Keywords

Introduction

Children and teenagers live in a digital age. Phones, tablets, laptops, desktops, watches, and other devices are ubiquitous in both the home environment and the school environment. Whether it is getting a snapchat notification at breakfast or learning a new Tiktok dance after school, youth’s exposure to digital media, whether it is a social media platform or an entertainment medium, is a phenomenon that occurs in a majority of households. Yet, what is the landscape in which digital content presents itself to youth and how do we screen and assess the amount of time as well as type of content our patients’ consume? To answer these questions, we need to first understand the backdrop of digital media and the prevalent trends of how children and teenagers participate in the virtual landscape.

Over the past two decades, children under the age of 18 have dramatically increased their time viewing screens: 12th graders’ internet use during leisure time doubled between 2006 and 2016 (from about 1 h a day to about 2 h a day.) In that same time, 8th graders' internet time increased by 68% and 10th graders' internet time increased by 75% [1]. In 2015, Common Sense Media, a nonprofit organization that examines children and teen media use, noted that 57% of teenagers spend more than 4 h per day with screen media [2]. However, these numbers appear outdated when examining screen media time and use during the COVID-19 pandemic. In the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) study, 5,412 adolescents between the ages of 12 to 13 were asked to assess their screen time use prior to the pandemic and postpandemic, with average screen time increasing from 3.8 h to 7.7 h; [3] 8–12-year olds are not far behind, averaging 4 h and 44 min of screen media a day [4]. Parental reports of teen screen time have also indicated significant changes as well. In a poll conducted by Morning Consult, 32% of parents believed their teens had used electronic devices daily for more than 4 hours before the COVID-19 pandemic. In contrast, as of June 2020, 62% of parents from the same sample population believed their teens had used electronic devices daily for more than 4 h [5].

If screen time use is increasing, on what device are children and teenagers consuming digital content? Per Pew research, 95% of U.S. teenagers have access to a smartphone, a two-fold increase over the 41% teen smartphone ownership reported in 2012 [6]. Children also follow a similar trend, with 53% of children 11 and younger owning a smartphone. As smart phone use has increased, other modalities have decreased in response. The number of teenagers watching television on a television set has decreased from 64% to 50% during the period 2015–2019, while the number of teenagers watching television on a smartphone has increased from 6% to 20% [4]. Tablet computers appear to follow a rising trend of use, albeit smaller, in the younger age groups. For example, when asked about the appropriate age for their child to have or own their own tablet, 65% of parents agreed that their child owning a tablet before the age of 12 was acceptable, while only 22% of parents believed it was acceptable to own a smartphone before the age of 12 [7].

Given the increase in screen time, what are children and teenagers consuming digitally? Per Common Sense Census in 2019, which analyzed the results of 1600 8–18-year olds about their relationship with screen media, tween screen time was dominated by television and video use (53%), gaming (31%), browsing websites (5%), and social media (4%.) Similarly, teens also consumed television and videos primarily (39%) and followed by gaming (22%). However, social media use rose significantly to 16% among teens compared to their younger counterparts [4]. Per the GlobalWebIndex Report of 2018, teens and young adults between the ages of 16–24 averaged 3 h on social media daily. Rates of multiple daily engagements in social media have also risen dramatically as well, rising from 38% in 2012 to 70% in 2018, including 16% who say they use it “almost constantly [8].”

Social media is vast and covers numerous platforms. With over 4.48 billion active social media users globally, giants such as Facebook, Instagram, Snapchat, and Twitter have dominated the digital playground [9]. In 2015, 71% of teens aged 13–17 reported they used Facebook as their primary social media platform, followed by Instagram (52%), Snapchat (41%), and Twitter (31% [6].) However, digital trends are altered at remarkably fast speeds. Pipler Sandler Investment Research surveyed 9,800 teens in the fall of 2020, asking which social media sites were most popular. Surprisingly, Snapchat had become the most favored social platform (34%), followed by the new social media platform Tiktok (29%), then instagram (25%), with Facebook falling last (2%.) Highest engagement or actual reported use tells a slightly different story, with Instagram used most (84%), followed by Snapchat (80%), then Tiktok (69% [10].)

