Pick one of these articles then do 3?of these concepts: ECOLOGICAL FRAMEWORK; DIVERSITY, EQUITY AND SOCIAL JUSTICE; WELLBEING (PERSONAL, RELATIONAL OR COLLECTIVE); STRENGTHS; RISK FACTO

Social Media and Youth Mental Health The U.S. Surgeon General’s Advisory

2023

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 2

Contents About the Advisory 3

Social Media and Youth Mental Health 4

Social Media Has Both Positive and Negative Impacts on Children and Adolescents

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The Potential Benefits of Social Media Use Among Children and Adolescents 6

The Potential Harms of Social Media Use Among Children and Adolescents 6

What Drives Mental Health and Well‑Being Concerns: 8 A Snapshot of the Scientific Evidence Potential Risk of Harm from Content Exposure 8

Potential Risk of Harm from Excessive and Problematic Use 9

Critical Questions Remain Unanswered 11 Known Evidence Gaps 11

We Must Take Action: A Way Forward 13 What Policymakers Can Do 15

What Technology Companies Can Do 16

What Parents and Caregivers Can Do 17

What Children and Adolescents Can Do 18

What Researchers Can Do 19

Acknowledgments 20

Endnotes 21

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 3

A Surgeon General’s Advisory is a public statement that calls the American people’s attention to an urgent public health issue and provides recommendations for how it should be addressed. Advisories are reserved for significant public health challenges that require the nation’s immediate awareness and action.

This Advisory calls attention to the growing concerns about the effects of social media on youth mental health. It explores and describes the current evidence on the positive and negative impacts of social media on children and adolescents, some of the primary areas for mental health and well-being concerns, and opportunities for additional research to help understand the full scope and scale of social media’s impact. This document is not an exhaustive review of the literature. Rather, it was developed through a substantial review of the available evidence, primarily found via electronic searches of research articles published in English and resources suggested by a wide range of subject matter experts, with priority given to, but not limited to, meta-analyses and systematic literature reviews. It also offers actionable recommendations for the institutions that can shape online environments—policymakers and technology companies—as well as for what parents and caregivers, young people, and researchers can do.

For additional background and to read other Surgeon General’s Advisories, visit SurgeonGeneral.gov

About the Advisory

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 4

Social media1 use by youth is nearly universal. Up to 95% of youth ages 13–17 report using a social media platform, with more than a third saying they use social media “almost constantly.” 2 Although age 13 is commonly the required minimum age used by social media platforms in the U.S.,3 nearly 40% of children ages 8–12 use social media.4 Despite this widespread use among children and adolescents, robust independent safety analyses on the impact of social media on youth have not yet been conducted. There are increasing concerns among researchers, parents and caregivers, young people, healthcare experts, and others about the impact of social media on youth mental health.5, 6

More research is needed to fully understand the impact of social media; however, the current body of evidence indicates that while social media may have benefits for some children and adolescents, there are ample indicators that social media can also have a profound risk of harm to the mental health and well-being of children and adolescents. At this time, we do not yet have enough evidence to determine if social media is sufficiently safe for children and adolescents. We must acknowledge the growing body of research about potential harms, increase our collective understanding of the risks associated with social media use, and urgently take action to create safe and healthy digital environments that minimize harm and safeguard children’s and adolescents’ mental health and well-being during critical stages of development.

Social Media and Youth Mental Health

Up to 95% of youth ages 13–17 report using a

social media platform, with more than a third saying they use social

media “almost constantly.”

