Social media use

All [35] deceased adolescents in our sample used social media. For fifteen adolescents, of whom twelve boys, social media was used primarily as a practical tool; to stay up to date about events or birthdays, or for school. They communicated through messenger apps but spent little time on social networking sites. For many young people [20], however, social media played an important role in their day-to-day lives. It was a way to stay in touch with peers, find people with similar interests, read about experiences of other young people, watch funny content, a safe space to (anonymously) vent their feelings, or to establish popularity by getting many friends or followers. All adolescents used communication media like WhatsApp and Facebook Messenger. Social networks [31 adolescents], and media sharing platforms [22 adolescents] were popular as well. Nine young persons frequented discussion forums or message boards. Eight out of these nine were girls visiting forums specifically related to mental health or eating disorders. Only a few [3 adolescents] used blogging and microblogging media.

Harmful effects of social media use

Themes relating to the harmful effects of social media were dependency and excessive social media use, social comparison and distorted perceptions about mental health, triggers and imitation, cultivation of a suicidal identity, challenges and impulsive behaviours, and victimization and entrapment.

Dependency and excessive social media use

Fourteen young individuals, who were often described by respondents as socially insecure, developed a dependency towards social media because they were anxious to be offline and miss out on conversations with peers or online content. Moreover, interactions with peers on social media affected their mood as much as real-life interactions, and they could become upset and distressed when they did not receive positive reinforcement from peers online.

Parent: “The pressure of social media was significant. WhatsApp, but also Facebook and other platforms. The pressure of ‘befriending and unfriending’ and talking about each other through social media has had a very negative impact on her.”

Insecurity and dependency were linked to excessive social media use. Eleven out of the fourteen adolescents actively responded to notifications throughout the entire day, even during dinnertime and late at night. Some spent up to eight hours a day browsing social media. While respondents did not attribute a direct effect of excessive social media use on suicidal thoughts or behaviours, they noted that it contributed to sedentary behaviours, feelings of anxiousness and loneliness, a decrease in face-to-face interactions, sleeping problems, and school problems.

Parent: “He didn’t sleep well, was ruminating too much… he was locked in his thoughts. […] He felt like he did so much for this person [online friend], and he get so little in return. That really bothered him, and he could no longer focus when he was in school.”

Social comparison and perceptions about mental health

The content posted by peers and role models presented norms for mental health and happiness that distorted some of the decedents’ perceptions about their own mental health. The emphasis on achievements, events and positive emotions presented a stark contrast with suffering from suicidal thoughts and created pressure. By consistently comparing their lives with the seemingly perfect lives of peers and influencers online, feelings of being different were reinforced.

Parent: “We tried to normalize it. ‘Honey, whatever you’re feeling, and those thoughts you have, a lot of people your age have those. It may seem from the outside like everyone has it made, everyone has a great live, everyone looks nice, everyone has nice clothes, money. But that is not reality, that’s just a shell. Like you see on social media, you know, that’s not life.”

Triggers and imitation of suicidal behaviours

For a group of thirteen adolescents, of whom twelve girls, there was a thin line between supportive and triggering online networks. By trigger we refer to online content that elicited feelings of distress in the adolescent. These adolescents actively looked for recognition and support in online communities but became entangled in communities where triggering content was openly shared. Content ranged from depressing quotes and memes to graphic depictions of self-harm and suicide. Parents berated how easy it was to find information about how to die by suicide on discussion forums and social networking platforms. Some respondents feared that adolescents may have become preoccupied with self-harm and suicidal behaviours by being consistently confronted with other peoples’ experiences in the matter.

Parent: “There is a world of websites filled with negative content. Experiences of people. […] And then there are these algorithms. If you frequently search for negative things on Instagram, then Instagram will show you more negative content. That not just makes it harder; it makes it look like that is all there is. Because that is the only thing that comes up.”

Parent: “On Instagram, you can follow a certain topic. She was taken in with depression as a topic. All these posts and memes about depression, she read those a lot. It occupied her. She also searched for ‘suicide.’ Continuously feeding those negative thoughts through social media. […] It is a downward slope. If you only surround yourself with negativity, that is all you can feel.”

This theme was most salient in eight girls who had been admitted into a healthcare facility. The girls were exposed to suicidal behaviours of fellow residents in real life. Parents described that WhatsApp groups were formed to support fellow residents, but that these channels were often used by young persons to vent; to share their thoughts and feelings. There was insufficient engagement and moderation of social media use in inpatient settings. While we found no conclusive evidence of clustering of youth suicides in our sample, next-of-kin warned that suicide-related content on social networking and media sharing platforms may promote imitation of suicidal behaviours.