This chapter will focus on educating the clinician on how to screen children and teen screen time and social media use. It will not focus on content outside of social media, that of which may include digital entertainment, such as netflix or youtube, or video game consumption. Those areas of digital entertainment are vast and require their own separate chapters. The first part of this chapter will discuss what aspects clinicians are looking for in the clinical interview that would raise concern. The second part of this chapter will explore how clinicians can ask questions regarding screen time and social media and how confidentiality should be approached.

Screening Strategies

Screen Time: The Overarching Areas of Emphasis and Interests are When, Where, and How Much?

Initially, the American Academy of Pediatrics originally suggested that there should be discouragement of media use under the age of 2, with specific parameters limiting time with screens for different age groups [11]. However, as the virtual playground has evolved, more nuanced recommendations have arrived on advising families on media use, specifically based on where and when screen time is occurring. But when does screen time occur and in what settings?

Screen time appears to peak in the late afternoon and into the evenings for the majority of children and teenagers, with a second smaller peak occurring in the morning for younger children. Regarding weekdays and weekend use, all family members tend to use electronics more comparatively on weekends than weekdays, with older children and teenagers having more screen time than their younger counterparts [12]. To further illustrate this trend, a sample of 1,448 children aged 7 and below and 1,517 children aged 7–10 were followed by their parents to assess their change in screen time. Parents noted that while their children watched 2 hours of TV on a weekday, that number rose approximately by 75% and 74%, respectively, on the weekend [13].

Regarding times of day, evening and night time screen use appear to be the most common for teenagers. Seventy five percent of American children and adolescents report the presence of at least 1 screen media device in their bedroom, with roughly 60% reporting regular use of these devices during the hour before bedtime [14]. Adolescent night social media use was typically driven by concerns over negative consequences for real-world relationships if they disconnected. These concerns were related to peer-exclusion and fear of violating social norms around online availability [15]. The consequences of screen time use at night are well documented. A meta-analysis of 20 studies examined 125,000 youth, and results indicated that bedtime media usage is associated with negative consequences on sleep. Insufficient sleep duration, poor sleep quality, and excessive daytime sleepiness were all such outcomes. The mere presence of a portable screen-based media device in the bedroom has adverse associations with sleep outcomes [16].School also plays a part in smartphone use. While recent data is still pending, Pew Research Center’s Internet and American Life Project from 2009 noted that 77% of teenagers bring their phone to school [17]. This number has certainly risen over the past decade.

Social Media Applications

There are numerous social media applications that can be accessed by phone, tablet, computer, and other smart devices with certain tech monoliths ruling the digital arena. Facebook (now known as “Meta”) continues to have the most active users with over 2.895 billion users globally in 2021, followed by Youtube (2.291 billion users), WhatsApp (2 billion users), and Instagram (1.386 billion [18]). However, attention has shifted to other platforms, namely, Tiktok and Snapchat, as these platforms appear to be targeting younger audiences and growing in popularity. Currently, Tiktok has 732 million active users globally, with 47.4% of Tiktok’s user base in the United States aged between 10 and 29 years old [19]. Snapchat has 293 million users globally, with 48% of their user base in the United States aged between 15 and 25 years old [20]. Though active in the teen community, only 39% of Instagram’s user base falls under the 13–24 age range [21]. Per Piper Sandler, an investment firm that takes stock of teen use and social media, Snapchat still remains the main social media application for teens, followed by Tiktok and Instagram [22]. For this chapter, we will go over how Tiktok, Snapchat, and Instagram work, and what parts of these applications clinicians should be aware of.

