# data[].attributes.body
Johnco, Carly, and Ronald M. Rapee. “Depression Literacy and Stigma Influence How Parents Perceive and Respond to Adolescent Depressive Symptoms.” Journal of Affective Disorders, vol. 241, Dec. 2018, pp. 599–607. ScienceDirect, https://doi.org/10.1016/j.jad.2018.08.062.

Chandra, Anita, et al. “Racial/Ethnic Differences in Teen and Parent Perspectives toward Depression Treatment.” Journal of Adolescent Health, vol. 44, no. 6, June 2009, pp. 546–53. ScienceDirect, https://doi.org/10.1016/j.jadohealth.2008.10.137.

Biernesser, Candice, et al. “Social Media Use and Monitoring for Adolescents With Depression and Implications for the COVID-19 Pandemic: Qualitative Study of Parent and Child Perspectives.” JMIR Pediatrics and Parenting, vol. 3, no. 2, Dec. 2020, p. e21644. pediatrics.jmir.org, https://doi.org/10.2196/21644.

Parental Support Is Key to Supporting Teen Depression | Charlie Health. https://www.charliehealth.com/post/how-parents-can-support-teens-with-depression. Accessed 25 Apr. 2023.

Cisneros, Veronica. “Parenting a Teenager with Depression - Outside the Norm Counseling - 92591.” Outside the Norm Counseling, 19 Mar. 2019, https://outsidethenormcounseling.com/how-to-lovingly-parent-a-depressed-child/.

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Questions:

|Broad question

Will invalidating reality make your child feel shame?

|Specific question

When does a parent accept the truth and help their family take the necessary steps to getting the right help?

|Alternatives

|What was the author's hypothesis?

|What were the alternative hypotheses?

Using lovingness while parenting a depressed teen is key to being helpful.

|Logic

|What was the logic of the hypothesis?

|i.e., if the hypothesis was true, what should we expect to happen?

If parents use loving tactics, then their child is more susceptible to getting out of depression.

|Methods

|Briefly describe the study design

|What were the independent and dependent variables?

Briefly describe the study procedure in everyday terms

N/A

|Results

What were the important results?

N/A

|Inferences

|What did the authors conclude from their study?

|How did the authors use the results to make inferences and conclusions

about the hypothesis and research question?

Accept your teen’s depression

Communicate openly about their depression

Encourage healthy habits to promote mental health

Talk to them about suicide

Begin counseling

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Social Media Use and Monitoring for Adolescents With Depression and Implications for the COVID-19 Pandemic: Qualitative Study of Parent and Child Perspectives

# data[].attributes.attachment_link.readable_text
Original Paper

¹ Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States

² Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of Pittsburgh, Pittsburgh, PA, United States

³ Center for Behavioral Health, Media, and Technology, University of Pittsburgh, Pittsburgh, PA, United States

Corresponding Author:

Candice Biernesser, PhD, MSW, MPH

Department of Psychiatry

University of Pittsburgh

BFT 313, 3811 O'Hara St

Pittsburgh, PA, 15213

United States

Phone: 1 412 586 9064

Email: lubbertcl@upmc.edu

Background: Although youth report many positive experiences with social media (SM) use in their daily lives, adolescents with depression are more vulnerable to the risks of SM use than adolescents without depression. Parents protect adolescents with depression from the risks of SM use by monitoring their child's SM activity; however, this comes into conflict with the adolescent's need for autonomy in their web-based communication. The implications of SM use and monitoring for adolescents with depression and their parents are of particular relevance to the COVID-19 pandemic, as rates of SM use have increased in response to physical distancing measures.

Objective: This study aims to explore parent and child perspectives regarding the use and function of SM in the daily lives of adolescents with depression and parents' perceptions of and experience with monitoring their child's SM use.

Methods: We conducted qualitative interviews with adolescents with depression (n=23) and one parent of each adolescent (n=23) between July 2013 and September 2014. The adolescents were patients seeking treatment for depression in Pittsburgh, Pennsylvania. Data analysis included dyadic analysis of the adolescents' and parents' perspectives and qualitative descriptions of individual parent interviews to explore their experiences with SM use and monitoring. The construct of parental knowledge and factors hypothesized to contribute to parental knowledge, including adolescent disclosure, parental solicitation, and parental control, were used to guide the codebook and dyadic data analysis.

Results: Dyadic analyses showed that parents and their children disagreed on the use and function of SM in the daily lives of adolescents with depression, with adolescents viewing SM as a forum for honest expression of their emotions, whereas parents felt that their children's posts were inconsequential and interfered with the adolescents' lives. Furthermore, parents reported using a wide range of strategies to gain knowledge of their child's SM use to monitor their safety on SM, including direct solicitation and indirect solicitation, such as keeping the child's passwords, asking friends or siblings about their child's SM use, and restricting SM behavior and access to devices.

Conclusions: Clinicians should support adolescents with depression and their parents in finding common ground for an effective and acceptable monitoring approach. Resources are provided for clinicians navigating conversations about SM use and monitoring with adolescents with depression and their parents during the COVID-19 pandemic.

JMIR Pediatr Parent 2020;3(2):e21644

doi:10.2196/21644

Keywords

Background

Adolescent SM Use During the COVID-19 Outbreak

The use of SM during the COVID-19 pandemic is estimated to have increased substantially. In their analysis of SM use from web-based data providers, The New York Times reported that the use of the popular SM sites Facebook and YouTube increased by 27% and 15%, respectively []. Increasing rates of SM use may be especially meaningful to young people, as physical distancing measures limit face-to-face interaction. Deprivation of peer interactions, in particular, is challenging during adolescence, a developmental stage during which peer influence and acceptance are important []. In the face of these concerns, SM may play an influential role. Studies of adolescent SM use show that aspects of prosocial face-to-face interactions that are protective to adolescent mental health, such as social support, social reward, and reduction of feelings of social exclusion, can be mirrored through active engagement on SM []. Although SM may play an important role in mitigating limitations to social interaction during the pandemic, there are also concerns associated with higher rates of SM activity. Prevention groups have raised concern that stress associated with the pandemic could contribute to higher rates of negative SM experiences, such as cyberbullying []. The potential for harmful SM interactions is complicated by reduced access to counseling and mentorship from educators []. In the current context, considering adolescents' SM use and the ways in which parents monitor their use is significantly important.

Use of SM in Adolescents With Depression

Adolescents with depression face vulnerabilities that place them at a higher risk of having negative SM experiences and unique opportunities for social support and connection than youth who are not depressed. Adolescents with depression use SM in positive ways; for example, engaging in entertainment, humor, or content generation can act as a distraction from depressed mood [], and these adolescents can also reach out to others for support in coping with depression or for social connection []. With regard to vulnerability to negative SM experiences, adolescents with depression are more likely to engage in risky SM behavior, such as talking to strangers and disclosing personal information [], and to be exposed to potentially harmful SM content, such as self-harming behaviors [,]. In addition, youth with depression are more likely to report internet harassment [], cyberbullying [,], and addictive internet use [] experiences that have been associated with fluctuations in mood states and heightened suicidal risk among adolescents [-]. Parents of adolescents in treatment for depression or suicidal risk have reported awareness of their child's heightened vulnerability to negative SM experiences and describe an urge to stay informed about their child's SM use to protect them from harm [].

Parent and Adolescent Perceptions Toward SM Use and Monitoring

Parental Monitoring and Knowledge of Adolescent's SM Use

Parental monitoring has been defined as the tracking or surveillance of a child's behavior and is often assessed through measures of parental knowledge []. Kerr and Stattin [,] hypothesize 3 primary sources of parental knowledge. These sources include (1) adolescents' voluntary sharing of information with their parents; (2) parents' solicitation of information from their child; and (3) parents' use of control, meaning setting rules and restrictions to limit their child's ability to engage in activities without informing their parents [,]. Thus, information sharing between parents and adolescents can occur through dialogue (eg, informal or formal monitoring discussions) or through behaviors (eg, parents' engagement in mediation of SM as a means to gain control). Of these sources, parental knowledge is most strikingly informed by adolescent disclosure.

Voluntary adolescent disclosure is considered to be a strong and consistent predictor of parental knowledge above and beyond parents' solicitation of information []. By the time of adolescence, youth are developmentally capable of making choices to voluntarily offer private information []. Keeping secrets, particularly when negative consequences are perceived, is also developmentally typical and impacted by contextual factors within the family, such as the degree of trust present between parents and adolescents and overall relationship quality [,]. Supportive parenting styles exhibited by warmth, affection, and responsiveness to adolescents' needs are more likely to facilitate voluntary disclosure [,]. Unsupportive styles of parenting, such as parenting that involves the use of psychological control or manipulation techniques such as love withdrawal, shaming, or guilt induction, act as barriers to voluntary disclosure [,].

These long-standing trends toward parental knowledge and control remain consistent within media studies. In their meta-analysis, Chen and Shi [] showed that parents' active engagement with their child's media use, namely, through openly discussing media use or parental co-use of media with their child, was effective in reducing SM risk behaviors. They also found that parental restriction alone was not associated with a reduction in risky behaviors.

Context of Parental Knowledge of SM Use Among Adolescents With Depression

Parental knowledge of SM use is of critical importance for the discussion of depression in adolescents. Open parent-child communication that is fostered through adolescents' voluntary disclosure is associated with reductions in depressed mood, improvements in self-esteem, and positive and realistic expectations toward media use [,]. Conversely, parents' engagement in unsupportive communication or deployment of control strategies (eg, setting rules that require their child to share information about their SM use) has been linked to increased depressive symptoms and poorer adjustment among adolescents [,,]. When parents' lack of support takes the form of negative reactions to adolescents' disclosures, adolescents are left feeling disconnected to their parent and respond by engaging in secrecy []. Secrecy could be detrimental in situations when a parent may need to intervene to address their child's depressed mood or suicidal thoughts.

Research Gaps

Parents' attempts to understand and explore their child's SM use may be especially challenging in the current era in which SM activity is ubiquitous and trends toward use among adolescents are increasing in the face of the COVID-19 pandemic. Little is known, however, about the context of parental monitoring of SM use among adolescents with depression. Understanding the context of how parents of adolescents with depression balance the unique challenges in weighing their child's unique vulnerabilities toward negative SM experiences and unique opportunities for social support and connection could offer important contributions for clinicians who are partnering with families to support youth with depression. First, similarities and differences in perspectives of adolescents with depression and their parents toward SM use and monitoring have not been explored. Considerations toward monitoring among youth with depression, who are more vulnerable to negative SM experiences, may be distinct from adolescents who are not depressed. Second, strategies that parents of adolescents with depression use to stay informed of their child's SM use are not well understood and may offer helpful guidance to parents of adolescents with depression on how to protect their child while supporting their emerging independence.

The exploration of these findings may be especially beneficial to providers engaged in the mental health care of adolescents who are recommended to assess the harmful and helpful influences of adolescents' digital lives []. Providers' ability to accurately assess the SM context is likely to be influenced by parent and child perceptions toward the use and function of SM. Furthermore, providers who wish to partner with parents to observe and protect adolescents' SM environments may face challenges if the child's and parent's preferences toward SM monitoring strategies are discrepant.

Aims

To offer insights for clinical practice with adolescents with depression and their families, we sought to explore the perspectives of youth with depression and their parents toward SM use and monitoring. Through interviews with adolescent and parent dyads, we aim to compare parent and child views toward the use and function of SM use in the daily lives of adolescents with depression. Through interviews with individual informants, we aim to explore parents' strategies and experiences with gaining knowledge of their child's SM use.

