Instructions
You will engage critically with two weekly readings from week 12. Discuss what you think of the readings, such as, the author’s argument/s and the material covered in the text.
When writing your paper, keep in mind the following. Each response paper should address some (not necessarily all) of the questions below:
- What is/are the central questions explored in the readings, and what are the key terms/concepts/frameworks used to answer or address these questions?
- What is/are the central argument(s) of each text?
- What kinds of evidence are used to support those arguments and why? How are the arguments in each of the readings related to each other?
- Make sure to engage and analyze both readings equally, and provide an analysis that threads and weaves the readings together.
Remember to:
- Critically engage with the texts
- Be analytical
- Use your voice
- Cite
- Make sure your similarity percent on turnitin is no more than 25%.
Journal of Pediatric Nursing (2014) 29, 65–73
“My Situation Wasn’t that Unique”: The Experience of Teens
in Abusive Relationships
Sharyl Eve Toscano PhD ⁎
University of Alaska, Anchorage, AK
Key words:
Freshmen;
Abusive relationships;
Teens;
Control
College freshman and sophomores with histories of high school dating violence were invited to
participate in a study about that experience. The shared experience described by ten participants was that
of being controlled. Control is established by creating a sense of responsibility and is maintained by
angry outburst, threats to self, and guilt. Participants described an expectation of constant contact that
included techno vigilance. In their stories, young women miss good and better times, hope for “the ideal
romance,” and continue to care and have concern for their abuser who is described as “troubled.”
© 2014 Elsevier Inc. All rights reserved.
TO DATE, MUCH of the knowledge about adolescent
dating violence has been attained through the Youth Risk
Behavior Survey (YRBS). Data derived from this relatively
large U.S. based survey have provided knowledge about the
incidence and associations in teen dating violence. On
average, teen dating violence rates using this survey are
consistently reported around 10% or about 1 in 10 (1999
YRBS, 9.23% (Howard & Wang, 2003); 2005 YRBS, 10.3%
(Howard, Wang, & Yan, 2007)). Study designs focusing on
specific populations report higher incidence: 28% in a female
adolescent African American sample (Raiford, Wingood &
Diclemente, 2007); 16% in a rural adolescents (Marquart,
Nannini, Edwards, Stanley & Wayman, 2007); and 26% in
an urban population (Jain, Buda, Subramanian and Molnar,
2010). There is minimal qualitative research aimed at
exploring the experience of physical and/or sexual abuse in
female adolescents’ dating relationships.
Research using the YRBS has resulted in reported
associations between dating violence and risky youth
behavior. For example, having multiple partners in an
18 month period (Tucker, Oslak, Young, Martin & Kupper,
2001), dating an older boy (Burcky, Reuterman & Kopsky,
1988; Stets, 1987), lack of academic affiliation (Saner &
Ellickson, 1996), an increased number of sexual intercourse
⁎ Corresponding author: Sharyl Eve Toscano, PhD.
E-mail address: setoscano@uaa.alaska.edu.
0882-5963/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pedn.2013.08.004
partners (Valois, Oeltmann, Waller & Hussey, 1999),
providing sexual favors, suffering from rejection, being
intoxicated, and/or having an association with peer-drinking
(Burcky, Reuterman & Kopsky, 1988) were all linked to
physical and/or sexual violence in adolescent relationships. One study also based on the YRBS, looked at
adolescents reporting interpersonal violence and forced
sexual intercourse and found these groups were similar in
that each was more likely to engage in risky behaviors,
such as riding with a drinking driver, driving while
drinking, being less likely to use condoms, and being less
likely to engage in health-enhancing behaviors, such as
routine health and dental visits, contraceptive use, condom
use, and sun protection.
Severe violence victimization such as child maltreatment
and childhood witness to parental violence was predictive of
perpetration of violence (Sims, Dodd & Tejeda, 2008). In
one urban sample, researchers found females were more
likely to be perpetrators of dating violence than men (Jain,
Buda, Subramanian & Molnar, 2010). Findings from a rural
sample suggest that females were 3.5 times more likely to be
hit, pushed, or threatened in a dating relationship (Marquart,
Nannini, Edwards, Stanley, & Wayman, 2007).
Girls reporting dating violence are also more likely to report
other violent behaviors, extreme sadness, suicidal actions, use
of illicit substances, and engagement in risky sexual behaviors
(defined as more than 2 partners in a 3 month period, use of
66
drugs or alcohol before sex, or failure to use condoms)
(Howard & Wang; 2003). Baynard and Cross (2008) reported
an increase in depression and suicidal thoughts and found an
increased risk of poor educational outcomes. In a population of
young women ages 14–21 seeking abortion, dating violence
was significantly related to severity of suicidal thinking
(p b 0.5) (Nugent, Cerel & Vimbba, 2011).
Some researchers report specific associated risk depending
on involvement in an abusive dating relationship. An
adolescent female’s risk of developing sadness and/or
hopelessness, considering suicide, engaging in physical
fighting, having recent sexual partners and unprotected
sex increases when they also report being in an abusive
relationship (2005 YRBS) (Howard, Wang & Yan, 2007). Manganello (2008) also reported an increase in unsafe sex practices.
There exists an abundance of research based on the YRBS
with researchers reporting on incidences and correlations
derived from this large data base. There are benefits to this
form of research but exclusive reliance on survey descriptive
research may fail to advance the state of the science of
adolescent dating violence where permutations of the same
data is reported with slight variations in packaging. Hickman, Haycox and Arnonoff (2004) suggest that research is
challenged by the almost exclusive use of major national data
sources, and that this results in premature conclusions and
inconsistencies among risk factors between studies. In
Jouriles, Platt and McDonald (2009) review of the literature,
they note that alternatives to one-time, self-reported survey
assessments are scarce in the literature. Instead, the literature
in the area of adolescent dating violence consist of study
designs aimed at surveying the occurrence of specific acts of
violence within a particular time period.
The Theory of Female Adolescents’ Safety as determined
by the Dynamics of the Circle (TFASDC) (Toscano, 2007) is
the resulted of a grounded theory study aimed at exploring
adolescent dating relationships. As concepts emerged from
narrative data analysis, concepts related to group membership and relationship characteristics resulted. According to
the TFASDC (Toscano, 2007), the following concepts might
be predictive of a relationship becoming negative and/or
abusive: beginning and/or ending a relationship, dating an
older boy, dating a boy who was not a member of the teen
group, being distant from or lacking membership in a peer
group, being isolated from her group, having a relationship
lasting a long period of time as well as becoming sexually
active. In subsequent survey research aimed at testing the
TFASDC model, 5 concepts from the TFASDC were found
to be associated with dating violence (being distant from a
group or lack of group cohesion, increased number of
dating partners, dating an older boy, increased length of
relationship, and increased number of sexual partners)
(Toscano, 2010).
In this study I used a retrospective approach in an attempt
to describe the experience of adolescent dating violence over
time. By asking college women about abuse in their
adolescent relationships, they include in their description
S.E. Toscano
multiple relationships and transitions. The purpose of this
study was to describe the lived experience of physical and/or
sexual abuse in female adolescents’ dating relationships.
Methods
Ten participants were recruited and interviewed. These
participants were recruited and selected from a larger survey
study aimed at investigating violence in adolescent dating
relationships. In that study, 188 participants ages 18–26,
with the majority (n-180) being 18–20 were recruited from
one of two college health service clinics and one college
campus center. All students were in their freshman or
sophomore year of college. The majority (n = 170) were
Caucasian with the remainder of the group consisting of
multiracial (n = 3), Hispanic (n = 5), Asian (n = 7), Black
(n = 1), and East Indian (n = 1). All study sites were located
in the North East Region of the United States. In the Toscano
(2010) study participants completed a survey which included
the Danger Assessment (Campbell, 1986). The DA is a 17item dichotomous (yes/no) measure aimed at identifying risk
factors associated with homicide committed against women
by their intimate partner. Participants who completed the
survey were invited to participant in an in depth interview if
they answered yes to any items on the Danger Assessment.
The initial study finished before reaching theoretical
saturation. After seven interviews were completed an
extension and revision to the IRB to include recruitment
using posters was filed and approved. The posters included
the same screening protocol and all participants answered
yes to one or more items on the Danger Assessment.
