Beyond Screen Time-Addictive Screen Use Patterns and Adolescent Mental Health

Abstract

Screen use, the time spent engaging with electronic devices such as mobile phones and tablets, can become addictive when individuals experience difficulty stopping despite attempts to do so, as well as symptoms of withdrawal, tolerance, conflict, and relapse (“Box: Social Media and Video Game Addiction Questionnaire”).¹ Adolescence is a vulnerable period for addictive behaviors, and recent findings suggest that young adolescents are particularly susceptible to screen addiction.^1,2 Notably, in the US, 48% of young adolescents report losing track of how much they are using their phone, 25% use social media to forget about their problems, and 25% admit to spending a considerable amount of time thinking about social media apps.^1,2 Furthermore, 17% have tried to reduce their social media use but cannot, and 11% acknowledge that their screen use has negatively affected their schoolwork.¹ These statistics highlight the need to study screen addiction and its specific health effects, as understanding these behaviors is crucial for addressing the risks they pose to adolescents’ well-being.

Emerging evidence suggests that addictive patterns of screen use may pose a greater risk to youth mental health and suicidality than total screen time,^{3 ,4} yet prior research has largely overlooked this distinction. In this issue of JAMA, Xiao et al⁵ address this gap by examining the longitudinal trajectories of addictive screen use across platforms with mental health and suicidal behavior/ideation in a sample of 4285 young adolescents (aged 9-10 years at baseline) from the US Adolescent Brain Cognitive Development (ABCD) Study. The study explored 3 key questions: (1) how patterns of addictive use of social media, mobile phones, and video games change over time; (2) how these trajectories relate to mental health and suicidal behavior and ideation; and (3) whether these associations remain after adjusting for total screen time. To capture these addictive patterns, the study used self-report questionnaires, including the 6-item Social Media Addiction Questionnaire and the 6-item Video Game Addiction Questionnaire. Adolescents completed these questionnaires virtually and rated their agreement on a Likert scale with statements related to compulsive use, difficulty disengaging, and distress when not using (Box).

Box. Social Media and Video Game Addiction Questionnaires.

Social Media Addiction Questionnaire^a

1. I spend a lot of time thinking about social media apps or planning my use of social media apps.

2. I feel the need to use social media apps more and more.

3. I use social media apps so I can forget about my problems.

4. I’ve tried to use my social media apps less but I can’t.

5. I’ve become stressed or upset if I am not allowed to use my social media apps.

6. I use social media apps so much that it has had a bad effect on my schoolwork or job.

Video Game Addiction Questionnaire^a

1. I spend a lot of time thinking about playing video games.

2. I feed the need to play video games more and more.

3. I play video games so I can forget about my problems.

4. I’ve tried to play video games less but I can’t.

5. I’ve become stressed or upset if I am not allowed to play video games.

6. I play video games so much that it has had a bad effect on my schoolwork or job.

^aResponse options are never, very rarely, rarely, sometimes, often, or very often.¹

One of the study’s strengths is the use of latent class linear mixed models to identify different trajectories of addictive screen use among adolescents. This method allows researchers to classify participants into subgroups based on their screen use patterns over time. Traditional analyses often consider screen time to be a fixed behavior, whereas these latent class linear mixed models offer a powerful approach to capturing the longitudinal changes in addictive screen use.⁶ This study identified adolescents with addictive use trajectories, such as persistently high, moderate increasing, or low levels of use.⁶ Understanding these trajectories could help identify potential mental health risks and inform preventive efforts.

The investigators found that, beginning at age 11 years, nearly 1 in 3 participants had an increasing addictive use trajectory for social media or mobile phones. In adjusted models, increasing addictive use trajectories were associated with higher risks of suicide-related outcomes than low addictive use trajectories. Similarly, high addictive use trajectories across all screen types were associated with suicide-related outcomes. The high addictive use trajectory for video games showed the greatest relative difference in internalizing symptoms, and the moderate increasing trajectory for social media showed the greatest difference in externalizing symptoms. Notably, baseline total screen time was not associated with suicide-related or mental health outcomes. These findings underscore the growing concern around addictive screen use, particularly for social media, mobile phones, and video games, and its significant impact on mental health.

