Young minds online

These monthly blog posts by the Public Mental Health Implementation Centre (PMHIC), 'Perspectives on public mental health', aim to highlight the voices of practitioners, patients, carers, and public health experts.

What are children and young people viewing online, and how does it affect their mental health? Jane Morris, psychiatrist and psychotherapist, and PMHIC Advisory Board member discusses this topic, and what parents and professionals can do to guide and support developing minds in their online lives.

This is a personal blog. Any views or opinions expressed within the content are solely the authors and do not represent those of the author’s employer. 

Sue Palmer’s book Toxic Childhood (2006) warned against leaving children to manage their own survival in an exploitative online ‘global village’. In the 2000s, even before smartphones, our child and adolescent mental health service was mystified by some elusive presentations that resolved a few days after admission. Younger colleagues and patients described the newish phenomena of online gaming and social media. No devices were allowed in hospitals then, and our ward was pretty effective in restoring circadian rhythms and healthier real-world interactions.

A medical student project (unpublished) discovered that our day patients spent considerably more time online than local school and college students, while the most screen time was reported by 16–25 year-olds presenting acutely after deliberate self-harm (DSH). They spoke of using social media to research and enact their DSH. We were concerned enough to call for the addition of an ‘Internet history’ to the standard psychiatric assessment (Cooney and Morris, 2009). Our peers seemed reluctant to countenance our concerns and argued that the Internet was a powerful positive force for health.

Since the 2000s, most aspects of life have moved online. The pandemic brought a 17% increase in entertainment screen time, with teenagers spending over 8 hours online daily (Rideout et al., 2022). We check our devices obsessively for practical, intellectual and entertainment opportunities, and for validation and belonging.

Of course, we have been ‘externalising’ our brains and minds for millennia – 3,000 years ago, Socrates criticised the development of writing as detrimental to memory and understanding. Marshall McLuhan famously pronounced ‘the medium is the message’ and warned that ‘we shape our tools, and thereafter, our tools shape us.’ Some online harms may reflect commercial pressures and psychological conditioning techniques, rather than the nature or content of online communication (McLuhan, 1994). Commercial interests have exploited and dominated new media. 

Harms to mental and physical health

The potential to use the Internet to improve global mental health seemed golden, but benefits too often stay theoretical while harms are actual and demonstrable. Personal choices and ubiquitous algorithms create individual experiences online. Experiences are diverse, with girls spending more time on social media, boys on gaming (Du Four, 2016). Young people from deprived and non-white communities spend more time online (Rideout et al., 2022). The mental stimulation and connectivity offered online may be beneficial to older people, but effects on developing brains relatively detrimental (Firth et al., 2019).

Firth and colleagues (2019) summarise how the Internet produces alterations in mental function, perhaps reflecting sustained brain changes, in attention, memory and social interaction. The hijacking of our attention span is a neglected consideration. It would be crass to endorse headlines like ‘social media causes attention deficit hyperactivity disorder’, but web hyperlinks and adverts are shown to damage sustained concentration even after logging off. Research with young gamers found that high-frequency Internet use over three years is associated with poorer growth of brain areas related to attention, impulse control and decision-making (Takeuchi et al., 2018). It’s probably not specific to gaming: school and university students are distracted by smartphones in class; watching videos on platforms like YouTube and TikTok is the media activity young people enjoy the most (Rideout et al., 2022), and these platforms host very short clips.

Such ‘induced attention deficit’ matters to us as doctors and therapists – our own attention and that of our patients are paramount in our effectiveness.

There are also concerns about how media can amplify addictive, obsessive or paranoid behaviour (including health anxiety, body-image obsession, gaming addiction and gambling), how using digital devices interferes with circadian rhythms and physical activity, and, of course, concerns about media content such as cyber-bullying, sexual and suicide-related exploitation.

‘The World Wide Web provided Molly a virtual sense of community, sadly full of similarly struggling people and with a marked lack of access to measured, professional help. Online, Molly found a world that grew in importance to her and its escalating dominance isolated her from the real world.’

Twenge (2017) reported a sharp rise in suicide and DSH for US girls from 2010–15, when smartphones became ubiquitous. Similar patterns are reported in the UK, with the Office of National Statistics 2019 data showing the highest suicide rate for 10–24-year-olds since records began. Rodway and colleagues analysed the online activity of young people who died by suicide, concluding that ‘there is significant potential for harm from online behaviour (normalisation, triggering, competition, contagion). Young people appear to be increasingly using social media to communicate distress, particularly to peers’ (Rodway et al., 2022).

The case for normalising openness about Internet histories

Thirteen years after our recommendation to take Internet histories during psychiatric assessments, Rodway and colleagues have urged ‘Clinicians working with young people who self-harm or have mental health issues [to] engage in discussion about Internet use. This should be a standard item during assessment.’ However, colleagues still seem reluctant to do this. We sense that people view content and behave online in ways that are uncomfortable to discuss, and we accord online life almost more privacy than the physical body, which doctors do expect to examine and scan.

We need ways to ask without seeming to condemn or accuse. Researchers caution us not to demonise all screen time – it can be creative and educational. Certainly, it is far from the only ingredient in a ‘toxic childhood’ or in suicide-related experiences, but we must acknowledge a new dimension in understanding the mind. As privileged experts, let’s examine the ways our patients are using the Internet, in a spirit of curiosity and collaboration.

Consultant Medical Psychotherapist and Child and Adolescent Psychiatrist; Honorary Senior Lecturer, University of Aberdeen; Vice Chair of the Royal College of Psychiatrists in Scotland; PMHIC Advisory Board Member