Case Study

Tess, age 14, was hospitalized on an inpatient psychiatric unit after an intentional acetaminophen overdose. She had no formal psychiatric history and had never had psychiatric treatment. Tess appeared hopeless and defeated as she confessed that she had been feeling sad and lonely since her family moved to their current location about two years ago. She stated that she had trouble making friends in her new school; her grades had also dropped from Bs and Cs to Ds and Fs. She had gone from being popular in her previous school to being a “loner” in her current school. Tess had only one close friend, of whom her parents disapproved; in fact, Tess had a legal charge pending for attempting to steal alcohol from a grocery store with this friend. She also embarrassedly admitted to a previous legal charge the year before for child pornography after posting a picture of a naked teenage boy, a “sext” message originally intended for someone else, as her MySpace picture for a period of less than 24 hours. When the boy discovered this, he was so mortified that he told his school guidance counselor he wanted to kill himself. The boy’s parents pressed charges, resulting in the child pornography charge. From this point on, Tess became progressively more depressed. Tess had feared that the judge would be “harder on her” for the alcohol theft charge, due to her prior legal history, which prompted her suicide attempt.

Today’s generation of adolescents use social media, the definition of which will include the Internet and cell phones for purposes of this article, to aid in the important social and emotional developmental task of incorporating sexuality into a sense of self and relationships.

The Pew Internet and American Life Project Survey (2009) reported that an estimated 93% of youth use the Internet regularly; surveys including the Sex and Tech Survey, the Teen Online and Wireless Safety Survey, and the Pew Internet and American Life Project have reported that 4–20% of teens (depending on age) have sexted (sent inappropriate sexual message/pictures via cell phone and/or email). In addition, for the first time, “sexting” appeared in the top ten health concerns for children (#10) in the 2011 Mott’s Children’s Hospital National Poll on Children’s Health, rated by 20% of adults as a big problem; Internet safety appeared at #6, rated by 23% of adults as a big problem.

Although this immediate access to information and to social connections can be beneficial in providing ever-present social support and rapidly accessed knowledge about sexual and general health issues, it can also be dangerous in how quickly information can be disseminated.

Teens can garner instant attention by taking a provocative picture and sending it as a text message by phone. Revealing photos can be uploaded onto a computer and sent by email through the Internet, where they remain permanently in “cyberspace.” Teenagers can use web cameras on interactive web sites and engage in sexual behaviors “live.” It is clear that the combination of impulsivity, limited judgment, sexual development/curiosity, and immediate access can lead to dangerous consequences.

New responsibilities for providers

This technology has both created complications for the millennial teen and added to the responsibilities of pediatric mental health care providers, who must now keep abreast of these new developments in social media, as well as current trends in adolescent sexual behavior, so that they may ask appropriate questions during evaluations. A thorough interview must include questions about use of the Internet and cell phones when talking to teens about hobbies, relationships with friends, romantic relationships, sexual history, substance use, and legal history.

Teenagers often do not voluntarily discuss sexual behaviors or dubious social media activities, so if the clinician does not specifically ask, critical information could be missed. This interview must be done in a confidential (unless, of course, there is a risk of danger for the patient) and non-judgmental manner in order to facilitate trust in the treatment relationship. Sometimes, inappropriate sexual use of social media or sexting is the presenting complaint, as referred by the parent, pediatrician, or therapist. Other times, it is an incidental finding discovered upon a routine evaluation (as with Tess), which will then require extra attention.

In order to develop a more thorough and accurate biopsychosocial formulation, mental health professionals must consider the motivation for the risky behavior on social media, the context in which it occurred, the developmental age and insight of the patient, associated symptoms, and past psychiatric history. Gathering of collateral information from parents and other treatment providers, including pediatricians, is also critical. In addition, teachers, guidance counselors, and principals can give valuable information and different perspectives on these adolescents and their social behaviors and academic performance.


Possible diagnoses may fall into categories of disruptive behavior, mood, anxiety, psychotic, pervasive developmental, substance abuse, and personality disorders. Because sexual exploration with sexting and online exposure via Facebook and other websites may be developmentally appropriate (albeit risky), careful assessment is also necessary to prevent pathologizing potentially normal adolescent behavior, given today’s pervasive use of this technology among teens.

However, whether the behavior is developmentally “normal” or pathological, psychoeducation about the dangerous consequences must be provided to both the patients and their families. This includes talking to the patient and family about the permanence of images and texts sent online and via phones, as well as the potential risks, including cyberbullying, cyberstalking, sexual predation, suicide, and the possibility of legal ramifications, such as in the case presented.

It is also common for colleges and employers to search the Internet for the names of their applicants; if inappropriate images and/or social networking site pages are discovered, it could affect the applicant’s chances of being accepted or hired. Therefore, psychoeducation to both adolescents and their parents about the risks of these behaviors can prevent teens from engaging in them or mitigate the dangerous consequences, as well as allow parents to set reasonable guidelines for the use of social media.

Depending on the diagnosis, other possible interventions include medications, hospitalization, individual therapy, family therapy, group therapy, and/or school services.

Full article, including a Case Report and conclusions, is available electronically to current subscribers.

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Liwei L. Hua, M.D., Ph.D., is a Clinical Assistant Professor and the Clinical Director of Child and Adolescent Psychiatry Ambulatory Services in the University of Michigan Department of Psychiatry, Child and Adolescent Section. She would like to acknowledge Drs. Adele Martel and Lois Flaherty for contributions to the original version of the article, as published in AACAP News, and their thoughtful comments on the current version.


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