Parent: “She also had this recovery account on Instagram. A lot of girls with an eating disorder or what not have these accounts. She allowed me to watch it from time to time, but I wasn’t allowed to follow her. She regularly showed me things. […] That they show each other wounds from self-harming, but also posts like ‘I don’t feel like living anymore, I quit.’ The things they had done. I saw all those things.”

Peer: “Sometimes it becomes a competition. Everything is competitive. How thin can you become? How deep can you cut? Those things. Who is the most disturbed? I think [name] did not feel a need to be the most disturbed one. But I believe she was the most disturbed one without even trying.”

Cultivation of a suicidal identity

Another theme emerged for a small group of adolescents who communicated often and openly about their suicidal thoughts. They developed what a peer referred to as a suicidal identity. This transcended frequent suicide-related communication, as it maintained that the young person became so entangled with their own suicidal thoughts and behaviours, that they found it hard to imagine their life without them. The adolescents for whom this theme applied were afraid of who they would be once they recovered because their mental health problems provided them with a sense of belonging and identity. The peer of a young girl explained.

Peer: It can be quire harmful, when you’ve built a life like that, because who will you be when that’s gone? […] Who will I be once I recover? If I just complete an education, who am I, what will it be that makes me interesting, what will it be that defines me? […] But I think that social media, like Tumblr and Instagram and all those platforms that [name] was on, that those helped her hang on to that identity, anchored it. ‘This is what I am, and this is what makes me, me.’ While there was so much more that made her, her.

Young people cultivated this identity through online peer-to-peer interactions and reinforcement, seeking either sympathy or disapproval. Next-of-kin worried that cultivating an identity around suicidal thoughts and behaviours, and specifically the fear of letting go of this identity, aggravated suicidal thoughts and hampered help seeking and openness to treatment and recovery.

Challenges

Challenges are online phenomena where (often young) people challenge one another to carry out specific tasks, sometimes sharing videos of themselves performing these tasks through social media. Five adolescents in our sample had participated in challenges. Three of these challenges involved physical harm. One girl suffered from intoxication following excessive water intake, following a challenge to drink as much water as possible to lose weight. One boy participated in a choking challenge, where a person asphyxiates themselves until nearly passing out for the thrill.

A young girl was known to have shown interest in a suicide-related challenge: the Blue Whale challenge. This challenge entails that a person follows a set of activities, imposed upon them by a curator. The activities are harmless at first, like setting an alarm in the middle of the night, but gradually evolve to tasks such as instigated self-harm. The final task is to end one’s own life. A girl talked about taking part in this challenge with a friend and had reached out to a curator online. As far as the respondents know, however, she never completed any of the more dangerous tasks in the challenge.

Peer: “She participated in a challenge, the Blue Whale challenge. You need to do different tasks. […] I know that it was directed at depressed people. I don’t have any examples, but these tasks were nothing like an ice bucket challenge or something.”

None of the respondents believed that the suicide could be attributed to participating in challenges, but they did acknowledge how challenges may incentivize impulsive behaviours in at-risk adolescents, resulting in a disregard for the consequences of potentially harmful behaviours.

Parent: She was regularly active on social media. At some point, she had an app, it was called Kik. You have all these young people posting stuff that gives you a thrill. […] She was so impulsive and impressionable. Just to be part of it. She was so impressionable by all that happened around her.”

Victimization and entrapment

Cyberbullying was reported in four cases. These adolescents received harmful messages or were threatened with violence through online media. Bullying could include the encouragement of suicidal behaviours. Two young people were pressed by peers to engage in self-harm or a suicide attempt. A young girl made a reference to the bully briefly before her suicide, while the event took place many years before, suggesting a lasting impact.

Parent: “[A boy in class] asked her: when will you commit suicide? And we found out, later, that this did not happen once, it was asked to her twenty times a day. […] A few days before [she took her life], she told her mother: ‘I can still see that boy sometimes’.”

Five girls and one boy were victim of cybervictimization, specifically online sexual transgressive behaviour. Online relations with the perpetrators started mutually but quickly developed into an unequal relation. The adolescents received unsolicited proposals, pictures, or videos, or were themselves forced to send pictures or videos involving nudity or sexual acts. In most cases, these were single events, and not associated with the suicide of the adolescents. However, two adolescents had traumatic experiences following cybervictimization which the respondents associated with the suicide. One boy had been the victim of online catfishing and was sexually assaulted by an older man. A young girl was the victim of sextortion by fellow residents of a care facility. They threatened to release nude pictures and videos of her on the web. Feelings of entrapment were often reported for bullied and victimized adolescents.

