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The Use of Social Media in Children and Adolescents: Scoping Review on the Potential Risks

Elena bozzola, giulia spina, rino agostiniani, sarah barni, rocco russo, elena scarpato, antonio di mauro, antonella vita di stefano, cinthia caruso, giovanni corsello, annamaria staiano.

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Correspondence: [email protected]

Received 2022 Jul 25; Accepted 2022 Aug 10; Collection date 2022 Aug.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( https://creativecommons.org/licenses/by/4.0/ ).

In recent years, social media has become part of our lives, even among children. From the beginning of COVID-19 pandemic period, media device and Internet access rapidly increased. Adolescents connected Internet alone, consulting social media, mostly Instagram, TikTok, and YouTube. During “lockdown”, the Internet usage allowed communication with peers and the continuity activities such as school teaching. However, we have to keep in mind that media usage may be related to some adverse consequences especially in the most vulnerable people, such as the young. Aim of the review is to focus on risks correlated to social media use by children and adolescents, identifying spies of rising problems and engaging in preventive recommendations. The scoping review was performed according to PRISMA guidelines, searching on PubMed the terms “social media” or “social network”, “health”, and “pediatrics”. Excluding articles not pertinent, we found 68 reports. Out of them, 19 were dealing with depression, 15 with diet, and 15 with psychological problems, which appeared to be the most reported risk of social media use. Other identified associated problems were sleep, addiction, anxiety, sex related issues, behavioral problems, body image, physical activity, online grooming, sight, headache, and dental caries. Public and medical awareness must rise over this topic and new prevention measures must be found, starting with health practitioners, caregivers, and websites/application developers. Pediatricians should be aware of the risks associated to a problematic social media use for the young’s health and identify sentinel signs in children as well as prevent negative outcomes in accordance with the family.

Keywords: social media, adolescents, children, social network, health, COVID-19

1. Introduction

Media device use is increasing year by year in Italy as well as in many other countries. An ISTAT report referred that in 2019, 85.8% of Italian adolescents aged 11–17 years regularly used smartphones, and over 72% accessed Internet via smartphones [ 1 ]. Almost 95% of Italian families with a child had a broadband internet connection [ 2 ]. Internet connection was mostly used to communicate with friends and to use social networks [ 1 ]. In 2020, COVID-19 pandemic represented one of the greatest disruptions for everybody’s everyday life, in Italy as well as all around the world. From the beginning of the pandemic period, media device and Internet access rapidly increased. In line, a 2021 CENSIS report revealed an even progressive increment of smartphone use by adolescents, which reached 95% [ 3 ]. In particular, the majority of adolescents (59%) admitted they use smartphone even more frequently than in the past with a daily use of more than 3 h in 46% of cases. Adolescents connected Internet alone (59%), consulting social media, mostly Instagram (72%), TikTok (62%), and YouTube (58%) [ 4 ]. In this context, social interaction over the Internet or simply social network consulting may play an important part in the lives of many young people, influencing them and their relationship with self-esteem and well-being [ 5 ]. Not being guided and monitored in Internet fruition, the young may be exposed to several risks, including cyberbullying which affects 7% of children aged 11–13 years and 5.2% of 14–17 years old adolescents or stalking which affects more than 600 minors in Italy. On social media, the young are more vulnerable and may display risk behavior, including pertaining substance abuse, sexual behaviors, or violence [ 6 ].

On the other hand, media and social networks are, actually, present in almost any house and are considered a great resource for anybody, including children and adolescents. Especially during “lockdown”, the Internet usage allowed communication with peers and the continuity activities such as school teaching. Social media services enable various form of communication verbally or visually by internet-based networking, bringing people together, facilitating instant connection and interaction, such as a like or a comment on something [ 7 ]. There was also a “school” use of smartphones and social media during lockdown which represented a tool of information and education [ 8 ].

In line, websites and applications that enable users to create and share content or to participate in social networking may be currently use as a definition of a social media. Facebook launched in 2004 and Twitter in 2006 were the first social media introduced, rapidly followed by many others [ 9 ]. Actually, Facebook with 2.9 billion monthly active users, YouTube with 2 billion, Instagram with 1.5 billion, and TikTok with 1 billion are the most accessed social media in the world [ 10 ]. As social media are spreading in every day’s life, regulatory models are required to address a broad range of challenges social media pose to the community, including privacy and protection of sensitive data.

Media usage is related to some adverse consequences especially in the most vulnerable people. The health emergency had a strong impact on the mental and psychological health of adolescents causing changing in their routine and daily activities. Forced isolation increased anxiety and stress especially in the most fragile individuals, such as children and adolescents, leading to a change in habitual lifestyles. The greatest risk was that of taking refuge in excessive use of smartphones, electronic devices, and social networks, running into a “digital overdose” [ 11 ].

A recent survey conducted by the Italian Society of Pediatrics in collaboration with State Police and Skuola.net investigated the relationship with media devices in times of pandemic, investigating the habits of adolescents on the use of media and social networks, underlined that 15% of them declared they “cannot stay without” their own media device [ 1 ].

The aim of the review is to focus on risks correlated to social media use by the young, identifying spies of rising problems, and engaging in preventive recommendations.

2. Materials and Methods

This scoping review has been conducted by The Italian Pediatric Society Scientific Communication Group in order to provide an overview of a complex research area. The aim is reviewing international literature disguising about social media and their effect on the pediatric age, including minors less than 18 years, to underline possible risks found so far, identifying the signs of a dangerous use, and to eventually give new recommendation based on these findings.

We define a risk as the possibility of something unfavorable happens, as an effect or an implication of social media usage and which may potentially affect human health. This scoping review has been performed according to the PRISMA Extension guidelines for Scoping Reviews [ 12 ].

An electronic search was undertaken on PubMed database on 23 January 2022. To avoid missing results that may be of note for our revision study, constructing our search in PubMed, we used all of the important concepts from our basic clinical question, avoiding unnecessary filters.

So, the search terms “social media”, “health”, and “pediatrics” in text or title/abstract were used, with the time span set as “all years”. The search on the selected database has produced n 651 among articles and reviews. Another research was made using “social network”, “health” and “pediatrics” as search terms in text or title/abstract, with the time span always set as “all years”. It resulted in 354 articles/reviews.

The two research were downloaded from PubMed and then uploaded to the web application “Rayyan” [ 13 ], a website used to screen and analyze articles, specific for writing reviews. Additional articles for potential inclusion were identified in a second stage by hand searching the reference lists in relevant articles.

Studies were considered eligible for this scoping review if they met the following inclusion criteria:

Full-length articles or reviews.

Pertaining to children and adolescents up to 18 years old.

Negative impact on a pediatric population using social media.

Social media meant as forms of electronic communication.

The exclusion criteria were:

Reports not in English.

Duplications.

Not pertinent field of investigation (e.g., use of the social media to promote healthcare, benefits of social media, social media used to debate on health-related issues, and social network meant as real social interactions).

The population analyzed was adult (>18 years).

The population had previous pathologies.

To reduce errors and bias, two researchers independently, two researchers conducted the screening process to identify articles that met all inclusion criteria. Using the web application “Rayyan” [ 13 ], duplicates were removed, then titles and abstracts were analyzed to exclude distinctly irrelevant articles. Finally, the eligibility of the articles was confirmed by evaluating the full text. Disagreements regarding inclusion/exclusion were settled by discussion between the researchers.

Relevant articles were selected on the web application “Rayyan” and grouped together based on the issue they were dealing with. Afterwards, data were compiled in a Microsoft Excel spreadsheet to calculate frequencies and percentages of the problems related to social media use, found in the research.

All the 1005 documents have been reviewed for relevance and eligibility.

As shown in the Figure 1 , through the help of the web application “Rayyan” [ 13 ] we removed before screening 9 duplicates, 25 foreign language works, and 49 publications dated before 2004. We excluded paper published before 2004, the year of Facebook foundation, because before that year “social networks” was a term used to mean “social interactions in real life”, as they were not pertinent to our research.

Flow chart of the selection process. * automation tools were used: 6 records were excluded by automation tools and 3 were excluded by authors. Twenty-five records were excluded because they were not written in English, these were identified using automation tools, but then checked by authors. ** 49 records were removed because they were published before 2004, and no social network existed before that year.

According to PRISMA guidelines [ 12 ], of the 922 works identified, all abstracts were analyzed, and 832 records were excluded. Around 66% of the excluded records were dealing with other topics (e.g., vaccines, promoting health by social media, social networks meant as real social interactions, and social lockdown during SARS-CoV-2 period), a percentage of 28% of the records corresponded to a wrong population: mostly parents, pregnant women, young adults, or children with pathologies (e.g., ADHD). About 6% of the excluded studies used social media tools to recruit people in their studies or to deliver questionnaires.

In conclusion, 90 were the records to be analyzed reading their full-length articles. The whole article of four of them has not been found (“reports not retrieved”), arriving at 86 reports assessed for eligibility. Figure 1 presents the flow chart of the selection process, adapted from PRISMA guideline [ 14 ].

Of the 86 reports attained, we read the whole length articles and then excluded 20 studies.

Of these twenty, 6 were excluded because not leading to any conclusion; 13 were dealing with wrong topics, such as: doctors’ social media knowledge; social lock down during the pandemic; social media marketing; underage and privacy; survey on how social media is perceived by adolescents; time consumed on social media; predictor factors of problematic social media use. Finally, one was not included because it focused on parents and families.

Searching through the cited studies in the included reports, two reviews which were not initially included in the research were added.

With 68 included reports analyzed, there were 15 reviews; of these two were systematic reviews, one validation study, and one editorial. Cross-sectional studies and longitudinal studies have been considered, eight and nine, respectively.

Many articles reported more than one issue correlated to social media use. The most frequent problems involved mental health, followed by diet and weight problems. Table 1 shows the problematic topics found to be related to social media use in children and adolescents and their prevalence, expressed as percentage, over the 68 reports analyzed.

Social media health related problems in a pediatric population. This table shows the issues found in this scoping review. Depression was argued in 19 reports, being the main topic found (27.9% of the whole study). Diet associated problems were discussed in 15 reports, cyberbullying in 15, psychological problems in 14, sleep related problems in 13, addiction in 10, anxiety in 10, sex related problems in 9, behavioral problems in 7, body images distortion in 6, reduced physical activity and related problems has been reported in 5 reports, online grooming in 3 reports, sight problems in 3, also headache in 3, and dental caries in total of 2 articles.

The most frequent problems found are related to mental health: depression, anxiety, and addiction.

Other problems are related to sleep, diet and nutrition, cyberbullying, psychological aspects, behavioral problems, sex, body image perception, physical activity, online grooming, sight, headache, and dental caries.

4. Discussion

4.1. social media and depression.

We identified 19 publications reporting a relationship between social media use and depression [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. Table 2 summarized the main finding regarding each article. Out of them, four investigated the impact of COVID 19 pandemic on both social media use and depression ( Table 2 ).

Social media and depression.

