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DOI: 10.1542/peds.2011-0054 published online Mar 28, 2011; Pediatrics

COMMUNICATIONS AND MEDIA Gwenn Schurgin O'Keeffe, Kathleen Clarke-Pearson and COUNCIL ON

Families Clinical Report�The Impact of Social Media on Children, Adolescents, and

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Clinical Report—The Impact of Social Media on Children, Adolescents, and Families

abstract Using social media Web sites is among the most common activity of today’s children and adolescents. Any Web site that allows social inter- action is considered a social media site, including social networking sites such as Facebook, MySpace, and Twitter; gaming sites and virtual worlds such as Club Penguin, Second Life, and the Sims; video sites such as YouTube; and blogs. Such sites offer today’s youth a portal for entertainment and communication and have grown exponentially in recent years. For this reason, it is important that parents become aware of the nature of social media sites, given that not all of them are healthy environments for children and adolescents. Pediatricians are in a unique position to help families understand these sites and to encourage healthy use and urge parents to monitor for potential prob- lemswith cyberbullying, “Facebook depression,” sexting, and exposure to inappropriate content. Pediatrics 2011;127:800–804

SOCIAL MEDIA USE BY TWEENS AND TEENS Engaging in various forms of social media is a routine activity that research has shown to benefit children and adolescents by enhancing communication, social connection, and even technical skills.1 Social media sites such as Facebook and MySpace offer multiple daily oppor- tunities for connecting with friends, classmates, and people with shared interests. During the last 5 years, the number of preadoles- cents and adolescents using such sites has increased dramatically. According to a recent poll, 22% of teenagers log on to their favorite social media site more than 10 times a day, and more than half of adolescents log on to a social media site more than once a day.2

Seventy-five percent of teenagers now own cell phones, and 25% use them for social media, 54% use them for texting, and 24% use them for instant messaging.3 Thus, a large part of this generation’s social and emotional development is occurring while on the Internet and on cell phones.

Because of their limited capacity for self-regulation and susceptibility to peer pressure, children and adolescents are at some risk as they navigate and experiment with social media. Recent research indicates that there are frequent online expressions of offline behaviors, such as bullying, clique-forming, and sexual experimentation,4 that have intro- duced problems such as cyberbullying,5 privacy issues, and “sexting.”6

Other problems that merit awareness include Internet addiction and concurrent sleep deprivation.7

Many parents today use technology incredibly well and feel comfort- able and capable with the programs and online venues that their chil-

Gwenn Schurgin O’Keeffe, MD, Kathleen Clarke-Pearson, MD, and COUNCIL ON COMMUNICATIONS AND MEDIA

KEY WORDS Internet, cyberbullying, online harassment, Facebook depression, sexting, social media, digital footprint, COPPA, advertising, social networking, bullying, adolescents, children

ABBREVIATION AAP—American Academy of Pediatrics

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

Guidance for the Clinician in Rendering Pediatric Care

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dren and adolescents are using. Never- theless, some parents may find it difficult to relate to their digitally savvy youngsters online for several reasons. Such parents may lack a basic under- standing of these new forms of social- ization, which are integral to their chil- dren’s lives.8 They frequently do not have the technical abilities or time needed to keep pace with their chil- dren in the ever-changing Internet landscape.8 In addition, these parents often lack a basic understanding that kids’ online lives are an extension of their offline lives. The end result is of- ten a knowledge and technical skill gap between parents and youth, which creates a disconnect in how these par- ents and youth participate in the online world together.9

BENEFITS OF CHILDREN AND ADOLESCENTS USING SOCIAL MEDIA

Socialization and Communication

Social media sites allow teens to ac- complish online many of the tasks that are important to them offline: staying connected with friends and family, making new friends, sharing pictures, and exchanging ideas. Social media participation also can offer adoles- cents deeper benefits that extend into their view of self, community, and the world, including1,10:

1. opportunities for community en- gagement through raising money for charity and volunteering for lo- cal events, including political and philanthropic events;

