Have you heard of the term “Facebook depression?” It is defined as depression that develops when preteens and teens spend a lot of time on social media sites and begin to show classic symptoms of depression.1,2 How about “cyberbullying” or “online harassment,” which are tactics that use digital media deliberately to communicate false and embarrassing information about another person?2,3 Another issue is “sexting,” which is sending, receiving, or forwarding sexually explicit messages, photographs, or images via digital devices.4 These are terms and problems that may be new to many clinicians, but need to be addressed with our teen patients.
Popular Social Media Sites: Advantages and Disadvantages
Facebook, Instagram, Snapchat, Twitter, and Vine Camera are some of the top sites teens use to interact online. There are also countless gaming sites and virtual worlds online where teens can roam, but the next wave of social media apps is already here. The app ooVoo allows you to make free video calls and voice calls, and send text messages to easily connect to your friends and family around the world, but if teens have it set for “anyone” to contact them, they may receive sexually explicit content. The app WhatsApp uses the Internet to send messages, images, audio, or video, and is similar to text messaging services; however, because it uses the Internet to send messages, anybody who can access the network and is in range of your signal could be looking into your chats and files. Whisper is an anonymous social networking app where users post confessions (either fact or fiction, by superimposing text on a picture), as well as a place to vent, come clean, or peer into other people's secrets. Skout is an app for “flirting” and can be used to meet and chat with new people (teens and adults are assigned to different groups based on the age entered at registration, but ages are not verified). Tinder, which is most commonly used as a dating app, pinpoints your geographic location via global positioning system.5 New social media apps aimed at teens are constantly appearing as parents and adults tend to use the more traditional sites such as Facebook, Twitter, and Instagram. Therefore, it's important that parents become aware of the nature of social media sites, because not all of them are safe or healthy environments.2
Social media sites offer multiple daily opportunities for connecting with friends, classmates, and people with shared interests. Social media sites allow teens to accomplish online many of the tasks that are important to them offline, such as staying connected with friends and family, making new friends, sharing pictures, and exchanging ideas. Improved media access can lead to positive, prosocial outcomes such as empathy, acceptance of diversity, social group acceptability, and respect for the elderly.6,7
Clinicians are now also faced with identifying how the concerning aspects of the media age, such as cyberbullying, sexting, driving while texting, online solicitation, Internet addiction, and media-related depression, are affecting virtually every aspect of adolescents' psychosocial and physical well being.7
Statistics of the Digital Age
According to a 2011 poll by the Council on Communications and Media, 22% of teenagers log on to their favorite social media site more than 10 times per day.2 Seventy-five percent of teenagers own cell phones, and 25% use them for social media, 54% use them for texting, and 24% use them for instant messaging.2,8 Twenty percent of teens have sent or posted nude or semi-nude photographs or videos of themselves via digital devices.2
Because of their limited capacity for self-regulation and susceptibility to peer pressure, children and adolescents are at risk as they experiment with social media. Recent research indicates that there are frequent online behaviors, such as bullying, clique-forming, and sexual experimentation, that have created problems such as cyberbullying, privacy issues, and sexting.2 Other problems include Internet addiction and sleep deprivation.
What Does the Law Say?
Thirteen years of age is the minimum age for use of most social media sites, as set by the US Congress in the Children's Online Privacy Protection Act (COPPA),2 which prohibits websites from collecting information on children younger than age 13 years without parental permission.
It is important that parents evaluate the sites on which their children wish to participate to be sure that the site is appropriate for that child's age.
Clinicians should advise parents that as their children start to become interested in the social media world, they need to ensure that they are having regular conversations with their children about the benefits and dangers of this form of communication.
Sex Trafficking: a Very Specific Danger Associated With Social Media Use
I had a 15-year-old girl in clinic who was doing well in school and was active in sports, but who one day met a man online. The man was actually 35-years-old, which she initially was not aware of. He told her how beautiful she was, listened to her problems, and started a romantic relationship with her. Her parents were completely unaware of the situation and thought their daughter was dating a school classmate. This man ended up convincing her to have sex with other men as a sign of her love for him and to have money for their future life together.
This event is an example of child sex trafficking, which occurs when a person engages a minor younger than age 18 years in commercial sex acts even if there is no apparent coercion.9 Sex trafficking is real. Teenagers frequently meet strangers online, become friends, and eventually end up being sold for sex. In some cases, teens are being sold by their peers, boyfriends or girlfriends, and classmates.
Physicians and parents should be aware of the possible indicators of victimization, which include unusual behavior such as being submissive, withdrawn, or fearful, relationships that seem to be controlling, suicide attempts, substance misuse or abuse, and old or recent injuries suspicious for being inflicted or with an inconsistent history.
Physician Screening for Social Media Use
Adolescents now spend 7 to 11 hours per day with different media, which is far more than the maximum 1 to 2 hours typically recommended.7,10 One-quarter of teenagers mostly go online via their cell phones.8 This suggests an unprecedented level of unsupervised Internet access. According to the most recent 2015 Youth Risk Behavior Surveillance Report,11 nationwide, 15.5% of students (ranging from 11%–21% across all states) reported having been electronically bullied, counting being bullied through email, chat rooms, instant messaging, websites, or texting. Also in the same report, among youth who drive, 41.5% have texted or emailed while driving a car.11 In addition, pornography is available by typing a few key words into a search engine. Failing to identify associated risk behaviors will lead to missed opportunities to improve health outcomes.