4.1.1. Before COVID-19 Pandemic

Investigating the impact of social media on adolescents’ wellbeing is a priority due to a progressive increase in mental health problems or addiction and access to Emergency Department [ 15 ]. As Chiu and Rutter stated, there is a positive relationship between internalizing symptoms, such as depression and anxiety, and social media use [ 15 , 16 ]. Depression is connected to a rapidly increased of digital communication and virtual spaces, which substitute face-to-face contact by excessive smartphone use and online chatting. The more time adolescents spend on social device the higher levels of depression are found out. In this sense, social media are representing a risk factor for depression in the young. Depression, anxiety, and behavioral disorders are among the leading causes of illness and disability among adolescents [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. Key findings which correlate to depression regarding social media exposure are repeated activities such as checking messages, investment, and addition [ 23 ]. The findings were similar all over the world.

For example, in Sweden, spending more than 2 h on social media was associated with higher odds of feeling [ 20 ]. In Egypt, as well, students who have problematic Internet use, have higher psychiatric comorbidities, such as depression, anxiety, and suicidal tendency [ 24 ].

Social media addiction and more precisely Facebook addiction was linked not only to depression but even to dysthymia, so that the expression “Facebook depression” was coined to identify a relationship between depression and social networking activity [ 15 , 25 , 26 ]. Individuals suffering from Facebook depression may be at an increased risk of social isolation and may be more vulnerable to drugs or behavioral problems [ 26 ].

Internet penetrance and connectivity are also connected to cyberbullying which can lead to depression and suicidality [ 27 , 28 , 29 ].

On the other side, physical activity may decrease depression and anxiety, potentially protecting the young against the harmful effect of social media abuse [ 16 ].

At last, even if a positive correlation between internalizing symptoms and media use device is noted, Hoge states that there is also evidence that social media communication may improve mood and promote health strategies in some occasions [ 18 ].

Finally, even if evidence revealed that social media use is linked to poor mental health, the relationship between social media and depression in adolescents is still to be completely understood. It is still unclear whether social media use leads to more depression or if these depressive symptoms cause individuals to seek out more social media, which could feed into a vicious cycle [ 16 ]. Keles’s conclusion as well suggest defining the relationship between internalizing symptoms and social media use as an association and not a causative effect [ 23 ].

4.1.2. After COVID 19 Pandemic

During COVID-19 pandemic, the state of emergency and social isolation determined an increase in time on screen not only as a source of online education, but to continuously access social media. According to recent data, a percentage of 48% of adolescents spent a mean of 5 h per day on social media and 12% spent more than 10 h. Moreover, with that increase in virtual time depression arose [ 30 ].

The degree of social media usage in children is a significant predictor of depression, which increases with each additional hour of social media use [ 31 ].

During the pandemic, depressive symptoms may have been reactive to the context of being afraid of the virus and necessitating social isolation [ 32 ].

However, in this peculiar period, schoolchildren who increased time spent on either smartphones, social media, or gaming had significantly elevated psychological distress, such as depressive symptoms, than those with decreased time spent on these internet-related activities [ 33 ].

4.2. Social Media and Diet

Out of the reports, 15 dealt with the association of social media use and diet [ 21 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. The problems were related to junk food marketing (9 reports) [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ] obesity (4 reports) [ 21 , 41 , 42 , 43 ], unhealthy eating behaviors (3 reports) [ 44 , 45 , 46 ], and alcohol marketing (2 reports) [ 21 , 47 ]. In Table 3 the retrieved articles dealing with social media and diet, and their major findings are presented ( Table 3 ).

Social media and diet.

4.2.1. Before COVID-19 Pandemic

Junk food marketing.

Reports found that children are exposed to the marketing of unhealthy foods on social media and to their persuasive techniques. Digital marketing represents a major threat for children and adolescents in Mexico, because of its persuasive techniques. Cola and soft drinks, sweetened juices and in general the so-called junk food have high followers on Facebook and Twitter. [ 34 ]. This may cause an increase in children’s immediate consumption of the promoted product, unhealthy behaviors and may led to obesity, as confirmed by several studies [ 34 , 35 , 36 ]. Reports agree on the youth major vulnerability to unhealthy food advertisement, including digital marketing, sponsored content, influencers, and persuasive design [ 34 , 35 , 36 ]. This contributes to the obesity epidemic [ 36 ].

Major social media platforms do not have comprehensive policies in place to restrict the marketing of unhealthy foods on their platforms [ 36 , 37 ]. Therefore, exposure to the marketing of unhealthy products, on social media may be considered a risk factor for related unhealthy behaviors.

Analysis of the advertising policies of the 16 largest social media platforms proved them ineffective in protecting children and adolescents from exposure to the digital marketing of unhealthy food [ 37 ].

Among social media, YouTube is particularly worrying considering the affinity of the young toward the platform. Unhealthy food advertisements predominate in YouTube content aimed towards children. In fact, analysis of advertisements encountered in YouTube videos targeted at children revealed that food and beverage ads appeared most frequently, with more than half of these promoting unhealthy foods [ 38 ].

As confirmed by an Irish study, adolescents are very attracted to junk food advertisements and are likely to share comments on their network: generalized linear mixed models showed that advertisements for unhealthy food evoked significantly more positive responses, compared to non-food and healthy food. Of all the advertising, they see in social media, they view unhealthy food advertising posts for longer [ 39 ]. This confirms the vulnerability of children towards ad and digital marketing.

Moreover, it has been demonstrated that adolescent heavy social media users (>3 h/day) are more willing to engage with food ads compared to light social media users, and are more willing to “like” Instagram food ads featuring many “likes” versus few “likes”, demonstrating the power of social norms in shaping behaviors. Adolescents interact with brands in ways that mimic interactions with friends on social media, which is concerning when brands promote unhealthy product. [ 40 ]. There is a need of more strict policies to limit digital marketing, which is becoming more and more intense, especially towards children and adolescents.

4.2.2. After COVID-19 Pandemic

During the COVID-19 pandemic, this phenomenon even increased. In fact, the combination of staying at home, online education and social media usage have all caused screen time to surge and the food industry has been quick to identify this change in their target audience and has intensified online advertising and focused on children. The COVID-19 experience led to an increase in risk and severity of inappropriate behavioral eating habits, affecting the health and weight [ 41 ].

4.2.3. Before COVID-19 Pandemic

Social media is the first independent risk factor for obesity in primary school children and the second for high school students. In both primary school and high school models, children’s social media use has the highest impact on child’s BMI [ 42 ]. In addition, heavy media use during preschool years is associated with small but significant increases in BMI, especially if used ≥ 2 h of media per day [ 21 ].

4.2.4. After COVID-19 Pandemic

Obesity and social media correlated through junk food advertisements [ 41 , 43 ]. During COVID 19 pandemic poor quality food, energy-dense, and nutrient-poor products consumption increased, leading to the risk of overweight and obesity. The phenomenon has been called “Covibesity” [ 41 ].

4.3. Unhealthy Eating Behavior

Some social media contents promote pro-anorexia messages [ 44 , 45 , 46 ]. These messages are no longer limited to websites that can be easily monitored, but instead have been transferred to constantly changing media such as Snapchat, Twitter, Facebook, Pinterest, and Tumblr. Consequently, pro-eating disorder content has become more easily accessible by the users. Pro-anorexia website use is correlated with a higher drive for thinness, lower evaluations of their appearance, and higher levels of perfectionism, and all correlates with eating disturbances [ 44 , 46 ].

In detail, there is a real bombardment of unhealthy messages on media promoting low-nutrition aliments and sugar-sweetened drinks [ 45 ].

It is likely that the suboptimal quality of online information on social media platform contributes to the development of unhealthy eating attitudes and behaviors in young adolescent internet users seeking nutritional information. They look for nutritional information on internet sources such as commercial websites or social media in order to lose weight. In this occasion, they may be exposed to higher risk of eating disorders due to the high quantity of misinformation. Moreover, they may find dangerous methods to rapidly lose weight with possible harm for their health [ 46 ].

Literature agrees on the risk of time spent on social media as well as on the poor quality and reliability of weight loss information on media [ 44 , 45 , 46 ].

4.4. Alcohol Marketing

Adolescents identify drinking brands to peculiar images of ideal adults. Brands know well this underlying psychological mechanism and promote that identity adolescents seek, with specific advertisement on social media [ 47 ].

Studies have shown that exposure to alcohol in TV or movies is associated with initiation of this behavior. The major alcohol brands have a strong advertising presence on social media, including Facebook, Twitter, and YouTube. Several studies underlined risky health behaviors, such as illegal alcohol use or overuse. Evidence suggests that peer viewers of this content are likely to consider these behaviors as normative and desirable. Therefore, targeted advertising via social media has a significant effect on adolescent behavior [ 21 ].

4.5. Social Media and Cyberbullying

We identified 15 publications reporting a relationship between social media use and cyberbullying [ 21 , 22 , 25 , 26 , 27 , 28 , 29 , 45 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. Table 4 summarized the main finding regarding each article ( Table 4 ).

Social media and cyberbullying.

Cyberbullying may be defined as any behavior performed through electronic or digital media by individuals or groups that repeatedly communicate hostile or aggressive messages intended to inflict harm or discomfort on others. Compared to bullying, cyberbullying may be even more dangerous as victims can be reached anytime and in any place. Moreover, anonymity amplifies aggression as the perpetrator feels out of reach.

Moreover, the ability to hide behind fake names provides bullies the opportunity to communicate in content and language they would not use in front of people [ 26 , 48 , 49 ]. As confirmed by Shah et al., the anonymity of cyberbullying increases the risk for inappropriate behaviors among adolescents [ 50 ].

In literature, cyberbullying has been identified in phone calls, text messages, pictures/video clips, emails, and messaging apps. This is a great public health concern: in Italy, 2015 ISTAT data showed that 19.8% of 11–17 years old internet users report being cyberbullied [ 49 ].

This phenomenon is increasing. In fact, the number of adolescents being cyberbullied at least once in their life increased from 20.8% in 2010 to 33.8% in 2016 [ 50 ].

Victims of bullies exhibit increased depressive symptoms, anxiety, internalizing behaviors, externalizing behaviors, and greater academic distractions [ 21 , 22 , 25 , 27 , 28 , 29 , 51 ].

Cyberbullying has been associated with higher risks of depression, paranoia, anxiety, and suicide than the traditional form of bullying [ 21 , 22 ]. According to a metanalysis of 34 studies, traditional bullying increased suicide ideation by a factor of 2.16, whereas cyberbullying increased it by a factor of 3.12 [ 39 ].

In adolescence, social media intense or problematic use and frequent online contact with strangers are all independently associated with cyberbullying [ 45 , 52 , 53 ]. In this contest, social media represent a risk factor for cyberbullying and for inappropriate behavior related to it. In fact, problematic social media use is an important driver of cyberbullying victimization and perpetration, especially among girls [ 50 , 53 ]. The highest percentage is observed in adolescents, aged 13 to 15 years as suggested by literature reviews and, in particular, by Marengo and Uludasdemir [ 53 , 54 ]. However, Marengo also suggests that in presence of social support, the phenomenon is attenuated [ 53 ].

Moreover, having daily access to the Internet and the sharing of gender on social media increased the likelihood of cyber victimization among adolescents aged 12–17 years. Those who use Tumblr and Snapchat were found to become victims even more frequently [ 54 ].

