According to the Pew Research Center, up to 95% of youth ages 13-17 report using a social media platform, with more than one-third (35%) indicating they use social media “almost constantly.”
U. S. Surgeon General Dr. Vivek Murthy — who has already raised the alarm on the youth mental health crisis in the U.S. — released an evidence-based advisory in May 2023. In it, he cited the dangers of social media and how content on these platforms, as well as the algorithms they use, target children and youth likely serving to exacerbate our nation’s youth mental health crisis.
Monica Barreto, PhD, is here to help us better understand this advisory and how social media affects the children she sees in her practice. Dr. Barreto is the Clinical Director of Behavioral Health for Nemours Children’s Health, Florida.
Carol Vassar, producer/host
Monica Barreto, PhD, Clinical Director of Behavioral Health, Nemours Children’s Health, Florida
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Carol Vassar, podcast host/producer (00:00):
Welcome to Well Beyond Medicine, the Nemours Children’s Health Podcast. Each week, we’ll explore anything and everything related to the 80% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you’re here, let’s go.
MUSIC (00:25): Well Beyond Medicine!
Carol Vassar, podcast host/producer (00:28):
According to the Pew Research Center, up to 95% of youth ages 13 to 17 report using a social media platform, with more than one-third, 35%, indicating they use social media, “Almost constantly.” U.S. Surgeon General Dr. Vivek Murthy, who has already raised the alarm on the youth mental health crisis in the U.S., released an evidence-based advisory in May 2023 on the dangers of social media to children and adolescents and how the content on these platforms and the algorithms used by them target children and youth, likely serving to exacerbate the nation’s youth mental health crisis. Here’s what he had to say.
Dr. Vivek Murthy, U.S. Surgeon General (01:13):
Parents want to know, is social media safe for my kids? And so we embarked upon a review of the data, the publicly available information that’s out there, and what we found reviewing that data and talking to independent researchers are two critical things. One is that there is not enough evidence for us to say that social media is, in fact, sufficiently safe for our kids, but we also found increasing evidence that social media use is associated with harms for our kids.
Carol Vassar, podcast host/producer (01:41):
To help us better understand this advisory and how social media is affecting the children she sees in her practice is Dr. Monica Barreto. Dr. Barreto is the clinical director of behavioral health for Nemours Children’s Health, Florida. We started our conversation with a question of whether or not this warning from the office of the surgeon general comes as a surprise to her from a clinical perspective. Here’s Dr. Monica Barreto.
Dr. Monica Barreto, Nemours Children’s Health (02:08):
Unfortunately, it’s not a surprise. It is having worked from the primary care setting to inpatient, outpatient, and emergency departments since the pandemic began in 2020, we have been seeing an increase in anxiety, depression, suicidal thoughts or attempts, and a lot of it does go back to that social interaction, and the social media, and the very easy access that children and teens have today. Because there are many harms to it, but also benefits, and hopefully, we can talk about both today.
Carol Vassar, podcast host/producer (02:37):
We can definitely talk about both. Let me quote the surgeon general right now. This is a direct quote from the report. There is broad agreement among the scientific community that social media has the potential to both benefit and harm children and adolescents. As you noted, we’ll talk about the benefits shortly. Let’s take a look at the harm. Ages 10 to 19 are especially critical when it comes to brain development in human beings. Does frequent social media use at this age affect how the brain develops, and if so, how?
Dr. Monica Barreto, Nemours Children’s Health (03:12):
Well, when we look at children and youth, just their brain and biological vulnerability to technology and social media, because we can see social media, but also phones, tablets, we see many little ones at restaurants looking at tablets very early, but it does. A brain develops in response to the environment that it lives in. So, many researchers have shown that, and reveal that technology and social media is associated with changes in the structural brain development, changing the size, the physical characteristics of the brain, but it also affects emotion regulation, which is part of the frontal lobe, which is also why some studies have also seen some worsening of inattention, impulsivity, as well as the amygdala that regulates emotion, which is often what we see, very big emotional responses to either cyber bullying or difficulties with friends, or comments and what kids and teens call trolling these days. Sometimes it’s their peers themselves. Sometimes I’ve seen in my own practice bullying through anonymous or fake profiles that other students create to bully others online.
