CCPR: What is the impact of social media use on child and adolescent mental health?

Dr. Weigle: Social media has transformed the world of children and adolescents, both for good and for ill (www.tinyurl.com/3jsnbbt7). More time on social media has small to moderate correlations with worse mental health (r=0.02–0.17), but this is partly because of the variability of young peoples’ experiences and habits with social media (Valkenburg PM et al, Curr Opin Psychol 2022;44:58–68). Young people with social support at school tend to have positive interactions on social media that protect against mental illness. Those without social support at school often rely on social media for interacting, but they have more negative feedback, more sensitivity to that feedback, and a greater likelihood of experiencing depression and social anxiety the more time they spend on social media (Shensa A et al, J Affect Disord 2020;260:38–44).

CCPR: Do kids learn about mental health on social media?

Dr. Weigle: Yes—more than from any other source, and the stigma is declining. However, most of the information comes from nonprofessional influencers and often contains misinformation or dangerous advice (www.plushcare.com/blog/tiktok-mental-health).

CCPR: What conditions are kids commonly self-diagnosing?

Dr. Weigle: Multiple personality disorder (aka dissociative identity disorder), autism, tics, Tourette syndrome, eating disorders, self-harm, suicidality, and (controversially) gender dysphoria. They may be seeking connection, embracing a sick role, or avoiding responsibility. (Editor’s note: See CCPR Jul/Aug/Sep 2023 for more on dissociative identity disorder and plural identity.)

CCPR: What about the role of cyberbullying in the mental health of kids and teens?

Dr. Weigle: Cyberbullying is a risk factor for depression and suicidality. Cyberbullying is characterized by a power differential; it’s intentional and repetitive—not two social equals arguing. Kids are often mean to each other. Online they expect fewer consequences, but whole communities are watching. Some victims may act inadvertently to provoke others. For instance, oversharing personal information online garners positive attention, but criticism as well. Many youths act online as both bullies and as victims, or they respond to bullying with threats or abuse that prolong the argument. Some interactions involve humiliation and ostracism—for example, when young people send nude pictures and those images get shared around. Cyberbullying can lead to school refusal, can result in self-harm, and is associated with suicidality in kids (Delgado B et al, Front Psychol 2019;10:1916; John A et al, J Med Internet Res 2018;20(4):e129; Bottino SMB et al, Cad Saude Publica 2015;31(3):463–475).

CCPR: How can we help kids who are involved in cyberbullying?

Dr. Weigle: Help kids consider their part in online conflict. When a child repeatedly provokes conflict, phone restriction may be necessary despite their worry about missing out. Have kids forward screenshots of what happened to school officials, the internet platform, or legal authorities depending on the situation.

CCPR: How often do teens send nude pictures?

Dr. Weigle: About fifty percent of kids send pictures during adolescence, usually in the context of a relationship (Englander EK, J Am Acad Child Adolesc Psychiatry 2023;62(10):Supplement S85). Those usually aren’t disseminated, and many kids report feeling better about themselves after sending them, closer to the person, or more confident. However, some young people—especially younger kids and LGBTQ+ youth—sext in a high-risk way, outside of a relationship. They might be appeasing someone who is pestering them or hoping to start a relationship.

CCPR: Are there legal implications for minors related to sexting pictures?

Dr. Weigle: Distributing child pornography is illegal, but prosecution is rare. Warning kids of prosecution is pointless because their friends do it and aren’t prosecuted. Still, in my clinical experience, some kids—often girls with little social support and learning disorders—are vulnerable to solicitations from older men who want nude pictures. Report those to Child Protective Services (CPS).

CCPR: What about kids who explore sex on the internet?

Dr. Weigle: Today’s teenagers generally see more pornography than their same-sex parent (Wright PJ et al, Arch Sex Behav 2023;52:373–383). Kids learn about sex online, especially if they attend schools where there’s no sex education. There are positives—learning the mechanics of intercourse, reduced stigma surrounding sexual orientation—but it can promote high-risk sex without a condom, cruelty, physical abuse, and even sexual assault (Koletić G, J Adolesc 2017;57:119–133). Some abused kids use pornography in posttraumatic reenactment. For example, I had a patient who had been abused by her stepfather and then distributed stepchild porn in a maladaptive effort to process traumatic experiences.

CCPR: How can we differentiate online sexual activity from child abuse?

Dr. Weigle: Most youth who engage in sexting do so with same-aged peers from school in a preexisting relationship. A smaller group under the age of consent send sexually explicit images—knowingly or not—to adults. These situations constitute abuse. Providers who suspect abuse must immediately protect the child and activate CPS. When a child is at high risk for revictimization, parents need to confiscate any internet-ready devices.

CCPR: Speaking of abuse, can you talk about online hate?

Dr. Weigle: Online aggression is common, related to race or otherwise. Sometimes the motive is unclear. Youth from marginalized groups frequently encounter racism online. Social media exposure to race-related traumatic events (police killings, detainment of immigrants) is associated with higher levels of depression and trauma symptoms among adolescents of similar backgrounds (Tynes BM et al, J Adolesc Health 2019;65(3):371–377). Such experiences can motivate youth to combat racism and connect with like-minded communities online, but some react with hurt or even suicidal statements online.

CCPR: Why do kids express suicidal thoughts online?