Recruitment via poster continued until theoretical saturation
was achieved. Participants were not matched to their original
survey data and students recruited via poster did not
complete the survey. Study participants reported in this
study were 18–20 years old, however, specific data on the 10
participants interviewed were not collected due to concerns
they could be identified. The sample did include diverse
students but given the small number of minority students
within the respective student body populations identifying a
student by race and including the specifics of their story may
pose a risk of individual identification. Instead, general
sample statistics from the larger survey study are provided.
The three additional students recruited via posters also
attended one of two colleges from which the original survey
was completed.
All study procedures adhered to the approved IRB
proposal. Students who completed the interview received a
$25 cash payment at the completion of the interview.
Interviews were audio-taped. All interviews were conducted
during the normal business hours of the respective
counseling programs existing at each study site. Both sites
had an emergency crisis call number and a back-up police
service on call counselor. Participants were informed prior to
The Experience of Teens in Abusive Relationships
the interview that any report of child abuse, homicidal or
suicidal thoughts would be reported to the police. Participants who identified themselves in the interview as being in a
current abusive relationship were counseled on resources
using the research pamphlet provided if they didn’t meet the
criteria necessitating an emergency counseling referral
(suicidal or other self-destructive thought/actions, violent
behavior, and/or loss of contact with reality or disturbed
speech). Most of the teens received counseling on resources,
none needed emergency referrals.
Analysis of the qualitative data adhered to the methods of
Phenomenology. I identified the essence or structure of the
phenomenon of the lived experience of adolescent dating
violence using the six research activities outlined by Van
Manen (1990): turning to a phenomenon, investigating an
experience as it is lived, reflecting on the essential themes,
describing the phenomenon through writing and rewriting,
maintaining an oriented relation to the phenomenon, and
balancing the research context by considering the parts and
the whole. Consistent with Van Manen’s principle of
balancing the research context by considering the parts and
the whole, I gave each participant a pseudonym in the final
representation of the data as a means to adequately track
individual narrative within the context of the whole. The
whole is reflected in the reader’s ability to see “Sam” within
the contexts of Sam’s story rather than representing Sam’s
story in the form of quotes that can’t be connected back to
Sam’s story. I removed all identifying information from their
stories. In phenomenology, trustworthiness is embedded in
the narrative. Does the narrative have meaning? Does it ring
true? As interviews progressed I did query participants
regarding emerging themes, particularly when a participant
was describing an emergent theme and had elicited a nuance
that had not yet been identified.
Results
The shared experience described by ten participants was
that of being controlled. Control is established by creating a
sense of responsibility and is maintained by angry outburst,
threats to self, and guilt. Participants described an expectation of constant contact that included techno vigilance. In
their stories, young women miss good and better times, hope
for “the ideal romance”, and continue to care and have
concern for their abuser who is described as “troubled”.
Meeting: “The Perfect Romance”
Despite the presence of abuse in participants’ relationships (indicated on their Danger Assessment survey), they
still believed in romance and talked about romantic ideals.
They described attributes of their boyfriend as meeting their
ideal image. This was particularly true in the early phase of
their relationships and in their descriptions of first meeting.
67
Part of dating their ideal mate included feeling unworthy of
the boyfriend’s attention. The boyfriend was typically
described by participants as older, a bit of a rebel, and
popular. The participants felt popularity was gained by
dating these boys.
(Kris) He was kind of a bad ass; that was cool … oh my
God this kid is actually paying attention to me. (Nat) …
and then I got him and I didn’t want to lose him … he
was very good looking, he rode a motorcycle and there
were so many thrill aspects … so many girls would want
to be in my spot. (Ann) He was just mister popular and I
wanted to have Mr. Popular with me.
Marriage or at least a long relationship was assumed or
hoped to follow loss of virginity. Due to this focus on
romance the women report staying or staying longer despite
the presence of abuse.
(Sam) … it’s just the perfect romance, who wouldn’t
want a life like that …. he was my first kiss. (Ann) I
thought I was in love and he was telling me that we were
going to grow up and get married … I wanted to be that
perfect couple that you hear about, the high-school sweet
hearts who … end up together … (Pam) I felt an
obligation to him; we’d lost our virginities to each other
we should be together for a while. (Steph) He was my
first in every aspect of a relationship, I just can’t move
past [that]…. (Nat) that was my first serious boyfriend
and that was part of the reason I think it took so long for
us to break up … to this day … I didn’t want to leave him
there’s nothing I could have done.
At some level the young women were aware of the fantasy.
(Nat) … every girl wants that even to this day … the thing
was, he was too much. (Ann) Every little girl plans her
wedding … you plan, your dress, the reception, the
flowers, where it’s going to be; the groom is faceless …
which it should be. (Sam) I wanted it (Sweet Home
Alabama: movie) so badly, it’s just the perfect romance
… I wanted it no matter how unrealistic it was.
Dating: Establishing Control
Controlling behaviors were described at the start, during
and after the breakup of the relationship. The following
quotes are typical of the early phase of dating, “(Jenn) He
definitely tried to stop me from being friends with certain
people and put (up) a lot of obstacles … (Pam) He like to be
there. He told me he was protecting me.” Some teens
reported controlling behaviors as beginning after separation
or distance. Prior to these separations the teens described
spending all of their time with the boyfriend. (Ann) “At the
beginning of the relationship he hadn’t really gotten into
controlling me … when he left … he didn’t know where I was,
he didn’t know what was going on”.
A common concept related to dating an older boy away at
college or away for military service was a demand for
68
S.E. Toscano
constant contact and accessibility. Problems arose when the
teen didn’t submit to those controls or were unavailable.
Often the separation seemed to be the initial spark of the
controlling behavior.
(Ann) If he couldn’t get a hold of me, that would be
really bad, like if for some reason I didn’t pick up my
phone, or if I didn’t have service. (Kris) The problems
started when I started becoming more independent … I
was working pretty much full time … he called me at
least 100 times on the work phone … he called me
screaming and the other hostess would pick up the phone
and he’d start screaming, the bar tender would pick up
the phone and he’d curse him out … I was like, this is
ridiculous I’m going to get fired. You’re going to get me
fired … it (got) more and more controlling.
Constant contact was the norm. Participants were required
to text throughout the day. When asked to describe
controlling text messaging participants responded similar to
Pam: “… Whenever my friends text me it was just hey what’s
up, you free tonight, things like that … he just liked keeping
tabs on where I was”. She further clarified it wasn’t the
number of text messages but the intent of the text message,
an intent to track or control the teen.
Participants introduced the term techno vigilance
and described how boyfriends used technology to keep
tabs on them:
(Steph) He had my passwords for my computer … he
hacked into my email … he broke into my Facebook …
(Nat) I was miserable … I didn’t have cell phone service
and I knew that [he] was going to be pissed off.
(Pam) He used to go through my phone, missed calls and
text messages.
In addition to using technology to track the whereabouts
and behaviors of participants, boyfriends also tried to limit
technology to isolate teens as Brit described: “He destroyed
my phone … he threw my laptop out of the car.
In addition to techno vigilance, boyfriends relied on
friends; this included the involvement of the boyfriends’
friends as Ann described: “He had a friend here that he’d ask
to keep an eye on me … it got to the point that I couldn’t even
go out with my girl-friends.”
Other forms of control were targeted toward the participants’ emotions. When Nat was asked if she would describe
her relationship as abusive she responded, “It was the most
controlling relationship I’d ever been in … it never got to the
physical aspect … he was very aggressive.” She went on further
to describe “word rage” where “he tore [her] apart”; this concept is evident throughout the transcripts: (Jen) “He both knew
how to say exactly what you needed and exactly what would
destroy you based on what he wanted”. (Brit) “He would just
blow up on me and make me feel like I was worth nothing”.
Despite their awareness of controlling behaviors, participants described an expectation of some level of control as a
measure of caring. This preconceived expectation affected
future relationships. Jen described this experience with a
new boyfriend after leaving a controlling relationship,
“He’s like I’m not going to tell you who you can and can’t
hang out with … I was like you don’t care about me so I broke
up with him”.
Throughout the interviews a common concept that
allowed the abuser more control over the participants was
a sense of guilt and responsibility they had developed during
the relationship. These boys often had a “troubled past” and/
or difficult life circumstances. The participants described
feeling they were the best part of the boy’s life and felt a
responsibility to care for or fix the boyfriend. The boyfriend
often reinforced this idea.