I think it’s very different from the environment that probably parents today grew up in. Kids leave school, but it stays with them in their pockets. It also has been significantly interrupting sleep, sleep deprivation, causing insomnia, and a lot of anxiety at bedtime, and it’s probably a lot of what we’ve been seeing here in our clinics. The worsening of anxiety, fear of either missing out on what’s happening with their friends, and also losing so much time just scrolling, worsening that isolation, and definitely worsening sleep. And parents, at times, don’t know that they’re scrolling and they’re online till 2:00, 3:00 in the morning, and then they’re irritable the next day. They can’t focus in school.
Carol Vassar, podcast host/producer (04:56):
And kids at this age, especially when they hit adolescence, need more sleep, don’t they?
Dr. Monica Barreto, Nemours Children’s Health (05:02):
They do. I always joke; I’m not sure who created the timing of the high school schedule because they get up so much earlier, and their circadian rhythm actually does shift, so they tend to get sleepy later but do wake up significantly earlier. The more sleep deprivation and staying up on their phones, I’d see more so in that middle school to high school age that sleep starts to become more difficult, or they just keep scrolling, and 30 minutes passes by, an hour passes by, and they’re just up.
Carol Vassar, podcast host/producer (05:32):
Now, adolescence, pre-adolescence are times when identity and self-worth are also in development. We talked about brain development. How does social media impact these areas? Does it do so positively? Does it do so negatively?
Dr. Monica Barreto, Nemours Children’s Health (05:48):
Both, but talking about the difficulties first, we start to see a shift when children move into that pre-teen, or what some of the kids I work with call their tween years, is the need for that social connection. That’s when we start to see developing of cliques, and groups, and wanting to fit in. Part of that fitting in is needing to be a part of social media, being connected, but sometimes it can fall to the negative. When we think about social media, I always tell the teens I work with, it’s like the movie reel. We always see the very exciting graphics and what the cool parts of the movie are, and we often do see that, editing of pictures. We’ve also been seeing a lot of disordered eating, low self-esteem, because we’re constantly comparing ourselves to what we’re scrolling.
The perfect pictures, I’ve had many kids tell me [inaudible 00:06:39] they are lying to their friends saying they do these really cool things so they fit in, because their life isn’t as cool as others, and it is that need to constantly one up, or be better, or compete. And oftentimes not knowing a lot of that can be a facade, or edited, or also trying to fit in and not seeing the normal part of life. We do have ups and downs, and we do have boring days. So, that constant comparing of how people look, or what should we be doing, or what is cool and not cool, does have a negative effect.
Carol Vassar, podcast host/producer (07:13):
Talk about some of the positive things. Are there any positive parts of social media with regard to identity and self-worth?
Dr. Monica Barreto, Nemours Children’s Health (07:22):
Yes, I do think on the other end, it’s how we use it, just like everything. An excess use of anything can be a negative. Social media can be fun. It can be exciting and even eventful. For some teens, yes, you can feel self-doubt, but also it does play a huge part of a teenager’s life. They can express their creative side. We’ve seen many people flourish and being able to post their music, or post their art, or express themselves, and also not feel alone. Multiple studies have found it can also be really helpful to be connected especially for marginalized communities, to find additional support or children, especially kids who love gaming. They make really great connections and friends. I’ve had many kids where they met somebody online from Tampa, and they’re best of friends, and their families meet together to hang out. It’s how do we teach children and teens to be safe online and use it as a tool, but not let social media run their life? I think that’s the balance that we want families and teens to learn.
Carol Vassar, podcast host/producer (08:21):
And I think, for some of the marginalized communities that you’re talking about, a lot of kids may feel isolated if they’re in a small town, in not a major city center. They can find empathy in a community online that could in fact be a lifesaver for them, can’t they?
Dr. Monica Barreto, Nemours Children’s Health (08:39):
Yes, and it can be for many, especially the LGBT community, racial and ethnic minorities, and also I’m thinking in small places. Sometimes even, I’ve had some kids that, in their schools, not a lot of kids or teachers look like them, and seeing that there is something else out their motivators. The difficulty is, how do we find, help them use it to boost their confidence, because we can… What happens if we also see social media, it has an algorithm that throws things that you’re looking for or have searched, and that’s where it can get tricky. Because, if we’re often searching things that are matching our negative emotions, maybe getting that. On the other hand, there are many uplifting things, lots of people that can be helpful in connecting and finding those communities, and also interests as well.
