Running

head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Elizabeth Blanton

Bon Secours Memorial College of Nursing

Nursing Research

NUR 4222

Christine Turner, PhD, RN Associate Professor

April 20, 2018

Honor Code: "I Pledge..."

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Abstract

Purpose: The purpose of this integrative review is to identify the mental health risks to

adolescents who use social media.

Background: There has been an increase in mental health issues among adolescents within the

past ten years; in addition, smartphones and social media became mainstream within this time

period. Researchers are exploring the relationship between social media use and the increase in

adolescent mental health issues.

Design and Search Methods: This is an integrative review, which used multiple online

databases to collect research. Three quantitative studies, one qualitative study, and one literature

review were used. Selected articles were reviewed to determine the effect of social media on

adolescent mental health.

Results and Findings: Evidence from the selected articles demonstrates that social media use by

adolescents can lead to adverse mental health outcomes. As the majority of adolescents use

social media, this puts youth at risk for developing mental health issues.

Limitations: The primary limitation is the researcher’s lack of experience in conducting an

integrative review. Other limitations include search restrictions on the research.

Implications for Practice: Healthcare providers, parents, and teachers can use findings to

monitor adolescents who use social media for signs of mental health issues and to set guidelines

for appropriate and safe social media use.

Recommendations for Future Research: Additional research is needed to explore the specific

mental health effects on adolescents who use social media, in addition to investigating the effects

on school age children.

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Integrative Literature Review

The purpose of this integrative review is to investigate and identify potential links

between social media use by adolescents to an increased risk of developing adverse mental

health issues. Between 2010 and 2015, there was an increase in adolescent depressive

symptoms, suicide-related outcomes, and suicide rates, especially among females (Twenge,

Joiner, Rogers, & Martin, 2017). Adolescence is a time where connectedness is very important

for normal development, and adolescents have feelings of perceived connectivity through social

media use (Barry, Sidoti, Briggs, Reiter, & Lindsey, 2017). In some cases, 87% of youth use the

Internet, and 51% use the Internet daily. Sixty-percent of youth between the ages of 13 and 17

have at least one social media profile (Richards, Caldwell, & Go, 2015).

As social media became mainstream in 2009, and smartphones were first introduced in

2012 (Twenge et al., 2017), researchers aim to explore if there is a link between social media use

and adverse adolescent mental health outcomes. The goal of this review is to discuss and

explore the results of published data in relation to the researcher’s PICOT question: Are

adolescents who spend more time using new media, such as social media and electronic devices,

at increased risk of developing mental health issues as compared to adolescents who spend more

time on non-screen activities since 2010?

Design and Research Methods

This integrative review focuses on five research articles. The researcher began the initial

research method by searching for articles in the online databases of PubMed, EBSCO CINAHL

Complete, and Ovid. Combinations of the following search terms were used: mental health,

effects on mental health, social media, new media, social networking, suicide, and adolescent.

The initial searches resulted in over 3,000 articles. The articles were then filtered by year (limit

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within the previous five years), English language, and relevance to the PICOT question. Only

articles with qualified authors were considered. Articles were further limited to those that were

full-text or available within the Bon Secours library. If articles did not meet the criteria

discussed, they were then excluded. Two articles required the assistance of the Bon Secours

Memorial College of Nursing’s librarian to obtain copies of the articles.

The final five, peer reviewed articles were ultimately selected based on their relevance to

the PICOT question. The articles needed to focus on adolescent mental health, not adult or

young adult mental health issues, in addition to specifically referring to mental health issues in

relation to social media use. The selected five articles were published between 2015 and 2017.

The articles included one qualitative article (Calancie, Ewing, Narducci, Horgan, & Khalid-

Khan, 2017), three quantitative articles (Barry, et al., 2017; Sampasa-Kanyinga & Lewis, 2015;

Twenge et al., 2017), and one systemic literature review (Richards et al., 2015).

Findings

The findings and results of the five reviewed studies indicate a positive correlation

between social media use and poor mental health outcomes in adolescents, which supports the

researcher’s PICOT question (Barry et al., 2017; Calancie et al., 2017; Richards et al., 2015;

Sampasa-Kanyinga & Lewis, 2015; Twenge et al., 2017). Findings are organized in the

following categories and are discussed in detail in the Discussion Section: adverse mental health

outcomes, social media variable, and age variable. A synopsis of the compiled research articles

is presented in Table 1- Article Evaluation Tables. The following paragraphs summarize the

findings of each article.