2. enhancement of individual and col- lective creativity through develop- ment and sharing of artistic and musical endeavors;

3. growth of ideas from the creation of blogs, podcasts, videos, and gaming sites;

4. expansion of one’s online connec- tions through shared interests to

include others from more diverse backgrounds (such communication is an important step for all adoles- cents and affords the opportunity for respect, tolerance, and in- creased discourse about personal and global issues); and

5. fostering of one’s individual identity and unique social skills.11

Enhanced Learning Opportunities

Middle and high school students are using social media to connect with one another on homework and group proj- ects.11 For example, Facebook and sim- ilar social media programs allow stu- dents to gather outside of class to collaborate and exchange ideas about assignments. Some schools success- fully use blogs as teaching tools,12

which has the benefit of reinforcing skills in English, written expression, and creativity.

Accessing Health Information

Adolescents are finding that they can access online information about their health concerns easily and anony- mously. Excellent health resources are increasingly available to youth on a va- riety of topics of interest to this popu- lation, such as sexually transmitted in- fections, stress reduction, and signs of depression. Adolescents with chronic illnesses can accessWeb sites through which they can develop supportive net- works of people with similar condi- tions.13 The mobile technologies that teens use daily, namely cell phones, in- stant messaging, and text messaging, have already produced multiple im- provements in their health care, such as increased medication adherence, better disease understanding, and fewer missed appointments.14 Given that the new social media venues all have mobile applications, teenagers will have enhanced opportunities to learn about their health issues and communicate with their doctors.

However, because of their young age, adolescents can encounter inaccu- racies during these searches and re- quire parental involvement to be sure they are using reliable online resources, interpreting the informa- tion correctly, and not becoming overwhelmed by the information they are reading. Encouraging par- ents to ask about their children’s and adolescents’ online searches can help facilitate not only discovery of this information but discussion on these topics.

RISKS OF YOUTH USING SOCIAL MEDIA

Using social media becomes a risk to adolescents more often than most adults realize. Most risks fall into the following categories: peer-to-peer; in- appropriate content; lack of under- standing of online privacy issues; and outside influences of third-party ad- vertising groups.

Cyberbullying and Online Harassment

Cyberbullying is deliberately using dig- ital media to communicate false, em- barrassing, or hostile information about another person. It is the most common online risk for all teens and is a peer-to-peer risk.

Although “online harassment” is of- ten used interchangeably with the term “cyberbullying,” it is actually a different entity. Current data sug- gest that online harassment is not as common as offline harassment,15

and participation in social network- ing sites does not put most children at risk of online harassment.16 On the other hand, cyberbullying is quite common, can occur to any young per- son online, and can cause profound psychosocial outcomes including de- pression, anxiety, severe isolation, and, tragically, suicide.17

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PEDIATRICS Volume 127, Number 4, April 2011 801 by on March 29, 2011 www.pediatrics.orgDownloaded from

Sexting

Sexting can be defined as “sending, re- ceiving, or forwarding sexually explicit messages, photographs, or images via cell phone, computer, or other digital devices.”18 Many of these images be- come distributed rapidly via cell phones or the Internet. This phenome- non does occur among the teen popu- lation; a recent survey revealed that 20% of teens have sent or posted nude or seminude photographs or videos of themselves.19 Some teens who have engaged in sexting have been threat- ened or charged with felony child por- nography charges, although some states have started characterizing such behaviors as juvenile-law misde- meanors.20,21 Additional consequences include school suspension for perpe- trators and emotional distress with accompanying mental health condi- tions for victims. In many circum- stances, however, the sexting incident is not shared beyond a small peer group or a couple and is not found to be distressing at all.4

Facebook Depression

Researchers have proposed a new phenomenon called “Facebook depres- sion,” defined as depression that de- velops when preteens and teens spend a great deal of time on social media sites, such as Facebook, and then be- gin to exhibit classic symptoms of de- pression.22–27 Acceptance by and con- tact with peers is an important element of adolescent life. The inten- sity of the online world is thought to be a factor that may trigger depression in some adolescents. As with offline de- pression, preadolescents and adoles- cents who suffer from Facebook de- pression are at risk for social isolation and sometimes turn to risky Internet sites and blogs for “help” that may promote substance abuse, unsafe sex- ual practices, or aggressive or self- destructive behaviors.