Dr. Weigle: Some kids feel less awkward typing into a phone than disclosing suicidality in person. The smaller screen on a smartphone feels more private than a tablet or computer, although their social media post may not be private at all. Some send indirect messages to peers, perhaps to garner support. Some kids find release in expressing depression, self-harm, and suicidality. Doing this can lead to getting help, but peers often don’t report it, and some try to help directly. Other peers become angry at kids they think are attention-seeking, which can exacerbate the problem.

CCPR: What about kids whose self-esteem is tied to hits or likes on social media?

Dr. Weigle: From my perspective, young people who dwell on quantitative social comparison feel worse. They believe their peers lead happier lives or have more sexual experiences, even though they know their peers only post happy moments.

CCPR: How can we assess social media use in kids and teens?

Dr. Weigle: Clinicians often feel uncomfortable asking, but kids will share if they think the clinician is curious and nonjudgmental. Ask kids to share their “For You” page on TikTok or their social media feed, and some posts. Their media might be about self-harm or eating disorders. Kids usually know this isn’t healthy but can’t set limits. Some set their feeds to filter out unhealthy material. Learn how and when they use social media. Using social media after bedtime disrupts sleep, increasing risk for depression. Lying in bed after school and scrolling through social media creates sleeping problems. Talk about their negative experiences on social media, including sexting.

CCPR: How do you discuss negative experiences?

Dr. Weigle: One of my patients was ostracized online and at school because of her relationship with her boyfriend. I said, “A lot of girls have a negative experience where they show a romantic picture and that gets passed on.” She responded, “Yes! That’s it!” Normalizing it and showing I wasn’t judgmental allowed her to feel comfortable talking. I had another patient who kept stealing his parents’ car. I said, “A lot of young men—especially homosexual men—use apps like Grindr to meet people, but they need a way to get there.” Once he knew I wasn’t judgmental, he confirmed that was why he’d been taking the car.

CCPR: Are there scales to assess social media use?

Dr. Weigle: The PRIUSS-3 is free: three questions with high sensitivity for problematic screen media use. Other gaming and social media scales have varying degrees of validation. We need one that evaluates for all the ways that social media can impact mental health.

CCPR: What advice do you give to kids and parents about social media use?

Dr. Weigle: Talk with your kids and use parental controls. When a child is just starting out with internet-capable devices, determine how often an online device will work, decide what information is searchable, and block social media. When the child uses the device responsibly, parents can lighten restrictions. In particular, we worry about devices interfering with sleep, which itself creates higher risks for a host of mental health problems related to attention, mood, etc. These controls don’t replace direct supervision. Parents should decide when children can use devices, defining screen-free zones (eg, bedroom) and times (eg, none before homework completion and none at the dinner table). The hardest part for many parents is moderating their own screen time—the biggest determinant of child media habits is parent media habits (Geurts SM et al, Compr Psychiatry 2022;116:152318; Yang GS and Huesmann LR, Journal of Broadcasting & Electronic Media 2013;57(3):356–373).

CCPR: How can parents know what teens are doing online?

Dr. Weigle: Be curious and nonjudgmental. Don’t rush to tell the kid what to do. Teens often worry parents will freak out or take their device. They’ll disclose more when parents make a rule that they will not restrict screen time based on what the teen tells them. Talk about screen habits and experiences. Show confidence in the kid’s ability to figure out the issues. This builds an ongoing problem-solving conversation.

CCPR: How can we help kids to have healthier relationships with screen media and social media?

Dr. Weigle: We want kids learning to moderate their own screen habits and experiences. Often they know what’s unhealthy usage or content. Many youths use strategies to moderate their social media use, and mental health professionals can help them do this more effectively (Harness J et al, J Adolesc Health 2022;71(3):324–333). If they are using their phone too often, they might set it to grayscale so it isn’t visually appealing, or they might turn it off at certain times. In research on limiting phone use, college students have better results than high school students. Another study showed that a video training effectively prepared pediatric providers to guide patients in making health changes on Instagram app settings (Harness J and Mohiuddin S, Acad Psychiatry 2023;47:222–223). I’ve had success getting patients to alter their social media settings to block triggering content, such as videos of self-harm or disordered eating behaviors. Sometimes individual and family psychotherapy may be indicated. Kids with developmental challenges may be more vulnerable and need additional help and support to manage social media impacts (Hassrick EM et al, Autism Adulthood 2021;3(1):72–84). (Editor’s note: See “Social Media and Mental Health Resources” table.)

CCPR: Do you recommend policy changes for social media use?

Dr. Weigle: Our AACAP social media policy statement recommends federal funding for research on the benefits and harms of social media. I support stronger social media safeguards for youth privacy and giving parents more control over their kids’ screen media. Social media companies could make their platforms healthier, saying, “Hey, you’ve been on for six hours—maybe you should take a break” or, “It’s 3 in the morning—maybe you should go to sleep.” They could limit endless feeds. Social media companies are motivated to get users to use more often. There is a push to hold them responsible for the psychological harm that they do to kids, like how cigarette companies were held responsible. Forty-nine US states are suing Meta for psychological harm done to young people. There are private lawsuits as well.

CCPR: Any summary thoughts?

Dr. Weigle: Social media plays a vital role in the mental health of kids and teens, for good or for ill. Don’t be afraid to ask about it. Take a one-down position that you are the learner and the kid is the expert. When we frame it that way, we often find that kids like to share their experiences on social media just like they do with other experiences.

CCPR: Thank you for your time, Dr. Weigle.