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 5

Social Media Has Both Positive and Negative Impacts on Children and Adolescents

The influence of social media on youth mental health is shaped by many complex factors, including, but not limited to, the amount of time children and adolescents spend on platforms, the type of content they consume or are otherwise exposed to, the activities and interactions social media affords, and the degree to which it disrupts activities that are essential for health like sleep and physical activity.6 Importantly, different children and adolescents are affected by social media in different ways, based on their individual strengths and vulnerabilities, and based on cultural, historical, and socio-economic factors.7, 8 There is broad agreement among the scientific community that social media has the potential to both benefit and harm children and adolescents.6, 9

Brain development is a critical factor to consider when assessing the risk for harm. Adolescents, ages 10 to 19, are undergoing a highly sensitive period of brain development.10, 11 This is a period when risk-taking behaviors reach their peak, when well-being experiences the greatest fluctuations, and when mental health challenges such as depression typically emerge.12, 13, 14 Furthermore, in early adolescence, when identities and sense of self-worth are forming, brain development is especially susceptible to social pressures, peer opinions, and peer comparison.11, 13 Frequent social media use may be associated with distinct changes in the developing brain in the amygdala (important for emotional learning and behavior) and the prefrontal cortex (important for impulse control, emotional regulation, and moderating social behavior), and could increase sensitivity to social rewards and punishments.15, 16 As such, adolescents may experience heightened emotional sensitivity to the communicative and interactive nature of social media.16 Adolescent social media use is predictive of a subsequent decrease in life satisfaction for certain developmental stages including for girls 11–13 years old and boys 14–15 years old.17 Because adolescence is a vulnerable period of brain development, social media exposure during this period warrants additional scrutiny.

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 6

The Potential Benefits of Social Media Use Among Children and Adolescents

Social media can provide benefits for some youth by providing positive community and connection with others who share identities, abilities, and interests. It can provide access to important information and create a space for self-expression. The ability to form and maintain friendships online and develop social connections are among the positive effects of social media use for youth. , These relationships can afford opportunities to have positive interactions with more diverse peer groups than are available to them offline and can provide important social support to youth. The buffering effects against stress that online social support from peers may provide can be especially important for youth who are often marginalized, including racial, ethnic, and sexual and gender minorities. , For example, studies have shown that social media may support the mental health and well-being of lesbian, gay, bisexual, asexual, transgender, queer, intersex and other youths by enabling peer connection, identity development and management, and social support. Seven out of ten adolescent girls of color report encountering positive or identity-affirming content related to race across social media platforms. A majority of adolescents report that social media helps them feel more accepted (58%), like they have people who can support them through tough times (67%), like they have a place to show their creative side (71%), and more connected to what’s going on in their friends’ lives (80%). In addition, research suggests that social media-based and other digitally-based mental health interventions may also be helpful for some children and adolescents by promoting help-seeking behaviors and serving as a gateway to initiating mental health care. , , 28, 29 27,268

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The Potential Harms of Social Media Use Among Children and Adolescents

Over the last decade, evidence has emerged identifying reasons for concern about the potential negative impact of social media on children and adolescents.

A longitudinal cohort study of U.S. adolescents aged 12–15 (n=6,595) that adjusted for baseline mental health status found that adolescents who spent more than 3 hours per day on social media faced double the risk of experiencing poor mental health outcomes including symptoms of depression and anxiety.30

Social Media Has Both Positive and Negative Impacts on Children and Adolescents

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 7

As of 2021, 8th and 10th graders now spend an average of 3.5 hours per day on social media. In a unique natural experiment that leveraged the staggered introduction of a social media platform across U.S. colleges, the roll-out of the platform was associated with an increase in depression (9% over baseline) and anxiety (12% over baseline) among college-aged youth (n = 359,827 observations). The study’s co-author also noted that when applied across the entirety of the U.S. college population, the introduction of the social media platform may have contributed to more than 300,000 new cases of depression. ,

If such sizable effects occurred in college-aged youth, these findings raise serious concerns about the risk of harm from social media exposure for children and adolescents who are at a more vulnerable stage of brain development.