PRIVACY CONCERNS AND THE DIGITAL FOOTPRINT

The main risk to preadolescents and adolescents online today are risks from each other, risks of improper use of technology, lack of privacy, sharing too much information, or posting false information about themselves or oth- ers.28 These types of behavior put their privacy at risk.

When Internet users visit various Web sites, they can leave behind evidence of which sites they have visited. This col- lective, ongoing record of one’s Web activity is called the “digital footprint.” One of the biggest threats to young people on social media sites is to their digital footprint and future reputa- tions. Preadolescents and adolescents who lack an awareness of privacy is- sues often post inappropriate mes- sages, pictures, and videos without un- derstanding that “what goes online stays online.”8 As a result, future jobs and college acceptance may be put into jeopardy by inexperienced and rash clicks of the mouse. Indiscrimi- nate Internet activity also can make children and teenagers easier formar- keters and fraudsters to target.

INFLUENCE OF ADVERTISEMENTS ON BUYING

Many social media sites display multi- ple advertisements such as banner ads, behavior ads (ads that target peo- ple on the basis of their Web-browsing behavior), and demographic-based ads (ads that target people on the ba- sis of a specific factor such as age, gender, education, marital status, etc) that influence not only the buying ten- dencies of preadolescents and adoles- cents but also their views of what is normal. It is particularly important for parents to be aware of the behavioral ads, because they are common on so- cial media sites and operate by gather- ing information on the person using a site and then targeting that person’s

profile to influence purchasing deci- sions. Such powerful influences start as soon as children begin to go online and post.29 Many online venues are now prohibiting ads on sites where children and adolescents are partici- pating. It is important to educate par- ents, children, and adolescents about this practice so that children can de- velop into media-literate consumers and understand how advertisements can easily manipulate them.

ON TOO YOUNG: MIXED MESSAGES FROM PARENTS AND THE LAW

Many parents are aware that 13 years is the minimum age for most social media sites but do not understand why. There are 2 major reasons. First, 13 years is the age set by Congress in the Children’s Online Privacy Protec- tion Act (COPPA), which prohibits Web sites from collecting information on children younger than 13 years with- out parental permission. Second, the official terms of service for many pop- ular sites now mirror the COPPA regu- lations and state that 13 years is the minimum age to sign up and have a profile. This is theminimumage to sign on to sites such as Facebook and My- Space. There are many sites for pread- olescents and younger children that do not have such an age restriction, such as Disney sites, Club Penguin, and others.

It is important that parents evaluate the sites on which their child wishes to participate to be sure that the site is appropriate for that child’s age. For sites without age stipulations, how- ever, there is room for negotiation, and parents should evaluate the situa- tion via active conversation with their preadolescents and adolescents.

In general, if a Web site specifies amin- imum age for use in its terms of ser- vice, the American Academy of Pediat- rics (AAP) encourages that age to be respected. Falsifying age has become

802 FROM THE AMERICAN ACADEMY OF PEDIATRICS by on March 29, 2011 www.pediatrics.orgDownloaded from

common practice by some preadoles- cents and some parents. Parents must be thoughtful about this practice to be sure that they are not sending mixed messages about lying and that online safety is always the main message be- ing emphasized.

THE ROLE OF PEDIATRICIANS

Pediatricians are in a unique position to educate families about both the complexities of the digital world and the challenging social and health is- sues that online youth experience by encouraging families to face the core issues of bullying, popularity and sta- tus, depression and social anxiety, risk-taking, and sexual development. Pediatricians can help parents under- stand that what is happening online is an extension of these underlying is- sues and that parents can be most helpful if they understand the core issues and have strategies for deal- ing with them whether they take place online, offline, or, increasingly, both.