4.6. Psychological Problems and Social Media

We identified 14 publications reporting a relationship between social media use and psychological problems [ 17 , 23 , 33 , 45 , 49 , 52 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. Table 5 summarized the main finding regarding each article ( Table 5 ).

Social media and psychological problems.

4.6.1. Before COVID-19 Pandemic

A high use of screen device has been correlated to a low psychological well-being among children and adolescents, especially among females [ 17 ].

For examples, in Canadians adolescents, the prevalence of loneliness was higher for daily computer-mediated communication users than non-daily users [ 55 ]. As well as for cyberbullying, adolescents may benefit from social support, family communication, and interaction to ameliorate feelings of loneliness [ 53 , 55 ]. Boer et al. confirmed that intense user reported more frequent psychological complaints than non-intense user as well as less family and friend support [ 56 ]. In line with this finding, in Lithuania a problematic social media use has been associated with two times higher odds for lower life satisfaction [ 57 ].

Moreover, an intense social media use correlated to either low school well-being and reduced social well-being (decreased family and friends support and relations) [ 56 ].

A relationship between poor life satisfaction, problematic social media use, and lack of social support was found not only in adolescents, but also in children [ 52 , 57 , 58 , 59 , 60 ].

Social media use is also correlated with conduct and emotional problems, attention deficit, peer problems, school impairments, and psychological distress [ 23 , 45 , 61 , 62 ].

Social networks and media device use correlate to low academic outcomes, reduced concentration, and procrastination. In fact, problematic smartphone use correlates to a surface approach to learning rather than to a deep approach, leading to reduced creativity, organization skills, own thinking, and comprehension of information [ 49 ].

4.6.2. After COVID-19 Pandemic

During this COVID-19 pandemic, primary school children reported significantly higher psychological distress than the period prior to the COVID-19 outbreak. Studies showed that schoolchildren who increased time spent on either smartphones, social media, or gaming had significantly elevated psychological distress than those with decreased time spent on these internet-related activities [ 33 ].

4.7. Social Media and Sleep

Extended use of digital media screen time correlates with sleep impairment [ 18 , 21 , 22 , 26 , 31 , 43 , 47 , 49 , 57 , 61 , 63 , 64 , 65 ]. Table 6 summarizes the evidence in literature ( Table 6 ). Exposure to screen-based devices, online social networking sites, and video-sharing platforms is significantly associated with sleep-onset difficulties in adolescents [ 18 , 49 ]. Findings from a meta-analysis of 20 cross-sectional studies show 53% higher odds of poor sleep quality among adolescents with consistent bedtime media use [ 63 ]. Moreover, the use of computers and smartphones among adolescents is associated with daytime sleepiness and fatigue, shorter sleep duration, later bedtime, and unfavorable changes in sleep habits over time [ 22 ]. Smartphones may be easily carried around and even taken to bed. Several sleep disorders correlate to both overall and night phone use among adolescents. It has been demonstrated that social media addiction in school students decreases students’ sleep efficiency [ 61 ]. Use of cellphones, particularly for nighttime texting, and consulting social media were associated with insufficient sleep [ 63 ]. A 5 or more hours daily of media devices use has been related to a higher risk of sleep problems when compared to a 1 h use daily [ 49 ]. This finding is confirmed by Buda who correlates problematic social media with about two times higher odds for a bad sleep quality [ 57 ]. Varghese as well associated social media use with sleep difficulties. Furthermore, YouTube user had two-times higher odds for sleep-onset difficulties [ 63 ].

Social media and sleep.

In addition, it seems that girls suffer more than boys from these sleep problems [ 57 ].

Sleeping problems, especially sleep duration, have been then associated with time spent on screen, problematic behaviors, and higher internalizing and externalizing symptoms [ 64 ].

Even among children, there is a problem with extended use of social media sites, which result in sleep deprivation due to delayed bedtimes and reduced total sleep duration and quality of rest [ 31 , 65 ]. The report by Hadjipanayis as well confirms that sleeping disturbances may be associated with the disruption of circadian rhythms due to the blue light emission from the electronic screen-based media devices [ 26 ]. Negative outcomes including poor school performance, childhood overweight and obesity, and emotional issues have all been associated with sleep deprivation [ 21 , 26 , 43 , 47 ]. Inadequate sleep quality or quantity associated to social media use represents a risk factor for metabolic conditions such as for diabetes, cardiovascular disease and for mental problem, such as depression or substance abuse [ 49 ].

4.8. Social Media and Addiction

Ten reports found correlations between social media use and risk of different types of addictions: with internet [ 17 , 24 , 49 , 51 , 52 , 66 ], with substance abuse [ 15 , 67 ], with alcohol addiction and gaming [ 67 ], with gambling [ 68 ], and with tobacco use [ 69 ]. In Table 7 , the major findings of the related reports are presented ( Table 7 ).

Social media and addiction.

Investigating the impact of social media on adolescents’ wellbeing is a priority due to a progressive increase in mental health problems and access to Emergency Department [ 15 ]. Chiu reported that mental health or addiction related emergency department access increased by almost 90% in ten years mainly among adolescents aged 14–21 years. The increment well correlates to an increase availability of social media [ 15 ].

High screen use associated with internet addiction is also confirmed by O’Keeffe who states that technology is influencing children’s lives from a very young age [ 51 ].

More than 7% of youth have problematic social media use, indicated by symptoms of addiction to social media [ 52 ]. Warning signs of internet addiction can be skipping activities, meals, and homework for social media; weight loss or gain; a reduction in school grades [ 41 ]. In detail: concern, loss of controlling tolerance, withdrawal, instability and impulsiveness, mood modification, lies, and loss of interest have been identified as risk factors for smartphone addiction. Females have almost three times more risk for smartphone addiction than males and it may be related to a stronger desire for social relationships [ 66 ]. Main problems correlated to addiction are low self-esteem, stress, anxiety, depression, insecurity, solitude, and poor scholastic outcomes. Smartphone addiction correlates to both fear of missing out (FOMO) and boredom. FOMO is the apprehension of losing experiences and the consequent wish to remain constantly connected with others, continuously checking social applications. Boredom is defined as an unpleasant emotional state, related to lack of psychological involvement and interest associated with dissatisfaction, to cope with boredom adolescents may seek additional stimulation and compulsively use smartphones [ 49 ].

As well as O’Keeffe, Hawi found out that children are starting to use digital devices at a very young age, and so should be screened for the risk of digital addiction. New scales of early identifications have been developed such as the Digital Addiction Scale for Children, validated to assess the behavior of children 9 to 12 years old in association with digital devices usage. Out of the sample size, 12.4% were identified as at risk of addiction and most of them (62.4%) were male. Nevertheless, results demonstrated that weekday device use among females causes more conflicts [ 66 ].

Different grading scales can test addictions. A study assessed 700 adolescents aged from 14 to 18 years and found out that 65.6% were having internet addiction, 61.3% were gaming addicts, and 92.8% Facebook addicts. Internet addict students had statistically significant higher age, higher socioeconomic scale score, male gender, and lower last year grades in comparison to non-addicts. Depression, dysthymia, suicide, social anxiety, and phobias were common comorbidities in addicted adolescents [ 24 ].

In undergraduate students, disordered online social networking use is associated with higher levels of alcohol craving and in pupils aged from 11 to 13, it is associated with a higher likelihood of being substance users [ 67 ]. In addition, excessive video gaming is associated with increased substance use [ 15 , 67 ].

One report showed greater risk for children and adolescents to develop gambling problems. In fact, the prevalence of adolescent gambling has increased in recent years. Across Europe, self-reported rates of adolescent gambling in 2019 ranged from 36% in Italy to 78% in Iceland. Adolescent problem gambling prevalence ranges from 1.6 to 5.6%. Not only adolescents but also children are widely exposed to gambling advertisements on television and via social media. In recent years, there has been an expansion in sports betting online, and this has been heavily promoted by advertising and marketing attractive to adolescents. Gambling is also promoted to children via social media: children are sharing and re-tweeting messages from gambling companies, they are active in conversations around gambling, and regularly consume and share visual gambling adverts. Lastly, there is also a strong relationship between gaming and gambling: in video games, children pretend to gamble and some video games would ask real money to play [ 68 ].

Finally, there might be a relationship between youth using tobacco and tobacco social media posts. It is not clear if the relationship can be cause-effect or only a correlation. Adolescents who participate in conversations about tobacco in social media by posting positive messages about tobacco are more likely to be past-month tobacco users. Posting even only one positive tobacco-related tweet was associated with greater odds of using cigarettes, e-cigarettes, or any tobacco product, compared to those who did not post positive messages about tobacco [ 69 ].

Finally, social media has been associated to social media use and may represent a risk factor for the young as it interferes with dailies activities leading to unhealthy habits. The easy access to social media by smartphone undoubtedly facilitates addiction.

4.9. Social Media and Anxiety

We identified 10 publications reporting a relationship between social media use and anxiety. Out of them, three investigated the impact of COVID 19 pandemic on social media use and anxiety [ 15 , 16 , 17 , 18 , 22 , 23 , 31 , 32 , 33 , 70 ]. Table 8 summarized the main findings ( Table 8 ).

Social media and anxiety.

4.9.1. Before COVID-19 Pandemic

Evidence agrees that the degree of social media usage in children is a significant predictor of anxiety and perceived stress levels and that it increases with each additional hour of social media use [ 17 , 23 , 31 ]. Anxiety may represent a risk factor for children and adolescents’ health as it influences the way they see their body, the way they feel, and it may impact on social acceptance and relations with peers.

The excessive use of at least one type of screen, including television, computer, social media, and video gaming, has been connected with anxiety symptoms in the pediatric age [ 22 , 23 , 31 ]. Furthermore, in Rutter’s study a significant association between depression and anxiety with social media use has been detached [ 16 ]. Nevertheless, it is still unclear if social media use provoke anxiety or if anxiety is the cause of excessive use of social media [ 16 ]. Emergency department visits for mental health, including anxiety problems, has arisen since 2009, likely linked to the increased use and the harmful effect of social media [ 15 ]. On the contrary, physical activity may protect the young against the harmful effect of social media, preventing depression and anxiety [ 16 ].

In a scientific report, Muzaffar confirmed that an association between anxiety and social media is of note. In detail, increased adolescent generalized anxiety symptoms were associated with increased Facebook use and repetitive Facebook habits. Anxious adolescents may not be able to control their discomfort to the point that they need to regularly go back to check their previous posting on Facebook [ 70 ].

The constant connection to social networks through digital devices, on its side, potentially contributes to feelings of anxiety. Adolescents and children suffering from social anxiety may prefer to interact with texting, instant messaging, and emailing than over face-to-face interactions. However, the behavior may increase risk in individuals vulnerable to social anxiety disorder because substituting digital media for interpersonal communication to avoid feared situations may be reinforced over time, making the person even more avoidant and worsening the symptoms and severity of social anxiety disorder [ 18 ].

However, in some studies, not just overexposure but also underexposure to social media was associated with adolescent anxiety, depression, and suicidal ideation [ 22 ].

4.9.2. After COVID-19 Pandemic

Screen time and social media use have increased during the pandemic. Social media has been helpful during lockdown to keep social relationships and not to discontinuate school activities. However, an excessive Internet use may negatively affect children and adolescents’ well being. So, during social lockdown, an elevated psychological distress and anxious symptoms have been described in schoolchildren who increased time spent on screen [ 32 , 33 ]. Children who increased by 15 or 30 min daily the time spent on internet presented a high level of psychological distress.

