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ADHD and the Involvement of the Unprecedented Rise of Social Media: A Literature Review 

Abstract: 

The objective of this literature review via PubMed and Google Scholar was to establish a connection between social media use and symptoms associated with attention deficit hyperactivity disorder (ADHD) from physiological and sociological perspectives. These factors indicate that social media has a possible correlation to the rise of ADHD cases and worsening symptoms. Physiologically, social media has an effect on the brain through dopamine that increases the severity of ADHD symptoms. Socioculturally, social media has some involvement in the unprecedented rise of ADHD cases through the rise of social media since the 2000s, social isolation, and social contagion. After more extensive research, underrepresented groups in ADHD are also another sociocultural factor that can correlate to the rise of ADHD cases and severity. Overall, with ADHD having long been known for creating difficulties for patients, understanding the rise of social media to potentially play a role in the rise of ADHD and worsening symptoms could help researchers later develop future treatments for people with the illness. 

 

Introduction: 

Clinically, the DSM-5-TR has defined ADHD as “a neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and hyperactivity-impulsivity” [1]. The diagnosis requirements for ADHD are also ambiguous with the frequency of the behavior occurring to be considered as “often” without any threshold; doctors involved with the diagnosis procedure must make their interpretation and judgment (which is how subjective views of race can play a role in interpreting ADHD) [2]. In our modern age, numerous pressures worsen this illness: isolation, social media, and the spreading of misinformation [3]. The rise of social media, especially during the 2020 pandemic, has raised concerns related to inattentiveness and addiction. The question this review is attempting to address is whether a link can be formed between the unprecedented rise of ADHD cases and social media use, particularly in adolescents or children. As social media usage rises in younger generations, the risks involved need to be understood to a greater extent than the current knowledge to provide more effective treatment. 

 

Results: 

Sociocultural Factors of ADHD

The Rise of Social Media

Since the 2010s, social media usage (SMU) has increased substantially, especially among adolescents [4]. In 2018, 45% of adolescents in the USA reported being online constantly compared to only 24% in 2015 [5]. For adolescents surveyed during the COVID-19 pandemic, the average daily SMU was 7.70 hours/day, exceeding pre-pandemic estimates of 3.8 hours/day [6]. Similarly, over the 20 years from 1997-2016,  a drastic change occurred with the estimated prevalence of diagnosed ADHD in children and adolescents increasing by 10.2% between 2015 and 2016, which is a more significant increase compared to the 6.1% between 1997 and 1998  [7]. This upward trend in diagnosed ADHD and SMU reflects the possible association between the two factors. With the nature of social media, reforming the platform is extremely difficult, as technology advances much faster than society can psychologically plan or account for. Because young people have become substantially addicted to the overload of information at the touch of their fingers and have been incentivized to do the same as their peers, a social dilemma or “collective action problem” has become evident [8]. This idea of configuring people together has created a strong collective identity that makes their interests as observable as possible to the public to attract others who share common interests [9]. Through this adolescents fear missing out, which drives them to be addicted to social media and lose their childhood independence, combined with social interactions [9].

In addition, dopamine, a neurotransmitter involved in reward pathways, lures users through feedback loops toward this social media addiction. Social media platforms diminish dopamine by utilizing variable work schedules (similar to slot machines), where unexpected rewards are given at random to engage users [10]. This randomness creates unpredictability and uncertainty (where the next spin on a slot machine could be a win), especially in newsfeeds where people encounter interesting information as a reward. Over time, steady dopamine release creates a deficiency in the brain, causing users to experience less pleasure when they are not engaged in addictive behaviors, such as scrolling through their social media. Research has shown regions in the brain in which dopamine D2/D3 receptor availability measures were lower in participants with ADHD than in controls [10].  During adolescence, the brain is oriented towards rewards as brain activity in the reward system (e.g., ventral striatum) peaks from reward response, while brain regions supporting cognitive control (e.g., dorsolateral prefrontal cortex) mature slower [10]. Since reward systems in the brain show greater activity in a social context, it could be inferred that social media is more rewarding to adolescents, correlating with worsening ADHD symptoms [11]. Because of this, social media is proposed to be attractive for adolescents with ADHD as children could go on smartphones which actively notify users with constant updates, allowing the adolescents to navigate profiles quickly [11]. ​​​​​​​​​​​​​​​​​​​​​​​​

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Social Isolation

The rise in social media usage has also caused social isolation and rising stress levels both of which may point to their potential correlation with the ADHD rise. In 2020, the COVID-19 pandemic isolated people, increasing loneliness, with ⅓ of adolescents reporting high levels of loneliness and an estimated half of 18-24-year-olds feeling lonely during the lockdown [11]. This has contributed to a further rise in anxiety, stress, depression, sleep problems, post-traumatic stress disorder, and suicidal behavior [12]. Through the analysis of 40,807 children and adolescents in pre-COVID-19 studies and 33,682 during-COVID-19 studies, Madigan and her colleagues found that there was evidence of an increase in depression symptoms (SMC, 0.26; 95% CI, 0.19-0.33; slight to small magnitude) and a slight increase in anxiety symptoms (SMC, 0.10; 95% CI, 0.04 to 0.16) [13]. According to the study conducted by Maria A. Rogers with 6,491 participants, the COVID-19 pandemic was observed to increase ADHD symptoms of inattention, hyperactivity, and/or impulsivity in children and adolescents before to during the pandemic [d = 0.270 (95% Cl. 0.158 < d < 0.382), Z = 4.723, p < .001] [14]. This unveils the necessity of addressing isolation and social media use to mitigate the mental health risks for young people due to the higher SMU since COVID-19.