Screen Time vs Addictive Screen Use

One of the study’s key findings was that addictive screen use trajectories were associated with suicide-related and mental health (eg, internalizing and externalizing symptoms) outcomes, while baseline total screen time was not associated with these outcomes. This highlights the need to conceptualize screen time and addictive use as separate constructs, particularly when examining associations with mental health outcomes.

Screen time as a measure may have practical benefits over screen addiction for purposes of brief screening and assessment with limited time in primary care and clinical practice. First, screen time is well understood and perhaps more easily assessed than screen addiction. Time spent on screens can displace other important activities, such as sleep, physical activity, and in-person socializing, which can all be beneficial for adolescent health and well-being. While Xiao et al⁵ found that total screen time categories were not associated with suicide-related or mental health outcomes, previous research has found prospective associations with depressive, conduct, somatic, and attention/hyperactivity symptoms⁷; conduct and oppositional defiant disorders⁸; and suicidal behaviors,⁹ although effect sizes were generally small. As a measure, total screen time is limited in that it generally does not account for the content or context of use, including harmful aspects such as addiction or exposure to cyberbullying and hateful content. Some screen time for education, communication, and socialization can have benefits, and digital literacy is increasingly essential for academic and professional success.

Furthermore, the meaning and impact of screen time can vary across populations, underscoring its limitations as a standard measure. Adolescents in minoritized groups may turn to screens to seek representation and foster online connections that are otherwise unavailable in their immediate physical, neighborhood, or school environments. Therefore, screen time may not be entirely harmful for these adolescents. For example, a study that prospectively assessed the relationship between screen time and mental health outcomes among early adolescents found that associations between screen time and depression were attenuated for Black adolescents compared with White adolescents.⁷ Additionally, sexual and gender minority adolescents in the ABCD Study reported higher addictive screen use compared with their heterosexual and cisgender peers, respectively,^10,11 which may reflect coping mechanisms or efforts to find identity-affirming communities online. Therefore, there is a need for more personalized guidance rather than a one-size-fits-all approach for screen use among adolescents. Future research should examine whether associations between addictive screen use and health outcomes differ across sociodemographic subgroups—such as gender, sexual orientation, and race and ethnicity—given known disparities in problematic screen use in these groups.¹

Although the study’s main findings highlight the importance of addictive screen use trajectories, addictive screen use and problematic screen use are not formally recognized by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), and there is no clear consensus in the field on their definitions.¹² The authors acknowledge that the reliance on self-reported data is a limitation, as it may introduce recall and social desirability bias. Measurement of screen use is typically self-reported, but it often underestimates actual usage compared with passive, objective sensing methods.¹³ Objective data, such as app-based tracking, would provide more accurate estimates of screen duration and offer insights into the types of engagement with smartphones, including the specific apps being used.¹³

Clinical and Policy Implications

The study’s findings have important clinical and policy implications for screen use in adolescents. While most interventions focus on limiting or monitoring screen time, the current study suggests that preventive strategies may also target trajectories or patterns of addictive screen use.¹⁴ The American Academy of Pediatrics advocates for a family media plan, which can be an individualized set of guidelines for each household. Prior research has shown that parental allowance of mealtime and bedroom screen use was associated with higher addictive screen use in adolescents.¹⁵ Therefore, parents could consider limiting screen use during meals and bedtime, and clinicians could educate parents on the risks associated with addictive and problematic screen use.

It is also noteworthy that the minimum age requirement for most social media platforms is 13 years; therefore, much of the study’s social media data represent underage use. These findings align with previous research reporting that 63.8% of participants younger than 13 years used social media,² and the current study further demonstrates features of addictive social media use among underage users. Recent federal and state legislation has proposed more robust age verification measures to address underage use.

The study by Xiao et al⁵ highlights the growing concern around addictive screen use among adolescents and its significant impact on mental health. Their findings suggest that addictive screen use is more strongly linked to negative mental health outcomes than screen time alone. These results emphasize the importance of addressing not just screen time but also addictive behaviors in adolescents. Moving forward, targeted policies and interventions, including stronger parental involvement and better age verification measures on social media, are crucial for mitigating the risks associated with screen addiction.