4.10. Social Media and Sex Related Problems

Studies have found social media use related to sexual problematic behaviors such as early sexual activity, exposure to pornography, and sexting. [ 21 , 22 , 26 , 50 , 51 , 71 , 72 , 73 , 74 ]. Table 9 summarizes the results ( Table 9 ).

Social media and sex related problems.

The prevalence of sex related problems cannot be accurately recorded as for a wide range of definition and sampling methods and the comparison among reports is difficult.

Especially for girls, higher social media use, associated with lower family affluence and poorer body image, are key to early sexual activity [ 71 ].

Social media use was found to be significantly associated with risky sexual behavior among pre-college students in Ethiopia. Facebook, Instagram, YouTube, and other platforms have been identified as a factor that alters adolescent’s perception and influences them to engage in risky sexual behavior. Those who view sexually suggestive Facebook photos have a higher chance of having unprotected sexual intercourse and sex with strangers [ 72 ].

Moreover, youth can be exposed to unwanted sexual material online, including unwanted nude pictures or sexually explicit videos through means such as pop-up windows or spam e-mails [ 73 ].

Children exposed to inappropriate sexual content are prone to high-risk behaviors in subsequent sexual encounters. [ 22 ] Sexting activities may also affect emotional and social wellbeing of adolescents; it is correlated to depression and risky health behaviors, such as substance use, alcohol consumption, and suicide [ 26 , 50 ]. The odds of risky sexual behavior were 1.23 higher in social media user than in other students [ 72 ]. Furthermore, on the internet, pornography is readily accessible by media device, so that Wana found out that 7% of students use social media for pornography. In most cases, adolescents admit they intentionally viewed materials [ 74 ]. Pornographic media depict a fantasy world in which unrealistic encounters result in immediate sexual gratification, and intimate relationships are nonexistent. Repeated exposure of the adolescent brain to the world of online pornography can make it difficult for adolescents to develop mature healthy sexual relationships [ 22 ].

Internet pornography usage has been documented in adolescents before the age of 18. Online pornography is often the first source of sex education for many adolescents, and exposure to violent pornography increases the odds of sexually aggressive behavior [ 50 ]. Peer advice as well as substance abuse are significant predictor for risky sexual behavior [ 72 ].

Finally, among adolescents 10–19 years of age, the rate of sexting ranges from 5 to 22% [ 50 , 72 , 74 ].

Sexting is the use of media to send nude or sexualized contents such as texts, photos, or videos. An extensive sharing of these contents through technology has been connected with a negative impact on the emotional and social wellbeing of adolescents involved. An earlier sexual debut such as the use of drugs and promiscuity have been all associated to the excessive use of sexting. It can also cause spreading of sexual content material without consent, to a third party as a method of bullying or revenge [ 21 , 26 , 51 , 74 ].

4.11. Social Media and Behavioral Problems

Out of the reports, seven explored the influence of social media and behavioral problems [ 22 , 49 , 64 , 75 , 76 , 77 , 78 ]. Table 10 outlines the highlighted findings ( Table 10 ). Behavioral outcomes usually cover five areas, including hyperactivity/inattention, emotional symptoms, conduct problems, peer relationship, and pro-social behavior.

Social media and behavioral problems.

For children aged 10–15 years old, limited time on social media has no effect on most emotional and behavioral outcomes (and can even positively impact social relationships), while there are strong negative associations between very long hours on social media and increased emotional distress and worse behavioral outcomes, which continue for several years [ 75 ].

In accordance to McNamee, the study by Okada conducted in Japan [ 76 ] among children aged 9–10 years old highlighted that mobile devices usage time of less than 1 h was a protective factor for behavior problems in boys. Instead, the usage time of 1 h or more was a risk factor in girls. Among girls, a dose–response positive association was found between duration of mobile devices usage and total difficulty score. A U-shaped association was found between duration of mobile devices usage and behavioral problems in boys: moderate use of mobile devices might be a tool for relaxation or alleviating distress through interactions with peers. However, in the subscale analysis, boys who use two or more hours of mobile devices showed higher risk of emotional problems and peer problems [ 76 ].

Moreover, the social media violent content exposure may be a risk factor for violent and aggressive behaviors. In this context, levels of aggression are directly proportional to exposure of types of violent media content. Electronic and social media showing contents with fights, stealing, dead bodies, and people’s belongings being destroyed influence young viewers, as per observational-learning theory, making them believe that reacting aggressively in response to perception of any offense is acceptable [ 77 ].

In line with Tahir’s report, Maurer underlined a significant association between exposure to media violence and aggressive behavior, aggressive thoughts, angry feelings, and physiologic arousal. Media exposure is also negatively related to personal adjustment and school performance and positively related to risk-taking behaviors [ 22 ].

Another study confirmed that longer the time spent on screens, higher the risk for behavioral problems among children 9–10 years old, and depending on the content type visualization, the risk for an aggressive and rule-breaking behavior. This association was mediated by sleep duration: longer sleep duration was associated with fewer problem behaviors [ 64 ].

Challenges and risk-taking attitudes are frequent in child and youth culture. However, online challenges take on new meanings when mediated by digital sociability; they appear as a powerful communicative resource to reaffirm belonging, recognition, and audience adherence. They are a media strategy adopted by youth in the construction of an internet-mediated identity in which risk and violence are crucial devices in building a self-image capable of maintaining an audience. Nevertheless, they can involve potential self-inflicted injuries to participants, with risks ranging from minor to even lethal [ 78 ].

Finally, an emerging problem is the social phenomenon called Shakaiteki Hikikomori (social withdrawal). Most of them are males and they usually experience a social reclusion range from 1 to 4 years. They refuse to communicate even with their own family and spend even more than 12 h a day in front of a screen [ 49 ].

4.12. Social Media and Body Image

On social media platforms such as Facebook, Snapchat, and Instagram, body image has become an important topic [ 17 , 25 , 45 , 46 , 50 , 73 ]. Table 11 summarized the evidence. ( Table 11 ). People post their most flattering photos and view those of others, creating an online environment that could be damaging to body image acceptance. Spending time on social media puts adolescents under a higher risk of comparing themselves to models that are more attractive. As a result, these unfavorable social comparisons of physical appearance may exacerbate body image apprehension [ 17 , 45 ].

Social media and body image.

Moreover, beauty trends are constantly reinforced through social media networks and image-editing tools are often used to alter images to fit beauty standards. Teenagers who, perhaps, are not aware of these digital changing made in commercial photos may become insecure of their image. This may reduce self-esteem and body satisfaction, mainly among adolescent girls, developing body image concerns, engaging in weight-modification behavior, and potentially developing eating disorders. Nowadays, adolescents, and, in particular, girls, need to fit “social media” standard for photo posting; they use to modify photos with specific programs in order to respect society beauty standard. In fact, 28% of girls aged 8–18 years admit to editing their photos to make themselves look more attractive prior to posting online [ 50 ].

In addition to social media causing body image problems, adolescents with body image misperception may look on the internet for advice on how to lose weight quickly. However, the suboptimal quality of online information contributes to the development of unhealthy eating attitudes and behaviors in young adolescents. It may be that the content of these sites promotes eating disorders by providing unhealthy weight loss advice [ 46 ].

Furthermore, the desire of perfection and selfie mania with repeated selfie can cause depression and self-harm. This is a typical symptom of body dysmorphic disorder [ 73 ].

Finally, this association between the use of social media, self-esteem and body image can be a correlation and not a cause-effect relation: girls with lower self-esteem and sensitive to body image complains may use social media more frequently than girls with a higher level of self-esteem. For example, users can make a “selective self-presentation” where they show themselves only in a positive way on their social media profiles [ 25 ].

4.13. Social Media and Physical Activity

Evidence supports a correlation between social media and physical activity [ 45 , 49 , 57 , 73 , 79 ]. Excessive use of smartphones and other digital devices can also cause physical problems, such as a more sedentary lifestyle [ 45 ], which is positively associated with childhood obesity. In addition, non-physiological postures assumed while using smartphones may lead to cervical rigidity and muscle pain resulting in neck strain or “Tech Neck”. Moreover, “texting thumb” is a form of tendinitis that comes from overusing the thumb from excessive texting, video gaming, and web browsing using a smartphone [ 49 , 73 ].

An Australian study found that non-organized physical activity declines between 11 and 13 years, especially in children with a large increase in activities of texting, emailing, social media, and other internet use [ 79 ].

Another study showed that problematic social media use is related to lower levels of vigorous physical activity, especially in girls [ 57 ].

In Table 12 are listed the reports related to this topic and their major content ( Table 12 ).

Social media and physical activity.

4.14. Online Grooming

Online grooming may be defined as a situation in which an adult builds a relationship with a minor finalized to a sexual abuse using social media. [ 47 , 80 ]. The risk of developing post-traumatic stress disorder in the victims is of note and may affect mental and well-being of children and adolescents [ 80 ].

Children are more vulnerable online as they often escape their parents’ control and may be more willing to share information or pictures about themselves than in real life.

Online grooming, differently to offline sexual abuse, is simpler to perpetrate, due to internet’s technology and accessibility. Furthermore, often the perpetrator misrepresents himself as another child or teenager, in order to establish a trusting relationship [ 21 ].

Teenage girls appear to be more at risk, even if the proportion of male victims is considerable too. In general, minors with problematic internet use are at greater risk of being groomed.

Sexual solicitation has been found to be more common in children spending longer time on internet on weekdays, being involved in sexting, having strangers in social networks friends list, playing online games, and chats. The risk is high even for adolescents whose curiosity and unconsciousness set them at risk of being deceived [ 80 ].

Table 13 presents the reports related to this topic and their major content ( Table 13 ).

Social media and online grooming.

4.15. Social Media and Sight

Studies have investigated the risk of social media on sight, in terms of visual imbalance [ 22 , 49 , 73 ]. Evidence underlines that children can develop ocular disorders from excessive screen time, including myopia, eye fatigue, dryness, blurry vision, irritation, burning sensation, conjunctival injection, ocular redness, dry eye disease, decreased visual acuity, strain, fatigue acute acquired concomitant esotropia, and macular degeneration. During smartphone use, there is a reduction of the blink rate to 5–6/min that promotes tear evaporation and accommodation, leading to dry eye disease [ 49 , 73 ].

In addition, excessive screen time and less time spent outdoors may lead to early development of myopia, particularly with smartphone and tablet use [ 22 ].

Table 14 presents the reports related to this topic and their major content ( Table 14 ).

Social media and sight.

4.16. Social Media and Headache

There are increased complaints of headaches related to staring at a screen for too long [ 62 , 73 , 81 ]. Reports dealing with social media and headache are listed in Table 15 ( Table 15 ).

Social Media and headache.

Headache is actually the most common neurologic disorder in the population, children and adolescents included [ 81 ]. It may negatively impact on children and adolescents’ well-being, leading to stress, tiredness, anxiety, and bad mood. Time of usage of media device has been directly connected to headache: in particular, adolescents using more than 3 h a screen have a significantly higher risk of headache compared with those using a device for less than 2 h ( p < 0.001). Spending even 2–3 h with a computer significantly increases the chance of suffering a headache in comparison with those using a computer for less than 2 h ( p < 0.01). Excessive use of electronic devices is considered a risk factor, especially for the development of migraine-type headache ( p < 0.05) [ 81 ].

