Executive Summary
In a 2023 report, a Surgeon General’s Advisory declared a mental health crisis in the United States, warning of its devastating impact on youth and advising the country to act urgently to protect children and adolescents.1 A shortage of adequate and accessible mental and behavioral health services exists in the United States,2 with barriers to accessing proper care exacerbating the problem. Barriers include high costs, lack of or inadequate insurance coverage and patients' unawareness of how to access care. Additionally, there is a shortage of trained professionals, which the COVID-19 pandemic exacerbated.3
Since 2011, the percentage of adolescents who experienced persistent feelings of sadness or hopelessness has continued to rise.4 In 2021, 42% of high school students reported feeling sad or hopeless almost every day for two weeks, with 29% experiencing poor mental health during the past 30 days. To uncover and understand what impacts mental wellness in youths, social media has become an area of focus, with researchers exploring the impact social media is having on young people.
It is important to note that environmental factors substantially impact adolescent brain development and contribute to mental wellness. Environmental factors range from those at the individual, family and community levels to others at the societal, state and national levels. Many environmental factors and their impact on development have been studied, and knowledge or predictability for impacts have been asserted by researchers, health care providers, caregivers and advocates — including an understanding of how factors impact mental wellness throughout and beyond adolescence. Social media is currently a prominent environmental factor being studied. While its impact is still understudied, we do know that it plays a significant role in the lives of many adolescents.
A 2022 Pew Research Center study found that approximately 95% of teens 13-17 years have access to a smartphone, and 90% have access to a desktop or laptop at home.5 And the use of social media on those devices is ever-present in the lives of teens, as 97% report using at least one of the seven major online social media platforms.6 YouTube continued to be the top platform among teens in 2023, with 93% reporting ever using the platform and 16% reporting they constantly visit or use the app or website.7 Since TikTok broke onto the scene in 2018, it has become one of the top social media platforms for teens, with 63% saying they ever use the platform and 17% describing its use as almost constant. Instagram, Snapchat and Facebook are other top preferred social media platforms for most U.S. teens.
Social media platforms operate around algorithms designed to keep users engaged as long as possible and returning for more. By utilizing programming that intakes massive amounts of data around the activities and engagement of the user, such as “likes,” reactions to content, time spent on certain pages, etc., these platforms can continue to deliver content the user will find relevant or interesting. This algorithmic tailoring contributes to the positives and negatives of adolescents using these platforms, making social media a “double-edged sword.”8
Benefits
Access to social media can offer many benefits to adolescents, the most common being social connection. More than eight in ten adolescents describe social media as boosting their sense of connectedness.9 An overwhelming majority report that social media makes them feel more connected to their friends (81%), helps them interact with a more diverse group of people (69%) and makes them feel they have people who support them through tough times (68%).6 Most teens also associate their social media use with positive rather than negative emotions and feel included rather than excluded (71% versus 25%) and confident rather than insecure (69% versus 26%).6
Social media can connect people with communities that provide positive and identity-affirming content,1 which can be valuable to adolescents as they develop. Platforms cultivated around personal preferences and connections allow adolescents to join others in building relationships and growing existing ones. These platforms enable teens to receive social support and express their thoughts and feelings.8 For youth, especially those in historically marginalized communities, these positive social media experiences can be crucial. Sharing photos, videos, status updates and written communication can help individuals experiencing loneliness and feelings of isolation.
In addition to creating and cultivating connections with others, teens use social media and the internet to access health information more readily, including information on mental health. Young people who may be suffering from mental health problems are spending time online searching for ways to understand and alleviate their symptoms.10 Many adolescents may be reluctant to seek out help from others when they are experiencing symptoms out of fear of stigma, mistrust for the health care industry or even a lack of awareness.11 Instead, they seek out information or support via a method they may trust or simply feel more comfortable accessing, such as social media and the internet. Social media offers a new opportunity to raise mental health awareness and share valuable resources.9 By utilizing the instantaneous accessibility of social media, there are extensive possibilities to reach adolescents who were previously inaccessible. Access to social media offers the opportunity to reduce health and education disparities within communities that are otherwise unable to access those needed resources.10
In-person interactions can be perceived as a casualty of increased time on social media, as adolescents’ daily interactions with friends are more likely to occur online. Teens have reported various reasons for lack of in-person socialization, including personal obligations (41%), other obligations of their friends (34%), difficulty finding transportation (32%), the ease of staying in touch online/by phone (33%) and parental restrictions (19%).6 Most teens report that social media is somewhat important for having meaningful conversations with friends (69%), and utilizing social media is at least somewhat important for keeping up with friends on a day-to-day basis (77%).12 It appears that online communication among teens supports “traditional” tasks of offline friendships.10
When communities are created and cultivated, this connection can play an important role in the interpersonal support that helps youths develop and navigate what can sometimes be a very tumultuous time in their lives. When used in the service of connection, social media can support and even boost well-being.
