Trick or tweet: Navigating social media’s impact on young people

Listen to a special Halloween-themed chat on social media’s influence on the health and well-being of young people. Melissa Garretson, MD, member of the American Medical Association Board of Trustees, joined host Alex McDonald, MD, of the Southern California Permanente Medical Group, to explore the challenges adolescents face online and how physicians can support their overall health. From screen time to sleep deprivation, Dr. Garretson shares strategies to help manage unhealthy social media use.

Guest

• Melissa Garretson, MD, Board of Trustees, American Medical Association

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello everybody. Welcome to today’s PermanenteDocs Chat. In honor of Halloween, we have titled this chat “Trick or Tweet,” and I can assure you the content is not only critical for Halloween, but year-round. Our guest today is Dr. Garretson, who is a pediatric ER physician and, among many hats, is also a member of the American Medical Association board of trustees. So welcome Dr. Garretson. We are excited to have you.

Melissa Garretson, MD: It’s really great to be here. Thanks so much, Dr. McDonald.

AM: As you can all surmise from the title — and [given] that Dr. Garretson’s a pediatrician — we’ll be discussing the impacts of social media on the health of young people and teenagers in particular.

Dr. Garretson, in your own words, tell us who you are and what you do.

MG: Thanks again for having me. I’m super excited to be here. I am Melissa Garretson, pediatric emergency physician in Fort Worth, Texas. I started out in private pediatric practice, and the thing I always like to say is I trained when there were no computers and there was no social media. The internet hadn’t been invented yet, so this is a challenging topic for all of us as parents. When our kids grew up knowing how to do all this, to try and outsmart our kids … we’re working on it.

The evidence linking social media to mental health issues

AM: Well, let’s start here with the tricks. Recently there’s been a lot of research coming out, particularly regarding the mental health impacts on young people, regarding anxiety, depression, sleep disturbances, body dysmorphia. It’s really becoming a scary epidemic, quite frankly, and we think that social media plays a role in that, but we’re not really sure, from my understanding. Can you tell us what kind of impacts you’ve seen and what impacts we know about social media is having on adolescents and young people?

MG: I think the thing we need to acknowledge first is how pervasive it is in terms of its impact on child brain health and development. And you have to look back, I think, to the adverse childhood events data that we have for children under 3 and the impact that that has on their brain development across their lives. Even as adults, they’re at higher risk of death. So, when you look at that and you look at 95% of 17-year-olds have social media and use it on a daily basis in this country. If that doesn’t blow your mind, I don’t know what does. Because there is nothing else that 95% of adolescents do altogether. Even eight- to 12-year-olds, 40% of kids use online social media. So, it behooves all of us to start looking at this data to continue to investigate and research the impacts that we have on brain development.

I think the hardest thing about brain development research is we have no easy way to measure neurochemical transmitters in the brain. We’re not going to do a brain biopsy. Some of this is anecdotal, some of this is self-reporting from kids. But we all know, you don’t have to think that far back, how traumatizing adolescence can be. And then you magnify that by everything you’re doing 24-7 being shared with everyone. It tends to be an incredibly intense spotlight. We see [the effects of] that in emergency department visits for deliberate cutting, depression, and suicide attempts, and a lot of anxiety that we are seeing in a lot of kids. Initially we all kind of blamed it on COVID-19. But when you actually look at the data, it actually started back about 2010, which in retrospect is about the time all the social media platforms got going and became very robust. So, you have to wonder if there’s very definitely a causal relationship to that.

AM: I think, like many things, COVID just magnified or put a spotlight on some of these preexisting problems and challenges. From my perspective, it’s so hard to tease out what is related to social media versus pressures from parents versus school; there’s so many different confounding variables when you look at mental health research regarding social media. And we have no control since 95% of young people are using social media on a daily basis. So, from my perspective, anytime I think about this or address this with a patient in the exam room or in the hospital, there’s just so many factors at play it’s really hard to tease out what’s what.

The role of social media in adolescent sleep deprivation and depression

MG: And I think one of the things that we can tease out very well, because we have a lot of data from pilots and stuff like that, is sleep deprivation. One way that all of us can help our patients, our families, and our loved ones do better around social media is to acknowledge the impact that screen time can have on sleep, whether it’s you’re on your phone, whether it’s the light from your phone, the actual discourse that’s occurring that causes kids to have difficulty with either falling asleep or staying asleep. We all know that sleep deprivation leads to poor choices and mental instability in terms of how you respond in stressful situations, which is why pilots have to have a regulated amount of sleep. And I think we can apply that to all of our lives.