Neuroscience research can be useful in enlightening the short- and long-term effects of social isolation. Social isolation causes the neuroendocrine pathways to initiate the hypothalamic-pituitary-adrenal (HPA) axis, which plays an important role in the body’s stress response [15]. HPA axis dysfunction and inflammation have been suggested to contribute to ADHD with higher rates of dexamethasone nonsuppression (abnormalities) in children with ADHD when compared with controls, making it more difficult for them to manage stress and cortisol levels [16]. As social isolation acts as a stressor, the body attempts to regain homeostasis, flattening the cortisol rhythm, and leading to higher cortisol levels [17]. In addition, socially outgoing children have less pronounced rates of increased cortisol (thus less stress) compared to isolated children [18]. Youth with ADHD have been shown to have lower basal and cumulative levels of cortisol in the morning and throughout the day than typically developing youth, (TD) youth [16]. ADHD children also have a less developed prefrontal cortex and other brain regions compared to non-ADHD adolescents; they are more vulnerable to the effects of stress with further developments of internalizing problems as they become adults [19]. A study conducted with 138 adolescents (ages 11-15 years old) showed that the subjects displayed ADHD symptoms that were associated significantly with higher cumulative diurnal cortisol (AUCg), morning cortisol, and afternoon cortisol [20]. Social isolation may lead to long-lasting consequences with behavioral abnormalities including attention disruption, cognitive deficits, impaired recognition memory, reversal learning, and inability for decision-making [21]. Thus, social isolation causes long-term stress sensitivity and inability to cope for these children and adolescents. 

 

Social Contagion

Social media’s effect on increasing social contagion and peer influence is another sociocultural factor that may also correlate to the rise of ADHD cases due to higher ADHD self-diagnosis. Social contagion is defined as “the spread of behaviors, attitudes, and affect through crowds and other types of social aggregates from one member to another” [22]. Social media readily promotes social contagion by provoking documentation of tics, eating disorder behavior, self-harm, suicidality, and gender dysphoria among adolescents [23]. Social contagions have led adolescents to slot themselves into ADHD through self-diagnosis due to the definition of ADHD having widened to milder or ambiguous symptoms where it would be considered normal because of social media becoming a main source of children's information [24]. For example, unreliable internet sources like TikTok influencers and Google have become sources of online health disorder diagnoses with hashtags, such as #ADHD with millions of views [25]. Another example is if an individual is surrounded by friends who are familiar with ADHD, they would likely assume that their behaviors are reflective of ADHD and self-diagnose themselves [26]. This makes distinguishing true ADHD symptoms from the assumed ones difficult, as effective diagnosis requires recognizing a range of criteria and development over time, which cannot be performed with these online self-diagnoses prevalent in social media. Due to social contagion, there has been evidence of overdiagnosis of ADHD in youth and adolescents (<18 y/o); this is particularly concerning since many mild cases tend to show greater harms than benefits when treated [24]. The overdiagnosis, and/or misdiagnosis of ADHD could have occurred due to this diagnostic inflation where the definition of ADHD had widened to encompass milder or ambiguous symptoms [24]. This rising trend undermines accurate diagnoses and, therefore, effective forms of treatment, further suggesting that some ADHD cases may not be true leading to unnecessary, and potentially harmful, treatments for adolescents. Despite many drawbacks of social media, social contagion can be positively utilized through the creation of online health communities that reduce the stigma of illnesses such as ADHD [27]. But with the nature of social media, the negative effects of social contagion could rise, as technology advances much faster than society can plan or account for. 

 

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Underrepresented Groups in ADHD

Despite the prevalence of ADHD increasing in the US, partly due to SMU, there are racial and ethnic disparities in the diagnosis and treatment of ADHD. Yu Shi, through a cohort study of 238,011 children examined the association of race/ethnicity in ADHD and discovered that Black, Hispanic, and Asian youth were substantially less likely to be diagnosed with ADHD compared to White children [28]. 

Racial disparities in the prevalence of ADHD diagnosis have been reported, with Black children having a higher prevalence compared with White children, while Hispanic children were 35% less likely to be diagnosed compared with White children; Asians reported having the lowest incidence rate from cultural values (e.g. the model minority myth) [28]. Implicit and racial bias from patient-provider interactions can also contribute to the disparity in ADHD diagnosis where thirteen studies reported that healthcare professionals had higher rates of associating Black Americans with negative words contrasted to White Americans, affecting health outcomes [29].  This is further being fueled by social media further emphasizing these stereotypes, tying with the spread of misinformation [3].