Recruitment and Sampling

As part of a larger qualitative study to inform an intervention using SM for adolescents with depression and their parents [], a convenience sample of adolescents aged 13 to 20 years diagnosed with depression and currently receiving treatment in Pittsburgh, Pennsylvania, and one parent of each adolescent were invited to participate in interviews. From July 2013 to September 2014, potential participants were informed about the study by clinicians treating patients for depression at 2 sites: (1) an academic adolescent and young adult medicine clinic with mental health services available or (2) a specialty psychiatric clinic for adolescents with depression and suicidality. Of the 31 adolescent-parent pairs (of which there were 31 adolescents and 30 parents because 1 mother had 2 children in the study) who filled out an interest form, 8 adolescents and 7 parents could not be reached for an interview; thus, 23 adolescents and 23 parents completed the study. Of these, there were 21 adolescent-parent matched pairs. One parent had 2 children in the study. Reporting of data collection and analytic methods follows the Consolidated Criteria for Reporting Qualitative Research [].

Data Collection

All interviews were conducted by the senior author, who was trained and experienced in qualitative data collection and analysis. She introduced herself to adolescents as a researcher and physician in Adolescent Medicine. Semistructured interviews were conducted over telephone (n=17 adolescents and n=17 parents) or in person in a private patient room in the clinical setting (n=6 adolescents and n=6 parents). Parent and child interviews were conducted separately. We obtained verbal consent from parents for themselves and from adolescents aged 18 years and older; for those aged 18 years and younger, we obtained parental permission and adolescent assent. The interviewer assured participants that the research team would guard confidentiality, specifically not sharing phrases said on SM, which could potentially be searched to identify them.

Data Analysis

Dyadic Analysis of Interviews With Parents and Adolescents

As the original focus of this study did not include dyadic-level analyses, a direct comparison approach could not be used because of differences in questions asked of adolescents and their parents. However, during the analysis of parent and adolescent interviews, similar descriptions of events or ideas by parents and their children created an organic opportunity to examine dyadic-level themes by way of content analysis. Using the Eisikovits and Koren model of dyadic analysis [], matched adolescent-parent dyadic transcripts were reviewed by horizontalization and cross-analysis for overlaps and contrasts between text, subtext, descriptive, and interpretive levels, with the description of an event that occurred in SM (eg, cyberbullying of the adolescent from the perspective of the adolescent and from the perspective of the parent) as the unit of analysis. Dyadic transcripts were reviewed by independent coders (the first and second authors) who noted these horizontal themes, and discrepancies were settled by team consensus.

Analysis of Individual Interviews With Parents

Participant Characteristics

Of those who completed the study (23 parents and 23 adolescents), the average age for adolescents was 16 years (range 13-20 years) and the average age for parents was 46 years (range 37-55 years). Most adolescents (18/23, 78%) and most parents (19/23, 83%) were female, and most adolescents (20/23, 87%) and parents (21/23, 91%) were White (3/23 adolescents, 13%, and 2/23 parents, 9%, were African American), which reflects the demographics of patients seeking care for depression at the 2 sites. At the time of enrollment, adolescents on average had received treatment for depression over 25.4 months (range 3-84 months). Most parents (19/23, 83%) and adolescents (22/23, 96%) used SM. Parents most frequently reported using Facebook (18/23, 78%), whereas adolescents' SM use was more diverse across platforms (10/23, 43%, used Facebook and 4/23, 17%, used Twitter, Tumblr, and Instagram).

Dyadic Analysis of Parent and Adolescent Interviews

We first summarized themes based on dyadic analysis of the interviews, on which we directly compared child and parent interpretations of shared events. This analysis aimed to understand parents' and adolescents' mutual and divergent interpretations of adolescents' use of SM in their daily lives. These themes included SM as a form of expression, the function of SM, SM as a space to discuss depression with others, interacting with strangers on SM, and parental monitoring of adolescents' SM use.

SM as a Form of Expression

Parents and adolescents generally disagreed on SM being a medium for individual expression. Adolescents viewed SM as a forum for honest expression of themselves and their emotions, whether positive or negative. Adolescents elected to express themselves through song lyrics that capture their emotions or what adolescents described as ranting about an event that happened to them. Parents, however, saw much of what their adolescent was posting on SM as inconsequential or something to do when they felt bored and that it could interfere with other activities in the adolescent's life. These themes are demonstrated in the following quotes from a parent and child dyad who had divergent views on adolescents' SM expression:

Just to post like whatever you want. Because it's your Twitter, so you can just say how you feel, like what you're doing that day. Just anything in general really. Like anything that you want. So, it shouldn't matter like what you post.
[Child perspective; age 16 years]

But when I saw what she-all the song lyrics she was putting on there, that caused me to have concern and... I just brought it up. And she thought it was funny. And she's, and you know-I said, 'I don't understand why you want to put these lyrics out there,' because they weren't good lyrics. And she says, 'Well, I'm expressing myself.' And I say, 'But why do you have to tell everybody? Like why'-I don't get it. I just don't get the whole thing. I'm just old-fashioned.
[Parent perspective]

Positive and Negative Functions of SM

Some parents and adolescents mutually described the potential of SM to be a protective, healing, or supportive space or a place to seek positive content. In other cases, parents and adolescents both offered clear examples of and reflections on the harms of SM use. For example, one parent was concerned about posts or forums that encourage self-harm behaviors (eg, cutting), which aligns with her daughter's concerns-who had a history of intentional self-harm-and was worried that such forums or posts would encourage her daughter to cut herself. Other examples had greater discrepancy, which typically occurred when one member of the pair was more ambivalent and the other had a stronger point of view. The following quotes present discrepant perspectives between a parent and child dyad on the use and utility of SM:

So I think that if I do something on that website, like if I make an edit to just something that I enjoy and I'm interested in, that's something that's good, and I can read the feedback that I get from it. And so as long as I'm busy rather than if I look up the tag of #sad, that might make me more sad. But it's kind of like, I get some sort of satisfaction from looking at sad pictures because it's something I can relate to, which is kind of weird.
[Child perspective, age 14 years]

She spends an inordinate amount of time. And while the people on there, cool, some of them have the same experiences and stuff, she's also not getting the face-to-face social stuff that I think she really needs, especially somebody going through what she's going through as far as the depression.
[Parent perspective]

SM as a Problematic Space to Discuss Depression With Others

Some parents and adolescents agreed that it was safer, more private, and more authentic to talk about depression with trusted friends offline; however, their reasoning was not always the same. Parents were concerned about negative consequences and expressed distrust with others on SM, or they preferred that their child talk to them directly. Adolescents, on the other hand, expressed worry about what others would think-that posting on SM would draw unwanted attention, be burdening to others, or simply felt it was not others' business. These viewpoints are demonstrated by the following parent and child dyad:

I don't want everybody to know my business, like what I'm dealing with on like a really personal level...a family member might see it and, well, they might tell another family member about it and it would just go around the whole family.
[Child perspective; age 17 years]

My thought's that if they feel that way, he should come to his mother and father and talk to them about it instead of putting it out there for everybody else. Some people is cruel, and they'll end up saying something that'll make him worse.
[Parent perspective]

Risks and Benefits of Anonymous Interactions on SM

Parents and adolescents had differing opinions about talking with strangers or interacting anonymously on SM. Parents expressed concern over their child being friends or having followers that were strangers or the lack of privacy in SM. In contrast, adolescents perceived that having strangers as friends on SM was not problematic and normative. These divergent perspectives are described by the following parent and child dyad:

I think it's because I was just younger and I didn't care who I was friends with, or you know, like you want to have so many friends on there so you just add whoever, type of thing.
[Child perspective; age 17 years]

How dangerous it is, and, you know, some of these people are older, 20s, 30s, they 're men. How she doesn't need to be, they don't need to see her pictures, they don't need to know anything about her, they don't know her period, that people are dangerous, you can't trust any, you know, everybody. You know, that people can find out anything they want to know.
[Parent perspective]

Parents' Monitoring of Adolescents' SM Use

Parent and adolescent perspectives on monitoring were predominantly divergent. In some cases, parents' attempts to view their child's SM content to prevent negative experiences left adolescents feeling resentful, particularly when the adolescent was excluded from this process (eg, a parent looking though their child's phone without the adolescent's permission). Furthermore, when parents restricted SM use, some adolescents defied their parents' wishes by creating secret accounts on SM or by engaging with strangers. In other cases, parents considered monitoring strategies that would protect the parent-child relationship, which might include having honest conversations with their child about privacy or safety issues surrounding sharing of information on SM. These efforts corresponded with adolescents citing examples of choosing not to disclose private matters on SM; however, adolescents rarely contributed their decisions regarding privacy to their parents' monitoring efforts, as is exemplified in the following quotes from a parent and adolescent dyad:

I really do think that she's too smart to share it with strangers. I mean, I really think I've educated her in that, you know, strangers are never your friends, and they're not who they say are-I think she's wiser than her years when it comes to that, but I'm sure a lot of parents think that and then something tragic happens.
[Parent perspective]

If it's something private, I think-I mean just from my opinion, I think, I just keep it to myself...I think that people would see it and just kind of like, maybe feel bad or like-and I just feel that they would know my personal business. And it's just like not necessary.
[Child perspective]

Analysis of Individual Parent Interviews

Drawing from the frequent divergent interpretation of adolescents' SM use and behaviors, themes were explored to identify the ways in which parents of youth with depression within this sample gain knowledge of their child's SM use and parents' attitudes and experiences with SM monitoring.

Parental Expectations

Parents had a variety of expectations both toward their adolescents' capacity to use SM in a healthy manner and in the potential of monitoring to have an impact on their child's SM use. Parents generally expected their child to use SM in a way that was healthy. As described in the following quote, some parents felt that their expectations were met, describing a sense of trust in their child to create and maintain prosocial SM relationships and to express their opinions and experiences of depression in a way that is healing:

I trust her, you know, quite a bit, really-I mean, fully-with the use of it. I think she's got a good head on her shoulders, and, so, yeah, I think she's managing her own positive experience of it.

Alternatively, other parents' expectations were unmet. They also had concerns that their adolescent was engaging in maladaptive behaviors such as oversharing (or being too trusting of sharing personal information on SM), which parents believed may have negative consequences, such as bullying, embarrassment, or future impact, on employment opportunities. Some informants were surprised to find their child's peers discussing risky behavior on SM (eg, sharing sexually explicit content). One parent offered an example of discomfort with photos shared by her child's friends:

...my daughters have a lot of friends with inappropriate photographs, and I don't think that they think they're inappropriate, but...I don't think teenage girls should be in bathing suits on the internet.

In addition, parents expressed both positive and negative expectations that their monitoring efforts would actually have an impact on their adolescents' engagement with SM. Some felt capable of intervening to improve their adolescent's SM interactions, for example, having an open conversation about cyberbullying. Alternatively, others were concerned that SM was too difficult to regulate or control and that intervening would be ineffective. The following quote offers an example of a parent's negative expectation:

...it's not a battle I choose to fight. I'm not going to-you can't-the internet in general is basically an unlimited freedom. You can see and do just about whatever your imagination can come up with.

Adolescent's Disclosure to Their Parents

Descriptions or perceptions that adolescents are telling their parents about their SM use or the impact of SM use on their mood varied. In some cases, when adolescents accepted their parent's monitoring, they were willing to openly discuss their SM use and its impact on them with their parents. One parent offered an example of her child openly disclosed information about her SM use:

...she's pretty-[name] is I would say much more open with me than, than I, than certainly I ever was with my parents...I just felt like my mom was so far, you know, like way into my business in the first place, that I didn't share, but [name] and I have a, have a pretty good relationship, I think and like she has no problem. Like she'll come to me for advice and say, 'What should I say to this person?'

Selective disclosure of behaviors was also observed, meaning that adolescents hid some aspects of their SM use from their parents in fear of a negative consequence. In these cases, adolescents feared that negative SM experiences may lead to parents deactivating their SM accounts, or they fear their parents will respond with rejection or disapproval.

Parental Knowledge

Several parents found it difficult to be knowledgeable about their children's SM behavior. As described in the following quote, parents reported being unaware of which platforms their child used and did not know if their adolescent was bypassing their rules regarding SM use:

I asked her not to get on Facebook anymore. And then she snuck, and she got on Facebook a second time, using a different name.