AM: Yeah, absolutely. You’re talking to a primary care doctor who’s constantly preaching diet, sleep, and exercise as the key pieces to a foundation of health regardless of anything else. You had me at sleep.

MG: And I say nothing good happens after midnight, so you and I are lockstep.

AM: That’s very true. I assume you do some overnight shifts also, so you have personal experience.

MG: I was the overnight doc for 20 years, and the number of times I’d walk into a room and the parents are asleep, the kids on their phone texting somebody, it’s 2, 3 a.m. I’m like, who are you texting? It’s 3 a.m. and nobody should be awake. And they [say], my friends. I [say], no, go to bed.

AM: That’s pretty true. Do we have any good studies regarding this or is this all more kind of expert consensus in general themes?

MG: A lot of it is review studies, right? You look at Pew Research who just recently published their report on social media use and online health. And we’ve got good data that shows an increase in depression and anxiety among social media users. Again, the cause and effect hasn’t been established. And again, that’s a tough causality to determine.

We have data that shows that suicide attempts have increased and now, thankfully, maybe plateaued, hopefully longer than just a year. But you do see some definite at-risk communities in online behavior and increased risk for depression and anxiety, especially in women or girls as the case may be. And then minoritized populations tend to have higher stress regarding this, and then the LGBTQ+ community as well. And again, I think it’s kind intuitive, right? Women have higher rates of depression in the general population. Minoritized populations have different stressors than traditional populations in our communities. Then you look at the LGBTQ+ [community] and understand the stress that they’re under, especially in this day and age, it is not something we would doubt that they’re under increased stress.

The potential for social media addiction in teens

AM: No question. And I guess I should give a full disclosure that I’m a parent of 2 teenage daughters currently, so I have both my personal and my professional hat here. We’ve heard this concept of social media addiction. Can you comment on that? What are some things that parents and physicians can do to help mitigate that?

MG: I think that’s an emerging field that we’re just starting to acknowledge. But 13% of 11- to 17-year-olds say that they’re addicted to their social media. If the child thinks they’re addicted to their social media, you’ve got to know we would think they’re addicted to their social media. One of the things I think that we need to acknowledge is that there are studies that we can do with imaging studies that look at brain stimulation regarding social media. And the amygdala and the prefrontal cortex are two of the things that light up when you’re doing some social media interventions and studies with that. The amygdala controls our emotional well-being and our sense of self. And the prefrontal cortex we all know helps us stop being impulsive and gives us a chance to be who we are as a person rather than just reacting in the moment.

When you get distortions in those [areas], a lot like other addictions, you can develop an addictive pattern. So, while I think no one’s really quite ready to say absolutely these are addictions, we are developing that same gaming addiction theory that we have regarding kids. I think the thing we do as parents is help set limits for our children to help stop that manipulation of their brain.

So many of the algorithms that social media companies use are black boxes, I don’t even know that the social media people who own those platforms even understand the black-box implications of those algorithms. So, understanding that there is some manipulation going on, there is some feedback loop that goes on that rewards you for continuing to click down the rabbit hole, sometimes in positive ways and sometimes in negative ways, right?

It is one of those things that we need to be aware of and teach our kids. And I always say we teach our kids to learn how to potty train and we teach them how to eat different foods and how to ride a bike and things like that. We need to teach them how to make smart choices regarding social media and online presence. And I think that’s one of the things that we as parents, when we have well-child checks with people, we need to include that in our guidance to them. And it needs to start pretty early since 40% of 8-year-olds and 8- to 12-year-olds are using social media.

Setting boundaries and guidelines for safe social media use

AM: You touched on so many great points that I want to highlight. One is having a framework over the use of these devices and technology, encouraging parents to set up guardrails and boundaries and set the parental guidance. Even though kids will probably figure out a way around it, at least you set that standard upfront. From my own personal experience, my 12- and 14-year-old have phones more for safety. They don’t have social media because they’re not allowed, and the phone is mine. I explicitly told them this is my phone, I’m allowing you to use it between the hours of 8 a.m. and 6 p.m., and then the phone shuts off outside of those hours so they can’t use it. My wife and I set very clear guidelines and boundaries from the beginning, which I think is much better than trying to crawl it back afterwards. That’s something that I’m often telling my patients and my patient’s parents from my own personal experience. I think that’s really key.