(Ali) His mom left him when he was two, his dad always
beat him … he would always say now that you’ve left me
I have no one … I didn’t have control over his life but … I
realized I pretty much was the best part of his life. (Nat)
A brother of mine got killed and he had a brother that
died as an infant and I thought I could help him through
that … I thought I could fix [it] for him and I couldn’t.
(Kris) He had lost his older brother … from a methadone
overdose … I do excuse a lot of his behavior … the stories
he’d tell me [about growing up] the things he’d have to
deal with. (Pam) His dad physically abused his mom …
he told me all these things and he said I’ll never do that
to you … I really wanted to help him … (Abby) He
needed me so much … I helped him … I felt important in
his life. I can take care of him.
Another way for the boyfriend to initiate or maintain
control was to make verbal threats to harm himself. Threats
toward self were effective in part due to previously
established guilt and responsibility (discussed above). This
was a common tool to prevent these young women
from leaving.
(Steph) He’s like I’m going to kill myself … there’s
nothing left for me (Ali) He would say I’m going to kill
myself … just make me feel bad, make me worry about
things and maybe talk to him more … (Nat) … [he said]
you were the last thing I was living for so I have no
problems throwing my life away … I was so shocked and
terrified … I tried to give him another chance…. He needs
me to bring him back to reality. (Jen) I went back to his
room that night … I was afraid he was going to hurt
himself, like actually hurt himself … (Pam) … obviously I
cared about him and I would never want someone to end
their life on my accord so I felt I needed to stay with him
so he would be okay … I was afraid … I kind of felt the
need to be there, be like an anchor for him, bring him
back to reality … he needs me to bring him back to
reality. [Despite plans to break up after the summer of
senior year, Pam continued this relationship into college
mainly d/t this fear of his suicide].
Other threats aimed at gaining or maintaining control
included threats of losing the relationship wherein the
boyfriend would threaten to leave or cheat on the participants
if they didn’t do what the boyfriend wanted. Displays of
aggression were also commonly described by participants.
The Experience of Teens in Abusive Relationships
Nat’s boyfriend knocked a bureau over when she said she
was going to get a ride home from a friend. After, she let her
boy-friend pick her up instead.
The teens themselves also reported participating in some
of these behaviors related to control including: threats of selfharm and threatening to end the relationship: “(Kris) The
thought of him breaking up with me I was like I’m going to
kill myself, I was so in love with him … I really did grab a
rope at one point and I was like I’m going to kill myself … I’d
threaten to leave just to see how much he cared, see if he
came after me. Steph had a somewhat different approach
when her boyfriend tried to control her behaviors, “If
anything I’d hang out with the guy more … a way to piss him
off”. This was a private victory as she clarified the secrecy of
her rebellion, “… without him even knowing, but knowing
that he’d be pissed off (if he knew).”
Intimacy: Sexual Pressure and Rape
During the course of the interviews participants described
rape as part of their experience of being in an abusive
relationship/s.
(Brit) … then he grabbed me by my clothes, I pushed
him off then he pushed me back and it became this
fight. I just ended up sitting there crying. I can’t really
do anything, he’s stronger than me and bigger so I just
felt helpless and that was the first time. (Steph) We
were in his car and I was trying to leave … he wouldn’t
let me … he started getting very aggressive and
forcefully pushed me and climbed on top of me … it
turned into like a, um, it turned into a rape … [after] I
just walked home and I didn’t deal with it … I
completely shut down.
There were developmental changes evident in the
stories specific to how teens defined and responded to
rape. Steph (above) did not define her relationship as
abusive but answered most of the Danger Assessment
items yes. She also did not define the above experience as
a rape until after she told the story to friends as a
sophomore in college: (Steph) “I told the story and they’re
like you were saying no and you were crying and you
were pushing him off you, that’s not sex, that’s rape.” At
age 14 Jenn describes the following:
… he came into (my room) and basically assaulted me by
coercing me and getting me to have sex with him … I
didn’t have the words for it when I was 14, I didn’t even
know what sex was.
Jenn did not feel empowered to say no to subsequent
sexual advances because of the rape: Jenn, “I kind of figured
I didn’t have the right to say no when I had been raped, that I
didn’t have the right to say no anymore”. This led to selfreported promiscuous behavior throughout Jenn’s teen years.
Sam also reported increased promiscuity following an event
she defined as sexual pressure; however, the act was
69
physically forced. Sam said this about her relationships
after the incident, “… after that I’d have on and off hook ups
with other boys who I didn’t even like that much … I just
wanted the attention.” Later Jenn recounts a party where the
boy who raped her was also there. She describes the
following:
When I went to sleep he raped me again … I almost went
to the ER that time … I didn’t know what it would do for
me because I didn’t really want to come forward … part
of me expected that to happen at the party … partly I
wanted it to happen so I remembered it this time … I
wanted that stamp of knowing of being a survivor …
(before) I wanted to blame myself because then it
wouldn’t happen again, if I had to blame him it could
happen again that’s a scary thing.
Despite naming an act as rape, participants still felt a level
of uncertainty:
(Jen) I didn’t feel like it was consensual but I also felt
like maybe there was some part of me that wanted it …
(Sam) I didn’t struggle … I thought I was going to get
hurt so I didn’t say anything.
Sam describes physical pressure but she does not define
this experience as rape:
… We were doing things and he kind of just pushed my
head down and there really wasn’t much I could do. I
never really said no but it made me really uncomfortable
… I didn’t struggle but there was physical pressure that
made me uncomfortable, that hurt my throat … I thought
I was going to get hurt so I didn’t say anything.
She goes on further to describe another form of pressure
related to future relationships, “… they knew about the situation
with this boy, he wasn’t supper popular … they thought they
kind of deserved the same thing[s] so I just didn’t say no.”
Some of this pressure came from within when she started
dating a boy she cared about, “we had been dating and it was
actually a relationship and I felt like if I did this with someone I
wasn’t really even dating that if I was dating someone that I
kind of had to do the same thing maybe even more.”
Sexual pressure was determined by other factors besides
prior sexual experiences. For example, Nat describes a
different sort of sexual pressure related to the age and/or
experience of the partner. For others, this expectation seemed
to be determined by the amount of time in the relationship.
(Nat) … I was 18 and he was 23 … there were things
because of age, I did do that I probably wouldn’t have
done because he was older and more experienced. (Pam)
He was like we’ve been together for a while we should
do this [have sex]. I was 15, I wasn’t ready.
In addition to feeling pressured to engage in sexual
activity participants described a second phenomenon: “regret
sex”. Regret sex was different than rape in that teens reported
no coercion or pressure but regretted the sex afterwards:
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S.E. Toscano
(Pam) I didn’t want to … it was consensual but after I
really regretted it… It kind of ate away at me a little bit
but I did let him do it … it just kind of seemed like it was
going to happen so you just go with it.
Breaking Up is Hard to Do
Participants talked about breaking up. Most were
reluctant to break up and describe the process as taking a
long time. There were multiple “break ups” before the final
split and contact continued where they describe further
violence. Some teens used anticipated separations to
facilitate a break up they had been planning.
Toward the end of the relationships teens clung to
better times.
(Brit) All the good times outweighed the bad … (Ali) I
missed the good times. (Ann) … it was all fun and good
at the beginning … it was literally the last week of the
relationship that I finally started to realize this isn’t good.
Boyfriends appeared to clamp down on control as teens
readied for college where there was going to be a physical
separation. Similarly some teens readied for the separation as
a mechanism to call things off.
(Abby) The fact that I was moving away [to college], I
knew that there was an end point … I’m gone there’s
nothing he can do. (Pam) We dated until the end of
senior year until I came here [college] and I was kind of
done with it.
In addition to leaving for college Abby’s boyfriend also had
a restraining order preventing him from contacting her. This
was not uncommon in the stories of participants. The restraining
order had the effect of ending these relationships and severing
contact, but often only for the duration of the order.
(Nat) … they arrested him for stalking … we’re not
allowed to be within 500 feet of each other (Abby)… he’s
not allowed to leave the state … Over [college] break I
keep in contact with him (Brit) … that’s how it ended …
he got arrested … we were ordered not to talk to each
other so I didn’t speak to him … [court order passes] …
After everything that’s happened and what he did to me I
feel like I shouldn’t talk to him but at the same time I feel
like I’ll always be there for him.