Tiktok is a short-form video sharing application that allows users to upload 0–180 s video clips. Each video clip can be linked with audio or associated sounds such as voice recordings, music, and dialogue. If a user is not creating videos themselves, they have the option to swipe through other users’ videos in a relatively quick manner. Tiktok’s digital layout offers five different choices that a user can select, including a home page, discover page, creation page, an inbox page, and personal page. Briefly, the home page features videos from creators that the user is actively following (such as a celebrity or a friend that often creates video content) or a “For You” page, which shows videos that Tiktok believes the user would enjoy. For the latter, Tiktok’s algorithm of picking those videos for users is based on numerous criteria, including accounts users follow, comments users have posted, themes behind videos that users watch (sports, video gaming, etc.), and most importantly, how long users have remained on a video (watching portions of a video vs. the entirety of the video.) On the discover page, users see the latest trending sounds or hashtags that are gaining popularity, and are encouraged to create content on the creation page with similar favorable attributes. The inbox page allows users to see how many individuals are actively liking, commenting, and sharing their videos. Finally, the personal page shows users their videos that they have personally uploaded, the amount of “likes” in total that their videos have received, the amount of followers they have, and how many accounts the user is following. Tiktok also has a messaging service in which users can direct message each other (also known as “DM” [23, 24].)

Snapchat is a social media application that prides itself on a simple concept: any picture or video that a user sends is only available to the recipient for a short time before it becomes inaccessible. Initially focused on person-to-person sharing, Snapchat has expanded to sending short videos, live video chatting, direct messaging, creating caricature-like bitmoji avatars, and sharing a chronological “Story” that’s broadcasted to all followers. When opening the Snapchat application, users are greeted to their phone’s camera interface. On the bottom of the screen, users will see a capture button, which they can either press (or hold) to take pictures and videos for up to 10 s long. After taking the “snap,” users can write texts, add stickers, or color on to their photos or videos, and then choose to either upload it to their story page where all users can see their content or directly message other users privately. If users wish to save their own photos or videos they have sent to others, they can save their media on the memory page. However, users are notified if others try to save their photos via taking a screenshot. Similar to Tiktok, Snapchat also has a discover page, where popular stories are posted by media outlets that expire after 24 h. One other aspect of Snapchat is the Snap map, a tool in which users can see the exact location of where people sent their latest snaps. This is an optional feature and users can put their profile in “ghost mode” for which no other user can see their location [25,26,27].

Launching in 2010, Instagram is the oldest of the 3 most consumed social media sites among teenagers. Similar to Facebook (which serves as owner now), Instagram allows users to follow other users’ content, generating a homepage with information known as a “feed '' on the user’s home page. The feed is filled with posts created by individuals, groups, and companies for which the user follows. Instagram also has an explore page (similar to Tiktok’s discover page) that hosts pictures and videos for which the user can interact with, leading to the application making similar recommendations in the future. At the top of the home page, users will see the “story” section, where other users have posted short video clips of the day’s events for which a population (selected or general) can view. Similar to SnapChat, these stories expire after 24 hours unless saved by the user who posted the story. Above the story section is a small icon linked to a DM service in which users can connect with each other (again, similar to Tiktok and Snapchat.) Other pages on the application include a shop page, where users can buy various products sold through the platform as well as a profile icon, where users can see how many followers they have or who they are following. As Instagram has had to adapt to compete with other social media applications, they have also jumped into the digital video market. Instagram Reels is similar to Tiktok, and allows users to post short videos with selected audio that other users can view. Instagram also allows for longer videos (several minutes to an hour) to be posted under the category of IGTV or Instagram television [28,29,30].

Reasons for Teenage Use of Social Media

In the digital age where over 85% of teenagers are on social media, clinicians may be scratching their heads to ask what’s the purpose behind their interest with these platforms [31]. A meta-analytic review of studies of the reasons behind Facebook addiction, for example, found that the major motivations to use facebook included relationship maintenance, entertainment, companionship, and simply “passing time [32].” Reasons are vast, but the leading category of interest appears to fall under the category of connection and peer support. A 2019 survey consisting of 6,247 respondents aged 13–29 reported that 84% of young individuals use social media for purpose of communicating with friends [33]. Fifty seven percent of teens aged 13–17 have made a new friend online, and 62% of teens share their social media username when they meet someone for the first time. Twenty-three percent of teens indicate that they spend time with friends on social media every day [34]. Regarding actual perceived support, gender differences exist, where 73% of girls endorse receiving emotional support from peers compared to 63% of boys. Teens also highlight that social media has made it easier to communicate with family and friends, with benefits including increased self-esteem and increased opportunities of self-disclosure [35]. Other aspects of connection stem from what teens post on social media sites. Disclosure of accomplishments, followed by family-related events and then emotional feelings tended to be highly popular on social media sites such as Instagram [6].