Some specific ways in which pediatri- cians can assist parents include:

1. Advise parents to talk to their chil- dren and adolescents about their online use and the specific issues that today’s online kids face.

2. Advise parents to work on their own participation gap in their homes by becoming better educated about the many technologies their young- sters are using.

3. Discuss with families the need for a family online-use plan that involves regular family meetings to discuss online topics and checks of privacy settings and online profiles for in- appropriate posts. The emphasis should be on citizenship and healthy behavior and not punitive action, unless truly warranted.

4. Discuss with parents the impor- tance of supervising online activi- ties via active participation and communication, as opposed to re- mote monitoring with a “net-nanny” program (software used tomonitor the Internet in the absence of parents).

In addition, the AAP encourages all pe- diatricians to increase their knowl- edge of digital technology so that they can have a more educated frame of reference for the tools their patients and families are using, which will aid in providing timely anticipatory media guidance as well as diagnosing media- related issues should they arise.

To assist families in discussing themore challenging issues that kids face online, pediatricians can provide families with reputable online resources, including “Social Media and Sexting Tips” from the AAP (www.aap.org/advocacy/releases/ june09socialmedia.htm),30 the AAP Inter- net safety site (http://safetynet.aap.org),31

and the AAP public education site, Healthy Children.org (www.healthychildren.org/ english/search/pages/results.aspx? Type�Keyword&Keyword�Internet� safety),32 and encourage parents to

discuss these resources with their children. Pediatricians with Web sites or blogs may wish to create a section with resources for parents and chil- dren about these issues and may sug- gest a list of or links to social media sites that are appropriate for the dif- ferent age groups. In this way, pedia- tricians can support the efforts of par- ents to engage and educate youth to be responsible, sensible, and respectful digital citizens.

LEAD AUTHORS Gwenn Schurgin O’Keeffe, MD Kathleen Clarke-Pearson, MD

COUNCIL ON COMMUNICATIONS AND MEDIA EXECUTIVE COMMITTEE, 2010–2011 Deborah Ann Mulligan, MD, Chairperson Tanya Remer Altmann, MD Ari Brown, MD Dimitri A. Christakis, MD Kathleen Clarke-Pearson, MD Holly Lee Falik, MD David L. Hill, MD Marjorie J. Hogan, MD Alanna Estin Levine, MD Kathleen G. Nelson, MD Gwenn Schurgin O’Keeffe, MD

PAST EXECUTIVE COMMITTEE MEMBERS Benard P. Dreyer, MD Gilbert L. Fuld, MD, Immediate Past Chairperson Victor C. Strasburger, MD

LIAISONS Michael Brody, MD – American Academy of Child and Adolescent Psychiatry Brian Wilcox, PhD – American Psychological Association

STAFF Gina Ley Steiner Veronica Laude Noland, [email protected]

REFERENCES

1. Ito M, Horst H, Bittani MLiving and Learning With NewMedia: Summary of Findings From the Digital Youth Project. Chicago, IL: John D. and Catherine T. MacArthur Founda- tion Reports on Digital Media and Learning; 2008.Available at: http://digitalyouth. i schoo l .berke ley . edu/fi les /repor t / digitalyouth-TwoPageSummary.pdf. Ac- cessed July 16, 2010

2. Common Sense Media. Is Technology Net- working Changing Childhood? A National

Poll. San Francisco, CA: Common Sense Media ; 2009 .Ava i lab le at : www. commonsensemedia.org/sites/default/ files/CSM_teen_social_media_080609_ FINAL.pdf. Accessed July 16, 2010

3. Hinduja S, Patchin J. Offline consequences of online victimization: school violence and delinquency. J Sch Violence. 2007;6(3): 89–112