According to recent studies, headache and somatic symptoms have been found mostly in patients with problematic social media usage, compared with non-problematic peers. There is a consistent association between the problematic use of social media and adolescent psychosomatic health [ 62 , 73 ].

4.17. Social Media and Dental Caries

The association between use of internet and social media has been studied in literature [ 35 , 82 ]. Table 16 summarizes the main findings ( Table 16 ).

Social media and dental caries.

The association between use of internet social media to obtain oral health information and dental caries has been highlighted in Almoddahi’s report [ 82 ]. In detail, problematic internet use has been associated with unhealthy lifestyles, poor oral health behaviors, and more oral symptoms such as toothache, bleeding gums, and poor self-perceived oral health. Caries and junk food have been both connected to excessive internet use and ads [ 82 ]. Therefore, social media may be a risk factor for caries, poor oral health, and dental outcomes.

In line with Almoddahi, Radesky underlines that advertisements on social media promote intake of foods that contribute to dental caries, such as fast food and sugar beverages [ 35 ]. Nevertheless, evidence suggests that smartphone applications may improve health and oral health when internet-based health interventions are in place. Delivering oral health information via social media may increase tooth brushing and dental outcome [ 82 ].

5. Limitations

From the literature, it is not possible to decide whether social media use causes internalizing symptoms and problematic behaviors examined in this manuscript or whether children and adolescents suffering from depression, anxiety, or other psychological distress are more likely to spend time on social media. We can just state that there is an association between social media use and health problems, but that is not necessarily cause-effect. Moreover, the articles included are different, ranging from reviewers to clinical studies to letters and to editors, so that it may be difficult to accurately compare them. Third, as specified in the materials and methods, we excluded reports not in English letter and not published in PubMed.

Nevertheless, through our manuscript we contribute to the existing literature to highlighting the impact of social media use on adolescents, providing advices to pediatricians in everyday practice.

6. Conclusions

Social media is increasingly being used by children and adolescents, especially during COVID-19 pandemic and the health emergency. Although social media use demonstrated to be of utility, an excessive or non-correct use may be a risk factor for mental health, including depression, anxiety, and addiction.

Social media use may also correlate to a non-adequate nutrition with consumption of junk food marketing leading to weight gain, obesity, dental caries, and unhealthy eating behaviors. Associations have been found also with increasing physical problems due to sedentary lifestyle, obesity, and non-physiological postures. On the other hand, social media can cause problems with body image visualization and acceptance, especially in young adolescent girls with lower self-esteem, who may look for contents for losing weight rapidly, and this can help the extension of anorexia disorders.

Children and adolescents who use social media for many hours a day, are also at higher risk for behavioral problems, cyberbullying, online grooming, sleep difficulties, eye problems, (such as myopia, eye fatigue, dryness, blurry vision, irritation, burning sensation, conjunctival injection, ocular redness, and dry eye disease), and headache. Moreover, uncontrolled social media use, can lead to sexting, exposure to pornography, exposed to unwanted sexual material online, and early sexual activity. Social media users meet more online risks than their peers do, with an increased risk for those who are more digitally competence.

Public and medical awareness must rise over this topic and new prevention measures must be found, starting with health practitioners, caregivers, and websites/application developers. Families should be educating on the dangers and concerns of having children and adolescence online. Prerequisite to inform families how to handle social media is to educate those responsible for training, including health practitioners. In detail, pediatricians should be reminded to screen for media exposure (amount and content) during periodic check-up visits. They need to keep in mind a potential correlation of problematic social media use with depression, obesity and unhealthy eating behavior, psychological problems, sleep disorder, addiction, anxiety, sex related problem, behavioral problem, body image, physical inactivity, online grooming, sight compromising, headache, and dental caries. Pediatricians can also counsel parents to guide children to appropriate content by consulting ratings, reviews, plot descriptions, and by a previous screening of the material. They should inform parents about the potential risk of digital commerce to facilitate junk food, poor nutrition and sweetened aliments, facilitating overweight and obesity. On the contrary, a healthy diet, adequate physical activity and sleep need to be recommended. Pediatricians may also play a role in preventing cyberbullying by educating both adolescent and families on appropriate online behaviors and on privacy respect. They should also promote a face-to-face communication and to limit online communication by social media. Pediatricians may encourage parents to develop rules and strategies about media device and social media use at home as well as in every day’s life.

Author Contributions

Conceptualization: E.B.; methodology: S.B.; formal analysis G.S. and A.D.M.; Resources R.A. and R.R.; writing E.S. and A.V.D.S.; visualization: C.C.; editing: A.S.; supervision G.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement.

Data available at Dr Bozzola’s study.

Conflicts of Interest

The authors declare no conflict of interest.

Funding Statement

This research received no external funding.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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• Published: 27 June 2022

“Why don’t I look like her?” How adolescent girls view social media and its connection to body image

• Alana Papageorgiou 1 , 2 ,
• Colleen Fisher 2 &
• Donna Cross 1 , 3  

BMC Women's Health volume  22 , Article number:  261 ( 2022 ) Cite this article

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Adolescent girls appear more vulnerable to experiencing mental health difficulties from social media use than boys. The presence of sexualized images online is thought to contribute, through increasing body dissatisfaction among adolescent girls. Sexual objectification through images may reinforce to adolescent girls that their value is based on their appearance. This study explored how sexualized images typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways.

In-depth interviews were conducted with girls aged 14–17 years (n = 24) in Perth, Western Australia. Data were analyzed using thematic analysis.

Participants identified body image as a major concern, reporting negative appearance comparisons when viewing images on social media. Appearance comparisons were perceived to exacerbate adolescent girls’ appearance-based concerns. Comparisons also influenced adolescent girls’ efforts to change their appearance and seek validation on social media. The importance of awareness and education from a younger age about social media and its influence on body image was emphasized, as was the need for strategies to promote positive body image and counteract negative body image.

The findings of this study have important implications for professionals working with adolescent girls and for the development of health promotion programs addressing social media use and body image concerns.

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Adolescence is an important period of development, with major physical, social, cognitive and emotional changes, and identity formation occurring [ 1 ]. Adolescence is also a time when young people begin to use social media, online platforms enabling social interaction through the creation of individualized online profiles and sharing of photos, videos and other media on sites or apps such as Instagram, Snapchat and Facebook [ 2 , 3 ]. Social media has been found to have both positive and negative impacts on the lives of adolescents. Positive aspects of social media use include increased peer connection and support, and opportunities to learn [ 4 , 5 , 6 ]. However, research has largely reported adverse influences from adolescents’ social media use, contributing to mental health difficulties including increased depression, anxiety, and self-harm behaviors, decreased socio-emotional wellbeing, low self-esteem and negative body image [ 7 , 8 , 9 , 10 ]. For girls, the combination of reaching puberty, their body changing, and the importance of approval from peers and romantic relationship formation can increase vulnerability to negative body image and research suggests social media may have a greater influence on their body dissatisfaction compared to boys’ [ 2 , 11 , 12 ].

Body image encompasses the thoughts, feelings, beliefs and attitudes one has about their body and appearance [ 13 ]. Body dissatisfaction is an important element of body image and can range in severity from having a preference for different body characteristics to the uptake of extreme action to change one’s body [ 14 ]. Body dissatisfaction has been linked to low self-esteem, decreased mental health and wellbeing, and the development of eating disorders among adolescent girls [ 14 , 15 , 16 , 17 ]. The potential harms associated with body dissatisfaction highlight negative body image as an important public health concern [ 18 ].

Time spent on the Internet has been associated with increased body dissatisfaction among adolescent girls, with the interaction allowed by social media and appearance-focused content influencing body image concerns through negative social comparisons and peer normative processes [ 11 , 19 , 20 , 21 , 22 ]. Images of attractive thin females, often photo-shopped with filters, feature frequently on social media platforms such as Instagram, promoting stereotyped beauty ideals subsequently affecting viewers’ body image and dissatisfaction [ 9 , 23 ]. The females in images on social media are more commonly peers rather than celebrities like those included in mass media, which may influence body image related attitudes and concerns more significantly, given peers’ relatability and relevance to girls’ daily lives [ 19 , 24 , 25 ]. A study investigating the effect of manipulated Instagram selfies on adolescent girls’ body image found such images resulted in poorer body image perception, especially among those with high levels of social comparison [ 24 ]. Given the increasing prevalence of image-sharing online, young people may need support to improve their self-esteem and become more informed consumers of digital images (e.g. being able to identify enhanced or photo-shopped images as unrealistic and unattainable).

While social media can also counteract negative body image messages with positive body image accounts, even these accounts have been identified as commonly featuring appearance focused content [ 26 , 27 ]. It seems the overwhelming message to adolescent girls is that their value is largely derived from their appearance [ 28 , 29 ]. Girls can now easily and frequently compare themselves to those they follow on Instagram, whether they are peers or celebrities. The role of social media on body image is also an important issue for consideration among adolescent boys; however, existing research suggests girls are more likely to report negative body image [ 29 , 30 ].

An increased level of female sexual objectification has been identified through images on social media, where gender inequality is reinforced through the depiction of girls and women as sexually available and objectified [ 31 , 32 , 33 , 34 ]. Sexual objectification through social media may then lead to adolescent girls’ internalization of conventional ideas of femininity, with subsequent effects on their mental health and wellbeing [ 34 , 35 , 36 , 37 , 38 ]. For body image development, sexually objectified images on social media provide ample opportunity for girls to evaluate themselves against such images which emphasize appearing ‘sexy’ as critical to identity and that their worth is based on constant observation and evaluation of their appearance [ 36 , 39 ]. Additionally, while masculinity ideals are featuring more frequently in the media, including social media, the sexualization of females remains pervasive compared to males [ 40 ].

Previous research conducted on the influence of sexualized media on females’ body image as an indicator of mental health has largely focused on the impact of conventional mass media [ 41 , 42 ], employed quantitative research methods [ 21 , 34 , 43 , 44 , 45 ], analyzed sexualized content in various forms of media [ 46 ], focused on pre/early adolescent girls [ 29 , 47 , 48 ] or young women [ 32 , 49 , 50 , 51 , 52 ]. There are few qualitative studies exploring the influence of sexualized images on social media or the role of social media use in body image development from the perspective of adolescent girls themselves. Of these, the focus has either been on sexualized content only [ 53 , 54 ], image-sharing practices on social media [ 31 , 33 , 55 ], or the influence of social media use broadly (without a focus on sexualized images) on body image [ 11 , 56 , 57 ]. To the best of the authors’ knowledge, there are no qualitative studies exploring adolescent girls’ perceptions of the influence of sexualized images on social media on their mental health, or body image, as referred to in the present study. Nonetheless, these studies illuminate the ubiquity of appearance-focused and objectified images girls encounter when using social media and the challenges they experience navigating sexualized ideals of femininity [ 31 , 53 , 54 ]. Focus groups with girls and boys found the importance of appearing attractive on social media [ 33 , 55 , 56 ] and the perception that social media negatively impacted one’s body image [ 57 ] were more prominent for girls. Additionally, focus groups with only girls reported they frequently use social media to engage in appearance-focused social comparisons and some girls in the study indicated they were dissatisfied with their appearance [ 11 ]. These findings, in combination with their limitations related to focus group methodology whereby participants may have provided socially desirable responses, warrant further in-depth exploration with adolescent girls. Therefore, the aim of this study was to explore how sexualized images of females’ bodies typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways. A generic qualitative approach [ 58 ] utilizing in-depth interviews with adolescent girls was used for this study. The findings reported here are part of a broader study that included interviews with parents of adolescent girls, secondary school staff in a support service role such as school psychologists and those on pastoral care teams, and youth mental health service providers. Only the findings from girls are reported in this paper.