Entertainment serves as a primary reward from social media use. In the UK, users of the social media site TikTok highlighted categories such as comedy, dancing, watching others lip sync songs, and animals as main reasons behind application use [36]. While Youtube continues to remain the top contender for entertainment purposes through streaming online video content, 36–40% of parents with children aged 13–17 report that Instagram and Tiktok are the most popular entertainment applications in their household [37]. Entertainment entities such as HBO, Netflix, Amazon, and even children’s television such as Cartoon Network and Nickelodeon have active, thriving social media accounts that boast millions of followers.

Education, prior to the pandemic, had less of a following compared to connection and entertainment. Per Common Sense Media, many teens agree that social media helps them to be more aware of current events, but there was a drop in the percent who “strongly agree” with that statement, from 26 percent in 2012 to 18 percent in 2018 [38]. However, one year into the pandemic, Common Sense Media released new data, highlighting that 8 in 10 youth (85%) have looked for health information online, with “depression,” “stress,” and “anxiety” among the top searches, with social media serving as a primary source of information [39]. Self-expression through content creation serves as a pillar, albeit smaller, when it comes to uses behind social media. In 2018, 37 percent of teens said creative posting, through text messages or video, was “somewhat” important, with girls highlighting this purpose as “very important” compared to boys [38]. However, like education, self-expression has increased significantly with the rising popularity of short-uploaded videos via snapchat, Tiktok, and Instagram’s Reels.

Gender Differences and Social Media

Significant evidence indicates that adolescent girls and gender minority youth are more emotionally invested in social media than their cisgender male youth [40]. Both populations have reported spending higher average daily hours on social media and higher frequency of checking social media [41]. Additionally, earlier age of onset of social media use has correlated with worse emotional well-being scores in females compared to males [42]. Theories suggest that adolescent females, in prepubertal and pubertal years, are often engaged in upward social comparison, or the ability to compare oneself to someone who is perceived as better than they are [43]. When teens view peer or celebrity profiles who post photos or text that highlight accomplishments (whether based on physical beauty, social status, wealth, or relationship status), values of self-esteem and self-evaluation can plummit [44].

Detrimental Effects of Social Media

A teenager’s mental health is connected to their digital world, depending on the state of the teenager’s emotional well-being. In 2018, Common Sense Media conducted a survey for teenagers asking questions relating to happiness, depression, loneliness, confidence, self-esteem, and parental relations. Questions such as “I am happy with my life” and “I often feel sad or depressed” were asked and based on the teenager’s response, a social emotional well-being (SEWB) score was calculated. The higher the score, the higher the social emotional well-being of the teenager. Results indicated that those who had “low” SEWB scores tended to find social media significantly more important and impactful to their day-to-day lives. Teenagers with low SEWB scores compared to teenagers with high SEWB scores reported feeling left out or excluded when using social media (70% vs. 29%), more likely to delete their social media posts, because they got too few “likes” (43% vs. 11%), felt bad about themselves if no one commented on or liked their post (43% vs. 11%) and were more likely to have been cyberbullied (35% vs. 5% [38].)

Self-esteem and worth also play a part in how a teenager interacts with social media. Self-esteem levels and emotional investment in social media are negatively correlated, highlighting that those who value their digital connection are more at risk for requiring external validation through likes, views, and amount of followers [45, 46]. Poor sleep also correlates with social media use. It is well known that adolescents who have access to screens late at night have poorer quality of sleep, shorter durations of sleep, and difficulty in falling asleep compared to their nonscreen time counterparts [47, 48]. However, night-time-specific social media use, with constant notifications, access to direct messaging other peers, and the fear of missing out on social activities, is now linked to worsening sleep quality among adolescents [49]. In return, poor quality of sleep leads to issues with executive function, motor control (potentially leading to motor vehicle accidents when sleepy teenagers drive to school), and difficulty with declarative and working memory [49,50,51,52].

