TV, social networks, video games and confinement: should we be worried about the mental health of teens?

I was lucky enough to grow up in the countryside, in the South of France, surrounded by vines, within easy reach of all my friends. My sister is six years older than me, so when I turned 12, she, and by extension we, got a PS1 for Christmas. Tomb Raider II, Abe (the Odyssey and the Exodus), the very first Rayman, Soulblade (the ancestor of Soulcalibur)… All these games punctuated my adolescence, and especially my school holidays, which I spent playing them over and over every year. This was also the time when we first had Canal +, and in particular channels such as MTV, Cartoon Network, Canal J and, when we went to my great-grandmother, the Holy Grail: Disney Channel. A lot of memories. In summer, when it was too hot to keep the shutters open, we took refuge in our bedrooms or in the living room to watch TV or to “play on our Playstation” in the dark, much to our father's dismay, who had not just bought but actually built a magnificent inground pool. He couldn't quite understand how ungrateful we were to prefer to stay stuck "in front of the TV" when we could go outside and enjoy the pool he never had when he was little. Back then, he was a little older than me today, and he felt out of touch with us. Today, I am too young to have teenage children, but I still feel out of touch with the generations that followed mine at the end of the alphabet (“Generation Z”), last letter before we start again with Generation Alpha. Why ? Well I don't have Instagram. Nor Twitter. I don't understand why TikTok is so popular, and I didn't even know what it was six months ago. Then I watched The Social Dilemma on Netflix. So I took Facebook off my phone, and it cut my screentime by 90%. Anyway, I feel old at 27, so I can hardly imagine what my father would have thought of young people today if he had been there to see them.

Ever since these new technologies have been around, there have always been fears, misunderstandings and prejudices regarding the effects that they could have on the development of adolescents, who are more inclined to use them. And that was before COVID-19, when you could take your bike to go see your friends. Today, video game sales, social media usage, and TV time [study is in French] have reached all-time highs, as the only outlets for a confined youth (and others too, but this is not the main topic of our article). So should we be worried - even more - about their effects on adolescent mental health?

First, it is important to keep in mind that adolescence (the age group between 10 and 19 according to the WHO) is a particularly critical period in terms of mental health. Over that period teenagers change, discover themselves, confront others and build the social and emotional habits that will become the pillars of their mental well-being in adulthood. Behaviors established during this transition period may also persist and influence future eating behaviors as well as future alcohol, tobacco and drug use. Despite this, adolescents are hardly visible in national statistics, falling in between childhood and young adults. Statistics on adolescents are therefore often measured at the supranational level, and these figures speak for themselves.

 According to the WHO: 

• 10-20% of the world's adolescents reportedly suffer from mental health problems, but these problems remain poorly diagnosed and under-treated
• Mental health problems account for 16% of the global burden of disease and injury among people aged 10-19
• Suicide is the third leading cause of death among 15-19 year olds

Behaviors established during this transition period may also persist and influence such things as future eating behaviors as well as future alcohol, tobacco and drug use.

This is explained by the fact that, at the household level, depressive or suicidal behavior can be interpreted as signs of the infamous “adolescent crisis”, and are therefore difficult to detect for parents and those around the family. The French Haute Autorité de Santé (HAS, High Authority for Health), for example, recalls that in this age group, no symptoms are specific to depression. It can therefore be difficult to distinguish between mildly depressive episodes, which are common in adolescence, and clinical depression [link is in French]. Likewise, it can be difficult for a teenager to express their feelings, and he/she often does not display pain in the same way as an adult does. It is therefore less obvious to interpret and detect. Finally, and like all people with mental health problems, adolescents can be victims of stigmatization [link is in French] from those around them, but few age groups are so sensitive to others, which multiplies its harmful effects tenfold.

All of this explains why the WHO estimates that half of mental health problems start before the age of 14, but most of these cases go undetected and untreated.

