Researchers using 4 years of interim data from a large, ongoing study of mental health and brain development in American children and adolescents have found that “high” or “increasing” addictive use of screen-based activities is not only commonplace, but is also associated with two to three times higher rates of suicidal ideation, suicidal behaviors, and other mental health problems, compared with those with “low” addictive or much weaker habitual screen use.
The new study, published in the Journal of the American Medical Association (JAMA), is an important contribution to the vigorous debate about how the advent and ubiquitous use of social media, mobile phones, and video games is affecting young people.
Considerable past research has focused on the potential impact of total screen time on youth mental health. Results have been inconclusive. The new study, while including screen time in its analysis, finds that it is not, by itself, specifically associated with elevated risk for suicidal ideation or behavior or what psychiatrists call internalizing and externalizing behaviors. (“Internalizing” refers to inward-directed problems such as anxiety and depression; “externalizing” refers to problems directed at others, such as aggression or rule-breaking.) Rather, the study finds, it is the role that high or increasing addictive use trajectories of screen-based activities play in the lives of young people that can specifically be linked with adverse mental health outcomes, including those associated with suicide.
BBRF Scientific Council member J. John Mann, M.D., a world authority on suicide at Columbia University and the New York State Psychiatric Institute, and the winner of 2022 BBRF Colvin Prize and a 2008 BBRF Distinguished Investigator, was senior member of the team. The paper’s lead author was Yunyu Xiao, Ph.D., of Weill Cornell Medicine.
The researchers based their study on the most recent release of data from the U.S. government-supported Adolescent Brain and Cognitive Development (ABCD) study, which has recruited over 11,000 youths ages 9 and 10 at 21 U.S. sites. These young people are being followed all the way through adolescence, to the transition to adulthood. Many kinds of measures are being taken periodically in the ABCD study, ranging from brain scans to blood draws to detailed mental health assessments, making possible a great variety of spin-off studies using portions of the total dataset, including the one just reported on screen use.
A total of 4,635 of the ABCD participants completed surveys at their 2-, 3- and 4-year follow-ups after joining the study. These follow-ups included self-reports of screen use and habits as well as self- and parental reports of mental health. Subtracting those with missing information, the cohort analyzed for the current study numbered 4,285 youths, who were 10 years old on average at the study’s baseline and 14 at the 4th follow-up. About 59% were White, 19% Hispanic, 10% Black, and 2% Asian. Two-thirds of their parents had a college degree or higher and 73% were married. About 40% of participants’ parents earned under $75,000 annually.
Establishing “addictive use” for the 3 screen-based modes—social media, mobile phones, and video games—was based on several self-report questionnaires, filled out annually over the 4-year interval monitored in the study. These included questions such as “I feel the need to use social media apps more and more” (1=never, 6=very often); “The thought of being without my phone makes me feel distressed” (1=strongly disagree, 7=strongly agree); and “I play video games so I can forget about my problems” (1=never, 6=very often). All of these have been shown to have high reliability in past studies.
Child and parent reports of suicidal behaviors and suicidal ideation over the prior year were assessed at year 4, using another well-validated questionnaire covering a spectrum of suicide-related outcomes. These included, for ideation: a “yes” reply to either: passive ideation; nonspecific active ideation; specific active ideation; active ideation with intent; or active ideation with plan and intent. Suicidal behavior was indicated with a “yes” reply to any of the following: preparatory actions for imminent suicidal behavior; interrupted attempt; aborted attempt; or actual attempt.
A final analytic component, the Child Behavior Checklist (CBCL), periodically filled out by parents, was used to indicate clinically significant adverse mental health-related behaviors, grouped as internalizing and externalizing.
“This study identified distinct trajectories of addictive use of social media, mobile phones, and video games from childhood to early adolescence, and found links to suicidal behaviors, suicidal ideation, and worse mental health outcomes,” the team reported.
For both social media and mobile phones, addictive use trajectories followed 3 different patterns, “and a substantial proportion of youths had addictive use trajectories that increased over the 4 years of observation, starting at age 10,” the team said. These patterns of increasing addictive use as the years passed, they noted, “would not have been predicted” based on assessments made at the beginning of the study, and were specifically associated with suicidal behaviors and ideation. “This underscores the potential importance of repeated assessment” of addictive screen use as children enter adolescence, they said.
Video game use was found to follow 2 trajectories, dubbed “high” and “low.” These were stable over time, which to the team means that those most at risk might be identified early, without the need for repeated assessment.
Almost 1 in 2 youths had a high addictive use trajectory for mobile phones, and more than 40% had such a trajectory for video games. “Many others had increasing addictive use over the 4-year observation period which ended with high addictive use.” Almost 1 in 3 had this “increasing addictive” trajectory for social media and 1 in 4 for mobile phones.
As for how these trajectories affected mental health risk: for social media and mobile phones, both the “high” and “increasing” addictive use paths were associated with 2 to 3 times greater risks of suicidal behaviors or ideation, compared with “low” addictive use trajectories (i.e., not all “addictive” use was linked with increased suicide risk—just “high” or “increasing” addictive use). Also, “high” and “increasing” addictive use of social media were found to be associated with higher internalizing and externalizing symptom scores compared with the “low” addictive use trajectory. The “high” addictive use path for video games was linked with higher risks of suicidal behaviors and ideation and higher internalizing symptoms compared with the “low” addictive use path.
Total screen time was not found in this study to be associated with suicide-related or mental health outcomes, nor did it alter the various findings regarding associations between addictive use trajectories and these outcomes. “Total screen time” and “addictive use” are likely two different constructs, the team said. This is not to say, however, that total screen time is not an important factor in mental health. For example, long periods on the phone or other screen activities are well understood to crowd out sleep, exercise, and face-to-face contact in many users—none of which are healthy. Both constructs are likely important, though in different ways.
The current study will likely lead to additional studies on monitoring the addictive element in the use of electronic devices among youth. It also calls urgent attention to the issue of developing effective preventive and treatment approaches for those youth who do become addicted to their screens.
