Social Media Use and Youth Mental Health: A Guide for Clinicians Based on Youth Voices

Clinicians need guidance on how to better support youth in their social media use. Directed by the voices of youth from our nationwide study, we would like to relay some additional guidance for clinicians surrounding this large task based on youths’ own experiences and advice.¹

Social Media Use Contributes to Both Well-Being and Ill-Being Among Youth

The culmination of research about social media’s effect on youth mental health has taught us that social media can contribute to both well-being and ill-being.² The degree of increase in well/ill-being depends on multiple variables including the baseline characteristics of the individual and the types and content of the social media consumed. For example, the effects of pro-anorexia content on Instagram for a 12-year-old with depression will be different than the effects of a subreddit about shared experiences as a transgender teen for a transgender 17-year-old. We know that for certain groups of individuals, there may be specific benefits afforded through social media that are not otherwise as available in real life. One such benefit is emotional, appraisal, and informational support for transgender youth.³ Furthermore, social media spaces can be safe places for community and connection for historically, persistently, or systemically marginalized groups.

Patient Assessment

Because there are so many variables, it can be difficult to develop an understanding about a patient’s social media use and make tailored recommendations within the context of time-limited health care appointments when there are many other topics to discuss. However, this understanding is an integral part of any mental health assessment and treatment plan. The American Academy of Pediatrics updated their HEADS³ psychosocial screening mnemonic to HEADS⁴ in 2018 by adding social media to “home life, education, activities, drugs, sexual activity, safety, and suicide and depression.”⁴ By using this extension, pediatricians are encouraged to ask the following 5 questions:

1. Which social media sites and/or apps do you regularly use?

2. How long do you spend on social media sites and/or apps in a typical day?

3. Do you think you use social media too much?

4. Does viewing social media increase or decrease your self-confidence?

5. Have you personally experienced cyberbullying, sexting, or an online user asking to have sexual relations with you?

Additional practical tips for providers include:

1. Ask about social media use at every visit. It is ok if you do not know everything about each platform. Be honest if you do not know something and ask for explanations. Showing interest and highlighting the connection between social media use and mental health as the provider is important.

2. Maintain a curious, nonjudgmental approach. It may be a good idea to ask patients about their friends’ behaviors and experiences on social media before asking about the patient’s own experiences in order to help them to feel comfortable talking about these topics. The clinician may also say something to normalize social media experiences that may be difficult to talk about by starting with, “I have had patients tell me about (experience on social media), have you ever experienced anything like that?”

3. Screen for cyberbullying. In our MyVoice study, the most common topic of advice respondents had for each other was about safety.¹ It is important for mental health clinicians to assess for safety, including cyberbullying (as a target or perpetrator), as it is a risk factor for suicide.⁵ Because youth may not consider their experiences as cyberbullying, clinicians can ask specifically about mean comments, name calling, hate speech, stalking, threats, embarrassing or private pictures shared without consent, or unwanted attention. Asking patients if anything has occurred on social media that made them feel unsafe or targeted may also provide important insights into youth’s social media experiences. A risk factor for cyberbullying (both as a target and as a perpetrator) is early ownership of a smartphone.⁶ Remember, youth are unlikely to tell anyone if they are being cyberbullied and if they do tell someone, it is likely to be a friend (not an adult), so asking every patient can make a big difference.⁶

4. Ask about online friendships, fake social media accounts and exposure to distressing content (such as pro-suicide, pro-self-harm, pro-eating disorder or dangerous challenges). Simply showing the patient that you are aware of these social media phenomena might make it easier for them to talk about their own experiences.

Motivational Interviewing

Motivational interviewing techniques can be used to navigate the patient’s ambivalence about their social media use and to determine the patient’s readiness for change. Many youths have already made efforts to change their social media use in some way, so it is important to ask about their motivation for making those changes in the past, what was difficult about making/maintaining the change and what they learned from those experiences. Understanding this can help the clinician and patient come up with a plan for change which anticipates those barriers from the past.

In Table 1, we outline some potential motivational interviewing questions to ask patients about their social media use. It is important to ask the patient both about what they like and do not like about social media as the goal is to help them to modify their social media use in a way that maximizes the benefit while minimizing the harm.

Youth Have Valuable Advice for Their Peers About Social Media Use

In November of 2020, over 800 youth aged 14 to 24 responded to the following 3 questions: 1) What advice would you give to young people who are new to social media? 2) Have you ever felt like you need to change your social media use (what you view, time spent, etc)? Why? and 3) Have you ever deleted or thought about deleting your social media account(s)? Why?¹ We learned that youth shared advice that coincided with guidance shared by professional organizations (American Academy of Child and Adolescent Psychiatry⁷ and American Academy of Pediatrics⁸), but they also shared advice that professional organizations have yet to comment on (Table 2). Their novel advice included more individual-focused aspects of social media such as awareness of self-worth derived from popularity metrics on social media and promotion of media literacy, including how to detect misinformation and edited photos. They also frequently reported that it is okay to take breaks from social media all together.