4. Lenhart A. Teens and Sexting. Washington, DC: Pew Research Center; 2009.Available at:

http://pewinternet.org/Reports/2009/ Teens-and-Sexting.aspx. Accessed August 4, 2010

5. Patchin JW, Hinduja S. Bullies move beyond the schoolyard: a preliminary look at cyber- bullying. Youth Violence Juv Justice. 2006; 4(2):148–169

6. A thin line: 2009 AP-TVT digital abuse study. Available at: www.athinline.org/MTV-AP_ Digital_Abuse_Study_Executive_Summary. pdf. Accessed July 16, 2010

FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 127, Number 4, April 2011 803 by on March 29, 2011 www.pediatrics.orgDownloaded from

7. Christakis DA, Moreno MA. Trapped in the net: will internet addiction become a 21st- century epidemic? Arch Pediatr Adolesc Med. 2009;163(10):959–960

8. Palfrey J, Gasser U, Boyd D. Response to FCC Notice of Inquiry 09-94: “Empowering Par- ents and Protecting Children in an Evolving Media Landscape.” Cambridge, MA: Berk- man Center for Internet and Society at Har- vard University; 2010.Available at: http:// cyber.law.harvard.edu/sites/cyber.law. harvard.edu/files/Palfrey_Gasser_boyd_ response_to_FCC_NOI_09-94_Feb2010.pdf. Accessed July 16, 2010

9. Jenkins H, Clinton K, Purushotma R, Robin- son AJ, Weigel M. Confronting the Chal- lenges of Participatory Culture: Media Edu- cation for the 21st Century. Chicago, IL: John D. and Catherine T. MacArthur Founda- tion Reports on Digital Media and Learning; 2006.Available at: http://digitallearning. macfound.org/atf/cf/{7E45C7E0-A3E0-4B89- AC9C-E807E1B0AE4E}/JENKINS_WHITE_ PAPER.PDF. Accessed July 16, 2010

10. Boyd D. Why youth (heart) social network sites: the role of networked publics in teen- age social life. In: Buckingham D, ed.MacAr- thur Foundation Series on Digital Learning: Youth, Identity, and Digital Media Volume. Cambridge, MA: MIT Press; 2007.Available a t : www.danah .org /papers / WhyYouthHeart.pdf. Accessed July 16, 2010

11. Boyd D. Taken Out of Context: American Teen Soc ia l i t y in Networked Pub- licsBerkeley, CA: University of California; 2008. Available at: www.danah.org/ papers/TakenOutOfContext.pdf. Accessed July 16, 2010

12. Borja RR. “Blogs” catching on as tool for instruction: teachers use interactive Web pages to hone writing skills. Educ Week. De- cember 14, 2005. Available at: www.iapsych. com/edblogs.pdf. Accessed July 16, 2010

13. Lenhart A, Purcell K, Smith A, Zickur K. Social Media and Young Adults. Washington, DC: Pew Research Center; 2010.Available at: http://pewinternet.org/Reports/2010/ Social-Media-and-Young-Adults.aspx. Ac- cessed July 16, 2010

14. Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemed E Health. 2009;15(3):231–240

15. Lenhart A. Cyberbullying. Washington, DC: Pew Research Center; 2007.Available at: www.pewinternet.org/Reports/2007/ Cyberbullying.aspx. Accessed July 16, 2010

16. Ybarra ML, Mitchell KJ. How risky are social networking sites? A comparison of places online where youth sexual solicitation and harassment occurs. Pediatrics. 2008; 121(2). Available at: www.pediatrics.org/ cgi/content/full/121/2/e350

17. Hinduja S, Patchin JW. Bullying, cyberbully- ing, and suicide. Arch Suicide Res. 2010; 14(3):206–221

18. Berkshire District Attorney. Sexting. Pitts- field, MA: Commonwealth of Massachusetts; 2010. Available at: www.mass.gov/?pageID� berterminal&L�3&L0�Home&L1�Crime� Awareness�%26�Prevention&L2�Parents� %26�Youth&sid�Dber&b�terminalcontent& f�parents_youth_sexting&csid�Dber. Ac- cessed September 7, 2010

