ( Box 2 ).