Participants discussed situations where they had made a
clean break. In these cases the cause of the break-up wasn’t
identified as abuse. Instead teens talked about
infidelity. Teens described abuse as forgivable but infidelity
crossed the line.
(Ali) He was always cheating … I didn’t really break up
with him because he was violent … [it] came out that he
had been cheating on me … I haven’t talked to him since.
(Sam) … I think with cheating there is this clear cut line.
Violence and Abuse
Participants in this study described violence and abuse
equal in severity to adult forms. Despite this, they did not
hold their abuser responsible. Even where injury had
occurred teens did not report feeling at risk. Instead they
hid their abuse and minimized personal risk.
A common theme was the feeling that their abuser was “a
violent person”.
(Ali) He did get arrested a bunch of times, he is a very
violent person … He just had a lot of anger problems …
(Abby) … he was on probation for steeling AK 47 s …
for drug money … (Brit) His dad was abusive … the first
time I hung out with him, the next morning I woke up
and him and his Dad were in a fist fight.
Teens described their experiences of physical abuse:
(Pam) … he wouldn’t stop, I have doubts about things
being an accident … (Ali) … we ended up being gone
longer than we were supposed to. Him and his friends go
mad and shot out my car’s headlights. (Abby) … he put
holes in walls, he broke my windshield. (Nat) I don’t
know if he thought I was leaving … but he punched the
window straight out … I ended up having to go to the
hospital to get stitches … (Kris)… he became really
frustrated with me [for wanting to go to a party] and
started screaming and took my head and just hit me into
the dash board … he actually took my head and was like
bang, bang, bang, bang and I was terrified.
The level of violence didn’t matter. Teens explained away
and did not hold the boyfriend responsible.
(Kris) I don’t think he ever really wanted to hurt me …
the anger just builds up. (Ali) I would always excuse this
as he really has problems. (Kris) When he is in that other
place I don’t know him at all.
Teens do not hold their boyfriends responsible even in
cases where there is physical evidence of harm.
(Nat) … but he’d grab on … my mom [asked] what is with
the finger prints, what’s on your arm? I’d say [boyfriends
name] and I were wrestling, he didn’t mean it … I don’t
think it was him necessarily but I would try fighting with
him still to leave and I don’t know, it was probably a
combination of the two. (Pam) I was like you need to stop,
you’re hurting me … at that point I have this rod in my ear
and there’s blood dripping from my ear … he’s like
I’m sorry babe I love you and he just walked out and
I’m just lying on the floor and I’m like what the hell
just happened.
Despite Pam’s ability to identify this as abuse she does not
hold her boyfriend responsible: “That was the only time he
had a temper but I don’t know if it was him or the fact that he
took steroids”.
Other participants didn’t try to make excuses and easily
recognized what should be done but described their personal
situation as different.
The Experience of Teens in Abusive Relationships
(Steph) It’s so frustrating because I talk to other women
who are in the same situation and I’m like no you need to
stop this right now. But with me it’s different. (Abby) I
was aware of how bad things were and how I’d read stuff
about this and I was like I’m never going to let myself
get into a relationship like that …but I can’t get out of it.
There’s nothing I could do … I’m not important in
anybody’s life anymore if I don’t have him.
Teens did not perceive any danger in their situation.
(Steph) I don’t think he would do anything violent again.
I think a lot of it was that night [and] him being very
overcome by emotion … I don’t think it would happen
again. (Sam) I never thought that would happen again.
The violence toward Kris, Pam, Ali, Steph, Sam, and Brit
continued into college. Interestingly, these participants
reported having broken off their relationships with these
boys earlier in the interview. It was only later in the interview
that they began talking of the continued abuse. Teens
continued to deny risk even when it was pointed out to them
as demonstrated in Kris’s interview:
(Kris) My Dad said you better be careful hanging out
with him because you’re going to end up like [name of
murdered college female] … I’m like Dad no one gets
killed in [name of state] … the person who killed her
followed her up from [name of state] … my Dad’s like
exactly [boy’s name] is following you up. I don’t want to
see you dead in a quarry.
In addition to feeling immune to the violence teens were
not likely to report it. Some worry about their own image;
others, like Brit, worry about the image of the boy: “I kept it a
secret [from family] … I didn’t want them [friends] to know, I
didn’t want to change it, I just wanted to be with him … it was
embarrassing.” Brit’s relationship continues into college and
the secrecy follows, “I lived with him, I said I was living in
the dorm … I lied to my parents all the time.” Participants
didn’t tell anyone but it seems they might not have been
asked and/or when asked they lacked the words to describe
their experience.
(Abby) My friends know small details but I’ve never told
in depth. No one has ever asked me this many questions
about it, from the outside they know it is bad but they
don’t ask inside questions … I was ashamed of it,
disgusted with myself.” (Steph) “From the outside it
looked like a very normal relationship.” (Sam) The
hardest part about telling my nurse was trying to tell her
what happened sexually without saying the words. I
didn’t want to say oral sex in front of them [adults]; this
is the first time I’ve told an adult about this.
One teen went to extraordinary measures to hide the true
nature of her relationship.
(Nat) … So we went and it was like a big thing because I
was 16 at the time and I didn’t have my parents there so
it turned into a big thing when I told them they went on a
71
business trip and this was my brother … I don’t know
how we pulled that off … one of the nurses came up to
me and gave me a card and it was a counseling card and
she was like, in the event that you want to call someone,
I was like I don’t know what you’re talking about, thanks
though and I just left.
Nat told a second story to her parents, a third story to her
boyfriend’s parents. All three stories attempted to explain a
broken windshield and Nat’s facial stitches occurring on the
same day.
Discussion
Teens in this study described hope for “the ideal romance”
and some attributed this ideal to media. A content analysis of
the four-book Twilight series revealed cases of sexual abuse,
stalking, threats, and intimidation whereas authors noted
descriptions of the series as a “wholesome” presentation of
teenage romance (Collins & Carmody, 2011). Findings from
another study further explain the media connection where
participants identified the existence of pressure from peers
and media to have and form relationships as a reason they
stayed in relationships that were violent. Participants in this
study describe the “ideal” romance and “remembering better
times” as reasons they stayed in otherwise violent,
controlling, or undesirable relationships. These findings are
particularly troubling in that participants in this study lacked
a clear representation of what a healthy relationship looked
like. In one study female African American teens with a
history of dating violence were 2 times more likely to report
non understanding of healthy relationships (Raiford, Wingood & Diclemente, 2007). In their stories, young women
miss good and better times, hope for “the ideal romance”,
and continue to care and have concern for their abuser who is
described as “troubled”. They developed expectations of
control based on previous experiences with control, such that
controlling behaviors became the expectation in future
relationships. In that sense, control equated to love.
Anticipatory guidance for teens needs to go beyond sex
education and pregnancy prevention. Teens need participatory guidance aimed at developing healthy expectations and
ideals for relationships.
The shared lived experience described by participants was
that of being controlled. Control is established by creating a
sense of responsibility. Control is maintained by angry
outburst, threats to self, and guilt. In a recently published
qualitative study participants also described dating violence
as including some form of manipulation and control (Ismail,
Berman, and Ward-Griffin, 2005).
Participants described an expectation of constant contact
that included “techno vigilance”. Based on participants’
differentiation between “normal” text messaging and controlling text messaging it is important for researchers to
consider the context and content of the text message rather
72
than simply the volume of texts. Other researchers, Draucker
and Martsolf (2010), reported similar findings where
technology was used for monitoring or controlling activities
and/or whereabouts of partners.
The experience of high school dating violence is replete
with sexual pressure and/or rape. As participants in this study
described, teens need the vocabulary to talk about their
experiences. Practitioners might be more successful if they
use neutral language that describes but does not name sexual
acts so as not to embarrass the teens. This differs from
current practice where practitioners are encouraged to use
accurate terms even with small children when talking about
human sexuality.
Zurbriggen (2009) points out a need to have information
about earlier experiences and that the roots of dating violence
begin early. In this study the experience of dating violence
follows and continues to the college setting. Therefore it is
important to ask about high-school dating relationships in
college age groups. It is also important to screen multiple
times even when teens screen negative. Raiford, Wingood
and Diclemente (2007) reported that 12% of teens not
reporting dating violence reported it at a one year follow up.
Findings from this study support that earlier experiences
appeared to set the teen up for later dating experiences, in
what teens expected from relationships, and specifically
in regards to aspects of those relationships such as
controlling behaviors.