 

 

Physiological factors: Social Media and Dopamine/Symptoms of ADHD and their Association with Dopamine

Social Media’s Effect on the Brain

The main areas/groups of the brain involved in ADHD are the ventral striatum and the central executive network. The ventral striatum is a region near the center of the brain encompassing the amygdala, thalamus, putamen, prefrontal cortex(PFC), and nucleus accumbens(NAcc). It is heavily involved with the prefrontal cortex and other emotional processors, particularly reward and pleasure with the purpose of dopamine release. The Nucleus accumbens in particular is activated during anticipation of rewards which is highly linked to ADHD [30]. The other brain system that provides a link between social media use and ADHD is the Central Executive Network (CEN). The CEN, unlike the ventral striatum, isn't a single area but multiple regions that are responsible for memory, decision-making, and problem-solving in anticipation of future goals[31]. These regions are known to control executive functions. Executive functions are the processes and skills needed to reach set goals. Executive functions include self-awareness, self-restraint, non-verbal and verbal working memory, emotional control, self-motivation, planning, and problem solving[30]. 

 

Social media’s adverse effects on the brains of especially adolescents have just recently begun to be studied. In a 2022 study, it was observed that 179 adolescents from ages 12-13 who habitually check social media such as Snapchat, Instagram, and Facebook had increased social feedback responses due to an increase in activity from dopaminergic centers of the brain such as the amygdala, posterior insula, dorsolateral prefrontal cortex, and ventral striatum. The study determined this through longitudinal brain scans of test subjects[31]. Other studies have observed the effects of social media on longitudinal brain structure and identified interactions within the ventral striatum associated with the approval/disapproval of peers on SMS[32]. The importance of the connection between the two studies is the involvement of the ventral striatum, which is a core part of the brain when dealing with dopamine and risk and reward, an executive function [33]. In a broad study on the effects of social media on the brain of both adults and adolescents, negative effects on sleep, addictive behaviors, emotional and social intelligence, social life, brain development, and existing ADHD symptoms were discovered[34]. A 2017 study discovered a link between the risk-taking behaviors of  34 high school students and the perceived popularity of social media posts. Participants were shown posts from their and other people’s Instagram posts in the categories neutral(pictures of people and food) and risky (smoking, drinking, partying)  with the like count manipulated. fMRI scans showed greater Nucleus Accumbens (NAcc) activity when a high schooler saw that their post was popular. Scientists also observed a decrease in the Dorsomedial Prefrontal Cortex (dmPFC) and Lateral Prefrontal Cortex (lPFC) regions of the brain when shown risky, but popular behaviors. These two regions are part of the Central Executive Network (CEN) which activates during tasks involving executive function[35]. All of these studies show some link between social media usage and the ventral striatum or other areas of the brain involved in executive function. 

 

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Methods: 

By focusing on the physiological and sociological perspectives of ADHD, we utilized PubMed and Google Scholar. To discover the detailed research papers within the scope of the focused topic, articles published since the 2000s, when the rise of social media usage occurred, were filtered through PubMed and Google Scholar to provide the strongest relevant literature available. Most articles were also excluded if the journal publication had an impact factor lower than two. The specific main keywords (search terms) include “Attention Deficit Hyperactivity Disorder (ADHD)” “dopamine”, and “social media.”

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Conclusion:

From a sociocultural perspective, there is evidence of an association/correlation between the unprecedented rise in ADHD cases and worsening symptoms with the higher usage of social media. Physiological studies cited show activation or lack thereof in areas of the brain such as the VS which are commonly linked with ADHD. Executive functions act as another link between the two with social media users being susceptible to having their CEN manipulated by social media. To preserve the mental health of future generations that become even more exposed to technology at earlier ages, the effects of social media need to be studied further when exposed to developing brains that do not have the possibility of permanently stunting future generations.

 

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Discussion:

As the internet and especially social media “native” generations are just becoming adolescents, not many studies have searched into the long-term effects of social media usage. A surprisingly small number of published studies have directly correlated social media use to dopamine directly. The studies that were found such as the 2022 one are limited in scale as well with a relatively small sample size causing there to be questions on correlation vs. causation. As social media use continues to grow in younger generations and those generations accessing it at a younger age, it is important to further study the medical and social implications of the widespread SMU particularly since negative effects have been found in brain development. With a correlating rise in ADHD symptoms, a true study with an ample sample size that analyzes the brains of both habitual SMS users and those with ADHD would also be beneficial in proving or disproving the notion that physiological changes in the brain caused by high SMU at a young age creates abnormalities resembling ADHD. Further study on the association of ADHD and SMU must be prioritized due to the unprecedented rise in cases and higher exposure to social media over the past decade. 

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