Some parents acknowledged that their adolescents had hidden concerning SM interactions from them. For example, one parent noted that her daughter hid photos posted on SM of her self-injuring:

Before she had her attempt of suicide, she had a GifBoom account that was very dark, and we didn't find out about it until later, but like had pictures of cutting-it almost was like a support group for that.

Other parents were more secure in their knowledge of their child's SM interactions, and at times, this impacted adolescents' SM behavior, often reducing personal content disclosed on SM. In the following quote, a parent described how their child being aware of familial monitoring corresponded with reduced sharing on SM:

Well, I have to be honest, she doesn't really share too much online from a Facebook standpoint, regarding how she feels or her depression, because she has many family members who are her friends on Facebook. And I think, and I'm trying to get into her mind, and I'm thinking that she doesn't put a lot of that out there because of who they are. Like if it's her Nana, which is her grandmother, or her grandfather, or her aunts and uncles, she doesn't put a lot of that out there, because she knows that they will read it.

Parental Solicitation

To gain knowledge of their child's SM use, parents engaged in solicitation. In some cases, solicitation involved directly asking the child about their SM use. Parents engaged in this direct form of solicitation both in person and on SM, predominantly in instances when they felt their child was having negative experiences on SM or based on a belief that SM was inherently harmful (eg, contributing to their depression or encouraging risky behavior). Parents not using this direct form of solicitation described not wanting to hover or be controlling and preferred trusting in their child to maintain healthy SM behavior.

Parents also engaged in indirect forms of solicitation, which may have included a parent looking through their child's phone or knowing the password to their SM accounts. Some parents felt this was an important way to learn previously unknown information about their child, such as new disclosures of risk-taking behavior described on SM or even to have a window to how the child feels or experiences their depression in a way that adolescents may not communicate with their parents. In the following quote, a parent described her experience with learning the utility of SM in providing information on her child's emotional state:

Her father and I both were very against her sharing these things online, or really even, we kind of wanted her to just not even have an online account or anything. But then we kind of were, I don't know, awakened to the fact that this is kind of the only window you have into your kid's emotions sometimes. You know, teenagers especially don't like to tell their parents what's going on or to talk about how they're feeling. And sometimes that's how you see how they're really feeling, is by some of the stuff they're posting, even if they don't realize that they're showing it, you can kind of just see their different moods. I think it definitely has given us some, I don't know, opportunities to talk that maybe we wouldn't have had before. Especially-it's very easy for kids to just come home and say, 'Yep, school was fine. I'm fine.' And the that's it, you know.

Adolescents were more accepting of indirect forms of monitoring when there was an agreement between the parent and child of how this would be done. For example, one adolescent noted that their parent having their account password information led to openness in communication surrounding SM. To protect their child's privacy and the parent-child relationship, some parents used other sources such as asking a friend, sibling, or other relative to assist in monitoring or using monitoring software.

Parental Control

Efforts to control adolescents' behaviors included restricting sites perceived to be harmful and attempting to restrict certain SM behavior. One parent described how their efforts to restrict their child's SM use were brought about by a desire to protect their child from harmful SM content:

Honestly right now, at this point in time, I have blocked most of the social networking sites from my daughter because of some of the things that I have seen on her wall and some of the things that I have seen that she posted. Because she's going through this, let's call it a difficult time in her life right now, I don't think that she needs to rehash and read, and see all these different things because it's just open- everything that is imaginable is on these social networking, and I just, I'm-I guess I'm trying to, to the best of my ability, is to protect her from seeing these different things...

Furthermore, some parents limited their adolescent's SM use after their child did something of which they disapproved. Disciplinary actions included restricting access to a certain SM site entirely or taking the child's phone away. In the following quote, a parent related her experience with restricting her child's access to Facebook:

So, I asked her not to get on Facebook anymore. And then she snuck and she got on Facebook a second time, using a different name. And the same thing was happening...so then finally after she did it the third time, we told her absolutely, positively not. She wasn't allowed to go even into Facebook to read it, to read anybody's comments, to even talk to anybody. She's not, at this point she's not allowed on Facebook at all.

Rule setting was enforced through both direct and indirect means of solicitation, including the use of monitoring software or by asking designated members of the child's social network (eg, a friend of the parent who is monitoring the adolescent on behalf of the parent). Attempts to restrict SM behavior varied by age, where some parents restricted the use of certain SM sites or any site before a certain age. Parents who did not engage in restriction reported a sense of powerlessness or loss of control. One parent described how she wished she could set rules but felt doing so would be ineffective and could damage her relationship with their child:

I wish I had the nerve to tell her she wasn't allowed to use it but it would just be such a barrier and it would just make her hate me and not talk to me, and there's no point-like I said, like I prepare her for the adult world, in a year and a half she'll be at college, and I don't want her to go off the deep end then and say, like, 'My mother would never let me do this, so now I'll show her...'

Another parent described a perception that attempts to control are ineffective and correspondingly a sense of lack of control:

We tried at first to completely like eliminate her having them, but we found that when you do that they just kind of find ways to do it behind your back, and then you have no way to know what's going on. So, she voluntarily will show me a lot of this stuff. You know, I still do fear that there's things out there that I'm not seeing. But I don't know if there's ever a way to monitor 100%. You're almost kind of kidding yourself if you think you are.

Principal Findings

This study uses rich qualitative inquiry to explore child and parent perspectives toward SM use and monitoring for adolescents with depression. Our study describes the experiences of adolescents with depression using SM to seek autonomy from their parents and the parents attempt to maintain knowledge of their child's SM use to offer protection because of concerns of a potentially unsafe environment for their vulnerable child. Although previous research has described the struggles between adolescents' and parents' overuse of SM [], this study's dyadic analysis of the perspective of adolescents with depression and their respective parents is unique. SM presents challenges through risky SM behaviors, negative SM experiences such as cyberbullying, and worsening mood [,,,], to which adolescents seeking clinical treatment for depression are especially vulnerable. SM also presents opportunities for social connection and supportive interactions, which are especially important for youth facing depression []. Conflict over the use of SM in the context of depression may create added challenges that youth without depression and their parents or caregivers may not have to address. This study offers findings that have implications for clinicians engaged in the treatment of adolescents with depression, who are heavy users of SM. Especially in the current context of the COVID-19 pandemic, clinical guidance for parental monitoring of SM is critical.

The findings from the dyadic interviews showed that although a few parents and adolescents agreed about the use and function of SM, most had discrepant perspectives. Discrepancy often stemmed from a difference in value placed on autonomous SM expression versus protection from the risks of SM use. These views can be considered with a report released from the United Nations International Children's Emergency Fund [], which considers children's rights for digital privacy. In accordance with the United Nations Convention on the Rights of the Child [], this report suggests that children have a right to digital privacy and that parents have a dual responsibility-both to protect their adolescent from web-based threats and to encourage free expression by their adolescent in web-based spaces. This dual responsibility appears to create conflict and discrepant views between adolescents and their parents.

For parents attempting to balance this dual responsibility, United Nations International Children's Emergency Fund's report suggests the extent to which privacy and access to SM is given should be considered based on the child's evolving capacity, for example, their age and maturity level. In the case of adolescents with depression, a child's capacity may also include the potential for heightened vulnerability to harmful SM experiences. At the same time, adolescents with depression report finding value in having a venue to express themselves emotionally and receive support through trusted SM friends. Furthermore, some studies found that these protective interactions had a healing effect, which positively influenced their mood. This suggests that although parents should take measures to protect their child from SM-related risks to their safety, they should also look for opportunities to allow their children to engage freely, particularly with supportive peers on SM.

The results of the individual interviews can be placed within the context of conceptualization of parental knowledge by Kerr and Stattin []. The sources of parental knowledge they have identified- adolescent disclosure, parental solicitation, and parental control -appear to be salient in understanding how parents engage in surveillance and monitoring of SM behavior of adolescents with depression. Consistent with the literature [,], adolescents voluntarily disclosed information about their SM use to their parents when they accepted their parents' monitoring strategies but were less likely to disclose when they perceived the potential for a negative consequence. When teens felt comfortable, they were willing to discuss their SM use and its impact on their mental health with their parents. Due to concerns about their children engaging in risky SM behavior, several parents were keenly interested in gaining information either by directly asking their child about their SM use or through overt or covert methods of viewing their child's actual SM content. Parents' engagement in covert forms of solicitation are potentially concerning because privacy invasions have been associated with increased secrecy and lower parental knowledge [,]. Parents engaged in a variety of control techniques, that is, rule setting surrounding their child's SM use and, in some cases, violation of parents' rules resulting in disciplinary actions. When parents engaged in controlling behaviors without their child's knowledge or buy-in, teens were not entirely honest with their parents about their SM experiences. When parents engaged in privacy invasions, adolescents became secretive and, in some cases, engaged in risky SM behavior without their parents' knowledge.

These results suggest that there is a unique context for parents of adolescents with depression for engaging in SM monitoring and unique consequences for their child's acceptance of their chosen monitoring strategies. The positive consequences of open parent-child communication that fosters voluntary disclosure are significant. Parents can be more aware of their child's SM activity to protect them from the negative influences of SM while fostering positive influences. Likewise, the negative consequences of SM monitoring strategies that contribute to a lack of knowledge are also considerable. As was evident in these interviews, when adolescents with depression do not accept their parents' use of SM monitoring, they have the potential to withhold information from their parents about risky SM communication, such as posting about self-harm or communicating with strangers. Lacking such information stifles parents' capacity to protect their child from harm. Further, restriction techniques that limit access to supportive SM interactions may have the consequence of reducing the protective influences of SM.

Implications for the Clinical Care of Adolescents With Depression

Understanding parent and child perspectives toward SM use and strategies parents deploy to learn about the SM activity of their child with depression could offer valuable insights toward clinical intervention planning. For example, the strategies parents use to procure information about their child's SM use could either support or discourage the child's voluntary disclosure of risky SM interactions or negative experiences. Such voluntary disclosure may be the most effective way for parents and clinicians to be knowledgeable about the level of risk within the child's SM environment. In addition, adolescents' voluntary disclosure to parents could result in a greater awareness of the protective aspects of their SM use, including sources of support that adolescents with depression may find critical to preventing their depressed mood from worsening. Understanding the context of adolescents and parents' perspectives toward SM use and monitoring could aid clinicians in opening lines of discussion that validate both parties' unique concerns to move toward the goal of an effective and acceptable monitoring approach.

In 2019, the American Association of Suicidology (AAS) [] released recommendations for parents and providers engaging in SM monitoring of adolescents at risk for suicide. According to the recommendations by AAS, clinicians should engage in a risk assessment of both the helpful and harmful influences of adolescents' engagement with SM and use this information to build a crisis intervention safety plan. It is considered a best practice for safety plans to be developed by clinicians in collaboration with parents. When engaging in risk assessment, clinicians should consider ways by which SM can offer meaningful opportunities for emotional expression and support for adolescents with depression and work with parents to consider how engaging in restrictive strategies could affect these helpful aspects of SM use. Clinicians should offer parents caution with strategies that involve privacy invasions that have the potential to weaken parent-child connections and may have the unintended consequence of placing children at higher risk. The risk assessment should also consider potential negative influences of SM, such as exposure to harmful or hateful content, and engage adolescents in considering ways to openly discuss negative SM experiences with their parents.

The Family Media Plan developed by the American Academy of Pediatrics [] may be instrumental in developing a mutually agreeable plan for parents and adolescents. This plan offers an opportunity for open discussion about critical topics such as screen time, use at important times of day such as while doing homework or before bed, appropriateness of media content, and rules for digital safety. Clinicians could be trusted confidants to adolescents with depression and their parents when considering these topics and work together with the family to find a middle ground between parents' desire for protection and adolescents' desire for autonomy toward a mutually acceptable monitoring approach.