Restraining orders have the effect of ending the
relationship for the duration of the order but contact is
often renewed once the order expires. Knowing restraining
orders work in this age group is important. It is equally
important to recognize they only work for the duration
of the order. Teens in this study reconnected even after a year
or more with no contact. Therefore young adults with
previous restraining orders in place may continue to be at risk
years later.
Ismail, Berman, and Ward-Griffin’s (2005) participants
reported that adults dismissed dating violence and treated it
as a minor problem. Based on the findings from this study,
abuse is occurring in teen relationships similar in form to that
occurring in adult relationships and teens often hide this
abuse. Participants reported I was the first adult they had
talked with about their abuse, adults need to talk with teens
about abuse.
The method of phenomenology results in rich narrative
description of an experience, the purpose of which is not
specifically to develop theory. It is important however to
consider where findings from this study contribute to the
state of the science of dating violence. According to the
Theory of Female Adolescents’ Safety as determined by
the Dynamics of the Circle (TFASDC) (Toscano, 2007), the
circle, consisting of two interacting same-sex peer groups
provides structure for each teenager as he or she navigates
the dating course. According to the Theory of Female
Adolescents’ Safety as determined by the Dynamics of the
Circle (TFASDC) (2007), the following concepts might be
S.E. Toscano
predictive of a relationship becoming negative and/or
abusive: beginning and/or ending a relationship, dating an
older boy, dating a boy who was not a member of the teen
group, being distant from or lacking membership in a peer
group, isolation from her peer group, having a relationship
lasting a long period of time, and becoming sexually active
(Toscano, 2007).
It is beyond the scope of this paper to review the grounded
theory leading to the development of the TFASDC.
However, several themes reported in this study are consistent
with the TFASDC (Toscano, 2007). In this study participants
described an increase in controlling behaviors during times
of independence and/or separation. This may be an extension
of the risk described in the TFASDC during the end of a
relationship or “break up”. Similarly, participants in this
study describe their abusive boyfriends as older which is also
predictive of dating violence in the TFASDC. Participants
further describe reluctance to leave relationships once they
have been sexually active and if they have been in the
relationship a long time. Descriptions which relate to fearing
the loss of the “ideal relationship” provides further
explanation for the TFASDC. They did not describe the
importance of the peer group as a major concept which is a
central factor of the TFASDC.
These interviews were retrospective. Teens appeared to
have a much better ability to reflect back on their experiences
compared to interviews in previous research where, despite
clear abstract definitions of abuse, teens currently in a
relationship seemed to struggle with labels and definitions
for specific acts occurring within their own relationships
(Toscano, 2007). In addition, the interview itself was
reflective, requiring the teen to process a four year period
of time through the lens of their current college age
developmental stage. I found the participants developed a
great deal of insight into their current situation by reflecting
on their high school experience.
In all interviews, I closed the interview, stopped the
research portion, and ended by offering educational resources (approved and reviewed by the IRB). It was clear to
me, the interviewer, that the interview itself had the effect of
raising personal awareness about their relationships and risk.
Interventions aimed at tapping into this form of reflective
practice in both college and high school age groups might be
beneficial in the practice setting. Selecting college students is
a limiting factor. Many participants described “leaving for
college” as a means to end their relationships. Further
research is needed on teens that stay and live within their
home community. What forms of “escape” do they utilize
what forms of control “trap” them?
The retrospective qualitative interview appears to have
both interventional and research generative effects. This
method holds promise in areas of research where complete
awareness of an event takes time. The resultant narratives
require time and reflection on the young adult’s recent yet
past experience of abuse. This poses as a limiting factor for
practicing nurses working with teens actively engaged in
The Experience of Teens in Abusive Relationships
abusive relationships as teens may lack the comprehension
described in this study by college students reflecting on the
recent past. The main goal of this narrative is to describe the
lived experience as a means to inform the reader. As
practicing nurses become informed it may help them become
more effective or at a minimum understand behavior. Using
qualitative inquiry contributes to the state of the science of
dating violence by providing much needed context where
there is already an abundance of surveys research.
Focusing on this area has the potential to affect many.
(Sam) “… My situation wasn’t that unique, it happens to
everyone.”
Acknowledgment
Funded by Sigma theta Tau Kappa Tau Chapter.
Previously presented at the 18th International Health
Research Conference (Montreal, Canada, October 2012).
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ANALYSIS
MENTAL HEALTH
CPD
Smartphones, social media use and youth
mental health
Elia Abi-Jaoude MSc MD, Karline Treurnicht Naylor MPH MD, Antonio Pignatiello MD
n Cite as: CMAJ 2020 February 10;192:E136-41. doi: 10.1503/cmaj.190434
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190434-ana
I
n the last decade, increasing mental distress and treatment
for mental health conditions among youth in North America
has paralleled a steep rise in the use of smartphones and
social media by children and adolescents.
In Ontario, the proportion of teenagers reporting moderate to
serious mental distress increased from 24% in 2013, to 34% in 2015
and to 39% in 2017,1 with parallel increases in health service utilization. Inpatient hospital admissions of children and adolescents for
mental health reasons increased substantially across Canada
between 2007 and 2014, while admissions for other medical conditions in this age group decreased by 14%.2 Between 2009 and 2014,
admissions to hospital for intentional self-harm increased by 110%
in Canadian girls.3 Suicide is now the second leading cause of death
for Canadian youth.4 A recent analysis of survey data found the
12-month prevalence of suicidal ideation, attempts and nonsuicidal
self-injury to be 8.1%, 4.3% and 8.8%, respectively, among adolescents aged 14 to 17 years, with all rates being higher in girls.5 Similarly, administrative data in the United States show that presentations to hospital for suicidal ideation or attempts among children
and adolescents almost doubled between 2008 and 2015, with the
highest increase for adolescent girls.6 Self-poisoning rates among
10- to 18-year-olds, which had declined in the US since the turn of
the century, increased substantially from 2011 to 2018, primarily
among girls.7 Surveys of high school students in the US have shown
a similar pattern for self-reported symptoms of depression, major
depressive episodes and suicidality over the last 2 decades.8,9
At the same time, social media use has increased markedly. In
the US, the proportion of young people between the ages of 13
and 17 years who have a smartphone has reached 89%, more
than doubling over a 6-year period; moreover, 70% of teenagers
use social media multiple times per day, up from a third of teens
in 2012.10 The percentage of Ontario’s teenagers who reported
spending 5 or more hours a day on social media increased from
11% in 2013, to 16% in 2015 and to 20% in 2017.1 An analysis of
Australian longitudinal data found that 86% of students owned
smartphones in grade 8, increasing to 93% by grade 11, with
increased use of social media communication with age.11
We review the evidence that links smartphone and social media
use with mental distress and suicidality among adolescents. We do
not review evidence for online gaming. Although most existing data
E136
KEY POINTS
•
•
•
•
•
Evidence from a variety of cross-sectional, longitudinal and
empirical studies implicate smartphone and social media use in
the increase in mental distress, self-injurious behaviour and
suicidality among youth; there is a dose–response relationship,
and the effects appear to be greatest among girls.
Social media can affect adolescents’ self-view and interpersonal
relationships through social comparison and negative
interactions, including cyberbullying; moreover, social media
content often involves normalization and even promotion of
self-harm and suicidality among youth.
High proportions of youth engage in heavy smartphone use and
media multitasking, with resultant chronic sleep deprivation,
and negative effects on cognitive control, academic performance
and socioemotional functioning.
Clinicians can work collaboratively with youth and their
families, using open, nonjudgmental and developmentally
appropriate approaches to reduce potential harms from social
media and smartphone use, including education and practical
problem-solving.
There is a need for public awareness campaigns and social
policy initiatives that promote nurturing home and school
environments that foster resilience as youth navigate the
challenges of adolescence in today’s world.
are observational, making causality difficult to establish, findings
from a few longitudinal, randomized and controlled studies suggest
that social media and smartphone use may be contributing to the rising burden of mental distress among youth. We consider the clinical
implications of existing evidence, to help practising clinicians to work
collaboratively with youth and families to mitigate potential negative
effects of social media and smartphone use on mental health.
How has use of social media been shown to
affect adolescents’ sense of self?