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Limits on the use of social media have resulted in mental health benefits for young adults and adults. A small, randomized controlled trial in college-aged youth found that limiting social media use to 30 minutes daily over three weeks led to significant improvements in depression severity. This effect was particularly large for those with high baseline levels of depression who saw an improvement in depression scores by more than 35%. Another randomized controlled trial among young adults and adults found that deactivation of a social media platform for four weeks improved subjective well-being (i.e., self-reported happiness, life satisfaction, depression, and anxiety) by about 25–40% of the effect of psychological interventions like self-help therapy, group training, and individual therapy.36

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In addition to these recent studies, correlational research on associations between social media use and mental health has indicated reason for concern and further investigation. These studies point to a higher relative concern of harm in adolescent girls and those already experiencing poor mental health,

, as well as for particular health outcomes like cyberbullying-related depression, body image and disordered eating behaviors, and poor sleep quality linked to social media use. For example, a study conducted among 14-year-olds (n = 10,904) found that greater social media use predicted poor sleep, online harassment, poor body image, low self-esteem, and higher depressive symptom scores with a larger association for girls than boys. A majority of parents of adolescents say they are somewhat, very, or extremely worried that their child’s use of social media could lead to problems with anxiety or depression (53%), lower self-esteem (54%), being harassed or bullied by others (54%), feeling pressured to act a certain way (59%), and exposure to explicit content (71%).44

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Social Media Has Both Positive and Negative Impacts on Children and Adolescents

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 8

Scientific evidence suggests that harmful content exposure as well as excessive and problematic social media use are primary areas for concern.

Potential Risk of Harm from Content Exposure

Extreme, inappropriate, and harmful content continues to be easily and widely accessible by children and adolescents. This can be spread through direct pushes, unwanted content exchanges, and algorithmic designs. In certain tragic cases, childhood deaths have been linked to suicide- and self-harm-related content and risk-taking challenges on social media platforms. , This content may be especially risky for children and adolescents who are already experiencing mental health difficulties. Despite social media providing a sense of community for some, a systematic review of more than two dozen studies found that some social media platforms show live depictions of self-harm acts like partial asphyxiation, leading to seizures, and cutting, leading to significant bleeding. Further, these studies found that discussing or showing this content can normalize such behaviors, including through the formation of suicide pacts and posting of self-harm models for others to follow.

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Social media may also perpetuate body dissatisfaction, disordered eating behaviors, social comparison, and low self-esteem, especially among adolescent girls. 51, A synthesis of 20 studies demonstrated a significant relationship between social media use and body image concerns and eating disorders, with social comparison as a potential contributing factor. Social comparison driven by social media is associated with body dissatisfaction, disordered eating, and depressive symptoms. , 55, 56 When asked about the impact of social media on their body image, nearly half (46%) of adolescents aged 13–17 said social media makes them feel worse, 40% said it makes them feel neither better nor worse, and only 14% said it makes them feel better.57

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Additionally, roughly two-thirds (64%) of adolescents are “often” or “sometimes” exposed to hate-based content. Among adolescent girls of color, one-third or more report exposure to racist content or language on social media platforms

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What Drives Mental Health and Well‑Being Concerns: A Snapshot of the Scientific Evidence

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 9

at least monthly. In a review of 36 studies, a consistent relationship was found between cyberbullying via social media and depression among children and adolescents, with adolescent females and sexual minority youth more likely to report experiencing incidents of cyberbullying.59, 60 Nearly 75% of adolescents say social media sites are only doing a fair to poor job of addressing online harassment and cyberbullying.61

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In addition, social media platforms can be sites for predatory behaviors and interactions with malicious actors who target children and adolescents (e.g., adults seeking to sexually exploit children, to financially extort them through the threat or actual distribution of intimate images, or to sell illicitly manufactured fentanyl). 64 Adolescent girls and transgender youth are disproportionately impacted by online harassment and abuse, which is associated with negative emotional impacts (e.g., feeling sad, anxious or worried).65, 66

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Nearly 6-in-10 adolescent girls say they’ve been contacted by a stranger on certain social media platforms in ways that make them feel uncomfortable.24

Potential Risk of Harm from Excessive and Problematic Use

Excessive and problematic use of social media can harm children and adolescents by disrupting important healthy behaviors. Social media platforms are often designed to maximize user engagement, which has the potential to encourage excessive use and behavioral dysregulation. 69,

