Screen Use and Social Media “Addiction” in the Era of TikTok: What Generalists Should Know

Abstract

While the term “screen addiction” or “social media addiction” is gaining steam in the popular media, preclinical, clinical, and population health research have not caught up with regards to the diagnosis and treatment of unhealthy screen use. The overarching goal of this article is to provide broad clinical tips to generalists, working outside the mental health specialty, on the evaluation and treatment of unhealthy screen exposure in children and young adults. We will clarify the difference between addiction and overuse, and why this distinction matters. Recognizing that screens are here to stay in the post-COVID era, we will provide guidance on how to reduce potential harms associated with screen exposure without necessarily requiring people to abstain or stop using screens.

An Introduction to Unhealthy Screen Use

Children and adolescents in the United States (US) are having relationships with their screens at younger ages than ever before, as levels of screen exposure have surged since the start of the COVID pandemic.¹ Per recent estimates, children 8–12 years spend four to six hours a day on their devices, increasing to nine hours per day for teenagers.² Against this backdrop, there are mounting concerns about the potential negative impacts that screen exposure is having on young people with regards to mental health consequences. Concern has also been raised about the potential for screen “addiction” or social media “addiction.”

The Language of Addiction and Why It Matters

Popular culture is saturated with the language of addiction. Consider the case of a person who consumes coffee every day who refers to themselves as having “caffeine addiction.” A recipe for corn tortillas in The New York Times referred to the masa’s “addictive” aroma and flavor.³ Alternatively, an individual may state that they enjoyed a “mildly addictive” television show that was featured on the summer’s Netflix “binge” list.⁴ While it is not our goal to regulate people’s language choices, we emphasize that the colloquial use of the term “addiction” in the case of unhealthy social media use may obfuscate diagnosis and treatment. Throughout this article, we will describe the distinction between the colloquial connotations of “addiction” in contrast to scientific definitions, and why these distinctions are essential.

While “regular use,” “unhealthy use,” and “use disorder” are often employed interchangeably in daily verbiage, these terms are not synonymous. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has a very specific definition of addiction (“use disorder”), typically used in the evaluation of substance use disorders, which can be distilled to several general principles: tolerance, cravings, withdrawal, greater amount consumed than intended, unsuccessful attempts to quit use, use despite knowledge of negative consequences, important activities given up due to use, recurrent use causing inability to fulfill role obligations, recurrent use resulting in physically dangerous situations, and continued use despite recurrent social problems.⁵ In contrast to “addiction,” the term “unhealthy use”⁶ is employed to cover the entire spectrum of behavior that increases the likelihood of negative consequences, pathological or not, ranging from at-risk use through overt addiction. Particularly when the science on “screen addiction” remains in such a nascent phase, “unhealthy use” may be a particularly useful⁶ descriptive term for describing all conditions of a behavior (in this case, screen exposure) that can be a target for preventive interventions.

To illustrate how “addiction” or “use disorder” is different from other use behaviors (that do not reach the threshold for addiction), let us consider a person who has been drinking caffeine for many years and describes themselves as “addicted to coffee” in colloquial settings. Over time, as this individual increases their coffee consumption from one cup, to two cups, and eventually five cups per day, they are developing tolerance. If a person stops drinking coffee, they may experience symptoms of fatigue, headaches, and irritability because their body has grown dependent⁷ on coffee. Importantly, this person is not necessarily “addicted” to coffee in the absence of frank functional impairment, apart from the need to drink an extra cup of coffee daily. Thus, this is a case of tolerance and dependence in the absence of a diagnosed, formal “use disorder.” An argument can be made that this person is experiencing a pattern of unhealthy caffeine use, as five cups of coffee per day constitutes a large enough caffeine dose to cause adverse health effects in some individuals; ⁸ however, unhealthy use does not equate use disorder (addiction) without fulfilling the aforementioned functional impairment criteria.

