Beyond Dogmatism: A Pluralistic Framework to Conceptualize Social Media Use in Children and Adolescents

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SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY

Social media (SM) use among teenagers has sparked widespread debate over its potential impact on mental health. A 2024 Pew Research Center survey found that most teenagers actively use platforms such as YouTube (73%), TikTok (57%), Instagram (50%), and Snapchat (48%).¹ Amid this rising engagement, legislative efforts to regulate or ban SM have intensified, often citing its influence on youth well-being.²

However, the relationship between SM use and mental health remains inconclusive. While some studies suggest weak associations with poor mental health outcomes, others highlight potential benefits.³ These mixed findings underscore the need for a more nuanced understanding of how teenagers interact with SM.

To date, most research has focused on time spent online, overlooking the complexity of SM interactions. This reductionist approach leaves clinicians without sufficient guidance for assessing its impact on adolescent mental health. Given its ubiquitous role in modern youth culture, a deeper exploration is necessary to equip clinicians with tools to evaluate SM’s diverse impacts during psychiatric evaluations.³

This article explores a pluralistic framework for understanding SM use, drawing from recent theoretical advancements proposed in the literature.^4-6 By integrating insights into who uses SM (between-person effects) and how they engage with it (within-person effects), the framework offers a comprehensive, individualized approach. Additionally, it outlines practical strategies for incorporating these insights into the psychiatric interview.

Conceptual Framework

Recent reviews have highlighted how current approaches often overlook key variables that contribute to the diverse effects of SM by focusing narrowly on time spent online. Two of these crucial variables are the quality of SM interactions and the individual user characteristics, which can shape outcomes in significantly different ways.^4,5 Central to this discussion is the distinction between between-person effects and within-person effects:

• Between-person effects examine how SM impacts mental health based on who the user is. Factors such as gender, socioeconomic status, and mental health history moderate how adolescents experience SM.
• Within-person effects focus on how adolescents use SM, encompassing the types of functions they use, the content they engage with, and how they interact with others on these platforms.

To bridge these concepts into clinical practice, I propose a schematic (Figure 1) that organizes these variables and guides clinicians in identifying key components of an adolescent’s SM use during the psychiatric interview.

Figure 1. A Guide to Identifying Key Components of an Adolescent’s Social Media Use

Understanding “Who the User Is”

Adolescents’ engagement with SM is shaped by personal characteristics, including gender, age, developmental stage, race/ethnicity, minoritized status, and mental health vulnerabilities among others. While some factors are dynamic, others are fixed, influencing how adolescents interact with the world and SM.⁵

The same features of SM may benefit some adolescents while adversely affecting others. By recognizing the role of these individual characteristics, clinicians can tailor their approach, helping adolescents navigate the complexities of SM more safely and effectively.

During the psychiatric interview, these individual differences can be explored through open-ended questions, allowing clinicians to understand how an adolescent’s personality, lived experience, and social context influence their relationship with SM. For a deeper dive into these connections, I encourage clinicians to review the evidence on individual differences highlighted in recent literature.^4,5

Identifying Type of Use

The second critical component of the framework focuses on how adolescents interact with SM—their interactions, engagement patterns, and motivations. However, due to the rapid evolution of platforms and their functions, identifying consistent metrics has been challenging. To address this gap, I propose a function-based framework that provides clinicians with a structured approach to assess adolescents’ SM use during interviews without relying on platform-specific knowledge.⁶ This framework categorizes SM use into 4 key questions (What? How? Who? Why?), each offering insights into associated risks or benefits (Figure 2):

1. What platform do they use?
   1. What functions do they engage with (video sharing, direct messaging)?
   2. What type of content do they interact with?
2. How are they engaging (eg, passively scrolling vs actively posting)?
3. Who are they interacting with (eg, friends, influencers, strangers)?
4. Why are they using SM (eg, connect, pass time, or seek information)?

Figure 2. A Framework for Categorizing Social Media Use

Platforms and Functions

SM platforms vary significantly in design, intended purpose, and user demographics.⁷ While some platforms initially dominated specific functions—such as Instagram for image sharing or TikTok for video sharing—most have evolved to incorporate multiple features. Adolescents often use different platforms for distinct purposes. For instance, Snapchat may be used for image sharing and messaging, whereas Instagram is used for similar purposes alongside curating an online identity.