Clinicians should attempt to add social media and Internet “literacy” to discussions with parents and patients. This can include topics such as co-viewing to foster communication and accurate interpretation of content, as well as setting limits such as parental controls, time for using media, or limiting access to media in one's bedroom. One strategy is to have all electronic devices in one public space in the home for use and for charging so that it is not in the adolescent's bedroom.
How to Use the Psychosocial Screen
The HEEADSSS (Home, Education/Employment, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) assessment is a time-tested psychosocial screening tool for adolescents. This tool allows providers to address not only social media concerns but various adolescent risk-taking behaviors.7
The physician should begin by spending some time alone with patients during office visits at whatever age they first exhibit the psychosocial changes associated with puberty. It is preferable to conduct the psychosocial interview when the adolescent is well. However, at every visit the adolescent should be assessed for new stressors and overall well-being. Starting the interview with nonthreatening conversation about the patient's hobbies or current events may help to ease anxiety, foster rapport and trust, and encourage disclosure. Then, the physician should ask the adolescent how they might be handling stress and whether their behaviors are safe. Young people tend to keep talking once they start talking. It is best, however, to explain the concept and limitations of confidentiality as part of this initial conversation.7 A strengths-based approach when talking to adolescents tends to be well received. Search for positives in the history and emphasize those. Approaches based on risk factors alone may induce feelings of shame and deter patient engagement, as well as set low expectations.7 Identify strengths early so that they can be built on when motivating the patient to change or when encouraging ongoing success,7 such as by looking for examples of past difficulties that the patient has successfully overcome. The ability to adapt to and overcome adversity is known as resilience and is highly protective against a wide range of bad outcomes. Adolescents will appreciate praise when it is warranted because many teens, especially those at high risk, never hear any praise from adults in their lives.7 Use reflective listening and pause to allow the teenager time to confirm and expand on his or her thoughts. Create a comfortable, trusting, nonjudgmental setting that communicates respect. Share concerns by challenging the patient with resolving ambiguity in their lives.
It may seem overwhelming to try and cover so many issues with the limited amount of time in a clinic visit, but the goal is not to cover every aspect in a single visit; rather, the goal is to establish an effective relationship in each case and leave the remaining questions for a later visit. The provider should feel free to add or remove priority questions based on the needs of the patient population, and HEEADSSS can be easily adapted to each clinic situation.
How to Handle the Digital Age
Ninety-three percent of teens have a computer or access to one at home, so it is important to place any computer in a common area so a parent can monitor a teen's use.12 Supervising preteens' access and usage on teen sites is important. Remind teens to have discretion when posting pictures, location, status, or messages online. Let adolescents understand they should only be “friends” or “followers” of people they actually know on social networking sites.
Remind parents to know how to use Instagram, Snapchat, Facebook, and other trending social media sites, ensuring they are friends or followers of their children on any of those sites. Teach children to never give personal information, answer questions about their birthdate, or fill out forms online. Teach teens to use privacy settings on their social media sites at all times.
It is important to have open conversations with preteens and teens about “what if” questions and role play what they may do when a difficult situation arises online or on social media. Remind parents that they should protect their children against social media related concerns.
- Moreno MA, Jelenchick LA, Egan KG, et al. Feeling bad on Facebook: depression disclosures by college students on a social networking site. Depress Anxiety. 2011;28(6):447–455. doi: . doi:10.1002/da.20805 [CrossRef]
- O'Keeffe GS, Clarke-Pearson KCouncil on Communications and Media. The impact of social media on children, adolescents, and families. Pediatrics. 2011;127(4):800–804. doi: . doi:10.1542/peds.2011-0054 [CrossRef]
- Cyberbullying. http://cyberbullyingwrt.weebly.com/definitions-of-cyberbullying.html. Accessed July 18, 2017.
- Merriam-Webster. Sexting. Available at: http://www.merriam-webster.com/dictionary/sexting. Accessed July 18, 2017.
- MakeAWebsiteHub.com. 60+ social networking sites you need to know about in 2017. https://makeawebsitehub.com/social-media-sites/. Accessed July 18, 2017.
- Bolton RN, Parasuraman A, Hoefnagels A, et al. Understanding Generation Y and their use of social media: a review and research agenda. J Service Manag. 2013;24(3):245–267. doi: . doi:10.1108/09564231311326987 [CrossRef]
- Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: the psychological interview for adolescents updated for a new century fueled by media. Contemp Pediatr. 2014;16–28. https://mmcp.dhmh.maryland.gov/epsdt/healthykids/.../sec._4_add_%20heeadsss.pdf. Accessed July 18, 2017.
- Pew Research Center. Teens, social media & technology overview 2015. http://www.pewinternet.org/2015/04/09/teens-social-media-technology-2015/. Accessed July 25, 2017.
- Department of Homeland Security. What is human trafficking? https://www.dhs.gov/blue-campaign/what-human-trafficking. Accessed July 18, 2017.
- Nielsen Company. State of the media: TV usage trends: Q3 and Q4 2010. http://www.nielsen.com/us/en/reports/2011/state-of-the-media-tv-usage-trends-q3-and-q4-2010.html. Accessed July 18, 2017.
- Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2015. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/ss6506_updated.pdf. Accessed July 25, 2017.
- Donnerstein E. The Internet. In: Strasburger VC, Wilson BJ, Jordan AB, eds. Children, Adolescents, and the Media. 3rd ed. Thousand Oaks, CA: Sage; 2013.