Our effort to differentiate between addiction, dependence, and unhealthy use—and caution against the cavalier use of the term “screen addiction”—is not merely a semantic exercise. In an article by Maia Szalavitz, Khary Rigg, and Sarah Wakeman,⁹ it was emphasized that semantic distinctions between dependence and addiction are clinically important, as the misdiagnosis of addiction can exacerbate stigma, hinder scientific communication, obfuscate diagnosis, result in inappropriate treatments, and even culminate in cases of overdose and suicidality.⁹ Notably, there is a history of researchers and physicians conflating addiction with dependence, particularly in the case of opioid use disorder, which has even adversely affected the accuracy of International Classification of Diseases (ICD) codes for use disorders in the electronic medical records. Szalavitz and colleagues shrewdly point out many drugs can cause dependence while remaining net-beneficial in keeping a chronic condition in remission.⁹ Furthermore, when people are tapered off such medications, like antidepressants and antihypertensives, they do not necessarily crave them or return to recurrent use.⁹ An editorial by the leadership of the American Society of Addiction Medicine echoes this sentiment, noting that the use of precise language is essential for clinicians to accurately communicate with researchers and policy makers in order to obtain epidemiological estimates and develop targeted treatments.⁶ If the term “addiction” is devoid of a precise clinical meaning, how are we supposed to develop effective interventions for it?

Screen Use, Unhealthy Use, and “Addiction”

While social media use has increased over the last decade among children and adolescents, the research base on the spectrum of screen use, unhealthy screen use, and “screen addiction” remains in an early stage of development. Broadly speaking, research on behavioral addictions lags in comparison to substance use disorders, and there is debate on whether behavioral addictions should be viewed through the framework of substance use disorders.¹⁰ At this current time, gambling disorder is the only behavioral addiction explicitly listed in the DSM-V; in addition to social media, other behavioral disorders such as addiction to sex, gambling, and exercise have been deemed to lack sufficient “peer-reviewed evidence to establish the diagnostic criteria and course descriptions” for the identification of such behaviors as mental health disorders.¹⁰ Still, several studies have found robust evidence for reward pathways implicated in substance use disorders (i.e., mesolimbic dopaminergic pathways) being activated in people with internet and gaming addictions^11,12 as well as in cases of people struggling with compulsive checking of social media feeds, notifications, and pornography.¹² Other analyses have demonstrated that short-term rewards from screen use can contribute to persistence of behaviors such as screen-checking, exacerbated by ease of access amid the small latency time between uses.¹³

Of note, habit-forming behavior does not equate addiction, and the extent to which social media use morphs into unhealthy use and formal use disorder remains poorly characterized. Some studies have found that even if young adults are not “addicted” to their phones, use can still lead to impaired social functioning, worse sleep quality, and intolerant boredom,^12,14,15 although the extent to which such impairment reaches the threshold for a formal psychiatric disorder is unclear. Even though some studies have suggested detrimental associations between screen time and self-reported measures of mental health may begin when screen time exceeds one hour per day,¹⁶ such self-reported variables do not necessarily equate functional impairment. Furthermore, there is increasingly a critique being made that screen quantity may be less useful than screen quality in capturing their risk of downstream harm. For instance, there is a vast amount of information that is accessible via the screens (i.e., online journals, Wikipedia, YouTube lectures) meant to enhance learning, and the premise of using absolute screen time as a proxy for unhealthy screen exposure has been the subject of critique.^17–19 While some studies^20,21 have suggested that co-viewing of educational programming may offset developmental risks posed by screen use in young children, this has been disputed by other analyses.^22–25

Currently, the American Academy of Pediatrics (AAP) recommends no screen exposure before 18 months, no more than one hour of high-quality programming per day for children ages two to five years, and that children over six years receive consistent limits on the quantity and quality of screen use, with co-viewing with parents encouraged for children,²⁶ with similar guidelines in place by the American Academy of Child and Adolescent Psychiatry (AACAP).² There remains no clear professional organization guidance on screen time objectives for children over five years of age and limited guidance on age cutoffs to which older children should be permitted supervised acquisition of phones or mobile devices,²⁷ with some analyses suggesting that age of screen device ownership is less important for mental health outcomes than the quality of screen device use.²⁸ As we struggle to delineate the risks and benefits of screen exposure, it is difficult for parents, and clinicians, to know what to recommend to their children and what limits to impose.