Two cross-sectional surveys of American and German university
students, respectively,12,13 found that students who spent more
time on the social media platform Facebook were more likely to
endorse feeling envy or sensing that others in their social
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© 2020 Joule Inc. or its licensors
Does social media addiction exist and can it
affect mental health?
One study of repeat survey data from 2013, 2014 and 2015 associated the extent of self-reported use of Facebook with subsequent
poor self-reported mental health and life satisfaction.19 Concerns
have been raised about social media platforms having been
deliberately designed — in highly sophisticated ways that use
behavioural psychology, neuroscience and artificial intelligence
— to promote behavioural reinforcement and behavioural addiction.20,21 Several cross-sectional studies have shown that high
proportions of youth appear to be addicted to their smartphones,22,23 but there is no standard or agreed-upon definition of
smartphone or Internet addiction; studies have used different
definitions and scales, varying from those that rely on behavioural addiction criteria, to measurement of the extent of functional impairment and level of device use.24,25 As such, reported
prevalence rates are highly variable.25
A systematic review identified Internet addiction as being particularly associated with self-harm or suicidal behaviour based on
7 included studies, all of which were cross-sectional school-based
surveys that used validated outcome measures and were rated as
high or medium to high quality.24 A recent large prospective study
of senior high school adolescent students in Taiwan found that
youth classified as experiencing Internet addiction had a significantly increased risk of having newly emerged self-harm or suicidal behaviour or both when re-evaluated 1 year later.26
Two systematic reviews have shown that media multitasking
is associated with negative effects on cognitive control, academic
performance and socioemotional functioning in youth.27,28 Most
existing studies, however, are cross-sectional, and measures are
heterogenous across studies with limited attempts to consider
individual and contextual differences, making it impossible to
establish causality. Youth with lower impulse control may be
more susceptible to deleterious effects of media multitasking. A
large longitudinal study of adolescents who did not have significant symptoms of attention-deficit/hyperactivity disorder
(ADHD) at baseline found that high-frequency digital media use
was positively associated with emergence of symptoms meeting
Diagnostic and Statistical Manual of Mental Disorders–4th Edition
(DSM-IV) criteria for ADHD over a 2-year follow-up period, even
after adjusting for known confounders.29
Can social media promote self-harm?
Youth communicate thoughts of suicidality and self-harm behaviours online, including sharing images of self-inflicted injuries.
Explicit depiction of self-injury — particularly cutting — on social
media is common, as shown by site content studies30,31 that found
photographs or live videos of self-injurious behaviour, many of
which had no warnings about graphic content. Of particular concern were viewers’ comments, which typically contained positive
feedback or personal disclosures about self-injury experiences, and
rarely offered encouragement or discussion of recovery. Such findings show the potential for mental illness romanticizing and messaging that normalizes self-harm among youth. Indeed, a systematic review that included 26 studies (using qualitative, descriptive
or cross-sectional methodology) found that social media platforms
included normalization of self-harm behaviour, discussions about
practical issues regarding suicidality and live depictions of selfharm acts.32 At the same time, there were also positive elements,
including providing a sense of community, suggestions for seeking
treatment and advice on stopping self-harm behaviour.
Do the effects of smartphones on social skills
affect mental health?
An observational study showed that spending more than a few
hours per week using electronic media correlated negatively
with self-reported happiness, life satisfaction and self-esteem,
whereas time spent on nonscreen activities (in-person social
interactions, sports or exercise, print media, homework, religious
services, working at a paid job) correlated positively with psychological well-being, among adolescents.33 Other observational
studies have linked spending more than 2 hours a day on social
networking sites and personal electronic devices with high rates
of suicidality and depressive symptoms among adolescent girls,
although youth who sustained high levels of face-to-face socializing were relatively protected against the negative consequences
of too much time online.13,34
Youth do increasingly interact online rather than in person, and
smartphones can interfere even with face-to-face interactions via
what has been termed “phubbing”: attending to one’s phone
when in the presence of others.35 A recent empirical field study
using experience sampling in 304 participants showed that even
the mere presence of phones on a table caused participants who
were randomly assigned to that condition to feel more distracted
and have lower enjoyment during social interactions compared
with those who were randomized to putting their phone away.36
CMAJ | FEBRUARY 10, 2020 | VOLUME 192 | ISSUE 6
E137
ANALYSIS
network were better off than they were. The term “FOMO” — fear
of missing out — has been defined as “a pervasive apprehension
that others might be having rewarding experiences from which
one is absent,”14 and has been associated with increased stress
related to Facebook use.15
A systematic review of 20 studies found that use of social
media was associated with body image concerns and disordered
eating.16 In a randomized study, female participants reported
more negative mood after just 10 minutes of browsing their
Facebook account compared with those who browsed an
appearance-neutral control website.17 Moreover, participants
who were high in appearance comparison tendency reported an
increased desire to change the appearance of their face, hair or
skin after spending time on Facebook, in comparison with those
who browsed the control website.17
The nature of social media interactions, which are arm’s
length, makes negative commenting both easy and more frequent than in-person interactions with peers. An Ontario survey
of middle- and high school students showed that the odds of suicidal ideation, plans and attempts were all significantly higher
among those who had experienced cyberbullying, even after controlling for a range of potential confounders.18
ANALYSIS
Phone use was also found to predict distraction, which in turn predicted greater boredom and worse overall mood.36
Does sleep-loss associated with use of social
media affect mental health?
An analysis of US annual survey data found an abrupt increase in
the proportion of adolescents getting insufficient sleep after
2011–2013, with more than 40% sleeping less than 7 hours most
nights in 2015.37 The study also showed an exposure–response
relationship between daily electronic media use beyond 2 or
more hours per day, and insufficient sleep.37 An analysis of survey
data from Ontario found that 63.6% of 5242 students aged
11–20 years slept less than recommended,38 also showing a significant relationship between use of social media beyond 1 hour
a day and odds of insufficient duration of sleep.38
In a 14-day, randomized, crossover experimental study under
well-controlled conditions, use of electronic screens before bedtime was shown to disrupt sleep in multiple ways: longer time to
fall asleep and decreased evening sleepiness, reduced melatonin
secretion, circadian clock delay, reduced amount and delay in
rapid eye movement sleep, and reduced next-morning alertness.39 A systematic review and meta-analysis that included
20 studies on the association between portable screen-based
media devices and sleep outcomes found that use of media at
bedtime was associated with decreased duration and quality of
sleep and excessive daytime sleepiness.40 Of note, the mere presence of portable screen-based media devices in the bedroom
was shown to disrupt sleep,40 possibly related to the temptation
to check media devices when they are present or owing to a conditioned response involving increased arousal.
Data from a longitudinal study of 1101 adolescents in Australia showed that poor sleep mediated the relationship between
nighttime mobile phone use and subsequent depressed mood,
externalizing behaviours and decline in self-esteem and coping
based on various validated scales.11 In another longitudinal study
involving 2286 adolescents in Europe, magnitude of Internet use
in general had a negative impact on mental health, but the most
robust effects came from the consequences — in particular, lack
of sleep from Internet use had a notable adverse effect on mental
health on 4-month follow-up based on measures from a validated depression, anxiety and stress scale.41
Are some individuals more susceptible to
mental health effects than others?