Implications for the COVID-19 Pandemic

As adolescents and their parents face unprecedented challenges, clinicians of youth with depression have an important role in helping families find a balance between concerns for safety on SM and autonomous communication with peers. Given the risk of social deprivation that ongoing physical distancing measures may have on adolescents, clinicians should work with parents to consider risks of limiting their child's access to supportive SM peers, while also offering guidance to reduce exposure to negative SM content (eg, cyberbullying or conversations or images pertaining to self-harm). Clinicians may benefit from using resources from Common Sense Media, which provide guidance for parents in safeguarding their children's physical and mental wellness as they access digital media during the pandemic []. In addition, the Suicide Prevention Lifeline's collection of web-based resources to support healthy coping during the COVID-19 outbreak may be beneficial contributions to safety plans for adolescents facing pandemic-related mental health challenges [].

Strengths and Limitations

This study offers a unique contribution to the literature by exploring parent and child perspectives toward SM use and monitoring of adolescents with depression. Despite the novelty of this study, it has limitations. First, this study was not intended to be a dyadic analysis of how both parents and their adolescents with depression perceived the adolescent's use of SM. Some aspects of the parent-child relationship related to SM use and monitoring may be unknown because they were not shared during the interviews. Second, the sample is predominantly White and female and from an academic medical institution, where many of the patients visiting the clinic may have had more severe forms of depression and, therefore, may not be representative of adolescents with depression and their respective parents. Moreover, these same patients were brought to the clinic by their parents, suggesting that these parents may be more proactive in their children's health, which may include their child's SM use. Third, the same interviewers conducted these dyadic interviews. In this situation, although the interviewer assured confidentiality and interviewed participants separately, the other party was virtually present in the interview space. This may make the other party (whether parent or adolescent) be selective of what they will tell the interviewer []. Finally, we have framed the relevance of these findings within the COVID-19 pandemic that has observed a sharp increase in SM use alongside a diminishment of parents' availability for monitoring []; however, these data were collected before the pandemic's onset. Therefore, potential differences in adolescents' and parents' perspectives toward within the current context and the evolving nature of SM use may not be represented. Despite these limitations, this study provides helpful insights into the challenges adolescents with depression and their parents face in approaching safety and acceptable SM monitoring.

Conclusions

Our interviews described the experiences of adolescents with depression and their respective parents on adolescents' use of SM in their daily lives, a topic that bears particular relevance during the COVID-19 pandemic when SM use has risen dramatically in response to physical distancing measures. The findings highlight the conflict over adolescents' growing need for autonomy versus the parents' need to protect their child with depression because of concern for their child's heightened vulnerability to the risks of SM use. Parents try to balance these 2 components by obtaining knowledge of their child's SM use through their child's voluntary disclosure, by soliciting information from their child, or through parental control techniques. Our study has highlighted the need for clinicians to partner with families to identify mutually agreeable monitoring strategies that meet both the parents' desire to be knowledgeable about their vulnerable child's SM use and the adolescents' need for independence in their SM interactions.

Acknowledgments

The authors would like to thank the adolescents and parents who participated in this study. This work was supported by the Agency for Healthcare Research and Quality (K12HS022989 and T32HS019486), the National Institute of Mental Health (T32MH018951 and K23MH111922), and the University of Pittsburgh Center for Behavioral Health, Media, and Technology.

Conflicts of Interest

None declared.

‎

Edited by S Badawy; submitted 19.06.20; peer-reviewed by S Byrne, L Kuhns; comments to author 21.07.20; revised version received 10.08.20; accepted 30.08.20; published 08.12.20

©Candice Biernesser, Gerald Montano, Elizabeth Miller, Ana Radovic. Originally published in JMIR Pediatrics and Parenting (http://pediatrics.jmir.org), 08.12.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited. The complete bibliographic information, a link to the original publication on http://pediatrics.jmir.org, as well as this copyright and license information must be included.

Background: Although youth report many positive experiences with social media (SM) use in their daily lives, adolescents with depression are more vulnerable to the risks of SM use than adolescents without depression. Parents protect adolescents with depression from the risks of SM use by monitoring their child's SM activity; however, this comes into conflict with the adolescent's need for autonomy in their web-based communication. The implications of SM use and monitoring for adolescents with depression and their parents are of particular relevance to the COVID-19 pandemic, as rates of SM use have increased in response to physical distancing measures.

Objective: This study aims to explore parent and child perspectives regarding the use and function of SM in the daily lives of adolescents with depression and parents' perceptions of and experience with monitoring their child's SM use.

Methods: We conducted qualitative interviews with adolescents with depression (n=23) and one parent of each adolescent (n=23) between July 2013 and September 2014. The adolescents were patients seeking treatment for depression in Pittsburgh, Pennsylvania. Data analysis included dyadic analysis of the adolescents' and parents' perspectives and qualitative descriptions of individual parent interviews to explore their experiences with SM use and monitoring. The construct of parental knowledge and factors hypothesized to contribute to parental knowledge, including adolescent disclosure, parental solicitation, and parental control, were used to guide the codebook and dyadic data analysis.

Results: Dyadic analyses showed that parents and their children disagreed on the use and function of SM in the daily lives of adolescents with depression, with adolescents viewing SM as a forum for honest expression of their emotions, whereas parents felt that their children's posts were inconsequential and interfered with the adolescents' lives. Furthermore, parents reported using a wide range of strategies to gain knowledge of their child's SM use to monitor their safety on SM, including direct solicitation and indirect solicitation, such as keeping the child's passwords, asking friends or siblings about their child's SM use, and restricting SM behavior and access to devices.

Conclusions: Clinicians should support adolescents with depression and their parents in finding common ground for an effective and acceptable monitoring approach. Resources are provided for clinicians navigating conversations about SM use and monitoring with adolescents with depression and their parents during the COVID-19 pandemic.

JMIR Pediatr Parent 2020;3(2):e21644

doi:10.2196/21644

Keywords

Background

Adolescent SM Use During the COVID-19 Outbreak

The use of SM during the COVID-19 pandemic is estimated to have increased substantially. In their analysis of SM use from web-based data providers, The New York Times reported that the use of the popular SM sites Facebook and YouTube increased by 27% and 15%, respectively []. Increasing rates of SM use may be especially meaningful to young people, as physical distancing measures limit face-to-face interaction. Deprivation of peer interactions, in particular, is challenging during adolescence, a developmental stage during which peer influence and acceptance are important []. In the face of these concerns, SM may play an influential role. Studies of adolescent SM use show that aspects of prosocial face-to-face interactions that are protective to adolescent mental health, such as social support, social reward, and reduction of feelings of social exclusion, can be mirrored through active engagement on SM []. Although SM may play an important role in mitigating limitations to social interaction during the pandemic, there are also concerns associated with higher rates of SM activity. Prevention groups have raised concern that stress associated with the pandemic could contribute to higher rates of negative SM experiences, such as cyberbullying []. The potential for harmful SM interactions is complicated by reduced access to counseling and mentorship from educators []. In the current context, considering adolescents' SM use and the ways in which parents monitor their use is significantly important.

Use of SM in Adolescents With Depression

Adolescents with depression face vulnerabilities that place them at a higher risk of having negative SM experiences and unique opportunities for social support and connection than youth who are not depressed. Adolescents with depression use SM in positive ways; for example, engaging in entertainment, humor, or content generation can act as a distraction from depressed mood [], and these adolescents can also reach out to others for support in coping with depression or for social connection []. With regard to vulnerability to negative SM experiences, adolescents with depression are more likely to engage in risky SM behavior, such as talking to strangers and disclosing personal information [], and to be exposed to potentially harmful SM content, such as self-harming behaviors [,]. In addition, youth with depression are more likely to report internet harassment [], cyberbullying [,], and addictive internet use [] experiences that have been associated with fluctuations in mood states and heightened suicidal risk among adolescents [-]. Parents of adolescents in treatment for depression or suicidal risk have reported awareness of their child's heightened vulnerability to negative SM experiences and describe an urge to stay informed about their child's SM use to protect them from harm [].

Parent and Adolescent Perceptions Toward SM Use and Monitoring

Parental Monitoring and Knowledge of Adolescent's SM Use

Parental monitoring has been defined as the tracking or surveillance of a child's behavior and is often assessed through measures of parental knowledge []. Kerr and Stattin [,] hypothesize 3 primary sources of parental knowledge. These sources include (1) adolescents' voluntary sharing of information with their parents; (2) parents' solicitation of information from their child; and (3) parents' use of control, meaning setting rules and restrictions to limit their child's ability to engage in activities without informing their parents [,]. Thus, information sharing between parents and adolescents can occur through dialogue (eg, informal or formal monitoring discussions) or through behaviors (eg, parents' engagement in mediation of SM as a means to gain control). Of these sources, parental knowledge is most strikingly informed by adolescent disclosure.

Voluntary adolescent disclosure is considered to be a strong and consistent predictor of parental knowledge above and beyond parents' solicitation of information []. By the time of adolescence, youth are developmentally capable of making choices to voluntarily offer private information []. Keeping secrets, particularly when negative consequences are perceived, is also developmentally typical and impacted by contextual factors within the family, such as the degree of trust present between parents and adolescents and overall relationship quality [,]. Supportive parenting styles exhibited by warmth, affection, and responsiveness to adolescents' needs are more likely to facilitate voluntary disclosure [,]. Unsupportive styles of parenting, such as parenting that involves the use of psychological control or manipulation techniques such as love withdrawal, shaming, or guilt induction, act as barriers to voluntary disclosure [,].

These long-standing trends toward parental knowledge and control remain consistent within media studies. In their meta-analysis, Chen and Shi [] showed that parents' active engagement with their child's media use, namely, through openly discussing media use or parental co-use of media with their child, was effective in reducing SM risk behaviors. They also found that parental restriction alone was not associated with a reduction in risky behaviors.

Context of Parental Knowledge of SM Use Among Adolescents With Depression

Parental knowledge of SM use is of critical importance for the discussion of depression in adolescents. Open parent-child communication that is fostered through adolescents' voluntary disclosure is associated with reductions in depressed mood, improvements in self-esteem, and positive and realistic expectations toward media use [,]. Conversely, parents' engagement in unsupportive communication or deployment of control strategies (eg, setting rules that require their child to share information about their SM use) has been linked to increased depressive symptoms and poorer adjustment among adolescents [,,]. When parents' lack of support takes the form of negative reactions to adolescents' disclosures, adolescents are left feeling disconnected to their parent and respond by engaging in secrecy []. Secrecy could be detrimental in situations when a parent may need to intervene to address their child's depressed mood or suicidal thoughts.

Research Gaps

Parents' attempts to understand and explore their child's SM use may be especially challenging in the current era in which SM activity is ubiquitous and trends toward use among adolescents are increasing in the face of the COVID-19 pandemic. Little is known, however, about the context of parental monitoring of SM use among adolescents with depression. Understanding the context of how parents of adolescents with depression balance the unique challenges in weighing their child's unique vulnerabilities toward negative SM experiences and unique opportunities for social support and connection could offer important contributions for clinicians who are partnering with families to support youth with depression. First, similarities and differences in perspectives of adolescents with depression and their parents toward SM use and monitoring have not been explored. Considerations toward monitoring among youth with depression, who are more vulnerable to negative SM experiences, may be distinct from adolescents who are not depressed. Second, strategies that parents of adolescents with depression use to stay informed of their child's SM use are not well understood and may offer helpful guidance to parents of adolescents with depression on how to protect their child while supporting their emerging independence.

The exploration of these findings may be especially beneficial to providers engaged in the mental health care of adolescents who are recommended to assess the harmful and helpful influences of adolescents' digital lives []. Providers' ability to accurately assess the SM context is likely to be influenced by parent and child perceptions toward the use and function of SM. Furthermore, providers who wish to partner with parents to observe and protect adolescents' SM environments may face challenges if the child's and parent's preferences toward SM monitoring strategies are discrepant.