Screen Time, Mental Health, and “Self-Medication”

There has been a burgeoning body of literature characterizing a high prevalence of co-occurring mental health conditions in people who have high levels of screen time exposure. Consider that in an analysis of almost 4,000 adolescents in Canada, an association between social media exposure and severity of depressive symptoms was observed in both within-person and between-person analyses.²⁹ Another study showed that compared to children with lower levels of screen use, peers with higher screen exposure had greater burden of attention deficit hyperactivity syndrome (ADHD) and anxiety disorder symptoms.³⁰ Studies have illustrated an increased burden of anxiety, social isolation, and depressive symptoms associated with screen exposure,^29,31–35 worse self-esteem,³⁶ and worse ADHD symptoms with more screen time.³⁷ Yet, most existing studies have measured screen time while remaining agnostic to whether patients’ screen use crossed the threshold for an addictive disorder, and it would thus be inappropriate to make inferences about “screen addiction” being precipitated by underlying mental health problems from the current data. Are our patients depressed, isolated and anxious, and seeking out connection through social media? Is screen time causing heightened feelings of isolation, anxiety, and depression? The correlation between mental health comorbidities and screen exposure do not equate causation, as a high amount of internet and social media exposure could represent both a cause and manifestation of another psychiatric disorder. In some cases, screen time has even been helpful for boosting social connectedness^38,39 or providing peer support in people struggling with depressive symptoms⁴⁰ and social anxiety.⁴¹

While we await more research to emerge on the pathophysiology of screen addiction and its overlap with other psychiatric conditions, clinicians should not miss out on the opportunity to diagnose and treat common co-occurring conditions, like major depressive disorder and generalized anxiety disorder. Interventions such as antidepressant initiation and psychotherapy referral, while awaiting intake with a psychiatry specialist, are efficacious in treating co-occurring mental health conditions and are within the scope of practice for pediatricians and family physicians. Although motivational interviewing⁴² and short term CBT⁴³ for screen addiction has shown promise, the development of targeted interventions remains in a nascent stage. To be clear, there is not enough data to suggest that unhealthy screen use is the result of patients trying to “self-medicate” underlying psychiatric illness (“SMH,” the self-medication hypothesis of addiction). The SMH has been criticized for encouraging clinicians to target only the underlying psychiatric illness and ignore addiction, on the premise that should underlying mental health issues be treated, addiction problems will resolve.^44,45 In other words, the SMH runs the risk of impeding recognition of addictive disorders, particularly in generalist settings where many patients do not identify as having an addiction problem.⁴⁴ Furthermore, there are myriad structural risk factors for addiction (i.e., family dynamics, social stressors, school environment), and it is often inappropriate to assume psychiatric problems uniquely contribute to addiction.

To Take Away the Screen or Not? Lessons From Harm Reduction Principles

Our article is not intended to be prescriptive, particularly amid an absence of diagnostic and treatment guidelines for unhealthy screen use. A tactful approach is needed for adult parents and physicians to be seen as credible when engaging children and young adults in conversation about screen time. A recent article noted that in an era of virtual connectivity and heightened screen time during the post-COVID era, people are in need for recommendations that aim for a healthy coexistence with screens rather than rigid adherence to current screen time guidelines.¹ In this context, screen overuse can be conceptualized through the lens of harm reduction, a framework that seeks to reduce the negative consequences associated with a particular behavior without necessarily requiring people to abstain or completely stop a behavior. Practical suggestions for engaging people in discussion about unhealthy screen use, informed by harm reduction perspectives,⁴⁶ include the following:

Be Practical

Heightened screen use is difficult to avoid in the post-pandemic world. However, this doesn’t mean there is nothing we can do to encourage safer screen use. Non-judgmentally, ask your patients about their screen use and social media use without assuming “addiction” or unhealthy use. Discuss the risks and benefits as able with parent and child. A useful screening tool called HEADSSS (home life, education, activities, drugs, sexual activity, safety, and suicide and/or depression) has been adapted for the assessment of social media use in patients older than 11 years ( Table 1).⁴⁷

Table 1.