Remaining on topic regarding vulnerable youth, teenagers with pre-existing psychiatric illnesses are also at risk of worsening their mental health while on social media. Research conducted in Canada highlighted that teenagers with depression were more vulnerable to experiencing negative experiences (loneliness, etc.) on social media sites such as Facebook [53]. Anxious adolescents tend to use social media more, and teenagers who utilized more hours of social media with pre-existing anxiety disorders tended to worsen their anxiety [54, 55]. Prevalence of eating disorders has also increased as social media use has risen among adolescents [56]. Teenagers often find themselves comparing their body shape and size to other users, subscribing to dieting trends, or following models and celebrities that pride themselves on their physique. Numerous studies have highlighted how photo-based media sites such as Instagram have served as risk factors for developing poor body image, increased perception of fatness, and greater disordered eating attitudes, particularly among adolescent females [57]. Those who have problematic social networking use, such as high degree of emotional investment in social media, are also more likely to develop disordered eating symptoms [58].

Signs of Youth at Risk

Engaging in social media use by teenagers isn’t necessarily a bad thing. Connection, support, education, entertainment, and self-expression are important for adolescent growth and maturation. However, certain behaviors and experiences can put teens at risk for demoralization, sexual and emotional abuse, self-harm, and suicidality. These experiences should be screened and assessed when discussing an adolescent’s activity on social media.

Cyberbullying is a well-documented and prevalent phenomenon plaguing teenagers and causing significant emotional distress. In a systematic review conducted in 2021, cyberbullying victimization and perpetration among those under the age of 18 globally ranged were 14.6–52.2% and 6.3–32%, respectively [59]. There are multiple different forms of cyberbullying including verbal violence, group violence, visual violence, impersonating and account forgery, sexual harassment, and cyberstalking (Table 2.1) [60]. Individuals who endure cyberbullying are more likely to endorse symptoms of anxiety, depression, and suicidal ideation compared to nonvictimized peers [61, 62]. Different social media sites such as Instagram, Snapchat, and Tiktok are notoriously connected to acts of cyberbullying. In a 2017 survey conducted by Ditch the Label, a nonprofit antibullying group, more than 1 in 5 12–20-year olds experience bullying specifically on Instagram [63]. Hate pages, a mixture of group violence and account forgery, are an example of cyberbullying, where a page is created to insult and demean a victim while encouraging others to post similar content about the victim [64].Bullying also occurs through SnapChat and Tiktok as well. In 2021, SnapChat had to suspend two particular applications that allowed users to send anonymous messages to other users after a teenager committed suicide, invoking an ensuing lawsuit by the parent of the teenager. The parent’s reason for the lawsuit stemmed from the numerous hateful and offensive messages that their teenager received from anonymous sources days prior to his suicide completion [65]. Tiktok has also faced its fair share of criticism, with users who post videos and then face an onslaught of racial, homophobic, and body shaming commentary by other users [66].