A generic qualitative research design was used for this study, an approach which is not informed by any one known qualitative methodology and its explicit or established set of philosophical assumptions [ 58 ]. A constructivist epistemology [ 59 , 60 ] guided the study to explore the unique perspectives of adolescent girls using one-on-one in-depth interviews to elicit their thoughts, knowledge and experiences [ 61 , 62 ].

Theoretical framework

Objectification Theory has been used to better understand the impacts of being female in a culture that sexually objectifies the female body [ 34 ] and suggests this leads to self-objectification whereby females internalize an observer’s perspective as a primary view of themselves and their bodies [ 63 ]. Adolescent girls may be particularly susceptible to self-objectification as adolescence is a developmental period of increased self-awareness, self-consciousness, and preoccupation with image and a time when identity is established [ 64 ]. When girls encounter sexualized images while using social media, they may self-objectify as they observe and view such content [ 65 ]. Additionally, the dual pathway model [ 66 , 67 ] provides a framework for understanding the mechanisms in which adolescent girls’ social media use can influence their body image. The dual pathway model suggests sociocultural appearance pressures and the internalization of appearance ideals lead to body dissatisfaction and subsequent risk factors for eating disorder development such as disordered eating behaviors [ 68 ]. Pressure to conform to appearance ideals through adolescent girls’ social media use and the extent to which they internalize these ideals may contribute to body dissatisfaction [ 9 ] and consequently, their likelihood of engaging in disordered eating behaviors with impacts on their mental health [ 68 ].

Participants

A purposive sample of twenty-four adolescent girls aged 14–17 years (Grades 9–11) was recruited for the study from the Student Edge (an Australian student membership organization) youth research panel (n = 13, 54.17%), non-government schools (n = 6, 25%) and through snowball sampling techniques (n = 5, 20.83%) in Perth, Western Australia between 2016 and 2018. Inclusion criteria to participate in the study included active use (i.e., one hour or more per day) of at least one social media platform (i.e., Instagram, Snapchat, Facebook). Most participants were 16–17 years of age (n = 14), spoke English as their first language, and attended a non-government school. One of the participants spoke English as a second language and seven of the participants attended two different all girls’ schools.

Full ethical approval to conduct this research was obtained from the University of Western Australia Human Research Ethics Committee. Student Edge emailed the relevant target audience from their membership base (girls aged 14–17 years in the Perth metropolitan area) and provided a link on their website to a screening survey. The screening survey explained the research project and what participation involved, asked students their age and gender, and if they would like to participate. Those who responded ‘yes’ and met the inclusion criteria for participation (n = 45) had their name, phone number and email address captured based on their Student Edge membership details. These details were then sent to the first author who made contact via phone and/or email to arrange an interview.

To recruit students from non-government schools, approval was first sought from the Catholic Education Office of Western Australia and the Association of Independent Schools of Western Australia then school principals, who were contacted by phone and email seeking their approval for project information to be distributed within their schools via email, newsletter items and flyers. Parents and students were provided with an information sheet describing the research and asked to contact the research team via phone or email if they were interested in participating. School principals were asked to nominate a school-coordinator to assist in arranging student interviews. Additionally, girls were recruited through snowball sampling methods, with those who participated in the study asked to distribute project information to other girls aged between 14 and 17 years.

Prior to participation in the study, written informed consent was obtained from both parents or guardians and adolescent girls. For those recruited from the Student Edge youth research panel, parent or guardian consent was required for students under 15 years to be eligible to become a member.

Adolescent girls participated in one-on-one semi-structured interviews with open-ended questioning undertaken by the first author between October 2016 and February 2018. During the interviews, girls were asked questions in relation to publicly available images of celebrities from Instagram using third person disclosures. These methods were used to enable discussion without participants having to reveal personal experiences which may have caused discomfort, and as a requirement of the study’s ethical approvals. The images were selected from celebrities with some of the largest numbers of female followers on Instagram at the time of data collection (Selena Gomez, Gigi Hadid, Kylie Jenner and Kendall Jenner), and for variation in parts of the body that were emphasized, and the presence of a sexually suggestive pose as used in previous studies [ 24 , 46 ]. Participants were shown each image and asked what girls their age looking at Instagram might think about the images and why, how the images might make them feel about themselves and why, and how the images might influence mental health (in both positive and negative ways). Participants were also asked for their opinions about the sexualization of girls through images on social media, and in what ways this could be positive or negative. Interviews concluded with asking girls what they thought might help or prevent any of the negative influences on body image they identified. Participants were also asked demographic questions, how often they used social media, and what types of social media they used.

Prior to data collection, the interview protocol was pilot tested with a convenience sample of two adolescent girls aged between 16 and 17 years to provide feedback on question development and types of responses received, as well as the skills of the interviewer. No changes were made to the protocol as a result of the pilot testing.

Ten of the interviews were conducted in person (at their school or a public location) and the remaining fourteen interviews via phone (by participant request). Interviews lasted between thirty minutes and one hour.

Data analysis

All interviews were audio recorded and professionally transcribed verbatim and imported into qualitative data management software NVivo 11 (QSR International Pty Ltd, 2018) for management, retrieval, and interrogation. Data were analyzed by the first author using thematic analysis as described by Braun and Clarke [ 69 ]. This involved immersion in the data through reading and re-reading interview transcripts, followed by the generation of initial codes from features of the data, with some of these forming repeated patterns across the data set. During the initial coding phase, full and equal attention was given to each data item. These codes were then collated into potential themes. Themes were reviewed at the level of the coded extracts to ensure they were coherent, with a candidate thematic ‘map’ created. These themes were then refined to ensure they accurately reflected the data set as a whole, with recoding occurring as required. The thematic ‘map’ of the analysis was then further refined to formulate clear definitions and names for each theme. Throughout analysis the first author discussed the generated codes and themes with the co-authors to ensure accuracy of meaning and interpretation.

The coding frame for thematic analysis included both inductive codes generated from the data itself and deductive codes present in the existing research literature [ 59 ]. Codes that did not reflect the data were amended to fit the data. Data were not molded to fit predetermined codes or discarded. To maintain confidentiality, each participant and other entity or institution was allocated a pseudonym during data analysis.

Data collection and analysis procedures were recorded in an audit trail by the first author to document comments, decisions and observations, and to demonstrate and clarify decision-making to ensure any interpretations made accurately reflected the data. This documentation maintains rigor in qualitative research by strengthening the dependability and confirmability of the study [ 62 , 70 ]. To increase credibility of the research, responses were checked during and on completion of interviews to ensure the representations of participants’ viewpoints were accurate [ 62 ].

As an introduction to participant interviews, adolescent girls were asked about their social media use. These questions related to the different types of social media they used most often, how many hours a day they spent using these (on both a weekday and weekend day), and the device used to access social media.

The most used social media among participants were Instagram, Facebook and Snapchat. An equal number of participants reported they either spent less than two hours, or more than three hours, using social media on a weekday. On a weekend day, most participants spent more than four hours using social media. Delineation between passive use such as scrolling social media app feeds or viewing stories, and active use involving liking, commenting, and sharing posts was not collected as part of this study. Mobile phones were the most commonly used device to access social media. Daily use of social media reported by participants in this study was greater than has been previously reported among Australian females aged between 14 and 24 years, who on average in 2018 spent close to fourteen hours each week, or about two hours per day, on social media [ 71 ]. Additionally, time spent on social media by girls in this study is outside of the Australian 24-h movement guidelines for children and young people aged 5–17 years which recommend limiting sedentary recreational screen time to no more than two hours per day [ 72 ].

Participants identified body image as a major concern in relation to adolescent girls’ social media use and its influence on mental health, reporting girls felt insecure and self-conscious about their appearance when using Instagram specifically. This was not necessarily related to content participants considered as sexualized. Images were identified as sexualized depending on the amount of skin exposed rather than a females’ pose in an image. Four overarching themes emerged from the data and provided an in-depth understanding of the ways in which the girls in the study described how social media use influences body image: ‘expectation’, ‘comparison’, ‘striving’, and ‘validation’. Participants also referred to ‘counteracting negative body image and influence of social media’. Additional quotes to support each theme described below are included as a supplementary file (see Additional file 1 ).

Expectation

Images of other females were perceived to add an expectation for adolescent girls to look a certain way in their own social media posts to obtain what they deem an acceptable number of ‘likes’ and positive commentary. Although this is often influenced by images of celebrities, girls interpreted these as less realistic and attainable, with sexualized images posted by peers and other girls their age having a greater influence on their likelihood to make negative appearance comparisons;

I guess, you know they’re celebrities, so something must have gone into it [a photo]. It’s not just a photo, but I think if it’s someone you know or someone your age, it’s like, “Wow, that really could be me,” or “People my age are looking like this or doing this kind of stuff.” So, I think it would have a worse effect. (Sana, 17 years)

This expectation was perceived to make girls feel pressured to look attractive in their social media posts, even if it meant not being themselves as described in the participant quote below;

Some girls try to look like that [the images shown] and then they’re probably not being themselves, but they’re being what they think they’re expected to be kind of, which is not very good. (Candice, 15 years)

Girls also talked about how expectations experienced from viewing sexualized images on social media would vary between girls, depending on how they already felt about their appearance;

I guess it depends on how the girls feel about themselves first because depending on how they feel about themselves will depend on how they view the photo. (Daisy, 16 years) I think in general it depends on the mood that you're in when you open your phone. If you're already in a vulnerable mindset or if you've been out all day at the beach or something and you'd come home, you'd probably take more notice of that and be like, "Oh, I wish I looked like that." (Charlotte, 17 years)

While asked about both potential positive and negative influences of sexualized images of females featured within social media, girls could not identify any positives and continually spoke of the negative influences;

I think it would definitely have a negative impact on their mental health because they’d probably really be upset if they can’t achieve those unrealistic body expectations. (Sophie, 17 years)

Expectations related to social media use and body image were also discussed in relation to the normalization of following certain types of Instagram accounts, such as those that are appearance-focused and of attractive females with many followers, and how this could then lead to appearance-based expectations;

I think it [following appearance-focused and popular attractive female Instagram accounts] becomes more accepted and it becomes okay. It’s almost like a visual effect I guess if one particular group of teenage girls follow celebrities or whatever, begin to follow those sort of things [appearance-focused and popular attractive female Instagram accounts] and all people follow them, their friends, it [trying to look like the females in those accounts] becomes more of an expectation. (Brooke, 16 years)

While encouraged to use third person disclosures during interviews, participants reported they made negative appearance comparisons when viewing images on social media. Negative appearance comparisons were made irrespective of whether images were considered sexualized. As in the discussions among girls related to expectation, both images of celebrities and peers influenced comparisons, however, the influence of peers was considered more prolific;

When I see girls my age [on Instagram], I just compare myself to them ‘cause I know it’s kind of reality, if that makes sense, to know that someone my age can look like that and then why don’t I look like that? I think that’s what a lot of girls would see. (Olivia, 16 years)

While images of peers were considered to have a greater influence on negative appearance comparisons among the majority of girls, not all shared this viewpoint;

I think they [girls] would still to a certain extent be like, “Oh, I still want to be them,” but I feel it would be less, because if they see, “Oh, they're just like a regular person, they’re not a celebrity,” then they’re not really worth looking up to. But some people might say, “Oh, I want that kind of life,” for a regular person, like, “Why can she have just such a great life but I don’t?” (Amelia, 16 years)

All four images shown in interviews were perceived by participants to influence girls their age in making negative appearance-based comparisons. Reasons included the celebrities’ current popularity among their age group and the perception that all were attractive. For some participants, the number of likes was considered to play a role in comparisons, with a higher number equating to level of attractiveness. For others, the negative comparison was considered irrespective of the number of ‘likes’. All but one of the images was considered sexualized (where the least amount of skin was exposed), but it was noted that when using Instagram, girls would be unlikely to pause and make this distinction while scrolling through images.