Aims

To offer insights for clinical practice with adolescents with depression and their families, we sought to explore the perspectives of youth with depression and their parents toward SM use and monitoring. Through interviews with adolescent and parent dyads, we aim to compare parent and child views toward the use and function of SM use in the daily lives of adolescents with depression. Through interviews with individual informants, we aim to explore parents' strategies and experiences with gaining knowledge of their child's SM use.

Recruitment and Sampling

As part of a larger qualitative study to inform an intervention using SM for adolescents with depression and their parents [], a convenience sample of adolescents aged 13 to 20 years diagnosed with depression and currently receiving treatment in Pittsburgh, Pennsylvania, and one parent of each adolescent were invited to participate in interviews. From July 2013 to September 2014, potential participants were informed about the study by clinicians treating patients for depression at 2 sites: (1) an academic adolescent and young adult medicine clinic with mental health services available or (2) a specialty psychiatric clinic for adolescents with depression and suicidality. Of the 31 adolescent-parent pairs (of which there were 31 adolescents and 30 parents because 1 mother had 2 children in the study) who filled out an interest form, 8 adolescents and 7 parents could not be reached for an interview; thus, 23 adolescents and 23 parents completed the study. Of these, there were 21 adolescent-parent matched pairs. One parent had 2 children in the study. Reporting of data collection and analytic methods follows the Consolidated Criteria for Reporting Qualitative Research [].

Data Collection

All interviews were conducted by the senior author, who was trained and experienced in qualitative data collection and analysis. She introduced herself to adolescents as a researcher and physician in Adolescent Medicine. Semistructured interviews were conducted over telephone (n=17 adolescents and n=17 parents) or in person in a private patient room in the clinical setting (n=6 adolescents and n=6 parents). Parent and child interviews were conducted separately. We obtained verbal consent from parents for themselves and from adolescents aged 18 years and older; for those aged 18 years and younger, we obtained parental permission and adolescent assent. The interviewer assured participants that the research team would guard confidentiality, specifically not sharing phrases said on SM, which could potentially be searched to identify them.

Data Analysis

Dyadic Analysis of Interviews With Parents and Adolescents

As the original focus of this study did not include dyadic-level analyses, a direct comparison approach could not be used because of differences in questions asked of adolescents and their parents. However, during the analysis of parent and adolescent interviews, similar descriptions of events or ideas by parents and their children created an organic opportunity to examine dyadic-level themes by way of content analysis. Using the Eisikovits and Koren model of dyadic analysis [], matched adolescent-parent dyadic transcripts were reviewed by horizontalization and cross-analysis for overlaps and contrasts between text, subtext, descriptive, and interpretive levels, with the description of an event that occurred in SM (eg, cyberbullying of the adolescent from the perspective of the adolescent and from the perspective of the parent) as the unit of analysis. Dyadic transcripts were reviewed by independent coders (the first and second authors) who noted these horizontal themes, and discrepancies were settled by team consensus.

Analysis of Individual Interviews With Parents

Participant Characteristics

Of those who completed the study (23 parents and 23 adolescents), the average age for adolescents was 16 years (range 13-20 years) and the average age for parents was 46 years (range 37-55 years). Most adolescents (18/23, 78%) and most parents (19/23, 83%) were female, and most adolescents (20/23, 87%) and parents (21/23, 91%) were White (3/23 adolescents, 13%, and 2/23 parents, 9%, were African American), which reflects the demographics of patients seeking care for depression at the 2 sites. At the time of enrollment, adolescents on average had received treatment for depression over 25.4 months (range 3-84 months). Most parents (19/23, 83%) and adolescents (22/23, 96%) used SM. Parents most frequently reported using Facebook (18/23, 78%), whereas adolescents' SM use was more diverse across platforms (10/23, 43%, used Facebook and 4/23, 17%, used Twitter, Tumblr, and Instagram).

Dyadic Analysis of Parent and Adolescent Interviews

We first summarized themes based on dyadic analysis of the interviews, on which we directly compared child and parent interpretations of shared events. This analysis aimed to understand parents' and adolescents' mutual and divergent interpretations of adolescents' use of SM in their daily lives. These themes included SM as a form of expression, the function of SM, SM as a space to discuss depression with others, interacting with strangers on SM, and parental monitoring of adolescents' SM use.

SM as a Form of Expression

Parents and adolescents generally disagreed on SM being a medium for individual expression. Adolescents viewed SM as a forum for honest expression of themselves and their emotions, whether positive or negative. Adolescents elected to express themselves through song lyrics that capture their emotions or what adolescents described as ranting about an event that happened to them. Parents, however, saw much of what their adolescent was posting on SM as inconsequential or something to do when they felt bored and that it could interfere with other activities in the adolescent's life. These themes are demonstrated in the following quotes from a parent and child dyad who had divergent views on adolescents' SM expression:

Just to post like whatever you want. Because it's your Twitter, so you can just say how you feel, like what you're doing that day. Just anything in general really. Like anything that you want. So, it shouldn't matter like what you post.
[Child perspective; age 16 years]

But when I saw what she-all the song lyrics she was putting on there, that caused me to have concern and... I just brought it up. And she thought it was funny. And she's, and you know-I said, 'I don't understand why you want to put these lyrics out there,' because they weren't good lyrics. And she says, 'Well, I'm expressing myself.' And I say, 'But why do you have to tell everybody? Like why'-I don't get it. I just don't get the whole thing. I'm just old-fashioned.
[Parent perspective]

Positive and Negative Functions of SM

Some parents and adolescents mutually described the potential of SM to be a protective, healing, or supportive space or a place to seek positive content. In other cases, parents and adolescents both offered clear examples of and reflections on the harms of SM use. For example, one parent was concerned about posts or forums that encourage self-harm behaviors (eg, cutting), which aligns with her daughter's concerns-who had a history of intentional self-harm-and was worried that such forums or posts would encourage her daughter to cut herself. Other examples had greater discrepancy, which typically occurred when one member of the pair was more ambivalent and the other had a stronger point of view. The following quotes present discrepant perspectives between a parent and child dyad on the use and utility of SM:

So I think that if I do something on that website, like if I make an edit to just something that I enjoy and I'm interested in, that's something that's good, and I can read the feedback that I get from it. And so as long as I'm busy rather than if I look up the tag of #sad, that might make me more sad. But it's kind of like, I get some sort of satisfaction from looking at sad pictures because it's something I can relate to, which is kind of weird.
[Child perspective, age 14 years]

She spends an inordinate amount of time. And while the people on there, cool, some of them have the same experiences and stuff, she's also not getting the face-to-face social stuff that I think she really needs, especially somebody going through what she's going through as far as the depression.
[Parent perspective]

SM as a Problematic Space to Discuss Depression With Others

Some parents and adolescents agreed that it was safer, more private, and more authentic to talk about depression with trusted friends offline; however, their reasoning was not always the same. Parents were concerned about negative consequences and expressed distrust with others on SM, or they preferred that their child talk to them directly. Adolescents, on the other hand, expressed worry about what others would think-that posting on SM would draw unwanted attention, be burdening to others, or simply felt it was not others' business. These viewpoints are demonstrated by the following parent and child dyad:

I don't want everybody to know my business, like what I'm dealing with on like a really personal level...a family member might see it and, well, they might tell another family member about it and it would just go around the whole family.
[Child perspective; age 17 years]

My thought's that if they feel that way, he should come to his mother and father and talk to them about it instead of putting it out there for everybody else. Some people is cruel, and they'll end up saying something that'll make him worse.
[Parent perspective]

Risks and Benefits of Anonymous Interactions on SM

Parents and adolescents had differing opinions about talking with strangers or interacting anonymously on SM. Parents expressed concern over their child being friends or having followers that were strangers or the lack of privacy in SM. In contrast, adolescents perceived that having strangers as friends on SM was not problematic and normative. These divergent perspectives are described by the following parent and child dyad:

I think it's because I was just younger and I didn't care who I was friends with, or you know, like you want to have so many friends on there so you just add whoever, type of thing.
[Child perspective; age 17 years]

How dangerous it is, and, you know, some of these people are older, 20s, 30s, they 're men. How she doesn't need to be, they don't need to see her pictures, they don't need to know anything about her, they don't know her period, that people are dangerous, you can't trust any, you know, everybody. You know, that people can find out anything they want to know.
[Parent perspective]

Parents' Monitoring of Adolescents' SM Use

Parent and adolescent perspectives on monitoring were predominantly divergent. In some cases, parents' attempts to view their child's SM content to prevent negative experiences left adolescents feeling resentful, particularly when the adolescent was excluded from this process (eg, a parent looking though their child's phone without the adolescent's permission). Furthermore, when parents restricted SM use, some adolescents defied their parents' wishes by creating secret accounts on SM or by engaging with strangers. In other cases, parents considered monitoring strategies that would protect the parent-child relationship, which might include having honest conversations with their child about privacy or safety issues surrounding sharing of information on SM. These efforts corresponded with adolescents citing examples of choosing not to disclose private matters on SM; however, adolescents rarely contributed their decisions regarding privacy to their parents' monitoring efforts, as is exemplified in the following quotes from a parent and adolescent dyad:

I really do think that she's too smart to share it with strangers. I mean, I really think I've educated her in that, you know, strangers are never your friends, and they're not who they say are-I think she's wiser than her years when it comes to that, but I'm sure a lot of parents think that and then something tragic happens.
[Parent perspective]

If it's something private, I think-I mean just from my opinion, I think, I just keep it to myself...I think that people would see it and just kind of like, maybe feel bad or like-and I just feel that they would know my personal business. And it's just like not necessary.
[Child perspective]

Analysis of Individual Parent Interviews

Drawing from the frequent divergent interpretation of adolescents' SM use and behaviors, themes were explored to identify the ways in which parents of youth with depression within this sample gain knowledge of their child's SM use and parents' attitudes and experiences with SM monitoring.

Parental Expectations

Parents had a variety of expectations both toward their adolescents' capacity to use SM in a healthy manner and in the potential of monitoring to have an impact on their child's SM use. Parents generally expected their child to use SM in a way that was healthy. As described in the following quote, some parents felt that their expectations were met, describing a sense of trust in their child to create and maintain prosocial SM relationships and to express their opinions and experiences of depression in a way that is healing:

I trust her, you know, quite a bit, really-I mean, fully-with the use of it. I think she's got a good head on her shoulders, and, so, yeah, I think she's managing her own positive experience of it.

Alternatively, other parents' expectations were unmet. They also had concerns that their adolescent was engaging in maladaptive behaviors such as oversharing (or being too trusting of sharing personal information on SM), which parents believed may have negative consequences, such as bullying, embarrassment, or future impact, on employment opportunities. Some informants were surprised to find their child's peers discussing risky behavior on SM (eg, sharing sexually explicit content). One parent offered an example of discomfort with photos shared by her child's friends:

...my daughters have a lot of friends with inappropriate photographs, and I don't think that they think they're inappropriate, but...I don't think teenage girls should be in bathing suits on the internet.

In addition, parents expressed both positive and negative expectations that their monitoring efforts would actually have an impact on their adolescents' engagement with SM. Some felt capable of intervening to improve their adolescent's SM interactions, for example, having an open conversation about cyberbullying. Alternatively, others were concerned that SM was too difficult to regulate or control and that intervening would be ineffective. The following quote offers an example of a parent's negative expectation:

...it's not a battle I choose to fight. I'm not going to-you can't-the internet in general is basically an unlimited freedom. You can see and do just about whatever your imagination can come up with.

Adolescent's Disclosure to Their Parents

Descriptions or perceptions that adolescents are telling their parents about their SM use or the impact of SM use on their mood varied. In some cases, when adolescents accepted their parent's monitoring, they were willing to openly discuss their SM use and its impact on them with their parents. One parent offered an example of her child openly disclosed information about her SM use:

...she's pretty-[name] is I would say much more open with me than, than I, than certainly I ever was with my parents...I just felt like my mom was so far, you know, like way into my business in the first place, that I didn't share, but [name] and I have a, have a pretty good relationship, I think and like she has no problem. Like she'll come to me for advice and say, 'What should I say to this person?'