To gain meaningful insights, clinicians should adopt a function-based approach rather than focusing on specific platforms.^6,7 This involves asking adolescents about the primary functions they use, such as:

• Image and video sharing
• Social networking
• Messaging
• Streaming (watching live content)

Exploring the type of content adolescents interact with is equally important. Algorithms and artificial intelligence often push curated content based on user behavior, which can amplify emotional states.⁵ Clinicians might consider asking adolescents to share their homepage or explore the type of content being promoted to them. This exercise not only helps clinicians better understand the adolescent’s digital environment but also offers an opportunity to educate them on the role of algorithms in shaping their online experiences.

Comparing an adolescent’s online persona with their real-life presentation can reveal valuable insights into self-perception, social pressures, and emotional vulnerabilities. These differences help clinicians better understand the adolescent’s mental health and identity.

Engagement Patterns

Engagement can be broadly categorized into consumption (viewing content) and contribution (liking, posting, commenting, or sharing). While these terms align with traditional definitions of passive and active SM use, they are more nuanced:

• Consumption includes activities such as watching videos, viewing pictures, or reading posts. While often seen as passive, consumption can be active when adolescents deliberately seek educational or informative content.
• Contribution involves interacting with or creating content, ranging from “liking” posts (minimal involvement) to live streaming or posting videos (direct, active involvement).

Consumption and contribution are not inherently good or bad; their impact depends on what adolescents engage with and how they process these interactions. Passive consumption of harmful content, such as videos promoting toxic beauty standards, can negatively affect self-esteem and reinforce maladaptive thought patterns. In contrast, active contribution, such as sharing personal stories or creative content, may foster identity and community but can also expose adolescents to criticism or burnout. Understanding these patterns provides important insights into the adolescent’s mental health risks and resilience factors.⁶

Social Interactions

SM interactions can vary widely, ranging from private exchanges with close friends to more public engagements with acquaintances or strangers.⁸ For clinicians, understanding these online dynamics provides valuable insights into an adolescent’s self-perception, emotional well-being, and social influences. Adolescents’ interactions can be broadly categorized as:

• Private interactions: Direct, often intimate exchanges with friends, family, or trusted individuals (eg, private messaging or small group chats)
• Public interactions: Engagement with a larger audience, such as commenting on or posting publicly visible content that strangers or acquaintances can access

Interactions on SM can also differ in directionality:

• Bidirectional interactions: Mutual exchanges, such as likes, comments, or shares, which can provide connection but also pressure to maintain an image
• Unidirectional interactions: One-way interactions, such as following influencers, which may still shape adolescents’ perceptions and emotions

Understanding whether an adolescent primarily engages in public or private interactions helps clinicians assess potential risks and resilience factors. Private interactions may foster supportive and meaningful connections among minoritized youth but can also expose adolescents to harmful exchanges, such as cyberbullying within peer groups.⁹ Additionally, public interactions often involve greater exposure to judgment and social comparison, which may amplify vulnerabilities related to self-esteem or validation-seeking behaviors.

Motivations and Drives

Additionally, understanding why adolescents use SM is essential. Are they seeking connection, combating loneliness, or merely passing time? These motivations often reflect underlying needs or vulnerabilities.¹⁰ Exploring these “whys” not only helps build rapport but also provides a deeper understanding of the adolescent’s SM habits. Demonstrating genuine curiosity and a nonjudgmental approach helps adolescents feel heard and validated, making them more likely to open up about sensitive topics. By understanding why they turn to SM, clinicians can better support adolescents in finding healthier ways to meet their emotional needs.¹¹

Creating a Formulation

By addressing the key questions of who, how, with whom, and why, clinicians can develop a detailed profile of an adolescent’s SM use that goes beyond simplistic metrics such as time spent online. This comprehensive formulation considers the unique interplay of the adolescent’s characteristics, behaviors, and motivations, providing a more granular understanding of their digital life.⁶

Developing a Use Profile

Each adolescent’s SM engagement can be conceptualized as a unique use phenotype, reflecting their patterns of consumption and contribution as well as the nature of their interactions (public vs private). This profile highlights individual risk and resilience factors associated with their digital habits. Using this framework, clinicians can stratify use types into 4 distinct categories (note that even this is a simplified version of what actually goes on):

1. Private Consumption: Viewing content in a personal, noninteractive way (eg, watching videos or reading posts)
2. Private Contribution: Sharing or interacting with a trusted, smaller audience (eg, sending photos or messages in private chats)
3. Public Consumption: Browsing or engaging with publicly available content (eg, following influencers or consuming viral media)
4. Public Contribution: Posting or sharing content visible to a wider audience, often seeking engagement or approval