Patient Guidance

Before suggesting any specific changes to social media use, it is important to understand the patient’s insight about how their social media use is affecting them, their motivation for change, and their buy-in. It is a good idea to tailor the social media modification recommendations around the patient’s goals.

Social Media Setting Changes

The information we gained from the MyVoice study informed our creation of an educational video describing different Instagram setting changes which mapped onto the recommendations made by youth in the study. The video (along with instructions for practical setting changes on multiple platforms) can be found here. The video demonstrates setting changes related to safety features, turning off like and view counts, time reminders, and changing content consumption. The contributors to ill-being described by youth can guide potential practical changes to social media use. If the patients are comfortable with it, the clinicians could even walk their patients through the setting changes in the office.

Caregiver Guidance

Social media evolves quickly, and its use is highly nuanced and personal to each individual and family. Because of this, caregivers are sometimes at a loss about the best way to support healthy social media use among their youth. Here are 3 pieces of advice that clinicians can invite parents/caregivers to consider:

1. Encourage families to be conscious of their own social media use in order to model the behavior they hope to see in their children. Nowadays, it is likely that children will first be exposed to social media by observing their caregivers using social media. Youth watch their parents/caregivers as examples and their behaviors can play a big role in creating norms about social media use. Youth are also unlikely to abide by social media house rules that their caregivers are not following.

2. Encourage families to talk to their children about their social media use. Caregivers and teens can learn about social media settings/tools and make changes to their use together. Many youths want to reduce or adapt their use because they recognize its negative effects. Caregivers can help them to achieve their own goals. Encourage families to continue talking and learning together, even if it feels like two steps forward, one step back.

3. Encourage families to keep certain places screen free, especially the bedroom. Social media was designed for users to maximize their time spent on the apps. This often leads to later and later bedtimes or interrupted sleep. Keeping bedrooms screen-free at night and avoiding screens during the hour before sleep could promote sleep quantity and quality. Sleep is paramount for adolescent mental health. If implemented, youth may need to go back to the traditional alarm clock if they had been using their phone for that purpose. It is also a good idea to keep family time/meals screen-free to facilitate conversation. One-on-one time between caregiver and child—without social media—when possible is always helpful.

Family Media Plans

Another great resource is the American Academy of Pediatrics’ Family Media Plans. Families can use this tool to browse a list of recommendations and choose which ones they would like to implement. Many of the recommendations have the potential to improve youth mental health. A few standout recommendations which add to our guidance include:

1. No social media use or texting while driving because we know distracted driving increases the risk for accidents.

2. Emphasize kindness, empathy, and respect online. It is important for families to promote kindness online just as they would encourage it at school or on the sports field.

Other Resources for Families

Although providing resources is not a substitute for the process of evaluating for social media’s impact on patient well/ill-being, motivational interviewing, and making tailored recommendations for change, it can be beneficial if done in tandem. Here are a few great resources for families who want to learn more:

1. Children and Screens

2. AACAP Facts For Families

Advocacy

A clinician’s job also includes advocating for policies that create healthier communities and a healthier society. Here are some topics that a clinician might consider advocating for:

-National level school-based curriculum about the risks and benefits of social media and media literacy. All youth should have the tools they need to navigate this technology. Just as drivers-ed evolved with the technology of cars, a national educational curriculum for social media use and media literacy should evolve with the technology of social media. It is also imperative that schools implement a separate mental health curriculum nationwide.

-Increased safety features and data protection for youth from the social media apps

-Increased transparency from social media apps about their internal data, algorithms, etc.

Dr Harness is a clinical assistant professor in the Department of Psychiatry at the University of Michigan. She practices in emergency psychiatry and pediatric consultation/liaison psychiatry and her research focus is media and youth mental health. Dr Chang is an associate professor in the Department of Family Medicine at the University of Michigan. She is a practicing family physician and health services researcher with a focus on promoting healthy behaviors among adolescents and young adults.

References

1. Harness J, Fitzgerald K, Sullivan H, Selkie E. Youth insight about social media effects on well/ill-being and self-modulating efforts. J Adolesc Health. 2022;71(3):324-333.

2. Valkenburg PM, Meier A, Beyens I. Social media use and its impact on adolescent mental health: an umbrella review of the evidence. Curr Opin Psychol. 2022;44:58-68.

3. Selkie E, Adkins V, Masters E, et al. Transgender adolescents’ uses of social media for social support. J Adolesc Health. 2020;66(3):275-280.

4. Clark DL, Raphael JL, McGuire AL. HEADS4: social media screening in adolescent primary care. Pediatrics. 2018;141(6):e20173655.

5. John A, Glendenning AC, Marchant A, et al. Self-harm, suicidal behaviours, and cyberbullying in children and young people: systematic review. J Med Internet Res. 2018;20(4):e129.

6. Nixon CL. Current perspectives: the impact of cyberbullying on adolescent health. Adolesc Health Med Ther. 2014;5:143-158.

7. Social media and teens. American Academy of Child & Adolescent Psychiatry. Updated March 2018. Accessed September 5, 2023. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Social-Media-and-Teens-100.aspx

8. Hill DL. Social media: anticipatory guidance. Pediatr Rev. 2020;41(3):112-119.