Related social media and young people podcast: Growing up with social media

The second piece is my understanding that there’ve been studies showing that when you go down that rabbit hole and someone likes your post, a little blip of dopamine goes off in your brain. And a lot of those same neurochemical pathways regarding social media as use disorder and drug and alcohol addiction. I think we have pretty clear evidence that it’s a setup for use disorder just like many other conditions. Is that accurate?

MG: I think that’s very true. And I think, again, as we’ve been having social media now for 14 years, we don’t have as much robust data as we do for other addictions. But it’s really easy to see how that setup and that algorithm is that same thing: I want to keep you here. The longer you’re here, the more I win, the more advertising I can do. It goes from there for sure.

Tips to help families regulate social media use

AM: We have a question in the chat here, which I think directly relates to this. How do doctors advise parents about how to talk to their kids and teens about regulating social media use without just getting a giant eye roll response? I don’t know the answer to that one. That’s a tricky one.

MG: I think you’re going to get an eye roll. I mean, you’re a parent, so if you don’t get an eye roll at least 3 times a day, I don’t know that you’re doing something right. As a parent, you should be getting eye rolls. But the thing about it, I think, is that it’s the actual conversation. And yes, they’re going to be like, you can’t tell me what to do and you can’t limit what I do. But yes, you can, and you do as a parent every day, when you make them get up and go to school, that’s an everyday thing we do. But I agree with you, one of the things that was so effective with my own children is the same thing as yours. Having the ability to have that conversation, doing it upfront and letting them help you set up what the rules are.

They’ve got some buy-in and there’s a website healthychildren.org that has sample family social media plans, and you can set that up yourself where you and your child go together and select how many hours, what sites, how often can mom and dad look over what you’re doing and help you as a parent engage in positive conversations. Social media isn’t all bad. This is a Halloween episode. It’s not all scary, but there are pitfalls. And so again, having that conversation, and I always with my kids too, because you hear all those horrible things in the news. If you make a mistake and post something online, I promise it’s not the end of the world. You have to tell me so I can help you, but I’m not going to be mad and you’re not going to disappoint me for the rest of your life, and this isn’t the end of your life. If you can tell me about it, please, I can help you. And it was a conversation we had all the time because kids are impulsive and they make poor choices in the moment, and that’s why we need to be there to help them.

AM: That’s great advice overall. I like to joke that my daughters have extremely strong extraocular muscles due to the number of times I make them eye roll every day. So I wear it as a badge of honor.

MG: You are doing it well. Good job.

The benefits of social media

AM: Well, let’s move to the treat side of things, since this is the Halloween episode. What are the positive benefits of social media? What are some of the fun elements and how do we use some of the creative benefits of social media to help our children, honestly?

MG: I think that there are safe spaces that children can go to where they share their likes, share their talents, display some of their artwork or their creative costumes in positive ways. And I think too, surrounding yourself in a friend group in your online presence with people who you are friends with and are supportive of you can be a nice way to make those connections when you can’t see each other, when you’re separated by illness or other things.

I think too, there are specific communities that benefit tremendously from that online support as well. The LGBTQ+ youth group is one of those places where you need as much support as you can get, and it truly does take a village to help raise well-adjusted kids.

I think too, when you have special talents, that you can share that and develop those further. You look at kids with cancer, they’re often in the hospital, away from their peer groups, they’re missing their social connections. Social media allows those kids to connect. It also allows those kids to not feel like they’re the only one in the whole wide world with this disease or going through similar things. And you can say that about any chronic disease, especially in children, that lifts them up to understand they’re not alone and there is hope. And look, there’s somebody who’s 15 when they’re 11, and you can get there, and there are ways to make it through this disease and not give up and not lose faith.

So, I think there’s tremendous positive opportunities. We as a society and as parents, need to make sure our kids are engaging in those positive experiences and able to identify when something is negative. And that, again, isn’t something you’re going to naturally know. We have to teach our kids what those things are.

The importance of modeling responsible social media behavior

AM: One piece of advice that I will often give my parents is to model good social media behavior. Sit with your kid and flip through Instagram and interact more with your teen. They won’t talk to you, right? Sit there with the phone looking at whatever the Instagram feed is or social media feed, and you can comment, and you can help verbalize how images may or may not impact you. And I think that’s a way that parents and kids can actually one, connect and bond, and two, model good behavior.

I like to use social media as a platform to amplify my own voice as a physician as a community member and give advice, but also model good behavior at the same time. As physicians, obviously you advise your parents in the exam room and in the hospital, but you can also, as a parent and as a member of humanity, you can model good social media behavior as well.