Although population-based studies suggest a link between social
media use and mental distress among youth, the impact of these
technologies may vary among individuals — and some may be
less susceptible to harm, as indicated by an emerging literature
of experimental studies. Girls and young women tend to spend
more time on social media than boys do, have more exposure to
cyberbullying and show tendency to experience more mental
health effects,10,34 which is consistent with recent epidemiologic
trends indicating that depressive symptoms, self-harm and suicidality have increased among young females in particular.5–9
E138
The context of social media use may mediate its effects. A
structural equation modelling analysis of a cross-sectional survey of 910 high school students in Belgium found that, among
girls, passive use of Facebook had a negative impact on mood
but active use had a positive impact on perceived online social
support, which in turn had a positive impact on mood.42 However, for boys active site use had a negative effect. A systematic
review of 70 studies found that while social media use was correlated with depression, anxiety and measures of well-being,
effects could be both detrimental (such as from negative interactions and social comparison) and beneficial (such as through
social connectedness and support) depending on the quality of
interactions and individual factors.43 Certain cognitive styles,
such as those that involve rumination and brooding, appeared
to exacerbate negative effects of social media.43 Moreover, the
negative impact of social media on depressive symptoms
appears to be much greater for adolescents with low levels of inperson interaction; in contrast, youth with high levels of face-toface socializing appear to be relatively protected against the
negative consequences of too much time online.34 A recent survey of 1124 college students found that while social media contact in the absence of a face-to-face relationship was associated
with depressive symptoms, the proportion of social media contacts with whom participants had a close face-to-face relationship was negatively associated with depressive symptoms.44 In
addition, the challenges associated with social media may be
especially risky for young people who are already experiencing
mental health difficulties, as suggested by the bidirectional relationship between use of electronic media and decrease in psychological well-being.33 Of particular concern for such vulnerable individuals is that educational or even promotional content
about suicide and self-harm is readily available and widely
accessed online.30,31
The role of individual differences in terms of the effects of
social media is a topic of active investigation. Recent experimental studies have shown relationships between individual characteristics and social media experiences. In a randomized study of
120 college students, those who scored highly on the tendency to
engage in social comparison based on measures from a validated
scale had poorer self-perceptions, lower self-esteem and more
negative affect after browsing the Facebook profile of an
acquaintance, relative to those randomized to the control conditions, an effect not seen among students who scored low on
social comparison traits.45 In another empirical study, 102 college students who were asked to take a selfie were randomized
to either of 3 conditions with different numbers of “likes” (average, above average and below average); those rated as having a
greater sense of purpose in life based on measures from a validated scale had lower sensitivity to feedback (based on number
of “likes”) on their self-photograph posts.46 A study that categorized participants by social comparison orientations (“abilitybased” versus “opinion-based”) found that different orientations
showed different emotional responses to being compared with
others, which in turn was related to life satisfaction.47 These early
findings offer some insights for the individualized care of youth
presenting with emotional and mental distress.
CMAJ | FEBRUARY 10, 2020 | VOLUME 192 | ISSUE 6
How might physicians use this evidence to
inform their practice?
CMAJ | FEBRUARY 10, 2020 | VOLUME 192 | ISSUE 6
E139
ANALYSIS
Despite the limitations of the evidence base at this time, clinicians may be able to use currently available knowledge in their
practice, combined with evidence on effecting behavioural
change in youth.
Clinicians treating youth with mental illness and those at risk
of mental distress can discuss with adolescents and their families
the known risks of social media and smartphone use to mental
health. Clinicians may choose to advocate for a harm reduction
approach, suggesting reduced use of social media and the Internet rather than abstinence for youth, given evidence that suggests prolonged use is associated with poorer mental health. A
recent large systematic review found that communication with
adolescents is most effective in the context of a therapeutic alliance that is open and nonjudgmental, elicits trust and emotional
safety, and offers a sense of inclusion and autonomy.48
Encouraging parents to be proactively involved in limiting
children’s and teens’ use of smartphones and social media may
be helpful, given that social media use appears to become problematic when it surpasses 1 to 2 hours daily.34,38 Results from a
recent meta-analysis suggest that while parental limits may be
effective at reducing the amount of media use by younger children, open discussion focused on positive engagement and guidance might be best for reducing media-related risks for adolescents; however, only 5 of the 52 included studies pertained to
social media, all of which were based on cross-sectional surveys.49 It is also worth reminding parents that they model smartphone use with their own behaviour; a randomized study
showed that heavy parental smartphone use was associated
with poorer quality of interactions with their children. 50 Youth
and their families can be encouraged to set boundaries for
smartphone and social media use. These could include such measures as using social media only for set times, and preferably only
in common living areas in the home. A further motivator may be to
discuss evidence showing an adverse impact of smartphones on
learning,51 and the benefit on academic outcomes when phones
are put away when studying, preferably in another room.52
A qualitative study that collected data via focus groups with
adolescent girls found that high levels of confidence, high media
literacy and sound appreciation of individual differences
appeared to mitigate negative effects of social media on body
image.53 The participants reported that “these characteristics
were nurtured by positive parental influence and a supportive
school environment.”53 These findings underscore the importance
of a nurturing home and school environment in fostering resilience as youth navigate the challenges of adolescence. An empirical study of the effect of Instagram browsing on affect in just
more than 500 adolescents found that randomization to conditions that provided greater contextual awareness regarding posts
by others mitigated against postbrowsing negative affect in teens
who reported higher levels of negative social comparison.54
Sleep hygiene measures specific to social media and smartphone usage are crucial, as several studies have shown that
increased smartphone use can disrupt sleep and shorten sleep
duration. These would include avoiding use of electronic screens
within 1 to 2 hours before bedtime, and not having portable,
screen-based media devices in bedrooms overnight.
The American Academy of Pediatrics provides a number of useful health and safety tips to support youth regarding the use of
social media,55 as well as a Family Media Use Plan that offers structure to the recommendations related to limiting use and having
discussions regarding appropriate use.56 Further, the American
Academy of Pediatrics has partnered with Common Sense Media
to produce a Family Media Toolkit that has useful information for
parents.57 Other practical strategies to mitigate negative effects
from using smartphones and related media are offered by the Center for Humane Technology (http://humanetech.com/), an organization developed by former technology industry members out of
concern for the potential deleterious effects of new media on
psychological states.
A motivational interviewing approach may be useful to help
young people start to make changes in their pattern of online
behaviour. Motivational interviewing is an intervention with
established effectiveness for adolescents with substance use,
which could be useful for youth who appear to have poor selfcontrol in their use of social media or smartphone. 58 This
approach should involve open, nonjudgmental exploration of all
aspects of a youth’s digital life, including positive and negative.
Some youth might benefit from habit reversal training to address
compulsive use, including having daily “nonscreen time” that
can be progressively increased. Sharing evidence that a randomized controlled trial found that participants assigned to not using
Facebook reported significantly greater “life satisfaction” and
positive emotions after 1 week, compared with controls who
were told to continue using the site as usual,59 may be helpful in
effecting change. Youth might be encouraged to inform their
friends that they are taking a break from, or otherwise limiting,
their social media use. Talking with youth about alternative ways
to connect, including meeting in person or even talking directly
by phone, could help with strategies to fill the social media gap,
reinforced by discussion of evidence that in-person interaction
may protect mental health.
At the system level, school and community-based programs
can institute limits on social media and smartphone use, along
the lines of those that have recently been shown to have a positive effect on healthy behaviours.60 However, such interventions
should be developmentally appropriate and aim to respectfully
ensure adolescents’ autonomy.61 Mobile-phone policies at the
school and classroom level have been implemented in several
jurisdictions, with mixed results.62 Enforcement of blanket bans
is often a challenge; rather, a more productive approach involves
negotiation between teacher and students, as developmentally
appropriate, in the context of a relationship built on mutual trust
and respect for autonomy.63,64
More broadly, public awareness campaigns can provide education on the impact of problematic use of digital media and promote healthy behaviours in this regard. Various social media platforms have placed bans and restrictions on content related to
self-harm.24 A qualitative study of focus groups involving a total of
66 adolescents found that while adolescents valued freedom and
ANALYSIS
privacy, they recognized a need for protection and most were in
favour of automatic monitoring in situations that were beyond
their control.65 Finally, there should be public discussion about the
extent to which social media companies can use features that are
deliberately designed to promote behavioural reinforcement and
addiction,20,21 particularly on platforms used primarily by youth.
Encouragingly, youth are increasingly recognizing the negative impact of social media on their lives and starting to take
steps to mitigate this.66 According to a recent poll, 54% of teens
felt they spend too much time on their cell phone, and about half
reported cutting back on the time they spend on it.67
Conclusion
Given the importance of engaging youth in mitigating potential
harms from social media, a prohibitionist approach would be
counterproductive. The American Academy of Pediatrics suggests that online relationships are part of typical adolescent
development.55 Indeed, for adolescents today, who have not
known a world without social media, digital interactions are the
norm, and the potential benefits of online access to productive
mental health information — including media literacy, creativity,
self-expression, sense of belonging and civic engagement — as
well as low barriers to resources such as crisis lines and Internetbased talking therapies cannot be discounted.
However, today’s youth could benefit from proven individual
and systemic interventions to help them navigate the challenges
brought about by use of smartphones and social media, protect
themselves from harm and use social media in a manner that
safeguards their mental health, against a background of policy
initiatives aimed at addressing the social, environmental and
economic factors that underpin family well-being and nurture
youth resilience.68
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Competing interests: None declared.
This article has been peer reviewed.