Carol Vassar, podcast host/producer (09:21):
I’m guessing that the mix of parents that you see now include millennials who themselves had some social media, the MySpaces or the Facebook pages early on in their probably adolescence. Talk about the mix of parents that you have, and how much they know about how social media has changed since those very early years in the mid-aughts.
Dr. Monica Barreto, Nemours Children’s Health (09:50):
I see a mix. I see the disconnect of, our youth today don’t know life without social media, and they also, what I see the most common is, they don’t know how to be bored and parents are like, what do you mean you’re bored? Go outside, play, read. And they’re like, but that’s boring. I think that’s the biggest disconnect where it is immediate reward, that needing to wait for reward or wait for something to happen. Kids are constantly having that engagement, whether it’s in the classroom, whether it’s with friends, if you put their phone away, they’re not sure what to do. And I think it’s, that is I think the disconnect between parents and this generation is, we knew how to be bored. We would be creative, we would go outside, we would do something, and it’s a different world. So, sometimes helping them meet in the middle, how do we find structure in the day?
How do we use social media as a privilege or something they can work towards instead of losing? We often, the first thing that we see is, well, they’ve lost their phone for a week or they have no games versus when I work with parents is, how do we use it as a tool to encourage them? And what I always call like an unlock system. These are things in the morning, and you’ve unlocked your phone and your tablets and your games. And then, there’s things that you have to do in the afternoon and they kind of, more so how do we provide positive reinforcement and structure versus unlimited play and then unexpected removal. And that often leads to many behavioral difficulties or outburst.
And also, a warning, if we have an hour of, you gave them an hour, let them know we got 10 minutes, five minutes. That can give them a chance to wrap up what they’re doing. Often it’s immediate like, it’s time to, and then we get an emotional response, and that’s usually what I help parents do. The structure, providing positive reinforcement and warnings, and just letting them know what’s coming and what’s the plan.
Carol Vassar, podcast host/producer (11:50):
And being bored is not a bad thing, and is actually beneficial, isn’t it?
Dr. Monica Barreto, Nemours Children’s Health (11:55):
It is. And we can get pretty creative when we’re bored. And when these things in parents who provide that structure and just open communication and expectations, it always tends to work.
Carol Vassar, podcast host/producer (12:07):
Are there children or adolescents who might be more vulnerable than others to what social media has to offer? Especially as you talked about, the algorithms will target you based on your previous places you visited on the internet or on social media. Are some kids just simply more vulnerable?
Dr. Monica Barreto, Nemours Children’s Health (12:27):
I think so, and I think that’s for many things. I think, of course, the younger the children are, the more vulnerable they are. And we do know lots of these social medias do have an age target from let’s approximately, usually it’s 13, but we know that many kids younger than that are being given social media. And it’s, one, knowing your child and teaching them from early on. Definitely younger kids are more vulnerable. They often aren’t seeing the negative side. In the surgeon general’s advisory, they did know I think seven, and six or seven and 10 youth have gotten messages from older individuals or people that they don’t know. So, that’s a really big vulnerability that scares lots of parents as it should. Also, children who have little self-esteem or already experiencing anxiety and depression, sometimes it is important to help them use it as a positive tool, because we can find ourselves in a loop of isolation only being on our phones because, yes, social media connects us, but it also disconnects us.
Many times we’ve been at a restaurant, we see families, the little ones are playing on their phones, the parents are checking their emails and we’re not connecting. So, oftentimes what we recommend is unplugging, whether that’s going, how I tell the kids, old school, and like we do in session, we pull out a board game and have no phones at the dinner table. And also, as kids, like putting those parental controls and using them, having the agreement, you can have social media and parents have the password, so we can have an open line of communication to monitor what’s happening online for the safety of everyone. But, definitely, if we’re struggling with mental health concerns for younger, those are all risk factors and definitely important to help kids be safe and know how to use it as a tool.
Carol Vassar, podcast host/producer (14:11):
Let’s talk about addiction. I know that even for adults and probably for kids as well, there is harm with regard to excessive use of social media. Is this considered an addiction and not just for kids and what can we do about it?
Dr. Monica Barreto, Nemours Children’s Health (14:28):
I would’ve to say from what I’ve seen clinically, yes, but also studies have shown that social media has a very strong effect on the brain and it can often stimulate effects like addiction, driving urges of dopamine to the brain that keeps the individual hooked, going back and over and over again. And also, these apps and these social medias are also built on making us want to pick it up again. We see the push notifications, the alerts, all of that is a trigger to, oh, did I check, or the phantom vibrate where kids all check their phone like, oh, I didn’t get anything, but that needing to check all of the time.