MG: Exactly. As a family, you make a commitment. We’re not going to have our phones at meals. Well, that means me too, right? It’s not just them. It’s me too. It goes down an hour before bedtime, so you don’t disrupt sleep as much. Same thing for the adults, right? Because my phone is my book, it is my work. That’s where I do all my documenting. It’s all right there. It is a very conscious choice that you have to think, okay, put it down. Put it down.

So yes, I totally agree, modeling for both our patients and our families is incredibly important. And I think just sharing the struggles, right? In my world, and when my kids were in that middle school, high school thing, I reached out to all of their friend’s parents. We all had conversations together. And I will tell you, there are a number of times when I was the mom that the kids would come to when they weren’t necessarily comfortable talking to their own parent about stuff that was making them uncomfortable. And then we could talk through it together, and then I could redirect them back to their parent in a better way that helped them feel more comfortable to do that. Not that I was taking a parent place, but they felt comfortable sharing with me because I was open in those conversations and that dialogue is critically important.

On possible regulations for social media use

AM: I think that makes perfect sense. Here’s a question, which segues to my next question, regarding putting restrictions or guidelines on social media. There are some people that want to legislate the role that government and local elected officials have regarding social media use. Are there any guidelines and is there a mandate or legislative effect fix that we can put on this?

MG: There’s lots of talk about legislative fixes. The surgeon general called for a warning label on social media platforms back in June of this year, and that would take an act of Congress to do. More than anything, the fact that the surgeon general called for that raises the awareness of every parent and every kid that perhaps this is a big issue, and we might need to pay closer attention to what our kids are doing online. That’s the first thing. I think there is a bill, the Children and Teens’ Online Privacy Protection Act, which does seek to set up on social media companies more responsibility to allow them to open up what their algorithms are, to help us understand what guardrails we can set up within the system, what they do with our kids’ privacy data. Which is a critical issue for all of us because who hasn’t been aware of the Change Healthcare debacle and the ability of online nefarious actors to steal data, right?

That’s huge. I think that it does behoove us to take that approach. I don’t think setting, you have to be 12 years old, or you have to be 20 years old, to do social media is going to work, right? This is an individual child thing. You raise your child; you’re going to have a better feel for when they’re emotionally ready to handle some of the stresses and the decision making involved in using social media. So, the American Academy of Pediatrics really hasn’t come down hard on an age before or after you should use social media. It’s more so an awareness of when your child is emotionally ready for this. And that’s going to be different in every child in each situation.

Understanding individual readiness for social media use

AM: I like to use the example of competency-based training in residency education. Not every resident or medical student is ready for every procedure or treatment option at the same point in their training, their career. And the same thing with children. They all develop very differently at different rates, and some are ready at different times than others.

At my children’s high school, they decided they would put guidelines and policies regarding social media use. And there were some people that wanted to ban cell phones entirely at school, but we took a different approach where we would ban [phone use] during instructional time, but they could use phones during passing period and at lunch. I think by simply banning it we miss an opportunity to teach our children, versus model good behavior and set policies that help them learn limits and learn how to live and interact with these little devices which are ubiquitous. That’s going to help educate them and help them become happier, more well-adjusted adults as well. But again, that’s my own personal bias.

MG: I think that’s true. And again, I think there are different situations. A lot of the conflict over cell phones in schools centers around safety and then lack of learning, because kids are [not] face forward looking at the teacher. And I do agree with you that it’s a learning opportunity for all of us. But it also behooves us in a scientific role to help teachers understand ways that they can teach. They’re struggling in the dark just like the rest of us trying to figure out the best practices for how to use social media and how to identify scary people who really aren’t the 15-year-old best friend you thought you had.

AM: This has been phenomenal. We could probably go on and on and on, but again, we try to keep these short and high yield. My last and favorite question, what makes you most proud to be a physician?

MG: Saving a life in the emergency department is a big deal, but really helping a family connect with one another when they’re at odds and they’re struggling with one another, helping them to be able to understand one another and move forward, that’s a lifetime kind of change for me. I really do like that. 90% of what I do in the emergency department is primary care pediatrics. It’s helping parents raise their children. And the other 10% is terrifying, in honor of Halloween.

AM: Dr. Garretson, thank you so much for joining us and sharing your insights and expertise today. We really appreciate your time.

MG: I appreciate it very much. Thanks so much.