In a quantitative study completed by Barry et al. (2017), researchers aimed to use

numerous assessment methods, including parental and adolescent perception of adolescent social

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media use in addition to parent and adolescent self-reporting of anxiety, depression, behavior

problems, connectedness, and loneliness to assess the impact of social media use on adolescent

mental health and psychosocial functioning. Two hundred and twenty-six adolescents ages 14-

17 were selected by Qualtrics, a company that maintains information on adults willing to

participate in survey-based research. The sample was composted of predominately Caucasian

individuals, limiting demographic diversity. Parents and adolescents completed an 82-question

survey about the adolescents’ mental health status and a separate survey created by researchers

about their social media use. Analysis of the data was completed using IBM Statistics SPSS,

Version 24. Correlations were examined for each hypothesis, and regression models were used

to predict symptoms. Researchers determined that adolescents who internalize their mental

health symptoms may be drawn to social media as a way to connect with others, but that

adolescents with the highest number of social media accounts report the highest feelings of

loneliness. Parents reported that students who experience hyperactivity/impulsivity, anxiety, and

depression were linked to increased frequency of checking social media accounts and an

increased number of social media accounts.

Calancie et al. (2017) conducted a qualitative study to explore whether adolescents who

have a primary diagnosis of anxiety would experience worsening anxiety symptoms from using

Facebook. According to the researchers, there are characteristics of adolescents with anxiety that

make them more susceptible to stressors related to Facebook use, such as low self-esteem, poor

problem-solving skills, and a desire to be accepted. A purposive sampling technique was used to

select eight participants from a child psychiatric clinic in a high-risk area of Ontario to join three

focus groups in order to gather data on their Facebook use. The groups were composed of four

boys and four girls, and discussions were conducted in a semi-structured interview style. The

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data was analyzed using an interpretive, inductive process and was then coded for privacy. A

three-tiered approach was used with major themes identified and then narrowed down with each

tier. The results supported the study’s hypothesis that adolescents with a primary diagnosis of

anxiety experience worsening anxiety when using Facebook.

Richards et al. (2015) conducted a literature review to determine the impact of social

media on the health and mental health of adolescents by searching Medline, Embase, and

PscyhINFO databases. Keywords that were used include: social media, Facebook, Twitter,

YouTube, MySpace, mental health, cyberbullying, self-image, health, and physical fitness.

Researchers only used papers that referred to children, young people, and college and university

students; papers that contained research pertaining to adults were excluded. The method for

organizing literature was not identified, and the final number of articles reviewed and selected

was not identified in the study. Researchers determined that teens are the most vulnerable to the

mental health risks of using social media, including depression, anxiety, isolation, and suicide.

There are also body image concerns for teen girls. One benefit of using social media is that it

can serve as an outreach tool for providing teens with health information.

In another study by Sampasa-Kanyinga and Lewis (2015), researchers used a quantitative

design to explore the association between social media use and self-rated poor mental health in

adolescents, in combination with the lack of support for adolescent mental health needs. In a

two stage (school and class), stratified (region and school type), cluster sample design,

researchers used data from a survey completed by students in Ottawa, Canada called the Ontario

Student Drug Use and Health Survey. Seven hundred and fifty-three students in grades 7-12

completed the survey. Researchers explored hours spent on social media, self-reported mental

health, psychological distress, suicidal ideation, age, sex, grade, subjective socioeconomic

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status, and parental education. A Taylor series linearization method was used for analysis.

Researchers determined that daily social media use of more than two hours was associated with

fair to poor self-rating of mental health, a high level of psychological distress, and suicidal

ideation. Students also reported that when they felt that they wanted to talk to someone about a

mental health concern, they did not know where to go to seek services; these students who

wanted support were also more likely to report using social media for more than two hours a

day.

In a study by Twenge et al. (2017), researchers explored if there was a link between the

increased use of social media and adverse adolescent mental health outcomes. Researchers

noted that adolescents’ depressive symptoms, suicide-related outcomes, and suicide rates

increased between 2010 and 2015, especially among females. Using a quantitative correlational

research design, researchers examined results of two nationally representative surveys, the

Monitoring the Future [MtF] Survey and the Youth Risk Behavior Surveillance System

[YRBSS], in addition to using data from the Centers for Disease Control and Prevention (CDC)

related to suicide for the time period studied. The combined sample size of 8th to 12th grade

student participants in the surveys was over 500,000. CDC data on suicide deaths was taken

from 1999 through 2015. A time-lag design was used to analyze the data, with samples of the

same age during different years, which eliminated age effects. Researchers examined

correlations between mental health indicators (depressive symptoms and suicide-related

outcomes) and screen and non-screen activities, with a focus on the time period between 2009

and 2015, as social media was first introduced in 2009. The findings supported the researchers’

hypothesis in that the more time adolescents spent on social media and electronic devices

positively correlated with depressive symptoms and suicide related outcomes. The less time

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adolescents spent on non-screen activities, such as in-person social interaction, print media,

sports and exercise, or religious services, researchers found a negative correlation with

depressive symptoms.