All participants acknowledged the editing behind photos on social media but this did not counteract them making negative appearance comparisons;

A lot of them [photos] are edited and things like that but you don't really think about that when you look at someone's profile, you just compare that to yourself and then, that just makes you feel really bad about yourself. (Emma, 17 years)

Similarly, an awareness of images on social media usually featuring someone at their best did not ameliorate negative comparisons;

‘Cause if they constantly see it – and especially if you’re scrolling, some people might be in bed or on the couch, kind of not looking their best, they compared themselves at maybe their worst, compared to them at their very best and immediately, they go, “Oh, wow, okay.” And they see themselves as so much lower because of the comparison. (Candice, 15 years)

Even when prompted, girls struggled to identify any potential positive comparisons with the images to which they are exposed on social media. Females on social media who post photos of themselves were considered confident and empowered by their appearance, but girls did not agree on whether this would make girls their age feel good about their own appearance.

The expectation perceived by participants and the comparisons made from viewing images on social media was seen to influence girls’ striving to look a certain way, portray an enviable lifestyle and obtain many followers, ‘likes’ and comments;

You’re constantly thinking about aspiring to be something that I know 90% of girls aren’t going to be that way. It’s not possible and people need to realize that you’ve got to be happy with who you are and that you're beautiful in your own way. (Matilda, 16 years)

Participants particularly spoke about the influence of images on girls wanting to change their bodies;

You just think, “Oh, that's possible” and then you try and shape your body to be like that, so you eat less and eating disorders occur. (Zoe, 16 years) Just seeing [images on social media] all the time and it can get you down and girls could think, “Oh, I need to have my body like that.” People are always saying, “Oh, I want to get a summer body,” all the time. (Madeleine, 14 years)

For some girls, fitness accounts on Instagram, in addition to celebrities and peers, were also perceived as influential in girls’ striving to change their bodies;

I think it [images of females on fitness accounts] just puts this really unrealistic vision of what you should look like, and what you should do with your body to girls my age. (Abbey, 17 years)

When discussing the images shown of two popular and attractive models, it was well known among girls that both had been, and were currently, Victoria’s Secret models. This led to considering the type of influence such images have on adolescent girls’ body image;

I do know that a lot of my friends follow [on Instagram] a lot of models and celebrities, especially like Victoria Secret models for instance. I mean I’ve never been into that and that’s just never been my thing but I think that a lot of girls my age are following models. I guess it [is] sort of a way for them to almost, like to see what they aspire to be, which is really sad. (Matilda, 16 years)

Intersecting with the themes of expectation, comparison and striving, participants frequently spoke about validation when discussing the influence of social media on body image. A currency of ‘likes’, comments and followers where girls are validated on their Instagram posts and accounts was evident throughout discussions with participants;

I feel that when people post photos of them in their bikini, they want that positive feedback and say, “Oh, you look so amazing.” And that's why they do it because they want the compliments. It's kind of a false representation of themselves because they're just doing it for the likes and the compliments. (Tahlia, 16 years)

This validation was perceived to reinforce to girls that their value is largely placed on their appearance and influenced the types of images they would consider posting of themselves.

Although not frequently identified by participants, some discussed behaviors of possible concern among girls regarding the influence of social media likes, as described by Charlotte (17 years):

If you went to a birthday or something and everyone is eating cake and heaps of food, I think you probably would restrict yourself a little bit more than you would have otherwise. And think, "Oh, they got these many likes and this, maybe I should stop eating a little bit.”

Counteracting negative body image and influence of social media

Participants discussed the importance of awareness and education from a younger age among girls about social media and its influence on body image. Year six (11–12 years of age) was identified by the girls as an optimal range for this to occur, when girls are starting to use social media and many are experiencing pubertal changes and becoming more aware of their bodies and appearance. Schools, parents, peers and online sources including apps were all perceived by girls as having the potential to play a helpful role in counteracting negative body image messages, particularly when awareness and education can be delivered by all of these sources.

A form of awareness and education commonly identified by girls included critiquing images on social media within the school curriculum, to improve ‘social media literacy’;

Just to be reminded that these things aren’t what they look like. Maybe videos or something that show how edited these photos get. Like, I've seen one and it was about magazine covers, and it was just the beginning of a woman, and then two hours of makeup and things like that later, the end of her. And then she got put on the magazine cover. So, maybe similar things for social media. (Sana, 17 years)

Although it was apparent throughout the interviews with the girls that they were already aware of the editing and enhancement of images on social media, as well as the tendency for images to portray females at their best, they struggled to apply this knowledge. This was especially the case when viewing images of their peers.

It was highlighted that messages to counteract negative body image were needed, including focusing on girls’ strengths rather than their appearance, diversity of physical appearance and that idolized physiques, such as those of celebrities are not the norm;

I think for me the thing that I would like to see is saying yes, this person might be really pretty and this person might not be, but that intelligence and sort of physical [ability] is just as important. I mean, trying to say, “Oh, don’t worry [not] everyone looks good all [the] time.” That’s not helpful ‘cause nobody really believes it. (Brooke, 16 years)

Participants discussed the use of social media to counteract negative body image and promote positive body image, with body positive and acceptance messages including imagery and quotes considered helpful;

There’re a lot of body positive pages, so they post photos of normal people, not like Kendall [Jenner] but people with stretch marks and not like that at all. And then you get quotes and all these amazing things, like people's stories. So you just have to balance it out, I think, which took me awhile to do because, at first, I was just following people like her [Kendall Jenner], which didn't make me feel too good, and then now, I just go half and half. (Ava, 14 years)

While identified by the majority of girls as helpful to counteract negative body image, only a few said they followed such profiles or accounts and some were not aware of any these.

Girl-focused support and programs were discussed as needed to help girls counteract negative body image and the influence of social media, as exemplified by Grace (15 years):

I would just say there needs to be more support directly aimed at girls. I mean just bringing awareness to the fact that social media isn’t the point of your value and your worth, and that people might think that’s stupid but it is really such a big thing and I noticed it with so many people. It’s not the epitome of who you are. There’s way more substance to your person than how many followers you have and just raising awareness and bringing a lot of support and teaching girls self-love and self-worth is important so that you don’t have to have a boy validate that or you don’t have to have ‘likes’ to validate that.

The role of apps in providing girl-focused support was also discussed by participants, although some expressed concern that girls may not seek out such an app;

If it was just like [a] ‘girls only’ app. Like little ways to de-stress. Where you like breathe and stuff like that, I think that it needs to be something like that, but the thing is I don’t know if many girls would use it, I guess. They’d be like, “Why do I need this? This isn’t a necessity for me.” I don’t think many girls know that it’s harmful for them to be comparing themselves to these girls. (Amelia, 16 years)

Both school and other sources such as online environments were identified as settings where such support could be provided. However, girls also stressed the importance of schools not just providing talks about body image or advising them to simply stop engaging with social media that is influencing them negatively, as described in detail by Rachel (17 years):

We have heaps of body image talks, but it’s like, okay, they’re good for the first one, and then they’re sort of repeating themselves and it’s not going in anymore. It’s just your natural instinct to look at someone [and compare yourself]. They’ve told us to go unfollow anyone on Instagram who’s making you upset or whatever. [Its] a lot easier said than done. ‘Cause you don’t really know what’s making you upset. You can be following lots of supermodels and them as a collective are making you upset, but you’re so intrigued on where they’ve got to in their life that you don’t wanna unfollow them.

The current study utilized in-depth interviews to better understand how sexualized images typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways. Body image was the only aspect of mental health highlighted by participants in this study, attesting to its importance in the minds of participants.

While studies have found sexualized images to influence body image among females [ 34 , 43 , 49 ], participants in this study did not highlight sexualization as a specific concern in relation to body image. The pervasiveness and normalization of sexualized images within social media may help explain why girls participating in this study did not consider such images as distinct from others [ 34 , 52 ]. However, the four overarching themes of expectation, comparison, striving and validation reported in this study highlighted that adolescent girls largely view their body in relation to their appearance, and suggests self-objectification is a prominent issue when exploring the relationship between social media use and body image. Previous studies have also found a connection between self-objectification on girls’ appearance concerns [ 40 , 51 , 52 ]. Consequently, preventing appearance concerns and negative body image among girls may be facilitated by the development of strategies from a young age to counteract self-objectification, appearance concerns and comparisons in relation to social media use [ 11 , 21 , 73 ].

Consistent with previous research, the influence of social media on adolescent girls’ body image was perceived as negative by the participants in this study [ 12 , 24 , 29 , 57 , 74 ]. Girls found it difficult to identify positive influences of social media on body image, with little to no discussion among participants, even when prompted during interviews. Participants perceived girls who posted photos of themselves on social media as confident and empowered by their appearance and were unsure whether this would have a positive influence on the body image of other girls their age or those who posted the images. While some existing literature suggests adolescents are unaware and naïve to negative influences associated with social media [ 2 , 23 , 75 ], this study found girls were well aware of how the experiences of expectation, comparison, striving and validation led to negative thoughts and feelings related to their body image. Girls were also able to suggest strategies to counteract negative body image and were able to apply critical thinking when viewing images of celebrities. These findings align with previous research that found adolescents to be critical users and generators of social media, with high media literacy and the ability to identify strategies that may help mitigate social media’s negative effects on body image [ 11 , 76 , 77 ].