Selective disclosure of behaviors was also observed, meaning that adolescents hid some aspects of their SM use from their parents in fear of a negative consequence. In these cases, adolescents feared that negative SM experiences may lead to parents deactivating their SM accounts, or they fear their parents will respond with rejection or disapproval.

Parental Knowledge

Several parents found it difficult to be knowledgeable about their children's SM behavior. As described in the following quote, parents reported being unaware of which platforms their child used and did not know if their adolescent was bypassing their rules regarding SM use:

I asked her not to get on Facebook anymore. And then she snuck, and she got on Facebook a second time, using a different name.

Some parents acknowledged that their adolescents had hidden concerning SM interactions from them. For example, one parent noted that her daughter hid photos posted on SM of her self-injuring:

Before she had her attempt of suicide, she had a GifBoom account that was very dark, and we didn't find out about it until later, but like had pictures of cutting-it almost was like a support group for that.

Other parents were more secure in their knowledge of their child's SM interactions, and at times, this impacted adolescents' SM behavior, often reducing personal content disclosed on SM. In the following quote, a parent described how their child being aware of familial monitoring corresponded with reduced sharing on SM:

Well, I have to be honest, she doesn't really share too much online from a Facebook standpoint, regarding how she feels or her depression, because she has many family members who are her friends on Facebook. And I think, and I'm trying to get into her mind, and I'm thinking that she doesn't put a lot of that out there because of who they are. Like if it's her Nana, which is her grandmother, or her grandfather, or her aunts and uncles, she doesn't put a lot of that out there, because she knows that they will read it.

Parental Solicitation

To gain knowledge of their child's SM use, parents engaged in solicitation. In some cases, solicitation involved directly asking the child about their SM use. Parents engaged in this direct form of solicitation both in person and on SM, predominantly in instances when they felt their child was having negative experiences on SM or based on a belief that SM was inherently harmful (eg, contributing to their depression or encouraging risky behavior). Parents not using this direct form of solicitation described not wanting to hover or be controlling and preferred trusting in their child to maintain healthy SM behavior.

Parents also engaged in indirect forms of solicitation, which may have included a parent looking through their child's phone or knowing the password to their SM accounts. Some parents felt this was an important way to learn previously unknown information about their child, such as new disclosures of risk-taking behavior described on SM or even to have a window to how the child feels or experiences their depression in a way that adolescents may not communicate with their parents. In the following quote, a parent described her experience with learning the utility of SM in providing information on her child's emotional state:

Her father and I both were very against her sharing these things online, or really even, we kind of wanted her to just not even have an online account or anything. But then we kind of were, I don't know, awakened to the fact that this is kind of the only window you have into your kid's emotions sometimes. You know, teenagers especially don't like to tell their parents what's going on or to talk about how they're feeling. And sometimes that's how you see how they're really feeling, is by some of the stuff they're posting, even if they don't realize that they're showing it, you can kind of just see their different moods. I think it definitely has given us some, I don't know, opportunities to talk that maybe we wouldn't have had before. Especially-it's very easy for kids to just come home and say, 'Yep, school was fine. I'm fine.' And the that's it, you know.

Adolescents were more accepting of indirect forms of monitoring when there was an agreement between the parent and child of how this would be done. For example, one adolescent noted that their parent having their account password information led to openness in communication surrounding SM. To protect their child's privacy and the parent-child relationship, some parents used other sources such as asking a friend, sibling, or other relative to assist in monitoring or using monitoring software.

Parental Control

Efforts to control adolescents' behaviors included restricting sites perceived to be harmful and attempting to restrict certain SM behavior. One parent described how their efforts to restrict their child's SM use were brought about by a desire to protect their child from harmful SM content:

Honestly right now, at this point in time, I have blocked most of the social networking sites from my daughter because of some of the things that I have seen on her wall and some of the things that I have seen that she posted. Because she's going through this, let's call it a difficult time in her life right now, I don't think that she needs to rehash and read, and see all these different things because it's just open- everything that is imaginable is on these social networking, and I just, I'm-I guess I'm trying to, to the best of my ability, is to protect her from seeing these different things...

Furthermore, some parents limited their adolescent's SM use after their child did something of which they disapproved. Disciplinary actions included restricting access to a certain SM site entirely or taking the child's phone away. In the following quote, a parent related her experience with restricting her child's access to Facebook:

So, I asked her not to get on Facebook anymore. And then she snuck and she got on Facebook a second time, using a different name. And the same thing was happening...so then finally after she did it the third time, we told her absolutely, positively not. She wasn't allowed to go even into Facebook to read it, to read anybody's comments, to even talk to anybody. She's not, at this point she's not allowed on Facebook at all.

Rule setting was enforced through both direct and indirect means of solicitation, including the use of monitoring software or by asking designated members of the child's social network (eg, a friend of the parent who is monitoring the adolescent on behalf of the parent). Attempts to restrict SM behavior varied by age, where some parents restricted the use of certain SM sites or any site before a certain age. Parents who did not engage in restriction reported a sense of powerlessness or loss of control. One parent described how she wished she could set rules but felt doing so would be ineffective and could damage her relationship with their child:

I wish I had the nerve to tell her she wasn't allowed to use it but it would just be such a barrier and it would just make her hate me and not talk to me, and there's no point-like I said, like I prepare her for the adult world, in a year and a half she'll be at college, and I don't want her to go off the deep end then and say, like, 'My mother would never let me do this, so now I'll show her...'

Another parent described a perception that attempts to control are ineffective and correspondingly a sense of lack of control:

We tried at first to completely like eliminate her having them, but we found that when you do that they just kind of find ways to do it behind your back, and then you have no way to know what's going on. So, she voluntarily will show me a lot of this stuff. You know, I still do fear that there's things out there that I'm not seeing. But I don't know if there's ever a way to monitor 100%. You're almost kind of kidding yourself if you think you are.

Principal Findings

This study uses rich qualitative inquiry to explore child and parent perspectives toward SM use and monitoring for adolescents with depression. Our study describes the experiences of adolescents with depression using SM to seek autonomy from their parents and the parents attempt to maintain knowledge of their child's SM use to offer protection because of concerns of a potentially unsafe environment for their vulnerable child. Although previous research has described the struggles between adolescents' and parents' overuse of SM [], this study's dyadic analysis of the perspective of adolescents with depression and their respective parents is unique. SM presents challenges through risky SM behaviors, negative SM experiences such as cyberbullying, and worsening mood [,,,], to which adolescents seeking clinical treatment for depression are especially vulnerable. SM also presents opportunities for social connection and supportive interactions, which are especially important for youth facing depression []. Conflict over the use of SM in the context of depression may create added challenges that youth without depression and their parents or caregivers may not have to address. This study offers findings that have implications for clinicians engaged in the treatment of adolescents with depression, who are heavy users of SM. Especially in the current context of the COVID-19 pandemic, clinical guidance for parental monitoring of SM is critical.

The findings from the dyadic interviews showed that although a few parents and adolescents agreed about the use and function of SM, most had discrepant perspectives. Discrepancy often stemmed from a difference in value placed on autonomous SM expression versus protection from the risks of SM use. These views can be considered with a report released from the United Nations International Children's Emergency Fund [], which considers children's rights for digital privacy. In accordance with the United Nations Convention on the Rights of the Child [], this report suggests that children have a right to digital privacy and that parents have a dual responsibility-both to protect their adolescent from web-based threats and to encourage free expression by their adolescent in web-based spaces. This dual responsibility appears to create conflict and discrepant views between adolescents and their parents.

For parents attempting to balance this dual responsibility, United Nations International Children's Emergency Fund's report suggests the extent to which privacy and access to SM is given should be considered based on the child's evolving capacity, for example, their age and maturity level. In the case of adolescents with depression, a child's capacity may also include the potential for heightened vulnerability to harmful SM experiences. At the same time, adolescents with depression report finding value in having a venue to express themselves emotionally and receive support through trusted SM friends. Furthermore, some studies found that these protective interactions had a healing effect, which positively influenced their mood. This suggests that although parents should take measures to protect their child from SM-related risks to their safety, they should also look for opportunities to allow their children to engage freely, particularly with supportive peers on SM.

The results of the individual interviews can be placed within the context of conceptualization of parental knowledge by Kerr and Stattin []. The sources of parental knowledge they have identified- adolescent disclosure, parental solicitation, and parental control -appear to be salient in understanding how parents engage in surveillance and monitoring of SM behavior of adolescents with depression. Consistent with the literature [,], adolescents voluntarily disclosed information about their SM use to their parents when they accepted their parents' monitoring strategies but were less likely to disclose when they perceived the potential for a negative consequence. When teens felt comfortable, they were willing to discuss their SM use and its impact on their mental health with their parents. Due to concerns about their children engaging in risky SM behavior, several parents were keenly interested in gaining information either by directly asking their child about their SM use or through overt or covert methods of viewing their child's actual SM content. Parents' engagement in covert forms of solicitation are potentially concerning because privacy invasions have been associated with increased secrecy and lower parental knowledge [,]. Parents engaged in a variety of control techniques, that is, rule setting surrounding their child's SM use and, in some cases, violation of parents' rules resulting in disciplinary actions. When parents engaged in controlling behaviors without their child's knowledge or buy-in, teens were not entirely honest with their parents about their SM experiences. When parents engaged in privacy invasions, adolescents became secretive and, in some cases, engaged in risky SM behavior without their parents' knowledge.

These results suggest that there is a unique context for parents of adolescents with depression for engaging in SM monitoring and unique consequences for their child's acceptance of their chosen monitoring strategies. The positive consequences of open parent-child communication that fosters voluntary disclosure are significant. Parents can be more aware of their child's SM activity to protect them from the negative influences of SM while fostering positive influences. Likewise, the negative consequences of SM monitoring strategies that contribute to a lack of knowledge are also considerable. As was evident in these interviews, when adolescents with depression do not accept their parents' use of SM monitoring, they have the potential to withhold information from their parents about risky SM communication, such as posting about self-harm or communicating with strangers. Lacking such information stifles parents' capacity to protect their child from harm. Further, restriction techniques that limit access to supportive SM interactions may have the consequence of reducing the protective influences of SM.

Implications for the Clinical Care of Adolescents With Depression

Understanding parent and child perspectives toward SM use and strategies parents deploy to learn about the SM activity of their child with depression could offer valuable insights toward clinical intervention planning. For example, the strategies parents use to procure information about their child's SM use could either support or discourage the child's voluntary disclosure of risky SM interactions or negative experiences. Such voluntary disclosure may be the most effective way for parents and clinicians to be knowledgeable about the level of risk within the child's SM environment. In addition, adolescents' voluntary disclosure to parents could result in a greater awareness of the protective aspects of their SM use, including sources of support that adolescents with depression may find critical to preventing their depressed mood from worsening. Understanding the context of adolescents and parents' perspectives toward SM use and monitoring could aid clinicians in opening lines of discussion that validate both parties' unique concerns to move toward the goal of an effective and acceptable monitoring approach.

In 2019, the American Association of Suicidology (AAS) [] released recommendations for parents and providers engaging in SM monitoring of adolescents at risk for suicide. According to the recommendations by AAS, clinicians should engage in a risk assessment of both the helpful and harmful influences of adolescents' engagement with SM and use this information to build a crisis intervention safety plan. It is considered a best practice for safety plans to be developed by clinicians in collaboration with parents. When engaging in risk assessment, clinicians should consider ways by which SM can offer meaningful opportunities for emotional expression and support for adolescents with depression and work with parents to consider how engaging in restrictive strategies could affect these helpful aspects of SM use. Clinicians should offer parents caution with strategies that involve privacy invasions that have the potential to weaken parent-child connections and may have the unintended consequence of placing children at higher risk. The risk assessment should also consider potential negative influences of SM, such as exposure to harmful or hateful content, and engage adolescents in considering ways to openly discuss negative SM experiences with their parents.