Harms
Harms associated with social media include cyberbullying and harassment, exposure to content showing inappropriate and harmful behavior, exposure to predatory behavior and interactions, social comparison, receiving incorrect information and oversharing of personal information.1 While these experiences are not exclusive to social media, they provide an easily accessible avenue for exposure. Many social media platforms are designed to allow for endless access to content and information. The amount of time youths engage with that content may impact their mental wellness and health. Research shows that individuals who spend three or more hours per day on social media can double the risk of poor mental health outcomes, including symptoms of depression and anxiety among children and adolescents.
How a young person engages with social media may also impact mental health. Researchers have termed two types of social media engagement: passive and active.13 Passive use includes scrolling through content posted by social media friends or browsing news feeds or profiles — all without active interaction. This can result in upward social comparison, which can negatively affect well-being. Active use includes chatting, messaging or interacting with content and others, which can increase connectedness, social capital and positively affect well-being. The environmental factors, attitudes and behaviors surrounding an adolescent may play a role in how they interact with social media and offer an opportunity to better understand the link between social media and mental wellness.
Nearly half (46%) of U.S. teens 13-17 years report having experienced at least one form of cyberbullying, such as offensive name-calling (32%), spreading of false rumors about them (22%), receiving explicit images they didn’t ask for (17%), constantly being asked where they are, what they are doing or who they are with by someone other than a parent (15%), physical threats (10%) and having explicit images of them shared without their consent (7%).14 Many teens (28%) reported having experienced multiple types of cyberbullying, with 31% of teens thinking their harassment or bullying had something to do with their personal attributes, such as gender (22%), racial or ethnic background (20%), sexual orientation (12%) or political views (11%).
White, Black and Hispanic teens do not statistically differ in having ever been harassed online, but specific types of online attacks are more prevalent among certain groups. Socioeconomic factors, such as household income, show that teens from households making less than $30,000 annually are twice as likely to be physically threatened online as teens living in households making $75,000 or more per year (16% versus 8%).14 A wide majority (93%) of teens from all backgrounds and genders say that online harassment and bullying is a problem for people their age, with 53% saying it is a major problem and 40% saying it is a minor problem.
Along with the risks of online cyberbullying, there are also the risks of accessing content that promotes self-injurious behavior by depicting, discussing or generally normalizing it.15 Negative peer experiences, such as cyber victimization, social exclusion and online conflict or drama, have consistently been associated with higher rates of self-harm and suicidal behavior and internalizing and externalizing problems.
Social comparison is a human trait that social media can exacerbate. Platforms create another dimension since social media does not exist in real time. Individuals engage in “selective self-presentation”12 by presenting posts, images and content that are altered and manipulated to project a more idealized portrayal of themselves. There is no requirement on platforms for honest transparency of the person posting, which can mislead other users. Youth are at more risk of this presentation, as their brains are still vulnerable and routinely engage in social comparison. Part of teen development is seeking out social connection and validation, so content cultivated around comparison may lead some youth to “engage in negative social comparisons regarding their own accomplishments, abilities or appearance” and become a risk for mental wellness issues.
Addressing the Impact of Social Media on Youth Mental Health
U.S. Regulatory Efforts
The Children’s Online Privacy Protection Act of 1998 is a U.S. federal law with specific requirements for websites and online services to protect the privacy of users under 13 years.16 These protective measures require sites to verify parental consent for the collection or use of personal information of young users, including seeking consent, displaying a privacy policy in any place where data is collected and outlining the legal responsibilities of a website operator, such as marketing, which targets children.
In 2022, the Kids Online Safety Act was introduced to the Senate with guidelines intended to protect minors using social media by requiring platforms to enact certain safeguards, restrict access to minors’ personal data and equip guardians with tools to supervise minors’ use of the platform.17
In 2023, the bipartisan congressional bill, Protecting Kids on Social Media Act, was introduced. This bill aims to protect young users by placing mandates on social media companies requiring age verification and parental consent for users under 18 years.18,19 The bill would also establish a pilot program to verify that the account user meets the age requirements/parental consent requirements by uploading a form of government-issued identification. If the bill is passed, a civil penalty will be enforced against social media companies that do not comply.
