By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Summary Points
- This comprehensive review encompasses 50 articles (38 cross-sectional and 12 longitudinal) from 2011-2023 focusing on screen time and mental health in adolescents, collectively involving a pool of 1,900,447 adolescents.
- Because of the heterogeneity in methods (including measurement of screen time and of mental health assessment), it was not possible to conduct a meta-analysis on the data.
- The most used device was the smartphone; 12 studies found no association between screen time and mental health difficulties, while the bulk of the remaining studies identified a small to medium effect size linking increased social media use and decreased mental health indicators, increased depression in girls, and increased weekday smartphone use with decreased mental health measures.
- The results suggest that factors like the type of screen, purpose of use, and content may hold more significance than the overall duration of screen exposure.
SYNOPSIS: This systematic review of 50 studies reveals a correlation between increased social media usage and decreased mental well-being in adolescents of both genders, more significant depression in girls, and an association of high weekday smartphone usage with reduced mental well-being across both sexes. However, the inconsistency of the findings necessitates additional studies before generalization.
SOURCE: Santos RMS, Mendes CG, Bressani GYS, et al. The associations between screen time and mental health in adolescents: A systematic review. BMC Psychol 2023;11:127.
In May 2023, U.S. Surgeon General Dr. Vivek Murthy issued a pressing public health advisory regarding the effect of social media use on youth. He expressed deep concern about the insufficient progress made in striking a balance between the benefits and detriments of social media use on children, stating, “As a consequence, I worry about the mental health and well-being of our children.” His recommendations urged researchers to concentrate future studies on the nexus between mental health and social media use in children and adolescents, with the goal of proving valuable data that can inform and help establish scientifically backed health standards and guidelines for this demographic.1
Adolescence, often defined as the period between ages 10-19 years, is a pivotal time of brain development. During this span, there are unique brain vulnerabilities and sensitivities. For example, as adolescents grapple with an emerging sense of self and identity formation, they are increasingly susceptible to external influences, such as social pressure and peer opinions. This period also is characterized by elevated risk-taking behaviors, mood fluctuations, and the potential emergence of mental health disorders, such as depression and anxiety.
It is the confluence of these factors, among others, that earmarks adolescence as a critical window of susceptibility to both the adverse and advantageous effects of various influences, including those mediated by unmonitored screen time and digital interaction. The cognitive, social, and emotional changes during this stage can be shaped and influenced by these external factors. This makes understanding the effect of screen time and digital behavior on adolescents a crucial area of study.1-3
This comprehensive systematic review by Santos et al looked not only at social media use in adolescents but at screen time in general. The goal of the investigation was to evaluate, consolidate, and synthesize existing research regarding an association between time spent exposed to electronic devices, the nature of the interaction involved (including the type of device), and any correlation with mental health outcomes in adolescents.
Santos et al incorporated 50 studies, published between 2011 and 2023, into this comprehensive review. In all, 1,900,447 adolescents were included. The majority of these studies (38) were cross-sectional, providing a snapshot of data at a single point in time. The remaining 12 studies were longitudinal, collecting repeated observations throughout an extended period. Participant ages in the studies ranged from 10 to 21 years, with a mean of 14.85 years (standard deviation 1.14 years).
While not all studies collected demographic data, the majority of those that did reported participants of medium socioeconomic status and primarily white ethnicity. Notably, some of the studies included data collected during the COVID-19 pandemic. Across all studies, the methods for gauging screen time and mental health were heterogenous but relied predominately on self-report or self-evaluation.
Results
Because of the widely diverse methodologies, the data from these 50 diverse studies could not be pooled into a meta-analysis. However, there are a few generalizations that emerge.
As for screen time and mental health, only 12 studies did not find an association between overall screen time and poor mental health outcomes. The bulk of the studies (21) found a small effect size for this association, while 10 studies found a medium effect size, and seven found the effect size to be medium to large.
Cross-sectional associations include the following:
- The smartphone was the most used device.
- In one study, six hours or more of video gaming was associated with anxiety symptoms in boys. In another study, girls reporting more than five hours of screen time had elevated anxiety scores compared to those reporting up to two hours.
- In three studies, increased computer use was associated with higher depressive symptoms.
- Longer use of smartphones during weekdays was associated with impaired well-being in two studies.
- Higher social media use was associated with impaired mental health in girls in three studies.
- Watching television was associated with both positive and negative effects on mood (specifically anxiety and depression) in different studies.
- Time spent online studying was associated with both positive and negative effects on mood in different studies.
Mental health outcomes from cross-sectional studies include the following:
- Psychosocial health outcomes: Participants reporting < 2 hours daily of screen time were approximately 2.5 times more likely to score higher on measures of psychosocial well-being.