The Family Media Plan developed by the American Academy of Pediatrics [] may be instrumental in developing a mutually agreeable plan for parents and adolescents. This plan offers an opportunity for open discussion about critical topics such as screen time, use at important times of day such as while doing homework or before bed, appropriateness of media content, and rules for digital safety. Clinicians could be trusted confidants to adolescents with depression and their parents when considering these topics and work together with the family to find a middle ground between parents' desire for protection and adolescents' desire for autonomy toward a mutually acceptable monitoring approach.

Implications for the COVID-19 Pandemic

As adolescents and their parents face unprecedented challenges, clinicians of youth with depression have an important role in helping families find a balance between concerns for safety on SM and autonomous communication with peers. Given the risk of social deprivation that ongoing physical distancing measures may have on adolescents, clinicians should work with parents to consider risks of limiting their child's access to supportive SM peers, while also offering guidance to reduce exposure to negative SM content (eg, cyberbullying or conversations or images pertaining to self-harm). Clinicians may benefit from using resources from Common Sense Media, which provide guidance for parents in safeguarding their children's physical and mental wellness as they access digital media during the pandemic []. In addition, the Suicide Prevention Lifeline's collection of web-based resources to support healthy coping during the COVID-19 outbreak may be beneficial contributions to safety plans for adolescents facing pandemic-related mental health challenges [].

Strengths and Limitations

This study offers a unique contribution to the literature by exploring parent and child perspectives toward SM use and monitoring of adolescents with depression. Despite the novelty of this study, it has limitations. First, this study was not intended to be a dyadic analysis of how both parents and their adolescents with depression perceived the adolescent's use of SM. Some aspects of the parent-child relationship related to SM use and monitoring may be unknown because they were not shared during the interviews. Second, the sample is predominantly White and female and from an academic medical institution, where many of the patients visiting the clinic may have had more severe forms of depression and, therefore, may not be representative of adolescents with depression and their respective parents. Moreover, these same patients were brought to the clinic by their parents, suggesting that these parents may be more proactive in their children's health, which may include their child's SM use. Third, the same interviewers conducted these dyadic interviews. In this situation, although the interviewer assured confidentiality and interviewed participants separately, the other party was virtually present in the interview space. This may make the other party (whether parent or adolescent) be selective of what they will tell the interviewer []. Finally, we have framed the relevance of these findings within the COVID-19 pandemic that has observed a sharp increase in SM use alongside a diminishment of parents' availability for monitoring []; however, these data were collected before the pandemic's onset. Therefore, potential differences in adolescents' and parents' perspectives toward within the current context and the evolving nature of SM use may not be represented. Despite these limitations, this study provides helpful insights into the challenges adolescents with depression and their parents face in approaching safety and acceptable SM monitoring.

Conclusions

Our interviews described the experiences of adolescents with depression and their respective parents on adolescents' use of SM in their daily lives, a topic that bears particular relevance during the COVID-19 pandemic when SM use has risen dramatically in response to physical distancing measures. The findings highlight the conflict over adolescents' growing need for autonomy versus the parents' need to protect their child with depression because of concern for their child's heightened vulnerability to the risks of SM use. Parents try to balance these 2 components by obtaining knowledge of their child's SM use through their child's voluntary disclosure, by soliciting information from their child, or through parental control techniques. Our study has highlighted the need for clinicians to partner with families to identify mutually agreeable monitoring strategies that meet both the parents' desire to be knowledgeable about their vulnerable child's SM use and the adolescents' need for independence in their SM interactions.

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Social Media Use and Monitoring for Adolescents With Depression and Implications for the COVID-19 Pandemic: Qualitative Study of Parent and Child Perspectives

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Background: Although youth report many positive experiences with social media (SM) use in their daily lives, adolescents with depression are more vulnerable to the risks of SM use than adolescents without depression. Parents protect adolescents with depression from the risks of SM use by monitoring their child's SM activity; however, this comes into conflict with the adolescent's need for autonomy in their web-based communication.

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Racial/Ethnic Differences in Teen and Parent Perspectives toward Depression Treatment

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Study design

Study enrollment occurred between January 2005 and March 2006. We recruited our sample from seven healthcare organizations in Los Angeles and Washington, DC (three of these sites each had more than one participating clinic, for a total of 11 clinics; two clinics contributed no patients, yielding data from nine clinics). We selected sites purposively to maximize diversity by patient race/ethnicity and whether the clinics were free, public, private managed care, or private insurance. We also

Sample characteristics

Table 1describes the sample sociodemographic characteristics by teen race. This sample was 76% female, 34% black/African American, 50% Latino, and 16% white. Overall, 45% of parents in this sample had completed at least some college, but fewer African Americans and Latino parents compared with white parents had completed at least some college ( p < .01). Fifty-nine percent of the Latino parents conducted their interviews in Spanish.

African American, Latino, and white teens have similar rates of

Discussion

This study provides key information about racial/ethnic differences in perspectives on depression treatment. In addition, this research adds to our current understanding of adolescent knowledge and viewpoints by analyzing the role of parents in influencing those preferences.

Although prior research has revealed that there are racial/ethnic distinctions in treatment views, we really know very little about whether these perspectives are shared by teens and parents for treatment of teens. This

Acknowledgments

This research was supported by an unrestricted grant to the RAND Corporation from Pfizer Inc. We wish to acknowledge the following sites for their participation in this study: Capitol Medical Group-Richard Jones, M.D.; Kathy McCue, C.R.N.P; Kaiser Permanente Mid-Atlantic-Mark Snyder, Tami Collins, M.D., Sima Bakalian, M.D.; Children's National Medical Center-Larry D'Angelo, M.D.; Children's Pediatricians and Associates-Ellie Hamburger, M.D.; Northeast Valley Health Corporation and San Fernando

# data[].attributes.attachment_link.title
Racial/Ethnic Differences in Teen and Parent Perspectives toward Depression Treatment

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Study enrollment occurred between January 2005 and March 2006. We recruited our sample from seven healthcare organizations in Los Angeles and Washington, DC (three of these sites each had more than one participating clinic, for a total of 11 clinics; two clinics contributed no patients, yielding data from nine clinics).

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Depression literacy and stigma influence how parents perceive and respond to adolescent depressive symptoms

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Abstract

Background

This study aimed to: (1) validate a measure of parental reactions, attitudes and understanding of adolescent depressive symptoms (PRAUD) and (2) examine the impact of adolescent and parent depressive symptoms, parental knowledge about adolescent depression (depression literacy), and parental depression stigma on parental responses to adolescent depression.

Method

Parents ( N  = 440) of adolescents aged 13-17 years completed an anonymous online questionnaire.

Results

Factor analysis suggested four patterns of parental responses to adolescent depressive symptoms: overprotection, criticism, distress and support. Internal consistency was good for all PRAUD subscales ( = 0.80-0.88). Higher parent and adolescent depressive symptoms, greater depression stigma and lower depression literacy were associated with more negative parental responses. Higher adolescent depressive symptoms and poorer parent depression literacy predicted overprotective responses, and depression stigma moderated the effect of parent depressive symptoms. Depression literacy moderated the effect of parent depression on supportive parental responses, and stigma moderated the effect α of adolescent depression. Higher levels of depression stigma and parent depression predicted critical responses, and depression literacy moderated the effect of adolescent depressive symptoms. Distress responses were predicted by higher stigma, and depression literacy moderated the effect of parent and adolescent depressive symptoms.

Limitations

Differences between the two sample recruitment sites.

Conclusions

There was evidence of more negative parental attitudes and responses among depressed parents and parents of depressed youth. Improving parental depression literacy and reducing depression stigma during treatment of adolescent depression may facilitate parental responsiveness, and in some circumstances, may help buffer against the negative impact of parental depression.

Introduction

Adolescence is a peak period for the development of depressive disorders (Lewinsohn et al., 1998), which often continues into adulthood (Rao et al., 1999). In addition to having a negative impact on academic performance, social relationships, and increasing the risk of substance use and suicidality (Lewinsohn et al., 1998, Rao et al., 1999), adolescent depression is associated with increased levels of conflict with parents (Lewinsohn et al., 1998). Unhelpful parent-child communication patterns can exacerbate negative emotionality in the adolescent. Parenting accounts for 8% of the variance in childhood depression (McLeod et al., 2007), and as a potentially modifiable factor affecting depressed youth, understanding factors that influence parental responses to adolescent depression may highlight important treatment targets.

Parental responses to adolescent emotional displays can provide implicit or explicit messages about the acceptability of particular emotions (Morris et al., 2007), and this can influence youth emotional functioning and regulation. Several studies have found increased critical and controlling parenting among parents of depressed youth (e.g., Asarnow et al., 1994, McLeod et al., 2007, Rapee, 1997, Sheeber and Sorensen, 1998), and others have noted increased emotional withdrawal and decreased support (Kashani et al., 1995, Pineda et al., 2007, Sheeber and Sorensen, 1998), however these relationships have been observed using measures of general parenting rather than measures specifically assessing parent responses to depression. Parental criticism and rejection can undermine self-esteem and trigger negative schemas that act as precursors to depression, while parental control can reduce the adolescent's experience of mastery and increase helplessness (Kaslow et al., 1994, McLeod et al., 2007). Critical and controlling parental responses may reflect parental attempts to change undesirable behaviours in their child, but are likely to be unhelpful and ineffective when these behaviours reflect symptoms of a clinical disorder (Asarnow et al., 1994).

The relationship between parenting responses and adolescent depression is bidirectional. Several studies have examined the interaction pattern between parents and depressed adolescents, showing reciprocity of negative affect (Pineda et al., 2007, Sheeber et al., 1998). Pineda et al. (2007) found that parents of depressed adolescents showed less supportive parental reactions (but not critical responses) to adolescent depressive behaviours compared to parents of non-depressed adolescents, and increases in adolescent depressive behaviours following critical or negative parenting. These findings suggest that parents of depressed youth are more likely to respond in ways that exacerbate the young person's negative mood and behaviours, perpetuating a negative interaction cycle. Conversely, parents of non-depressed youth showed increased support following depressive behaviours, suggesting a potential protective role of these parental behaviours (Pineda et al., 2007). Identifying problematic parental responses to adolescent depressive behaviours is useful to inform treatment targets, however most studies use lengthy qualitative coding schemes (e.g., Asarnow et al., 1994, Pineda et al., 2007, Sheeber et al., 1998) that, while ideal for research contexts, are impractical for clinical settings. Similar to anxiety-specific self-report measures of parental attitudes and reactions that have been developed (e.g., Parental Attitudes, Beliefs and Understanding of Anxiety Scale [PABUA] and Parental Beliefs about Anxiety Questionnaire [PBA-Q]; Francis and Chorpita, 2010 ;Wolk et al., 2016), there is a need to develop a practical measure of parental responses to adolescent depressive symptoms that could serve as a quantitative adjunct to clinical observation or qualitative coding.

In addition to the need to develop a practical depression-specific measure of parental responses, there is also considerable scope to examine why parents respond in particular ways. Although parent mental health problems are one factor that may impact parenting styles, parents' attitudes and beliefs are also likely to influence their parenting responses. Specifically, parental knowledge about mental health problems (i.e., mental health literacy) and their level of mental health stigma are likely to influence how they respond to their child's depressive symptoms. Mental health literacy reflects accurate knowledge about causes, symptoms and treatment of mental disorders, and has the potential to improve outcomes for youth, primarily by facilitating help-seeking (Kelly et al., 2007). Given youth preference for discussing mental health problems with a friend or family member (Burns and Rapee, 2006; Offer et al., 1991), ensuring parents have adequate knowledge about depression may improve the support youth receive. Parents who understand the nature of depression may also be more supportive of adolescent emotions, and less critical, controlling, distressed or overprotective. However there is little research examining parental mental health literacy and even less examining it's potential to moderate parenting responses.