Adolescents are particularly exposed to social networks, video games and TV, even without confinement. According to a Statista survey [study is in French] conducted on a sample of more than 1,000 people, the average age of registration on social networks in France in 2018 is 12.8 years, and a large majority (63%) have created their account between 11 and 14 years old. Up to 5% had an account before they were even old enough to receive a letter from Hogwarts (11), though it's supposed to be impossible before one reaches 13 years of age. 76% of 12-17 year olds and 93% of 18-24 year olds [study is in French] declared having been present on social networks in the last twelve months. The same goes for video games. According to a 2017 SELL study [study is in French], 95% of 10-14 year olds and 92% of 12-18 year olds play video games (all media combined). And for TV, 80% of 4-14 year olds [study is in French] say they watch so-called linear TV (i.e. the traditional viewing mode, as opposed to video on demand, for example), which makes it the most used viewing mode compared to YouTube or replay. So can we make a connection between these statistics and those of the WHO on adolescent mental disorders? Sure, but maybe not the one we're thinking of.

As always, it is good to remember that the causes of mental disorders are complex and manyfold. For adolescents, for example, the quality of their family life, their relationships with their peers, exposure to violence (parental abuse, harassment and sexual violence) and socio-economic problems are well-documented risks for their mental health.

For example, certain behaviors such as excessive use of TV or video games can be a way for the adolescent to isolate himself or herself, which is, according to the HAS [link is in French], a symptom and not a cause of depressive behaviors. We should therefore be vigilant and take this behavior seriously if the person has other symptoms related to depression or emotional disorders (also listed in the HAS article linked above).

Excessive use of TV or video games can be a way for adolescents to isolate themselves, which HAS says is a symptom and not a cause of depressive behavior.

Furthermore, social networks and video games in particular can be catalysts for certain disorders. The mechanics of social media can encourage comparison between peers and can damage a teen's self-image, and therefore lead to lower self-esteem. According to Psycom [French organization that communicates about mental health], it is this decrease in self-esteem that can be the cause of depressive behaviors. This excessive focus on body shape is quite common during adolescence, as the body goes through significant changes. That said, this overexposure to faces embellished by filters and bodies staged to match unrealistic canons of beauty can accentuate the adolescent's sense of “not belonging to the norm”. This can lead to cases of dysmorphophobia, a mental disorder where the young person is excessively worried that a part of their body or whole body is misshapen, and that this may lead to rejection or judgment on the part of the young person's peers. Even more than a damaged self-image, dysmorphophobia can sometimes lead to more concerning behaviors, such as eating disorders or the use of cosmetic surgery (which can in turn further accentuate the dysmorphophobia). If the use of cosmetic surgery to look like stars has existed since long before social networks, the latter seem to have accentuated the trend. Cosmetic surgeons have called this new behavior "Snapchat dysmorphia", or the use of cosmetic surgery to look like a version of yourself, but with a filter. In 2019, for the first time in France, 18-34 year olds are more likely than those over 50 [study is in French] to have plastic surgery. In response to this growing problem, Instagram has decided to ban certain filters.

These same excesses can be found in video games. Since 2019, the WHO has also recognized gaming disorder, or video game disorder, as a pathology in its own right. This pathology is defined as "a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences" and affects only a tiny fraction of the players. However, this decision has sparked debate, both in the scientific community and that of gamers. The lack of scientific proof is questioned, in particular on the supposed causal link between the excessive practice of video games and behavioral disorders.

Since 2019, the WHO has also recognized gaming disorder, or video game disorder, as a pathology in its own right.

In a 2018 debate paper published in the Journal of Behavioral Addictions, several researchers from the Trimbos Institute (The Netherlands), the universities of Oxford, Johns-Hopkins, Stockholm and Sydney argue that “But even if patients are simultaneously (A) intensively playing video games and (B) functionally impaired to a clinically significant level, the question remains whether A causes B and whether there is benefit from formalizing a disorder based on this assumption”. They add that the restriction of pathology to video games seems arbitrary, given that many activities can also be sources of addiction: “We acknowledge that some individuals may overdo gaming, just as they may overdo social media, work, or sex, or tan to excess or, indeed, dance”. In this sense, the researchers would like more clarity on the WHO's decision to focus on video games instead of establishing a more general concept of behavioral addiction, which could be applied to other activities.