Adapted HEADS4 Social Media Use Screener for Generalists

Do you have your own cell phone? Tell me about the social media apps and sites that you use (examples: Instagram, TikTok, Snapchat, Facebook, iMessaging) How much time do you spend on social media each day? If the patient has a smartphone, consider examining their weekly usage to obtain a more accurate data point. Note that >120 minutes/day has been considered a concerning response. How do you feel about the amount of time you are spending on social media? Alternatively: Do your parents think you use social media too much? How does social media affect your mood? Have you experienced or witnessed cyberbullying? Or sexting and people asking to have sexual relations with you?

Recognize That Everyone is Different

Screen use is a complex phenomenon with a continuum of behaviors ranging from severe use to complete abstinence. Some forms of use are safer than others and this should be discussed with children upfront. Remember that use and unhealthy use aren’t the same as addiction.

Be Mindful that People Do Things for a Reason

People are responsible for their screen use, which should be assessed for potential perceived benefits by the patient and weighed against risks. It can be helpful for parents to be curious and listen for why their children are drawn to the screen. Parents can ask their children to educate them about their social media applications, as they may know far more about TikTok than the parents do. This can open the door for a more fruitful discussion, as opposed to attempting to scare children about the negative effects of screens on the brain (or trying to take their iPhones away by force). Studies have shown positive outcomes between parent-child discussions and screen use problems.^48,49 Although many people obtain relief of psychiatric symptoms from addictive behaviors, unhealthy use (or use disorders) can also worsen psychiatric symptoms.⁴⁴

If There are Treatable Co-occurring Mental Health Problems, Treat Them Without Assuming Self-Medication

Discussion about the reasons why patients are drawn to the screen can also provide clues for potential mental health etiologies associated with unhealthy use (i.e., distractibility and poor impulse control as a sign of ADHD, ruminations and social comparisons as a sign of an anxiety disorder). If this is the case, a referral to a child and adolescent psychiatrist and/or psychotherapist is in order. Patients could potentially be started on an antidepressant with a therapy referral while waiting for psychiatrist intake. Importantly, avoid the temptation of Occam’s razor⁴⁴ and do not assume that people are escalating their screen time to self-medicate underlying psychiatric problems,⁴⁴ especially as the evidence base has not demonstrated causality. While we should treat co-occurring psychiatric conditions like depression and anxiety, we need to avoid thinking that underlying psychiatric problems are the only etiologies contributing to unhealthy screen use. Other structural factors like family distress,⁵⁰ poverty,⁵¹ or lack of government allocation for extracurricular programming⁵¹ may be present.

Remember that Improvement Will Not Happen Overnight

Overall well-being and functional status is often a more worthwhile goal than cessation of screen use. Listening and encouragement of changes, or even motivation to change, can be significant.

Try To Model Appropriate Screen Interactions and Routines Surrounding Screen-Related Behaviors

Parents can model screen-free quality time, which may correspond to increased engagement with their children.¹ Parents can create times when phones are left at home by the entire family or create a charging station for everyone’s phones, so that they are kept out of the bedroom to minimize impact on sleep. During the waking hours, the family can consider co-viewing television or video content together, which can provide impetus for screen-free discussion. Some have also proposed incorporating movement while using screens (i.e., standing desks) to reduce sedentary time.

Do Not Shame the Patients or Their Families

Patients and their families should be subject to non-judgment and shared decision-making. They may experience much guilt and shame surrounding their unhealthy screen use, particularly since many people have been unable to follow current guidelines for optimal amounts of screen use in children during the COVID pandemic.¹

Conclusion

This article provides broad suggestions for the diagnosis and evaluation of unhealthy screen use for generalists. We note that screen use, unhealthy use, and formal “addiction” (use disorder) represent three distinct entities, stressing that sloppy language can come with negative consequences for patient care. We also take a harm reductionist approach to the treatment of unhealthy screen use, noting that in the absence of well-defined diagnostic and treatment guidance, generalists retain the ability to screen and treat common co-occurring conditions such as a depression and anxiety while waiting for specialist referrals.

In closing, one of our addiction psychiatry colleagues often remarks that “Cake isn’t [necessarily] good for you; getting in a car isn’t [necessarily] safe… Life has risks.” In the case of screen time, the complete elimination of screens in a person struggling with unhealthy screen use may not be practical in an era of increased virtual learning and social connectivity via smartphones, laptops, and tablets. After all, life has risks and screens are a part of modern life, especially in our post-COVID new “normal.”