When adolescent psychiatrist Dr. Drew Pate counsels patients or speaks to parenting groups, questions about social media use inevitably arise.
Parents wonder if their children's constant use of Instagram, Facebook or Snapchat is healthy. Teenagers talk about the pressure to post the perfect photo or compete with the pristine lives their peers present on the Internet.
"When you talk to parents and see kids in the office, we hear more and more about the potential damage being caused by social media outlets," said Pate, who works for Sheppard Pratt Health System. "I think almost any adolescent who is involved in any social media has probably had some negative affect from it."
Researchers and scientists still are trying to figure out how social media use affects young people. So far the evidence is mixed and there's no broad consensus on the long-term consequences of excessive social media use.
Studies have shown the around-the-clock world of social media takes a mental and emotional toll on some young people. It has been linked to increased anxiety, depression and decreased relationship skills. One study found social media can be more addictive than cigarettes and alcohol for some people.
Social media also can have a positive affect, however. Some research has found that social media can be a resource for teens to find social support when they are struggling with life issues, and that they can use the different online platforms as a way to express themselves. Some teens are able to build friendships and relationships through the interaction they have with others on the Internet.
A study published earlier this year by the University of Pittsburgh School of Medicine with support from the National Institutes of Health found that the more time young adults spent on social media the more likely they were to have problems sleeping and experience symptoms of depression.
Another study by the Johns Hopkins Bloomberg School of Public Health found that incidents of major depressive incidents have increased dramatically among teens, particularly among girls, and that cyberbullying may be playing a role.
At American University, researchers found a link between social media use and negative body image, which can lead to eating disorders.
And in a recent survey of young people conducted by The Royal Society for Public Health in London, Instagram and Snapchat were found to be the worst for adolescents and their mental health. The poll asked 1,479 people aged 14 to 24 to rate social media apps on issues such as body image and anxiety.
The survey report said young women in particular are bombarded with edited images that mask people's flaws and imperfections.
"This practice is contributing to a generation of young people with body image and body confidence issues," the report said.
Representatives for Instagram and Snapchat did not respond to requests for comment.
Teenagers are already self-conscious and vulnerable to what others say, said Pate, the Sheppard Pratt psychiatrist. They may start comparing their lives to those of people on social media. They may misconstrue comments people make on social media as directed at them when they are not. The social cues such as tone or facial expressions are not visible like they are in a live interaction, making it easier for teens to misinterpret what someone says.
"The problem with teenagers is they are much more in the moment and not as forward thinking as we get to be as adults," said Pate, pointing out that the human brain is not fully developed until about age 25.
One psychiatrist with the University of Maryland Medical System believes that excessive social media use should be designated formally as an addiction so that official guidelines on its use could be established.
"The more rapid and the more image loaded it is, the quicker and the greater the chance of an addiction," said Dr. Bankole Johnson, chairman of the University of Maryland School of Medicine's department of psychiatry and director of its brain science consortium research unit. "If you were gambling and you increase your frequency of gambling, the greater chance of becoming addicted to gambling."
But some experts warn against painting the impact of social media with broad brush strokes. And researchers point to studies that have found beneficial affects.
Another study by the Johns Hopkins Bloomberg School of Public Health found that social media helped teenagers who played video games excessively and suffered from symptoms of depression. Heavy gamers who had a network of friends on social media seem to be immune to the problems suffered by some who played the games a lot and didn't have similar social networks, said researcher Michelle Colder Carras, a post-doctoral fellow in the Bloomberg School's department of health.
"Engaged gamers play a lot but don't necessarily have problems with video game addiction, depression or anxiety," she said.
Carras said that care needs to be taken when making a direct link between mental health and social media use. She said the survey by The Royal Society for Public Health doesn't show that the social media caused anxiety and other issues. It didn't delve into whether the teenagers already had mental health problems or if those problems could have been linked to something else.
"They just went out and talked to young people about their feelings about the social media platform," she said.
Researchers with the National Center for Telehealth & Technology, one of the Department of Defense's Centers of Excellence for Psychological Health and Traumatic Brain Injury, said social media can help promote suicide prevention information, such as hotlines and support groups. But they said the overall negative and positive impacts that social media can have are not yet clear.
"More research is needed on the degree and extent of social media's negative and positive influences, as are evaluations of the effectiveness of social media-based suicide prevention programs," the researchers wrote in an analysis published in the American Journal of Public Health.
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The Royal Society listed several suggestions it says could ease the affects of social media on the emotional health of teenagers. Sites like Instagram could highlight when people have digitally altered their image or post warnings about the dangers of too much social media use, the group said. It also suggested that schools teach safe social media use and called for more studies to be conducted on how it affects the mental health of teenagers.
The University of Maryland's Johnson said social media-related emotional problems in teenagers are often detected when they have other problems, such as learning and behavioral difficulties.
Some teenagers might need to be weened off social media completely if it is causing intense emotional issues, Pate said.
Others might need regulated or tightened security measures so they are only socializing with a select group of people. Parents can help by monitoring and limiting the amount of time their children spend on social media.
"It boils down to what the kids can manage and handle when it comes to the stress created by these sites," he said. "We want the kids to individualize their own approach."