It follows that, when assessing patient exposure to the risk of video game addiction, individual factors such as self-esteem, and environmental factors, such as family, school or the work environment should also be taken into account in order to understand the underlying causes of this excessive behavior. These underlying factors may be accentuated by the fact that there are, to varying degrees, in the three media (television, video games and social media) mechanisms that encourage excessive behavior. The isolation sought by watching TV, for example, will prevent adolescents from participating in social activities, which can increase their anxiety and lead them to isolate themselves even more [link is in French]. For social networks, the way algorithms work (presented in detail in the Netflix documentary The Social Dilemma) makes it possible to offer users content that will interest them so that they stay online as long as possible, thus creating “filter bubbles” which will tend to show images of people to whom adolescents compare themselves, for example, because these are potentially the images that make them react the most.

Social networks also feature reward and stimulation mechanisms very similar to those that can make video games addictive. Therefore, the very nature of video games is an important risk-factor for addictions. For example, their model can be based on virtual earnings (weapons, items and armor for example) or real (streaming subscriptions or monetary earnings in tournaments). The “online” dimension will encourage players to confront one another, which is all the more captivating for people who struggle to socialize in real life. There is therefore a difference between the “intrinsic” pleasure that a video game provides (we play it because it makes us happy), and the “extrinsic” pleasure, namely playing a game because we are forced to play it, by other people or via the very gaming mechanics in play.

We must therefore be aware of these mechanisms, but they cannot in themselves represent the only cause of mental disorders in adolescents.

The debate on the links between mental health and our various virtual hobbies - and in particular video games - was recently revived by a study by a researcher from Oxford [link is in French] which showed that... video games could be beneficial for our mental health, especially in times of confinement. The study, conducted on the games Animal Crossing: New Horizons for Nintendo Switch and Plants vs. Zombies: Battle for Neighborville showed that those who reported playing expressed significantly more "wellbeing" signals than those who did not.

Video games have also played a very important role in reducing the isolation of adolescents and the general population during the COVID-19 crisis. 18 companies in the video game sector have notably launched the #PlayApartTogether campaign, allowing players to participate in events and disseminate the WHO's social distancing and barrier gestures instructions, which, despite the 2019 episode, received this campaign very positively [link is in French]. Likewise, social networks have been essential instruments for staying connected with loved ones [link is in French]: they have made it possible to maintain a social link, to be informed, to be entertained, to work or to play sports, and these benefits do not apply only to periods of confinement. Among other benefits, the Canadian Psychiatric Society highlights the fact that “online communication can encourage isolated or socially anxious adolescents to reveal themselves to their peers and to new contacts, which may increase feelings of socializing and reduce depressive symptoms ”.

18 companies in the video game sector have notably launched the #PlayApartTogether campaign, allowing players to participate in events and disseminate the WHO's social distancing and barrier gestures instructions.

 

Networks are also places where adolescents can find validation and support from their peers and other people close to them. In its article, the Canadian Psychiatric Society quotes in particular a recent survey carried out in Great Britain where "68% of the teenage respondents said to have received social support online during difficult times." Many groups are especially dedicated to discussing mental health issues and are very useful for sharing experiences and finding support from people who have had similar experiences. An article in L’information Psychiatrique [The Psychiatric Information, link is in French] estimates that "most mental illnesses are represented on Facebook through more than 500 discussion groups for each of them." The article also shows that the Facebook pages of mental health professionals and organizations allow them to communicate information about mental disorders more widely, thereby helping to increase their visibility and encourage an open dialogue around them.

Like social media support groups, video games can also have beneficial uses for people with mental health problems. There is in particular a psychologist (defining himself as “psygamer”) who uses the video game The Legend of Zelda: Breath of the Wild as a therapeutic support to treat the addictions of teenagers to Fortnite [link is in French], proving that it is not necessarily the activity of playing a video game itself that will cause the addiction, but that it's rather the relationship that the person entertains with it that is important to explore.

The conclusion of this article is therefore that, like everything, nothing is “good” or “bad” per se, especially when it comes to mental health: our psychological balance depends on complex relationships between different individual factors, our environment, and the way we interact with it. This is also true for teenagers. While it is not clear whether their use of social media, TV or video games is the cause of their discomfort, they are nevertheless signals that should not be underestimated.