Many states have become more involved in regulating social media in some capacity. More than half of states in the U.S. have enacted bills, adopted resolutions or have pending legislation to protect young social media users, many of which are focused on age verification, parental consent and upholding federal regulations.20
In 2023, a bipartisan effort was put forth by 33 states when a lawsuit was filed against Meta (formerly called the Facebook company) in the Northern District of California.21 The lawsuit claims that Meta routinely collects data on its users, including children under 13 years, violating federal law. In early 2024, New York City designated social media as a public health hazard, comparing it with other public health hazards like tobacco and guns.22
International Regulatory Efforts
The Children’s Code (i.e., Age Appropriate Design Code) is a United Kingdom-based internet safety and privacy code of practice by the Information Commissioner’s Office that falls under the Data Protection Act of 2018.23 This code applies to any internet-based service likely to be accessed by anyone under 18 years, even if the intended audience is not youth under 18 years. While this code is U.K.-based, it does apply to any company that processes the personal data of U.K. children — whether they are a U.K. company or not. To conform with the code requirements, website code designers must implement safeguards that provide the highest level of privacy by default when children may use the sites. This includes not allowing access to other users' data, switching off geolocation tracking and restricting behavioral profiling, such as algorithmic curation or targeted advertising. This code does not apply to institutions processing information for educational purposes.
In 2023, the U.K. passed the Online Safety Act. This bill takes a zero-tolerance approach to protecting children and holding social media platforms responsible for the content hosted on their sites.24 Under this new law, social media platforms will be expected to prevent illegal content from appearing on their sites or remove the content quickly to minimize the exposure, including self-harm content, thereby preventing children from accessing harmful and age-inappropriate content and providing parents and children clear and accessible ways to report problems online. This law will hold social media platforms legally liable to enforce the restriction of harmful or illegal content from appearing on sites through fines if they fail to follow through on these protective efforts.
The European Union has adopted the Digital Services Act Package, which aims to create safer digital spaces and protect users' rights while establishing a level playing field for businesses.25 The act has two parts: the Digital Services Act and the Digital Market Act.
The DSA primarily focuses on online intermediaries and platforms, such as online marketplaces, social networks, content-sharing platforms, app stores and online travel/accommodation platforms. All platforms must publish their user numbers, and any with more than 45 million users will be designated as a very large online platform or a very large online search engine, requiring them to comply with the strictest rules under the DSA within four months of designation.26 These requirements mean these VLOP/VLOSEs must identify, analyze and assess systemic risks linked to their services, such as illegal content; fundamental rights, such as freedom of expression or consumer protection and children’s rights; public security and electoral processes; and gender-based violence, public health, protection of minors and mental and physical well-being. Once identified, risks must be mitigated via an established internal compliance function and audited annually. The DSA also requires that vetted researchers are allowed “to access the platform data when the research contributes to the detection, identification and understanding of systemic risks in the EU.”
Research Efforts
Access to data collected by social media platforms may offer better insight for researchers hoping to learn more about the association between social media and mental health. Historically, however, data have not been made accessible to independent scientists.27
Existing research about social media use by youths often is built on an overreliance on cross-sectional and correlational data10 and does not examine social media use across youth development.28 This makes it difficult to determine whether social media use leads to mental health issues or whether individuals with mental health issues are simply more vulnerable and likely to use the platforms in harmful ways.10 Therefore, further research studying the longitudinal effects of social media use by youths is imperative to examine whether their use precedes and/or predicts mental health outcomes.12 Research into social media use and discoveries about the causal relationship with mental health may not only help negate the potential harms to mental wellness but also allow for developing interventions for social media use to promote better mental health.29
Regulatory Efforts on Transparency and the Challenge of Privacy Versus Freedom
Social media can be an asset for adolescents and their communities, but understanding how best to regulate it to protect users and mitigate potential harms is an ongoing debate at the state and national levels in the United States and internationally. Mental health and its effects are complex, with varying goals an individual might have during social media use served by different behavior patterns. In turn, these goals and behavior patterns are likewise produced by distinct patterns of use and outcomes.9 Continued research is vital to understanding how users of all ages interact with social media. Answers to many research questions may lie in the data that social media companies collect on users and have been hesitant or unwilling to share. In recent years, the following legislation has been introduced to gain access to data for independent researchers to examine while still protecting the platform user, especially children and adolescents.
In 2022, the Platform Accountability and Transparency Act was introduced to provide independent researchers access to platform data via privacy-protected and secure pathways developed by the Federal Trade Commission to understand what information is being collected from users.30
In 2021, the Social Media DATA Act called for social media platforms to provide information to academic researchers to better understand online targeted advertisements.31 This work would be done under the supervision of the FTC to ensure any research with confidential data complies with consumers’ right to privacy.