So, I do, and I’ve seen many and I would say even older children become emotionally dysregulated when a parent suggests not having their phone. And I think it ties down to that anxiety of missing out, and what if I don’t catch it, or what if I don’t get enough likes? But, I think, again, I think anything in overuse, we can feel addicted to it and feel like we can’t survive without it. And I have seen some teens unfortunately in that situation
Carol Vassar, podcast host/producer (15:32):
Now, I know that social media platforms generally speaking, have a minimum age. It’s usually around 13. We also know that sometimes a lot of times kids are on it younger. In your clinical opinion, how young is too young to have access to social media?
Dr. Monica Barreto, Nemours Children’s Health (15:48):
I think those advisories are there for a reason, but I also think the maturity level, [inaudible 00:15:54] also shown that there’s a debate. Is there a hard age or the maturity of the child, and I think it’s a little bit of both. From what I see a lot, from parents is starting that more so in the middle school years. I think another pressure for parents is the child feeling, often being made fun of, because they’re not on Snapchat, or TikTok, or not having kind of that gap socially because they’re not connected. But, definitely, I do think what I see mostly is starting in that sixth, seventh grade, but regardless of when we start, it is important to monitor, to know those passwords, to know what your children are doing, and especially if we are and more in that 11, 12, we shouldn’t be going to sleep with our phone, because that’s a very easy, just like I can’t go to sleep, so I’m going to grab my phone and I’m going to scroll.
So, what often parents do is, we put the phone to charge a little further from the bed or in the kitchen. There are also lots of parental controls and some that even some parents teach me. There’s one that’s called Bark that they can put on their computer and it actually helps filter out some of the non age appropriate sites, or also filter some of what can become through social media or ads. Also, I do see, think the apps are getting better at increasing safety for children, and using those controls, and helping educate parents of what can they do to help their child feel socially connected, but also help them feel safe.
Carol Vassar, podcast host/producer (17:17):
It’s a hard balance for parents and something that parents have been dealing with since basically the dawn of social media. I would put that around the mid 2000s, around the MySpace, beginning of Facebook timeframe. Parents aren’t the only ones responsible though, and I think the surgeon general points that out in his report. Let’s talk about some of the communities that he says can do more and how you think that they might be able to do more in protecting our kids from the dangers of social media. So, let’s start with policymakers and lawmakers. What do you think can happen in that area?
Dr. Monica Barreto, Nemours Children’s Health (17:56):
And I think what the surgeon general had noted in strengthening protections to ensure greater safety for children, developing more specific age-appropriate standards as was recommended and protecting them, and accessing harmful content that encourages what we’ve mostly seen in the mental health world as eating disorders, violence, substance abuse, and I will say I have seen some of those changes. I remember just a few years ago, like you had said, in the 2000s, there were hashtags like pro-ana, promoting anorexia and eating disorders, and today if you were to search for that, you can’t. It doesn’t come up. Some of these social medias actually direct you to a website that is more so helping them on how to get help. Having those things being cued to supportive helplines or the suicide hotline can be really helpful, and having a higher standard for data privacy, not just for children, but I think in general for users.
Carol Vassar, podcast host/producer (18:50):
What about researchers? I know the surgeon, in general, says there is some research out there. The research indicates this is dangerous or pointing towards dangerous prospects for our children. What more research do you think needs to occur at this point to prove or disprove dangers or possibly the positive aspects of social media?
Dr. Monica Barreto, Nemours Children’s Health (19:12):
I think the difficulty were there with research, and as I think it was noted in the advisory is, we need longitudinal studies. We need randomized control trials. We need to prove not just a correlation but a causation, that takes time, and I don’t think it’s time that we have. I think we do need to act and put these protections in as was recommended. At least in the field of psychology, that research is increasing. I read some studies on the benefits that we have talked about, as well as studies on the dangers, and I think it’s finding how do we meet that in the middle. I would also like to see outreaches and how do we get children back connected with their day-to-day in the present, because oftentimes, we get lost in social media.
Carol Vassar, podcast host/producer (19:53):
The in real life social aspect of life, which has its own wonderful benefits and existed long before social media did, certainly.