Each category carries unique implications for mental health, offering clinicians a lens to evaluate both potential vulnerabilities and strengths.¹²

Mapping Risks and Resilience

Table. Risk and Resilience Factors Associated With Social Media Use Patterns

• FOMO (Fear of Missing Out): The feeling of anxiety or apprehension that one might be missing out on social experiences or opportunities that others are having, often triggered by seeing posts on social media.
• Comparison Trap: The tendency to constantly compare oneself to others on social media, often leading to feelings of inadequacy, envy, and low self-esteem.
• Filter Bubble: A state of intellectual isolation that can result from personalized searches when a website algorithm selectively curates information a user would liketo see based on information about the user, such as location, past click-behavior, and searchhistory. The user gets used to an information feed that agrees with their viewpoints, isolating them from opposing perspectives.
• Passive Loneliness: The feeling of loneliness or isolation that can result from passively scrolling through social media feeds without actively engaging with others.
• Conformity Pressure: The pressure to adhere to social norms or expectations, often amplified on social media where individuals may feel compelled to present themselves in a certain way to fit in.
• Creation Fatigue (Burnout): A state of mental and emotional exhaustion caused by the pressure to constantly create and share content on social media.
• Contagion: In the context of social media, this refers to the rapid spread of emotions, behaviors, or information (including misinformation) through social networks.
• Secondary Bullying: When someone witnesses an act of bullying and then participates in it or spreads it further.
• Catfishing: The practice of creating a fake online identity to deceive someone, often in a romantic context.
• Selective Connection: Choosing to connect with specific people or groups on social media, rather than trying to maintain a large network of superficial connections.
• Prosocial Behavior: Actions intended to benefit others, such as offering support, sharing helpful information, or engaging in acts of kindness.
• Minority Spaces: Online communities or groups that provide a safe and supportive environment for individuals who belong to marginalized or underrepresented groups.

By pairing an adolescent’s use profile with associated risk and resilience factors (as summarized in the Table), clinicians can identify potential areas of concern or protective influences. For instance, adolescents engaging in public contribution might feel pressure to maintain a curated online image, increasing their risk for stress, anxiety, or body image issues. On the other hand, private consumption of educational or supportive content can foster growth, learning, and emotional well-being. This approach encourages clinicians to view SM use as a spectrum of experiences, rather than a binary of “good” or “bad.”

Next Step: Open Dialogue

To assess risk factors and encourage adaptive behaviors, clinicians should engage adolescents with curiosity and a balanced, nonjudgmental approach. Rather than focusing solely on maladaptive behaviors or negative consequences, clinicians can highlight ways the adolescent has used SM positively (eg, for learning, creativity, or self-expression). Encouraging adolescents to teach clinicians and parents about the platforms they use or to share content they enjoy fosters understanding and builds trust within the clinician-adolescent dyad.

These engagements provide opportunities to explore the adolescent’s motivations and challenges while promoting media literacy. Adolescents can be guided to critically evaluate their use, understand feedback mechanisms designed to reinforce engagement, and recognize the influence of curated content on their behavior and emotions.

For both clinicians and parents, a valuable grant-funded resource is PsychChild (https://www.psychchild.com/), which offers user-friendly descriptions of SM and gaming platforms along with their mental health implications. Additionally, clinicians can refer to my recent work, which outlines comprehensive questions to incorporate into psychiatric interviews, helping to evaluate the diverse aspects of SM use and detect potential harmful interactions.

Concluding Thoughts

This pluralistic framework equips clinicians with tools to better assess adolescents’ SM use during psychiatric interviews. By exploring who they are, how they engage, with whom they interact, and why they use social media, clinicians can create personalized formulations that guide interventions, foster resilience, and mitigate risks. Further research is needed to move beyond screen time metrics and examine patterns of interaction, the role of algorithms, and individual differences. Understanding these nuances is key to clarifying the relationship between SM and adolescent mental health outcomes, if a direct one exists. As SM evolves, embracing its complexity is essential to supporting young people in navigating these digital spaces safely and meaningfully.

Dr Hamati is a third-year psychiatry resident at Northwestern University, with a special interest in child and adolescent mental health. His work focuses on the intersection of social media, gaming, and mental health, aiming to develop practical frameworks to address digital influences in clinical practice.

Acknowledgments: The author would like to thank Ashvin Sood, MD, for his invaluable mentorship and insightful discussions, which greatly contributed to the development of this framework.

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