70 Push notifications, autoplay, infinite scroll, quantifying and displaying popularity (i.e., ‘likes’), and algorithms that leverage user data to serve content recommendations are some examples of these features that maximize engagement. According to one recent model, nearly a third (31%) of social media use may be attributable to self-control challenges magnified by habit formation. Further, some researchers believe that social media exposure can overstimulate the reward center in the brain and, when the stimulation becomes excessive, can trigger pathways comparable to addiction. 72 Small studies have shown that people with frequent and problematic social media use can experience changes in brain structure similar to changes seen in individuals with substance use or gambling addictions. 74 In a nationally representative survey of girls aged 11–15, one-third or more say they feel “addicted” to a social media platform. Over half of teenagers report that it would be hard to give 24

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What Drives Mental Health and Well‑Being Concerns: A Snapshot of the Scientific Evidence

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 10

up social media. Nearly 3-in-4 teenagers believe that technology companies manipulate users to spend more time on their devices. In addition, according to a survey of 8th and 10th graders, the average time spent on social media is 3.5 hours per day, 1-in-4 spend 5+ hours per day and 1-in-7 spend 7+ hours per day on social media.31

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Excessive and problematic social media use, such as compulsive or uncontrollable use, has been linked to sleep problems, attention problems, and feelings of exclusion among adolescents. Sleep is essential for the healthy development of adolescents. A systematic review of 42 studies on the effects of excessive social media use found a consistent relationship between social media use and poor sleep quality, reduced sleep duration, sleep difficulties, and depression among youth. Poor sleep has been linked to altered neurological development in adolescent brains, depressive symptoms, and suicidal thoughts and behaviors. On a typical weekday, nearly 1-in-3 adolescents report using screen media until midnight or later. While screen media use encompasses various digital activities, social media applications are the most commonly used applications by adolescents.58

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In a recent narrative review of multiple studies, problematic social media use has also been linked to both self-reported and diagnosed attention-deficit/ hyperactivity disorder (ADHD) in adolescents, although more research is necessary to understand whether one causes the other. A longitudinal prospective study of adolescents without ADHD symptoms at the beginning of the study found that, over a 2-year follow-up, high-frequency use of digital media, with social media as one of the most common activities, was associated with a modest yet statistically significant increased odds of developing ADHD symptoms (OR 1.10; 95% CI, 1.05-1.15). Additionally, social media-induced fear of missing out, or “the pervasive apprehension that others might be having rewarding experiences from which one is absent,” has been associated with depression, anxiety, and neuroticism.84

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What Drives Mental Health and Well‑Being Concerns: A Snapshot of the Scientific Evidence

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 11

Nearly every teenager in America uses social media, and yet we do not have enough evidence to conclude that it is sufficiently safe for them. Our children have become unknowing participants in a decades-long experiment. It is critical that independent researchers and technology companies work together to rapidly advance our understanding of the impact of social media on children and adolescents. This section describes the known gaps and proposes additional areas for research that warrant urgent consideration.

Known Evidence Gaps

The relationship between social media and youth mental health is complex and potentially bidirectional. There is broad concern among the scientific community that a lack of access to data and lack of transparency from technology companies have been barriers to understanding the full scope and scale of the impact of social media on mental health and well-being. Most prior research to date has been correlational, focused on young adults or adults, and generated a range of results. Critical areas of research have been proposed to fill knowledge gaps and create evidence-based interventions, resources, and tools to support youth mental health. Thus, there is an urgent need for additional research including on, but not limited to, the following questions:

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• How do in-person vs. digital social interactions differ in terms of the impact on health, and what are the unique contributions of social media behavior to social connectedness, social isolation, and mental health symptoms?

• What are the potential pathways through which social media may cause harm to children’s and adolescents’ mental health and well-being? For example:

» How does social comparison affect one’s sense of life satisfaction and in-person relationships?

» How does the use of social media, including specific designs and features, relate to dopamine pathways involved in motivation, reward, and addiction?

• What type of content, and at what frequency and intensity, generates the most harm? Through which modes of social media access (e.g., smartphone, computer) and design features? For which users and why?