Discussion and Implications

The five articles that were selected for review support the researcher’s PICOT question

by demonstrating that adolescents who use social media more often experience adverse mental

health effects. The researcher framed the review according to the following categories: adverse

mental health outcomes, social media variable, and age variable. The following paragraphs

discuss the major categories of the selected articles and their relevance to the researcher’s PICOT

question and the articles’ implications to practice.

Adverse Mental Health Outcomes

The findings and results of the five reviewed studies indicate a variety of adverse mental

health effects on adolescents from the use of social media, including increased anxiety,

depression, increased loneliness, increased hyperactivity/impulsivity, fear of missing out, body

image concerns, and increased risk-taking behaviors (Barry et al., 2017; Calancie et al., 2017;

Richards et al., 2015; Sampasa-Kanyinga & Lewis, 2015; Twenge et al., 2017). Researchers in

the five studies identified these adverse mental health effects through a variety of methods, such

as analyzing results of surveys completed by adolescents and/or parents and by conducting focus

groups with adolescents. The trend in increasing mental health issues among adolescents

between 2010 and 2015 (Twenge et al., 2017) prompted much of the current research on the

topic. The results of this research are helpful for healthcare providers who care for adolescents,

teachers, and parents to highlight the need to monitor adolescent social media use, to limit the

amount of time adolescents use social media, to monitor adolescents who use social media for

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signs of developing mental health issues, and to be especially mindful of youth with existing

mental health issues who use social media (Barry et al., 2017; Calancie et al., 2017). Future

research needs include exploring the specific effects on adolescent mental health, looking more

closely at what types of mental health issues arise from social media use and how to prevent the

issues from occurring (Twenge et al, 2017). This theme relates to the PICOT question by

exploring the adverse mental health outcomes that can arise from social media use.

Social Media Variable

While all five articles support the findings that general social media use adversely affects

the mental health of adolescents, two articles specify that it is the increase in time that

adolescents use social media or use social media for a specific amount of time per day that

directly increases the risk of developing mental health issues (Sampasa-Kanyinga & Lewis,

2015; Twenge et al., 2017). Sampasa-Kanyinga and Lewis (2015) determined that daily social

media use of more than two hours was associated with fair to poor self-rating of mental health, a

high level of psychological distress, and suicidal ideation. In this study, researchers found that

25.2% of students reported using social media for more than two hours every day. This is a

significant number of adolescents at risk of experiencing adverse mental health outcomes. A

second study by Twenge et al. (2017) found a positive correlation between an increased amount

of time on social media and depressive symptoms and suicide related outcomes. This is an

important implication for parents and teachers, as they should learn that increased social media

use could be a risk factor or indicator of mental health problems in youth. Limiting daily screen

time to two hours or less may be a tool for parents to use in helping their adolescents and

children reduce their risk of adverse health effects from social media use (Sampasa-Kanyinga &

Lewis, 2015). Parents should also ensure that they are closely monitoring their adolescents’

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social media use, as this has been shown to have a positive effect on adolescent mental health

(Barry et al., 2017). For future research, several studies have identified that social media has

some benefits in that it can be a means to distribute health information to youth, so research is

needed to explore how to employ the positive effects of social media in order to assist those

youth with mental health risks (Sampasa-Kanyinga & Lewis, 2015). This theme is relevant to

the PICOT question as it differentiates that an increased use of social media correlates with an

increased risk of adverse mental health issues.