- Resiliency scores: Participants reporting high screen time with < 8 hours of sleep had lower self-esteem and resiliency scores.
- Well-being: Watching television only on weekends was associated with higher well-being measures while higher weekday smartphone use was associated with lower measures in this area.
- Mixed findings regarding mental health outcomes: Higher use of electronic games was associated with decreased psychological well-being in both sexes in some studies, while other studies showed no association with mental health outcomes.
Longitudinal associations include the following:
- Higher social media use was associated with depressive symptoms in girls but not in boys.
- One study found television watching improved anxiety symptoms and inattentiveness.
- An 11-year study found that increased television and computer use was predictive of hyperactivity, conduct problems, and inattention in girls.
Mental health outcomes from longitudinal studies include the following:
- Worse measures of mental health: Increased time on social media had a significant association with worse mental health in one recent study.
- Increase in psychological well-being: A decrease in total screen time was associated with an increase in psychological well-being in one study.
- Self-esteem: Girls reporting non-recreational use of computers had higher self-esteem than peer e-gamers in one study.
Commentary
Santos et al undertook a commendable and timely endeavor to uncover and synthesize what is known regarding the connection between screen usage and mental health outcomes in adolescents. At first look, the results appear to be scattered and have little clinical use, but a deeper dive into the data is more revealing.
Because of several factors, investigating the relationship between screen time and adolescent mental health poses numerous challenges. One significant factor is the rapid and ever-evolving nature of digital technology. Within a relatively short span of an adolescent’s life, they likely have witnessed technology becoming increasingly accessible, captivating, and potentially influential. This alone creates difficulties in evaluating studies in this field.
For example, when comparing studies, it is crucial to consider whether the effect of Facebook in 2011 was comparable to that of Instagram in 2019 and how these platforms compare to the influence of the current-day phenomenon, TikTok. These considerations highlight the complexities involved in gaining a full understanding of the effect of screen use and mental health outcomes in the adolescent population. Another factor to consider in this review is that multiple studies overlapped with the years of the COVID-19 pandemic, a time when screen use replaced daily social interaction for many children and may have taken on a unique role in their lives.
For their part, Santos et al conclude that screen time may not be a useful concept and that the type, use, and content of the screen is more significant in affecting mental health in adolescents. This is a clear avenue for future studies.
Many professional organizations have incorporated the idea of the purpose of screen time into guidelines for parents and teens. For example, the American Academy of Pediatrics recommends that guardians “consider the quality of interaction” with digital media and not just the quantity or time spent.4 The American Academy of Child and Adolescent Psychiatry recommends limiting teen “recreational” screen time to less than two hours daily.5
Additional work is needed to advance the field, including standardizing a methodology to draw generalizations. Objective means of reporting the type, use, and content of screen time also will enable more accurate analysis. Additionally, broadening the study population to include diverse socioeconomic and ethnic groups and standardizing assessments of mental health outcomes will help enhance the validity and applicability of the findings.
Finally, it is important to acknowledge the presence of possible confounding factors that could be affected the results. For example, factors like more parental supervision or involvement, adequate sleep duration, and physical activity levels may affect both screen time and mental health outcomes. Controlling for these variables in future studies is essential.
For now, there are clinically relevant messages to convey to teens and parents. The findings from these 50 studies indicate a concerning association between certain types of screen time and poorer measures of mental health during adolescence. Specifically, high smartphone use on weekdays and excessive social media use, particularly among girls, appear to be particularly problematic. Encouraging parents and adolescents to develop a thoughtful plan for screen use may help mitigate some of the mental health difficulties reported in these studies.
References
- U.S. Department of Health and Human Services. Social Media and Youth Mental Health. Washington; 2023.
- Park A. The U.S. Surgeon General fears social media is harming the ‘well-being of our children.’ Time. Published May 26, 2023. https://time.com/6282893/surgeon-general-vivek-murthy-interview-social-media/
- Andrews J, Ahmed S, Blakemore S-J. Navigating the social environment in adolescence: The role of social brain development. Biol Psych 2021;89:109-118.
- American Academy of Pediatrics. Question: What are some screen time guidelines for social media applications? Updated May 21, 2023. https://www.aap.org/en/patient-care/media-and-children/center-of-excellence-on-social-media-and-youth-mental-health/social-media-and-youth-mental-health-q-and-a-portal/middle-childhood/middle-childhood-questions/screen-time-guidelines/
- American Academy of Child & Adolescent Psychiatry. Screen time and children. Updated February 2020. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-And-Watching-TV-054.aspx
This systematic review of 50 studies reveals a correlation between increased social media usage and decreased mental well-being in adolescents of both genders, more significant depression in girls, and an association of high weekday smartphone usage with reduced mental well-being across both sexes. However, the inconsistency of the findings necessitates additional studies before generalization.
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