Adolescent girls in this study identified the importance of peers in relation to making appearance-based comparisons, with differences in the comparisons made to peers or celebrities, suggesting body image may be more negatively influenced by viewing images of peers on social media. This finding aligns with previous studies identifying peers as having a significant influence on body image concerns among girls [ 11 , 24 , 73 ]. Participants perceived peers as more relatable than celebrities, who they considered as less realistic and attainable. With images on social media more frequently featuring girls’ peers (although images of celebrities are also prominent), this finding adds to existing research highlighting peer appearance comparisons as an important component to address when developing programs aimed at the prevention and early intervention of body dissatisfaction and appearance-based concerns among girls [ 21 , 73 , 78 ]. Additionally, this study found girls were not able to apply critical thinking skills when viewing images of peers, suggesting girls need support to apply these cognitive skills to prevent or minimize peer appearance-related comparisons.

Participants also suggested that some adolescent girls may be more at risk than others of making negative appearance comparisons. This was discussed in relation to how girls already felt about their own appearance and their mood when using social media and viewing images. In relation to how girls already feel about their own appearance, positive body image could play a protective role in influencing the likelihood of making negative appearance comparisons while using social media. Positive body image refers to love and respect of one’s body and emphasizes acceptance and appreciation of its functions irrespective of whether it meets dominant societal appearance ideals [ 79 ]. An important characteristic of positive body image pertinent to the influence of girls’ social media use on their body image is protective filtering, whereby positive-body related information is accepted while negative information is rejected, maintaining positive body image [ 79 , 80 ]. Among a sample of adolescents with positive body image, expressing strong criticism against appearance ideals was found to foster protective filtering and thus helped to uphold positive body image [ 81 ], whilst in another study of adolescent girls, protective filtering also suggested benefits to body image [ 11 ]. Conversely, a recent qualitative study exploring adolescents’ processing and protective filtering of social media content and perceived protective benefits of these strategies for body image found that although girls in the study displayed aspects of engaging in protective filtering, this did not necessarily translate to protective effects to their body image and they experienced difficulty internalizing positive body-related messages and accepting and appreciating their own bodies [ 57 ]. While the present study did not collect data about participants’ own body image, findings support the importance of girls’ varying levels of body image when developing interventions aimed at reducing negative appearance comparisons when using social media.

Participants in this study also considered that a girls’ mood when using social media and viewing images may place some girls at greater risk of making negative appearance comparisons. This finding suggests that body dissatisfaction could be state-based and mediate the influence of viewing images on social media and body image, with the immediate impact of exposure to such images influencing body dissatisfaction. Research conducted with women who had trait-level appearance ideal internalization and body dissatisfaction found appearance comparisons, and in particular upward comparisons (to those deemed more attractive) predicted increased state body dissatisfaction [ 82 ]. Adolescent girls who internalize appearance ideals and those with elevated trait body dissatisfaction may be at greater risk of making negative appearance comparisons when using social media and thus may be an important sub-group to consider for intervention. Previous research has also found that girls with higher social comparison tendencies [ 24 ] and those focused on gaining approval from others about their appearance, experience more negative effects on their body image as a result of using social media [ 29 ]. Gaining approval from others when using social media through ‘likes’ and comments was mentioned frequently among girls in this study and was perceived to provide validation of one’s appearance and thus, reinforcing a focus on appearance. At the time of this study, Instagram had not yet begun its trial of no longer displaying the amount of ‘likes’ on posts. Further research with adolescent girls could explore their views on this change and its influence on appearance-based comparisons and social media activity among this group.

The role of schools, parents, peers and online sources in counteracting negative body image was highlighted by participants in this study, with emphasis placed on body image awareness, education and support being delivered by each of these sources. This finding supports existing research recommending an ecological approach to adolescent body image development, where all interactions in a girls’ environment can be influenced to prevent body dissatisfaction related to social media use [ 83 ]. Parents are a key influence on girls’ body image [ 84 , 85 ], and research has found they can play a protective role in preadolescent and adolescent social media appearance comparisons and body dissatisfaction [ 86 , 87 ]. Schools provide a setting in which content can be delivered in the classroom and whereby families, peers, teachers and other school staff can be engaged and involved in the implementation of health promotion interventions with a focus on body image [ 88 ]. When planning such interventions, it is important to consider girls’ age and developmental stage, as well as the influence and interaction of individual, family, peer, online, community, and school environments on their body image to counteract negative body image.

Congruent with research investigating social media literacy interventions as an emerging approach to address specific challenges to body image posed by social media [ 89 ], participants in this study perceived improved social media literacy among adolescent girls from a younger age, taught within the school curriculum, as important to counteracting negative body image. Social media literacy focuses on the interactions among users of social media, whether friends, other peers or celebrities, as well as developing the skills to examine the messages underlying commercial media advertising, including health and fitness, seen on social media [ 78 ]. This finding aligns with previous research which has observed favorable effects on body dissatisfaction, internalization of the thin ideal, appearance comparison, and self-esteem among girls following a pilot social media literacy intervention adapted from the ‘Happy Being Me’ program [ 90 ]. However, a recent randomized controlled trial found less effectiveness as a stand-alone intervention, with the appearance-comparison component found to be more effective [ 78 ]. Participants in the present study also identified appearance-based comparisons as a topic of concern to them, suggesting the need to include both social media literacy and appearance-comparison content in body dissatisfaction prevention interventions.

When discussing strategies for counteracting negative body image and the influence of social media, participants also referred to the importance of promoting positive body image through messaging focused on girls’ strengths rather than their appearance, body acceptance and ways to challenge unrealistic societal appearance ideals. This finding aligns with sociocultural theories such as the dual pathway model [ 68 ] suggesting the pressure among girls to conform to appearance ideals and the extent to which they internalize such ideals are important factors to target in interventions aimed at this group. To this effect, cognitive dissonance intervention the Body Project has a strong body of evidence supporting its effectiveness in increasing body appreciation and reducing thin-ideal internalization and body dissatisfaction among adolescent girls when implemented in schools [ 91 , 92 , 93 , 94 , 95 ]. The theoretical premise of the Body Project is that when there is a discrepancy between an individual’s beliefs and actions, they experience discomfort i.e. cognitive dissonance, which they then try to avoid, becoming motivated to re-assess their beliefs to align with their actions [ 96 ]. In the intervention, this is facilitated by group discussions and activities with adolescent girls where girls actively challenge appearance ideals with subsequent decreases in thin-ideal internalization and body dissatisfaction [ 91 ]. Additionally, research indicates acceptability of the intervention among adolescent girls, with the group setting contributing to their sense of belonging, particularly when facilitators are considered relatable, such as undergraduate female university students [ 95 , 97 ].

The finding that any negative influence of social media on body image was not necessarily in relation to sexualized content highlights the importance of undertaking research with girls to better understand the mechanisms of social media’s influence on their body image. In this study, participants made negative comparisons with images of females on social media regardless of whether they were considered sexualized, with the influence of peer appearance comparisons more prominent. Research with adolescent girls will also enable them to inform and co-develop interventions to support their body image development and prevent or reduce harms experienced from their social media use in relation to body image, targeted to the needs and interests of their age group.

The current study contributes new knowledge from the perspective of adolescent girls to the existing literature on adolescent girls’ social media use and its influence on their body image. The findings of this study suggest that social media can have a negative influence on girls’ body image through negative appearance comparisons when viewing images on social media, exacerbating appearance-based concerns and body dissatisfaction. While negative comparisons were made irrespective of whether images were considered sexualized, findings suggested a level of self-objectification among adolescent girls whereby they viewed themselves in relation to their appearance. The important role of peers in appearance comparisons was also evident in this study. Participants also identified strategies to prevent and counteract negative body image, which have important implications for the development of health promotion programs addressing social media use and body image concerns among adolescent girls for prevention and early intervention that can minimize potential harms. For parents and professionals working with adolescent girls, particularly in the school setting, the findings can be applied in their work by providing education about social media and its influence on body image and strategies to prevent and counteract negative body image to support girls.

Limitations

This study has several limitations that should be considered when interpreting its findings. This study was exploratory and limited by a small number of self-selected participants (n = 24). Therefore, its findings cannot be used to make assumptions about the population of girls aged between 14 and 17 years in Perth, Western Australia and does not claim to be representative of the broader population of girls. Findings may vary in other areas of Western Australia, Australia and internationally. However, qualitative research often uses smaller samples enabling the collection of in-depth information and providing direction for further research.

Additionally, participants’ own body image concerns/body dissatisfaction were not assessed as part of this study. The participating girls’ feelings about their body image may have influenced their perceptions of how social media influences body image among other girls.

The interpretation of this study’s findings may also be influenced by the characteristics of the participating girls. There were slightly more participants in this study aged between 16–17 years old, and these girls may have been using social media for longer compared to younger participants. Age and more years of experience using social media may have influenced participants’ interest in issues related to social media and thus their interest in participating in the study. In addition, all but one of the girls were from an English-speaking background and findings may differ among girls from culturally and linguistically diverse backgrounds, as they may not feel they meet Western appearance ideals and may also experience different perceived sociocultural appearance-related pressures depending on their cultural background. Another limitation of this study was that most participants attended non-government and co-educational schools. It is possible that findings may be different among samples where girls largely attend government or all girls’ schools. As most participants attended non-government schools and were from higher socioeconomic backgrounds, they may have had increased access to digital technology and therefore use of social media. Additionally, girls from high socioeconomic backgrounds may experience differences in perceived appearance ideals compared to girls from different backgrounds. It would be useful for future research to explore further the perceptions of girls in government schools and all girls’ schools to allow for comparisons, especially in relation to peers and sexualized images with those in non-government and co-educational schools.

This study provides some insight into the influence of social media on adolescent girls’ body image from the perspective of girls in Perth, Western Australia. Further research should engage with adolescent girls to identify and investigate the impact of strategies to prevent and counteract negative body image related to social media utilizing an ecological approach to encompass all aspects of girls’ lives.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available to protect the anonymity and confidentiality of the participants. Requests to obtain datasets can be made to the corresponding author.

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Acknowledgements

The authors thank Student Edge and the schools and students involved in this research.

Alana Papageorgiou was supported by a Western Australian Health Promotion Foundation (Healthway) Scholarship (file number: 24235) and an Australian Government Research Training Program Scholarship at the University of Western Australia. Donna Cross’ contribution to this paper was supported by a National Health and Medical Research Council Research Fellowship (GNT1119339). The funders had no role in the design of the study, the collection, analysis or interpretation of data, in the writing of the manuscript, or the decision to submit the manuscript for publication.

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All authors designed the study and AP undertook the data collection. AP conducted data analyses with assistance from CF. AP was responsible for writing the manuscript and DC and CF were responsible for reviewing and contributing to the manuscript. All authors read and approved the final manuscript.

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Full ethical approval to conduct this research was obtained from the University of Western Australia Human Research Ethics Committee and the relevant school authorities. Written informed consent was obtained from both parents or guardians and adolescent girls. For those recruited from the Student Edge youth research panel, parent or guardian consent was required for students under 15 years to be eligible to become a member. All methods were carried out in accordance with relevant guidelines and regulations.

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Additional file 1.

. Thematic table illustrating additional quotes from interview findings.

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Papageorgiou, A., Fisher, C. & Cross, D. “Why don’t I look like her?” How adolescent girls view social media and its connection to body image. BMC Women's Health 22 , 261 (2022). https://doi.org/10.1186/s12905-022-01845-4

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Received : 18 March 2022

Accepted : 21 June 2022

Published : 27 June 2022

DOI : https://doi.org/10.1186/s12905-022-01845-4

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