Age Variable

Two of the selected articles identify the significance of the age of those individuals being

studied, the period of adolescence (Barry et al., 2017; Richards et al., 2017). Barry et al. (2017)

point out that adolescence is a stage of development in which connectedness is more important

than in the college age young adult. Connectedness is one of the primary appeals of social

media. This would account for the significant amount of time adolescents are found to be using

social media. Fifty-one percent of youth use the Internet daily, and 60% of youth between the

ages of 13-17 have at least one social media profile (Richards et al., 2015). This places teens and

adolescents in a most vulnerable position for developing mental health issues. Parents have the

chance to help their adolescents find ways for inclusion with their peers in activities other than

by using social media. One way for parents to help their teens is through encouraging

participation in non-screen activities. Twenge et al. (2017) demonstrated that non-screen

activities, such as in-person social interaction, sports and physical activities, and religious

activities had a negative correlation with depressive symptoms and were good ways to engage

youth and help them be less susceptible to having mental health issues. Future research should

include exploring the effects of social media use on the school age child, as younger children are

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beginning to use social media (Richards et al., 2015). The PICOT question focuses on the

mental health risks to adolescents, and this theme emphasizes and identifies why there is a need

to explore the risks to adolescents.

Limitations

The researcher faced numerous limitations when completing the integrative review. First,

the researcher has never completed an integrative review, thus the researcher’s lack of

experience as a student in conducting thorough research and analysis of the studies could result

in an incomplete integrative review on the chosen subject. Second, this integrative review may

not be a complete review of the topic, as the search of articles was limited to the previous five

years; however, the topic reviewed is relevant to a current trend between 2010 and 2015, which

required a narrow timeframe for the literature search. Finally, only five articles were ultimately

selected to examine in the integrative review, which limits the results.

Major limitations of two of the selected studies include a small sample size and samples

that were either purposive in their sampling technique or lacked demographic representation

(Barry et al.; Calancie et al., 2017). These limitations could affect the reliability of the results

and could introduce bias. In addition, two other studies include self-reporting in the surveys

used for data collection (Sampasa-Kanyinga & Lewis, 2015; Twenge et al., 2017). The use of

self-reporting can result in under-reporting or over-reporting of mental health concerns. Finally,

in the literature review by Richards et al. (2015), the study does not identify the number of

articles reviewed or selected for use in the review, and the method for organizing the literature

by theme was not discussed.

Conclusions

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The findings of the selected articles support the researcher’s PICOT question that the use of

social media by adolescents leads to adverse mental health outcomes, such as increased anxiety,

depression, suicide, increased hyperactivity/impulsivity, fear of missing out, body image

concerns, and increased risk-taking behaviors (Barry et al., 2017; Calancie et al., 2017; Richards

et al., 2015; Sampasa-Kanyinga & Lewis, 2015; Twenge et al., 2017). Increased social media

use or social media use of at least two hours per day are specific risk factors for developing

mental health issues (Sampasa-Kanyinga & Lewis, 2015; Twenge et al., 2017), and adolescents

should be monitored for developing mental health issues if they fit this social media use profile.

Adolescents are at particular risk of experiencing harm from social media use due to the stage of

their development, which encourages them to seek connectedness with peers and prompts a

desire not to be excluded (Barry et al., 2017; Richards et al., 2017).

A recommended change in practice for providers would be to counsel parents on limiting

their children’s social media use to no more than two hours per day (Sampasa-Kanyinga &

Lewis, 2015) and to encourage parents to be more involved in monitoring their children’s social

media use (Barry et al., 2017). As social media use and smartphone technology is a relative

recent phenomenon, as is the decline in adolescent mental health, more research is needed to

continue exploring the adverse effects of social media, screen time, and new technology on

adolescents, the school age child, and young adults.

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References

Barry, C. T., Sidoti, C. L., Briggs, S. M., Reiter, S. R., & Lindsey, R. A. (2017). Adolescent

social media use and mental health from adolescent and parent perspectives. Journal Of

Adolescence, 611-11.

Calancie, O., Ewing, L., Narducci, L. D., Horgan, S., & Khalid-Khan, S. (2017). Exploring how

social networking sites impact youth with anxiety: A qualitative study of Facebook stressors

among adolescents with an anxiety disorder diagnosis. Journal of Psychosocial Research on

Cyberspace, 11(4), article 2.

Richards, D., Caldwell, P. Y., & Go, H. (2015). Impact of social media on the health of children

and young people. Journal Of Paediatrics And Child Health, 51(12), 1152-1157.

Sampasa-Kanyinga, H., & Lewis, R. F. (2015). Frequent Use of Social Networking Sites Is

Associated with Poor Psychological Functioning Among Children and

Adolescents. Cyberpsychology, Behavior & Social Networking, 18(7), 380-385.

Twenge, J. M., Joiner, T. E., Rogers, M. L., & Martin, G. N. (2017). Increases in depressive

symptoms, suicide-related outcomes, and suicide rates among U.S. adolescents after 2010 and

links to increased new media screen time. Clinical Psychological Science, 6(1), 3-17.