Parent: “I know they were allowed to be on the computer for half an hour a day, and they could go on Facebook, but a lot more happened there, because in that time she sent nude pictures of herself, and videos too, under pressure. Some inpatient boys told her: ‘send me some nudes of yourself, or I will tell the staff that you have cigarettes and a lighter in your room.‘ And that escalated.”

Supportive use of social media

Next-of-kin of ten adolescents emphasized the supportive aspects of social media. Supportive elements of social media as perceived by respondents were recognition and understanding, peer support, recovery stories and coping strategies, and healthy networks.

For adolescents, social media presented a tool to seek recognition and understanding, which they found more easily in communities of peers with similar problems. Notably, the feeling of not being understood in the offline world strengthened their urge to seek interactions with peers online. They sought help and support from role models and peers to deal with their psychological problems, like coping strategies that helped others and recovery stories. It helped normalize their suicidal thoughts and made them feel less alone in their struggles. Some adolescents felt empowered when using social media to share their experiences to help others.

Peer: “That is also what she tried to express. You shouldn’t only look at the negative things, because that will not help you recover.”

A specific theme relating to supportive effects was found in a group of girls in inpatient settings. Social media were a necessity for them to sustain relations with friends and family outside of the care facility. These adolescents witnessed the daily distress of peers, and many had witnessed suicidal behaviours of fellow residents. Online interactions with friends and family outside the clinic firstly made them feel looked after and, secondly, counterbalanced the exposure to psychiatric problems and systematic suicidal behaviours of fellow residents.

Experiences with monitoring and engaging adolescents about social media

Interestingly, although five peer respondents expressed worries about the impact of social media to vulnerable adolescents in the interviews, none of them reported to have engaged their fellow peers about such concerns. By contrast, at least nineteen parents had often tried to engage the adolescents about their social media activities because they worried about the harmful effects and the impact on the youth’s mental health. Adolescents were naturally reserved about their social media use towards their parents, which caused parents to be ill informed about online behaviours. Several parents mentioned feeling frustrated that while they started the conversation with an unjudgmental attitude, adolescents refrained from open conversation. They furthermore experienced various challenges that made them feel inapt to address the issue properly. Common themes included unfamiliarity, secrecy and anonymity, and restriction and resistance.

Unfamiliarity

Most parents were not familiar with the functionalities of social media platforms and unaware about developments and trends on social media. Consequently, engaging an adolescent was difficult because parents did not know what kind of questions would incite open conversation. Illiteracy towards the gaming community and associated media platforms was specifically addressed, including game chat servers and forums.

Parent: That was an unknown world to us. I learned about it. ‘Are you behind your computer again? See some friends!’, I would say. But that’s just what they do with each other. He had a lot of friends online, including neighbourhood friends. […] They organize tourneys. They would game the whole weekend. His tiredness was a problem because they would go on all night”.

Parent: There are other chat programs for gaming about which we know little. He was on the dark web, those kinds of places. He had a vast number of chat communities with gamers from all over the world.”

Online anonymity

Respondents of twelve cases reflected on the secrecy and anonymity of social media behaviours. Young persons were adept at hiding their online activities, ranging from simply deleting their browser or search engine history to using virtual private networks. Several adolescents created a second account on social media platforms, under another name. At least five young girls used this account to enter communities anonymously and to share explicit suicide-related communications. Respondents note that these young girls wanted to prevent that suicide-related content would reach next-of-kin in real life because they were afraid of judgment or consequences. A few parents were so anxious to be knowledgeable, that they created a secret account themselves to monitor the youth or asked a sibling to provide them with information about suspicious online activities of the youth.

Restriction and resistance

To maintain control and involvement, parents monitored online activities, or set time limits for internet use. However, active restricting often did more harm than good, explained parents. Restriction triggered a strong, emotional response, and adolescents took extensive measures to stay connected. To illustrate, one girl bought a new phone every time her parents took her phone.

Parent: “At some point we took her phone away, turned out she had a second one. I think she even got a third one. There was no stop to it. The [restriction] had mostly to do with her running away [from the clinic]. And to make sure she finally got a good night’s rest instead of all those notifications.”