Table 2.1 Outlined here are the different types of cyberbullying
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Sexual exploitation via digital media is an unfortunate reality for children and teenagers. Nearly 1 in 7 children aged 9–12 shared their own nude photos in 2020, almost tripling the number from just one year earlier [67]. The number of sexual texts (“sexts”) children and teens have attempted to send (including girls as young as 6) has risen over 183% during the pandemic [68]. Perception of sharing sexually explicit images of oneself is also shifting. Recently, 40% of teenagers agreed that “it’s normal for people my age to share nudes with each other” [69]. Additionally, nearly 40% of children have either received and/or sent a “sext” by the age of 13 [69]. Social media applications serve as a medium for nude photos (“nudes”) as well. Articles, such as “How to Sext on Snapchat Like a Pro,” highlight ways in which users can send sexually explicit content to each other [70]. Instagram has also created a “vanish mode,” a feature in which users can have their messages deleted after a chat box is closed. Vanish mode has been characterized by many users as manner in which sexually explicit images can be sent between users without the fear of future exploitation [71]. However, consequences of nude pictures being released into the online universe are well known. Adolescent teenagers, primarily girls, have suffered from their intimate photos being shared with peer groups without their consent [72]. Per the Federal Bureau of Investigations (FBI), online sexual exploitation comes in many forms, with perpetrators coercing victims into providing sexually explicit images or videos of themselves, often in compliance with the offender(s) threats to post the images publicly or send the images to victims’ friends and family [73]. Through direct messaging and introducing themselves or “liking” posts gaining a child or adolescent’s attention via social media platforms, sexual offenders often target vulnerable youth by gaining their trust through validation and affirmation. Once a connection is created, coercion and manipulation by a sexual offender can lead to the child or adolescent sending sexually graphic texts and photos, which then the sexual offender can use to extort their victims into dangerous behaviors (sexual favors, crime, etc.)

As discussed earlier, teenagers aim to connect with their peers regarding their vulnerable feelings through various forms of communication on social media. However, the content of messages can also place recipients of those messages in precarious positions, primarily when those messages relate to self-harm and suicide. Posts relating to nonsuicidal self-injurious behavior (NSSIB) have dramatically increased. For instance, teens posted between 58,000 and 68,000 images with hashtags (markers that are picked up by social media algorithms to send to users who also use similar markers in their posts) related to some form of self-injury in February of 2018. By December of 2018, that figure has increased to over 112,000 images with notable hashtags including #selfharm, #hatemyself, and #selfharmawareness [74]. Clinicians have also reported similar findings when interviewing teens. A study surveying 94 licensed clinicians found that 30.9% reported at least some of their clients who self-injured had utilized the internet to share NSSIB images with other peers [75]. The dangers of viewing NSSIB online stem from contagion, or the spreading of ideas and information that can be acted on by parties who may have not been actively participating in NSSIB. Individuals with a history of NSSIB who are actively exposed to NSSIB-related content may have cravings to enact self-injury [76]. Gender is also an important factor to consider.

Screening

As highlighted, understanding how social media works, what social media applications are most commonly used, the purpose behind social media, and the detrimental effects of social media are incredibly important for clinicians. During the psychiatric interview, a child or teen may seem to have a straightforward day-to-day routine, but their digital world can be incredibly complex. Below are questions in which clinicians can use to determine if a child or teenager is suffering from, or at risk for, negative consequences of social media use. Questions for both parents and the child/teenager are included in Table 2.2 [77].

Table 2.2 Questions parents and clinicians should use to better understand social media usage
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Confidentiality and Specific Considerations

Children and teenagers sharing aspects of their digital presence can be an incredibly vulnerable experience. Their digital interactions and experiences highlight parts of their identity that the majority of their caregivers may not know about. Therefore, when screening for screen time and social media use, clinicians should understand the bounds of confidentiality and when confidentiality needs to be respectfully breached. For example, if a child or teenager reports following diet trends on social media in an attempt to lose weight, a thorough history regarding disordered eating and compensatory mechanisms to lose weight should be taken. However, if a patient is not in significant medical or psychiatric danger, the clinician should only encourage the child or teen to disclose this information to the caregiver. However, if the patient is rapidly losing weight, utilizing laxatives or diuretics to lose weight, or is restricting their calorie count significantly, a caregiver should be involved and consideration for a higher level of care (eating disorder unit, adolescent medicine referral) should take place.