Dr. Monica Barreto, Nemours Children’s Health (20:03):
One important thing is, I think you just made me think when you said, real life, for a lot of these kids and teens, which I think is a disconnect in parents. In our world when we think about social media, it’s just online. It’s a thing that just turn it off, and it goes away. But, for kids and teens, this is real life. The breakup to the posts or the fights online, it is very real to them. So, it is important to open communication, validate your children. That comment seems like it really hurt. How do you feel? Check in with them, because, to them, it is real. It is part of their day-to-day. And opening that communication and helping children and teens feel safe coming to a parent is the most important thing, aside from policies and what we can do technology-wise, the communication between a child and a parent.
Carol Vassar, podcast host/producer (20:51):
Tech companies also play a role here. The algorithms, as we’ve talked about, target kids in certain ways that might not be appropriate for them. Talk a little bit about that.
Dr. Monica Barreto, Nemours Children’s Health (21:03):
Well, I think a lot of it is, as we all know, kind of that clickbait, and I think it is important. That’s something that on the developing side, and like you had said, technology makers can help in not providing that clickbait. Because kids don’t know, they’re going to click, and then they’re going to get scared, and they’re either going to go tell mom and dad or shut down. Even in small games that we often see as to get extra coins in a game, you have to watch an ad. And what that ad is can be dangerous for some kids, or can lead to some worries, or leading them then to the black hole of the internet.
Carol Vassar, podcast host/producer (21:36):
From your practice, and of course, not going into any detail because of privacy concerns. Do you have examples where social media has played a clear role in the mental health status of a patient, and how did you address it?
Dr. Monica Barreto, Nemours Children’s Health (21:49):
Several. If we think more of the younger children, sometimes I’ve seen a lot of anxiety on missing out. This just happened last week where a young kind of in that tween middle school age of the worry of what if I don’t post something on the weekend? What if I don’t use the right filter or making sure their body looks thin enough? So, yes, I do think there is a lot of anxiety around not missing out, not posting, or not commenting or liking someone else’s post. I think there’s a lot of anxiety around that. But, what I do see a lot is the sleep. It’s usually at nighttime. So, what I help parents do is kind of adjust, whether we’re talking about gaming or social media, kind of structure in their day. There are certain things they have to do in the morning, and then they earn their time on their game or their phone.
Then they have things and expectations and chores in the afternoon, and then they earn their free time and their technology time. And then, at bedtime, we then unwind and unplug. At least it’s always better an hour, but at least 30 minutes before bed. Put their phone to charge, not under their pillow, and engage in a relaxation routine. Shower, brushing their teeth, reading, doing mindfulness if it’s something that helps them to just decrease, not just because of social media, but also the blue lights that are on our screens actually send signals to the brain’s alertness. So, it actually does the opposite when we’re trying to fall asleep.
Carol Vassar, podcast host/producer (23:19):
Where do you see this social media and mental health concern in three years, five years? Put on your magic future lens for us.
Dr. Monica Barreto, Nemours Children’s Health (23:32):
Well, I think if we can help children learn how to find balance, I think it can continue. As we’ve seen technology, it can build wonderful things. It can build connections, opportunities, careers for some individuals, but if we don’t learn that balance, we’re not going to get out of this mental health crisis. I think the most important is teaching the skills of how do we be mindful in our day-to-day, and use social media as a tool and not a crutch.
Carol Vassar, podcast host/producer (24:05):
Thanks for listening to our conversation on the surgeon general’s advisory on social media and kids with me, Carol Vassar, and our guest, Dr. Monica Barreto. What do you do to protect your kids when they’re using social media? What more do you believe can and should be done by technology companies, researchers, parents, and policymakers to ensure that the social media experience for kids is healthy and safe? Continue the conversation with us by leaving your voicemail at nemourswellbeyond.org. That’s nemourswellbeyond.org. While you’re there, check out our other episodes, subscribe to the podcast, and leave us a review.
Thanks to Che Parker, Cheryl Munn, and Susan Masucci for this week’s production assistance. Join us next week as we delve into genomics as applied to pediatrics with a worldwide leader on the topic, Dr. Pankaj Agrawal, chief of neonatology and professor of pediatrics and genetics at the University of Miami Jackson Health. Until then, remember, together, we can change children’s health for good well beyond medicine.
MUSIC (25:14): Well Beyond Medicine!