19. National Campaign to Prevent Teen and Un- planned Pregnancy. Sex and Tech: Results of a Survey of Teens and Young Adults. Washington, DC: National Campaign to Pre- vent Teen and Unplanned Pregnancy; 2008. Available at: www.thenationalcampaign. org/SEXTECH/PDF/SexTech_Summary.pdf. Accessed July 16, 2010

20. Gifford NV. Sexting in the USA. Washington, DC: Family Online Safety Institute Report; 2009.Available at: www.fosi.org/cms/ downloads/resources/Sexting.pdf. Ac- cessed July 16, 2010

21. Walker J. Child’s play or child pornography: the need for better laws regarding sexting. ACJS Today. 2010;XXXV(1):, 3–9. Available at: www.acjs.org/pubs/uploads/ACJSToday_ February_2010.pdf. Accessed July 16, 2010

22. Davila J, Stroud CB, Starr LR, et al. Romantic and sexual activities, parent-adolescent stress, and depressive symptoms among early adolescent girls. J Adolesc. 2009; 32(4):909–924

23. Selfhout MHW, Branje SJT, Delsing M, ter Bogt TFM, Meeu WHJ. Different types of In- ternet use, depression, and social anxiety: the role of perceived friendship quality. J Adolesc. 2009;32(4):819–833

24. Melville K. Facebook use associated with de- pression. Science A Go Go. February 3, 2010. Available at: www.scienceagogo.com/

news/20100102231001data_trunc_sys. shtml. Accessed September 7, 2010

25. Irvine C. Excessive chatting on Facebook can lead to depression in teenage girls. Daily Telegraph. January 31, 2010. Available at: www . t e l egraph . co .uk / t echno logy / facebook/4405741/Excessive-chatting-on- Facebook-can-lead-to-depression-in- teenage-girls.html. Accessed September 7, 2010

26. Herr J. Internet entangles college students in a web of loneliness and depression. Tru- man State University Index. February 27, 2007. Available at: www.trumanindex.com/ 2.10111/internet-entangles-col lege- students-in-a-web-of-loneliness-and- depress ion -1 . 1462681 . Accessed September 7, 2010

27. Sturm S. Social networking psych studies: research shows teen Facebook users prone to depression. TrendHunter. Available at: www.trendhunter.com/trends/depression- from-facebook. Accessed September 7, 2010

28. Barnes S. A privacy paradox: social net- working in the United States. First Monday. 2006;11(9). Available at: http://firstmonday. org/htbin/cgiwrap/bin/ojs/index.php/fm/ article/view/1394/1312. Accessed July 16, 2010

29. Kunkel D, Wilcox BL, Cantor J, Palmer E, Linn S, Dowrick P. Report of the APA Task Force on Advertising and Children. Section: psychological aspects of com- mercialization of childhood. February 2004. Available at: www.chawisconsin. org/Obesity/O2ChildAds.pdf. Accessed July 16, 2010

30. American Academy of Pediatrics. Talking to kids and teens about social media and sex- ting. Available at: www.aap.org/advocacy/ releases/june09socialmedia.htm. Accessed September 7, 2010

31. American Academy of Pediatrics. Safety net. Available at: http://safetynet.aap.org. Ac- cessed September 7, 2010

32. American Academy of Pediatrics. Internet safety. Available at: www.healthychildren.org/ english/search/pages/results.aspx?Type� Keyword&Keyword�internet�safety. Ac- cessed September 7, 2010

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DOI: 10.1542/peds.2011-0054 published online Mar 28, 2011; Pediatrics

COMMUNICATIONS AND MEDIA Gwenn Schurgin O'Keeffe, Kathleen Clarke-Pearson and COUNCIL ON

Families Clinical Report�The Impact of Social Media on Children, Adolescents, and

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