The Federal Child Abuse Prevention and Treatment Act (CAPTA) requires each state to have provisions or procedures for requiring certain individuals to report known or suspected instances of child abuse and neglect [78]. Currently, any sexting from a child to an adult is required by law to be reported to the respective children’s services agency in the state in which the child resides [79]. However, sexually explicit images of children and teenagers shared, distributed, received, or kept by other children and teenagers is a relatively new phenomenon in the legal and professional realm of mandated reporting. Sexting laws are state dependent, meaning if a state does not have specific sexting laws, federal mandates and guidelines can apply and rely on child pornography laws [79]. Child pornography is considered a more severe crime than sexting, and therefore, clinicians should be aware of which laws apply in their state [80]. For example, in California, if a 15 year old sends a nude photo of themselves to a 17 year old voluntarily, and discloses this information to their mental health provider, California state law currently identifies such action as obscene sexual conduct of a minor and requires the clinician to report the action to their respective child service agency. In this scenario, the 15 year old is both the perpetrator and the victim, and if there was coercion or persuasion by the 17 year old to receive the text, they are also required to be reported by the clinician [79]. Highlighting what can be reported to child service agencies at the beginning of treatment relationships will help keep children and teenagers safe as well as prevent surprise breaches in confidentiality.

Regarding self-harm, mental health providers should be more well versed in when to report to parents about their children’s safety. When children and teens disclose that they have been coming across images or text of self-harm on social media, clinicians should further explore what social media applications are providing this data and how it is affecting the teen. If the effects of contagion are leading to increasing thoughts of self-harm, clinicians should encourage the teen to disclose how they are feeling to their caregivers with clinician assistance. If the teen begins participating in self-harm or is distributing images of their self-harm online through social media platforms, clinicians should be informing the respective caregivers as well as developing a safety plan. At this point, safety needs to be prioritized over the therapeutic alliance.

Conclusion

Children and teenagers are living in the digital world. There is little uncertainty that screen time, social media use, and online interactions have increased over the decade, even more so during the COVID-19 pandemic. The smartphone has become the medium in which children and teenagers access each other. Furthermore, social media, through applications like Tiktok, Snapchat, and Instagram, have served as a bridge for teens to express themselves, connect with peers, and enjoy entertainment as well as educational content. However, with the expansion of technological innovation via virtual playgrounds, teens and children are also experiencing detrimental effects to their mental and physical health. Sleep deprivation as well as exacerbation of pre-existing mental illness such as depression and anxiety correlate with increased screen time use and social media exposure. Additionally, cyberbullying, sexual exploitation, and self-harm are also becoming more apparent dangers that children and teenagers face when they set their foot in a digital landscape. Our job as mental health providers is to screen and assess our patient’s experience of the digital world and to do so, we need to continually educate ourselves of what our patients see when they open their phones.

Multiple Choice Questions

  1. 1.

    Per Common Sense Media, what percentage of U.S. children 11 and younger have access to a smartphone?

    1. A.

      32%

    2. B.

      46%

    3. C.

      53%

    4. D.

      72%

    Correct Answer: C. Pew Research conducted a study in 2018, examining smart phone use. Approximately 53% of children 11 and younger had access to a smartphone, which was much higher than the previous decade.

  2. 2.

    Which social media application originally developed popularity through the sending and receiving of digital pictures that vanished from user’s accounts after 24 h?

    1. A.

      Tiktok

    2. B.

      Snapchat

    3. C.

      Instagram

    4. D.

      Twitter

    Correct Answer: B. Founded in 2011,Snapchat is a social media application that prides itself on a simple concept: any picture or video that a user sends is only available to the recipient for a short time before it becomes inaccessible. This feature has been now copied by other social media sites such as Instagram.

  3. 3.

    You are a clinician in California interviewing a 17-year-old patient who endorses sending and receiving nude photos from another 17-year-old teenager. They note that the act was consensual. What are your responsibilities as a clinician regarding mandated reporting?

    1. A.

      Report to the respective state child state service agencies.

    2. B.

      Do not report to respective state child state service agencies and parents as the patient notes that acts were consensual.

    3. C.

      Speak with parents about texting as intervention only as behavior can be mediated in an outpatient setting.

    4. D.

      Consider discharging patient from practice as they are engaged in child pornography.

    Correct Answer: A. In the state of California, minors sending nude photos to each other are considered a form of obscene sexual conduct and requires the clinician to report the action to their respective child service agency. In this scenario, the 17 year old is both the perpetrator and the victim. It is of the utmost importance that clinicians recognize their state laws and how to help educate their patients on safe and legal practices.