Affiliations: Department of Psychiatry (Abi-Jaoude, Pignatiello), The
Hospital for Sick Children; Department of Psychiatry (Abi-Jaoude),
Toronto Western Hospital, University Health Network; Department of
Psychiatry (Treurnicht Naylor), University of Toronto; Faculty of Medicine (Pignatiello), University of Toronto, Toronto, Ont.
Contributors: All of the authors contributed to the conception and
design of the work. Elia Abi-Jaoude and Karline Treurnicht Naylor
drafted the manuscript. All authors revised the manuscript critically for
important intellectual content, gave final approval of the version to be
published and agreed to be accountable for all aspects of the work.
Acknowledgements: The authors acknowledge the valuable contributions of the anonymous reviewers and journal editors.
Correspondence to: Elia Abi-Jaoude, elia.abi.jaoude@utoronto.ca
CMAJ | FEBRUARY 10, 2020 | VOLUME 192 | ISSUE 6
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10/29/2018
What’s Causing Depression And Anxiety In Teens? | Time.com
Alison Heyland, 18, shown at her home in Maine, was part of a group that makes lms to raise awareness about depression, anxiety and selfharm Lise Sarfati for TIME
MENTAL HEALTH
Teen Depression and Anxiety: Why the Kids Are Not
Alright
Susanna Schrobsdorff
Oct 27, 2016
TIME
Health
T
For more, visit TIME Health.
he first time Faith-Ann Bishop cut herself, she was in eighth grade. It was 2 in the
morning, and as her parents slept, she sat on the edge of the tub at her home
outside Bangor, Maine, with a metal clip from a pen in her hand. Then she sliced
into the soft skin near her ribs. There was blood–and a sense of deep relief. “It makes the
world very quiet for a few seconds,” says Faith-Ann. “For a while I didn’t want to stop,
because it was my only coping mechanism. I hadn’t learned any other way.”
The pain of the superficial wound was a momentary escape from the anxiety she was
fighting constantly, about grades, about her future, about relationships, about everything.
http://time.com/4547322/american-teens-anxious-depressed-overwhelmed/
1/11
10/29/2018
What’s Causing Depression And Anxiety In Teens? | Time.com
Many days she felt ill before school. Sometimes she’d throw up, other times she’d stay
home. “It was like asking me to climb Mount Everest in high heels,” she says.
It would be three years before Faith-Ann, now 20 and a film student in Los Angeles, told
her parents about the depth of her distress. She hid the marks on her torso and arms, and
hid the sadness she couldn’t explain and didn’t feel was justified. On paper, she had a good
life. She loved her parents and knew they’d be supportive if she asked for help. She just
couldn’t bear seeing the worry on their faces.
For Faith-Ann, cutting was a secret, compulsive manifestation of the depression and
anxiety that she and millions of teenagers in the U.S. are struggling with. Self-harm, which
some experts say is on the rise, is perhaps the most disturbing symptom of a broader
psychological problem: a spectrum of angst that plagues 21st century teens.
Adolescents today have a reputation for being more fragile, less resilient and more
overwhelmed than their parents were when they were growing up. Sometimes they’re called
spoiled or coddled or helicoptered. But a closer look paints a far more heartbreaking
portrait of why young people are suffering. Anxiety and depression in high school kids have
been on the rise since 2012 after several years of stability. It’s a phenomenon that cuts
across all demographics–suburban, urban and rural; those who are college bound and
those who aren’t. Family financial stress can exacerbate these issues, and studies show that
girls are more at risk than boys.
In 2015, about 3 million teens ages 12 to 17 had had at least one major depressive episode
in the past year, according to the Department of Health and Human Services. More than 2
million report experiencing depression that impairs their daily function. About 30% of girls
and 20% of boys–totaling 6.3 million teens–have had an anxiety disorder, according to
data from the National Institute of Mental Health.
Experts suspect that these statistics are on the low end of what’s really happening, since
many people do not seek help for anxiety and depression. A 2015 report from the Child
Mind Institute found that only about 20% of young people with a diagnosable anxiety
disorder get treatment. It’s also hard to quantify behaviors related to depression and
anxiety, like nonsuicidal self-harm, because they are deliberately secretive.
For a limited time, TIME is giving all readers special access to subscriber-only stories. For
complete access, we encourage you to become a subscriber. Click here.
http://time.com/4547322/american-teens-anxious-depressed-overwhelmed/
2/11
10/29/2018
What’s Causing Depression And Anxiety In Teens? | Time.com
Still, the number of distressed young people is on the rise, experts say, and they are trying
to figure out how best to help. Teen minds have always craved stimulation, and their
emotional reactions are by nature urgent and sometimes debilitating. The biggest variable,
then, is the climate in which teens navigate this stage of development.
They are the post-9/11 generation, raised in an era of economic and national insecurity.
They’ve never known a time when terrorism and school shootings weren’t the norm. They
grew up watching their parents weather a severe recession, and, perhaps most important,
they hit puberty at a time when technology and social media were transforming society.
“If you wanted to create an environment to churn out really angsty people, we’ve done it,”
says Janis Whitlock, director of the Cornell Research Program on Self-Injury and Recovery.
Sure, parental micromanaging can be a factor, as can school stress, but Whitlock doesn’t
think those things are the main drivers of this epidemic. “It’s that they’re in a cauldron of
stimulus they can’t get away from, or don’t want to get away from, or don’t know how to get
away from,” she says.
In my dozens of conversations with teens, parents, clinicians and school counselors across
the country, there was a pervasive sense that being a teenager today is a draining full-time
job that includes doing schoolwork, managing a social-media identity and fretting about
career, climate change, sexism, racism–you name it. Every fight or slight is documented
online for hours or days after the incident. It’s exhausting.
“We’re the first generation that cannot escape our problems at all,” says Faith-Ann. “We’re
all like little volcanoes. We’re getting this constant pressure, from our phones, from our
relationships, from the way things are today.”
http://time.com/4547322/american-teens-anxious-depressed-overwhelmed/
3/11
10/29/2018
What’s Causing Depression And Anxiety In Teens? | Time.com
Lise Sarfati for TIME
Steve Schneider, a counselor at Sheboygan South High School in southeastern Wisconsin,
says the situation is like a scab that’s constantly being picked. “At no point do you get to
remove yourself from it and get perspective,” he says.
It’s hard for many adults to understand how much of teenagers’ emotional life is lived
within the small screens on their phones, but a CNN special report in 2015 conducted with
researchers at the University of California, Davis, and the University of Texas at Dallas
examined the social-media use of more than 200 13-year-olds. Their analysis found that
“there is no firm line between their real and online worlds,” according to the researchers.
Phoebe Gariepy, a 17-year-old in Arundel, Maine, describes following on Instagram a girl in
Los Angeles whom she’d never met because she liked the photos she posted. Then the girl
stopped posting. Phoebe later heard she’d been kidnapped and was found on the side of a
road, dead. “I started bawling, and I didn’t even know this girl,” says Phoebe. “I felt really
extremely connected to that situation even though it was in L.A.”
That hyperconnectedness now extends everywhere, engulfing even rural teens in a national
thicket of Internet drama. Daniel Champer, the director of school-based services for
Intermountain in Helena, Mont., says the one word he’d use to describe the kids in his state
is overexposed. Montana’s kids may be in a big, sparsely populated state, but they are not
isolated anymore. A suicide might happen on the other side of the state and the kids often
know before the adults, says Champer. This makes it hard for counselors to help. And
nearly 30% of the state’s teens said they felt sad and hopeless almost every day for at least
two weeks in a row, according to the 2015 Montana Youth Risk Behavior Survey. To address
what they consider a cry for help from the state’s teens, officials in Montana are working on
expanding access to school-based and tele-based counseling.
Megan Moreno, head of social media and adolescent health research at Seattle Children’s
Hospital, notes a big difference between the mobile-social-tech revolution of the past 15
years and things like the introduction of the telephone or TV. In the olden days, your mom
told you to get off the family phone or turn off the TV, and you did it. This time, kids are in
the driver’s seat.
Parents are also mimicking teen behavior. “Not in all cases, obviously, but in many cases
the adults are learning to use their phones in the way that the teens do,” says Moreno.
“They’re zoning out. They’re ignoring people. They’re answering calls during dinner rather
than saying, ‘O.K., we have this technology. Here are the rules about when we use it.'”
http://time.com/4547322/american-t…
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