In 2022, the Digital Services and Oversight and Safety Act allowed academic or non-profit researchers, certified by the FTC’s Office of Independent Research Facilitation, to access data to develop a deeper understanding of how social media platforms impact society while complying with the FTC’s established security requirements.32
An ongoing challenge is finding the balance among three competing interests: protecting users’ personal privacy and wellness, protecting the company’s data privacy and protecting society’s freedom of speech concerns. The balance should include holding social media companies accountable throughout all stages of product development and ensuring they prioritize youth mental health and well-being in the use of their products while not imposing an overreach of government control on companies’ free market rights and users’ free speech rights.33
When independent researchers are able to access and analyze existing social media data, there is a growing understanding of how users engage with social media, leading to better support for mental wellness and protection from the potentially harmful effects of social media.
Opportunities for Intervention
Since family physicians care for patients across their lifespan, they are ideal partners in supporting parental and guardian efforts to maintain and improve youth mental wellness. When interacting with adolescent patients, family physicians should routinely screen for mental health concerns. This should include not only time spent using social media but also assessing problematic and/or harmful use.34 They can also help monitor an individual's mental wellness over long periods to assess how mental health fluctuates and consider individual environmental factors that may impact a youth patient. If a youth patient is presenting with symptoms of anxiety, depression, addiction,1,35 body dysmorphia36 or other concerning behaviors, it can be beneficial to assess for exposure to harmful social media interactions.34 It can also be important to assess social media use that may benefit a patient, such as LGBTQ+ adolescents for whom social media use may provide critical support.37
When physicians interact with adolescents and their parents or guardians, creating a “context of a therapeutic alliance”15 is an effective way to establish communication or dialogue. This includes creating an environment for adolescent patients that is “open and nonjudgmental, elicits trust and emotional safety and offers a sense of inclusion and autonomy.” This approach has the bonus benefit of bolstering trust in the health care system for future encounters.
Motivational interviewing is one effective approach for family physicians to use when communicating with youths about other health concerns, and it may be an effective communication tool when discussing social media use in the exam room. This environment allows advocates to provide individualized support for young people experiencing mental wellness issues and provide individualized recommendations to interact with social media safely and healthily.
When communicating with parents or guardians, it can be important to explain why banning social media entirely would be ineffective. Young people have a biological drive to seek out social belonging, so prohibitive efforts around social media use may be impractical as teens can still find ways to access these platforms. Encouraging parents or guardians to discuss the benefits and harms of social media use with their teens and supporting them in teaching children critical thinking skills when reading online material can foster open communication about social media use and the content teens encounter. When teens have more robust social media literacy, they are less likely to suffer from the negative effects associated with social media.15,38
Parents or guardians may not be able to control every piece of content children interact with on social media, but they can make efforts to model healthy social media practices for their teens. Doing so can be as simple as making active efforts to unfollow users or content that is idealized or overly edited and promotes harmful actions and refrain from interacting with content they would not want their child to spend time viewing. Setting aside designated time for the family/support system away from social media or devices altogether can allow the opportunity to develop and grow in-person social relationships.
Conclusion
While social media has the potential to be a great asset to the education and wellness of adolescents as they develop, it is also essential to consider the risks. As more data becomes accessible and research continues to improve, so will better insights into how social media impact young people. Each individual develops differently, with varying sensitivity to their environment and content consumed on social media. While controlling for each adolescent would be impossible, physicians, parents, guardians and policymakers can continually support young people using social media and advocate for their mental wellness.
References
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21. Office of the Attorney General for the State of California. Meta Multistate Complaint. Accessed March 5, 2024. https://oag.ca.gov/system/files/attachments/press-docs/FINAL%20Meta%20Multistate%20Complaint%2C%20N.D.%20Cal.%20%28REDACTED%2C%20CONFORMED%29.pdf
22. The Official Website of the City of New York. Transcript: Mayor Adams lays out future-focused vision for working-class New Yorkers in third State of the City address. Accessed March 5, 2024. https://www.nyc.gov/office-of-the-mayor/news/068-24/transcript-mayor-adams-lays-out-future-focused-vision-working-class-new-yorkers-third-state
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34. American Psychological Association. Health advisory on social media use in adolescence. Accessed March 5, 2024. https://www.apa.org/topics/social-media-internet/health-advisory-adolescent-social-media-use.pdf
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37. Berger MN, Taba M, Marino JL, et al. Social media use and health and well-being of lesbian, gay, bisexual, transgender, and queer youth: systemic review. J Med Internet Res. 2022;24(9):e38449.
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(April 2024 BOD)