Critical Questions Remain Unanswered

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 12

• What are the beneficial effects of social media? For whom are the benefits greatest? In what ways, and under what circumstances?

• What individual-, community-, and societal-level factors may protect youth from the negative effects of social media?

• What types of strategies and approaches are effective in protecting the mental health and well-being of children and adolescents on social media (e.g., programs, policies, design features, interventions, norms)?

• How does social media use interact with a person’s developmental stage for measuring risk of mental health impact?

Critical Questions Remain Unanswered Known Evidence Gaps

It is critical that independent researchers and technology

companies work together to rapidly advance our

understanding of the impact of social media on children

and adolescents.

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 13

Our children and adolescents don’t have the luxury of waiting years until we know the full extent of social media’s impact. Their childhoods and development are happening now. While social media use can have positive impacts for some children, the evidence noted throughout this Surgeon General’s Advisory necessitates significant concern with the way it is currently designed, deployed, and utilized. Child and adolescent use of platforms designed for adults places them at high risk of “unsupervised, developmentally inappropriate, and potentially harmful” use according to the National Scientific Council on Adolescence. At a moment when we are experiencing a national youth mental health crisis, now is the time to act swiftly and decisively to protect children and adolescents from risk of harm.

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To date, the burden of protecting youth has fallen predominantly on children, adolescents, and their families. Parents face significant challenges in managing children and adolescents’ use of social media applications, and youth are using social media at increasingly earlier ages. Nearly 70% of parents say parenting is now more difficult than it was 20 years ago, with technology and social media as the top two cited reasons. While nearly all parents believe they have a responsibility to protect their children from inappropriate content online, the entire burden of mitigating the risk of harm of social media cannot be placed on the shoulders of children and parents. Nearly 80% of parents believe technology companies have a responsibility to protect children from inappropriate content as well.89

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We must provide children and their families with the information and tools to navigate the changing digital environment, but this burden to support our children must be further shared. There are actions technology companies can take to make their platforms safer for children and adolescents. There are actions researchers can take to develop the necessary research base to support further safeguards. And there is a role for local, state, and federal policy to implement protections for our children and adolescents.

The U.S. has a strong history of taking action in such circumstances. In the case of toys, transportation, and medications—among other sectors that have

We Must Take Action: A Way Forward

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 14

widespread adoption and impact on children—the U.S. has often adopted a safety-first approach to mitigate the risk of harm to consumers. According to this principle, a basic threshold for safety must be met, and until safety is demonstrated with rigorous evidence and independent evaluation, protections are put in place to minimize the risk of harm from products, services, or goods. For example, the Consumer Product Safety Commission requires toy manufacturers to undergo third-party testing and be certified through a Children’s Product Certificate as compliant with the federal toy safety standard for toys intended for use by children. To reduce the risk of injury from motor vehicle accidents, the National Highway Traffic Safety Administration requires manufacturers to fit new motor vehicles with standard airbags and seat belts, among other safety features, and conduct crash tests to be compliant with the Federal Motor Vehicle Safety Standards. Medications must demonstrate safety to the Food and Drug Administration before being made available and marketed for use. Given the mounting evidence for the risk of harm to some children and adolescents from social media use, a safety-first approach should be applied in the context of social media products.

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To better safeguard the mental health and well-being of children and adolescents, policymakers, technology companies, researchers, families, and young people must all engage in a proactive and multifaceted approach. Through the recommendations below, we can provide more resources and tools to children and families, we can gain a better understanding of the full impact of social media, and we can maximize the benefits and minimize the harms of social media platforms to create safer, healthier online environments for children.

We Must Take Action: A Way Forward

We can maximize the benefits and minimize

the harms of social media platforms to create

safer, healthier online environments for children.

Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory 15

• Strengthen protections to ensure greater safety for children interacting with all social media platforms, in collaboration with governments, academic organizations, public health experts, and technology companies.

» Develop age-appropriate health and safety standards for technology platforms. Such standards may include designing technology that is appropriate and safe for a c

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