Depression stigma is another factor that may influence how parents respond to young people's depressive symptoms. Depression stigma can include ignorance and misinformation about depression, but is distinguished from mental health literacy by the incorporation of prejudicial attitudes and behavioural discrimination (Thornicroft et al., 2007). Common stigmatising beliefs include perceptions that people with depression are unpredictable or dangerous, that depression is due personal weakness and is controllable, and feelings of guilt or embarrassment about experiencing depression (Reavley and Jorm, 2012). Incorrect attributions and stigma about adolescent depression from parents is likely to negatively impact how parents respond to youth and delay help-seeking. Similar to depression literacy, the impact of parental depression stigma on parenting has not been examined.

This study had two aims: (1) to develop and examine the psychometric properties of a questionnaire measure assessing parental reactions, attitudes and understanding of adolescent depressive symptoms (PRAUD); and (2) to assess whether parental depression literacy and depression stigma predict parental responses to adolescent low mood and depression, and whether these factors moderate the impact of parent and youth depressive symptoms. We expected that PRAUD would reveal overprotective, supportive, critical, controlling and distressed responses to adolescent depression. For aim 2, we expected that depression literacy and stigma would moderate the relationship between parent and adolescent depressive symptoms and PRAUD subscales, such that better literacy and lower stigma would result in more positive and less negative parental responses, but that this relationship would be weaker among depressed parents and parents of depressed adolescents given existing evidence suggesting higher levels of negative parental responses amongst depressed parents (Pineda et al., 2007).

Section snippets

Participants

Participants were 440 parents of adolescents aged 13-17 years who completed an anonymous online questionnaire. Participants were recruited from two sources. Community participants ( N  = 197) were recruited via advertisements on social media, community newsletters, and online parenting networks for a study on "What is it like to be the parent of a teenager?" Another 273 participants were recruited for a study of "Beliefs about teen depression", from Amazon Mechanical Turk (MTurk), an online

PRAUD psychometric analysis

An exploratory factor analysis was conducted using principal axis factoring and direct oblimin rotations to allow non-orthogonal factors. Each factor was required to have ≥ 4 items loading ≥ .40. Diagonal values in the anti-image matrix were ≥ .67 suggesting adequate inter-item correlation. Twenty-three items were removed due to low communality values (< 0.40), one item due to low factor loading (< 0.4) and five items due to cross-loading (> 0.4). The final 29 items were entered into a revised

Discussion

There were two primary aims for this study: first we aimed to develop and validate a measure of parental responses and attitudes to adolescent depressive symptoms (PRAUD). Second we aimed to use this new measure to examine factors that impact on how parents perceive and respond to adolescent depression - namely, whether parental depression literacy and stigma influence parental responses, and moderate the effect of parent and child depressive symptoms. A four factor structure was found for the

Contributors

Carly Johnco developed and conducted the study analysed the data and drafted the manuscript. Ron Rapee assisted with development of study aimsand design, and edited the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

Declarations of interest: none

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# data[].attributes.attachment_link.title
Depression literacy and stigma influence how parents perceive and respond to adolescent depressive symptoms

# data[].attributes.attachment_link.description
This study aimed to: (1) validate a measure of parental reactions, attitudes and understanding of adolescent depressive symptoms (PRAUD) and (2) examine the impact of adolescent and parent depressive symptoms, parental knowledge about adolescent depression (depression literacy), and parental depression stigma on parental responses to adolescent depression.

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I am a strong believer that social media has affected the world in many positive ways, but at the same time has created detrimental and fatal situations especially for teenagers in America. The past few years talking about mental health has become less of a stigma, and people have begun to have open dialogue about issues like depression and anxiety. From my research, I have learned that teenagers often struggle with depression more because their parents are uneducated on mental health and often disregard their concerns and or don’t know how to deal with a depressed teen. Society needs to continue talking about issues like mental health and people apart of the older generations should educate themselves on the topic not just for themselves but to make sure they are helpful for their kids or future children.

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Having a positive parent-teen relationship is important especially for those who are dealing with depression. Being able to have open communication about topics like this can ultimately save the lives of teenagers. Using nurturing and supportive tactics can help guide children during tough times. If you feel that you can be more educated on topics, like depression, and other mental health illnesses use empirical articles for your research!

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I learned a lot about what it means to find a research article this semester. My number one tip is to question everything. I was not critical enough before this class. Now I know how to keep looking into information and questioning it. Another tip is to always look into who the research is written by. You may be able to tell right away if it is pseudoscience just based off that information.

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A few key take aways :
1. Adolescents especially those of African-American or Latino have shown to have lesser knowledge on mental health then their white peers.
2.  Racial/ethnic differences in depression treatment perspectives exist and these are influenced by parental views.
3. We need more research on ways parents have been successful when dealing with mental health illnesses.

Conversations about mental health have become less of a stigma and more of an important topic. Social media has created platforms that put unnecessary pressure in regards to beauty standards and other aspects that lead to depression in teens. Making sure that parents have open communication with their children is important for not just mental health but for their safety. I also have a notice from my research and personal experience that certain cultures still are dealing with stigma is in regards to mental health. They need to be broken in order to save lives.

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As stated in one of the articles, “relationship between parenting responses and adolescent depression is bidirectional.” (Johnco&Rapee,2018). This means that both of these ideas can influence each other. Parental responses can cause or make adolescents' depression worse. From my research parents saying “I love you” has no evidence or proper research on its effects on adolescents with depression but the second half of the myth “and showing it often”  was proven in my research. The articles that I chose were all within the past 15 years and we’re proven credible. Some limitations that I ran into include not having enough credible evidence to generalize my research. I also did not find the proper articles to go exactly with my original statement.

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Questions:

| Broad Question

Can changing parent-teen relationships and how healthy or unhealthy the relationship is contribute to adolescent depression?

| Specific Question

What can change in order to create a healing environment and a reduction in depressive symptoms?

Alternatives:

| Hypothesis

Proper parental support is detrimental when dealing with a depressed teen.

Logic:

| If the hypothesis is true, then what?(If then statement)

If parents listen to the steps provided in the article, then they will help support their teen through depression.

Methods:

N/A

Results

| What were the important results?

N/A

Inferences

| What did the authors conclude from the study?

| How did the authors use the results to make inferences and conclusions about the hypothesis and research questions? |

Some ways that parents can help their teen include:

Parent-teen therapy

Healthy parenting practices

Attachment based family therapy

Medication

Sleep

Physical activity

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Questions:

|Broad question

What are the parent and child perspectives regarding the use and function of SM in the daily lives of adolescents with depression?

|Specific question

What are parents’ perceptions of and experience with monitoring their child’s social media use?

|Alternatives

|What was the author's hypothesis?

|What were the alternative hypotheses?

Adolescents with depression are more vulnerable to the risks of SM use than adolescents without depression.

|Logic

|What was the logic of the hypothesis?

|i.e., if the hypothesis was true, what should we expect to happen?

If parents protect adolescents with depression from the risks of SM use by monitoring their child’s SM activity they can help keep their child safe. However this comes into conflict with the adolescent’s need for autonomy.

|Methods

|Briefly describe the study design

|What were the independent and dependent variables?

Briefly describe the study procedure in everyday terms

They conducted qualitative interviews with 23 adolescents with depression  and one parent of each adolescent between July 2013 and September 2014. The participants were patients seeking treatment for depression. Data analysis included dyadic analysis of the adolescents’ and parents’ perspectives and qualitative descriptions of individual parent interviews to explore their experiences with social media use and monitoring.

|Results

What were the important results?

Dyadic analyses showed that parents and their children disagreed on the use of social media in their daily lives. Adolescents viewed SM as a platform for honest expression of their emotions, whereas parents felt that their children’s posts were inconsequential and interfered with the adolescents’ lives.

Parents also reported using strategies to gain knowledge of their child’s social media  use to monitor their safety. This included direct solicitation and indirect solicitation, such as keeping the passwords or asking friends or siblings about their accounts.

|Inferences

|What did the authors conclude from their study?

|How did the authors use the results to make inferences and conclusions

about the hypothesis and research question?

Clinicians should support adolescents with depression and their parents in finding common ground for an effective and acceptable monitoring approach. Resources are provided for clinicians navigating conversations about SM use and monitoring with adolescents with depression and their parents during the COVID-19 pandemic.

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Questions:

| Broad Question

What racial/ethnic differences in teen and parent depression knowledge and treatment preference exist?

| Specific Question

Are parent perspectives on treatment associated with teen knowledge and treatment preference and does this differ by race?

Alternatives:

| Hypothesis

Racial differences in parents and teens can determine their knowledge toward depression and depression treatments.

Logic:

| If the hypothesis is true, then what?(If then statement)

Parents' knowledge about depression and depression treatments will directly influence their child’s view on it as well.

Methods:

In the end 324 people completed the baseline interview. Teens and parents of participants who were designated as “depressed” were invited to participate further in the study. After a depressed teen was enrolled, the next teen who screened as “nondepressed” from that same clinic, and of the same gender, was invited to participate as well. Nondepressed teens were matched to depressed teens by clinic and gender. Participants were interviewed at two separate points in time. One shortly after the diagnostic interview and again approximately 6 months later.

Results

| What were the important results?

Latino and African American teens had lower scores on antidepressant knowledge and counseling knowledge than white teens. These racial differences were greater among parents. Parent antidepressant knowledge had an impact on teen knowledge, also teen knowledge about medication and counseling were associated with a willingness to seek active treatment.

Inferences

| What did the authors conclude from the study?

| How did the authors use the results to make inferences and conclusions about the hypothesis and research questions? |

Racial/ethnic differences in depression treatment knowledge exist, but are more pronounced for parents than for teens. Teens who talk to parents who have more knowledge about depression treatment are associated with more teen knowledge and that knowledge is associated with greater willingness to seek depression treatment.

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Questions:

| Broad Question

How do we validate a measure of parental reactions, attitudes and understanding of adolescent depressive symptoms?

| Specific Question

What is the impact of adolescent and parent depressive symptoms, parental knowledge about adolescent depression, and parental depression, stigma and parental responses on adolescent depression?

Alternatives:

| Hypothesis

Measurements will show that parents have overprotective, supportive, critical, controlling and distressed responses to adolescent depression. They expected that depression literacy and stigma would moderate the relationship between parent and adolescent depressive symptoms. such that better literacy and lower stigma would result in more positive and less negative parental responses, but that this relationship would be weaker among depressed parents and parents of depressed adolescents given existing evidence suggesting higher levels of negative parental responses amongst depressed parents

Logic:

| If the hypothesis is true, then what?(If then statement)

Better literacy and lower stigma would result in more positive and less negative parental responses, but that this relationship would be weaker among depressed parents and parents of depressed adolescents.

Methods:

The research had 440 respondents complete an anonymous online questionnaire. The respondents were aged 13-17. Participants  were recruited two different ways. One way was via advertisements on social media, community newsletters, and online parenting networks for a study on “What is it like to be the parent of a teenager?”. The other method which produced 243 participants was recruited for a study of “Beliefs about teen depression”, from an online community where users completed tasks in exchange for reimbursement. They used measurements like PRAUD and the CNNE-A depending on the topic to calculate the answers from the questionnaires.

Results

| What were the important results?

1. Developed a measure of parental reactions to adolescent depression.

2. Parental responses were overprotection, criticism, distress and support.

3. Depressed parents reported more negative attitudes and responses.

4. Parents of depressed youth reported more negative responses.

5. Parent depression literacy and depression stigma impacted parental responses.

Inferences

| What did the authors conclude from the study?

| How did the authors use the results to make inferences and conclusions about the hypothesis and research questions? |

Evidence showed negative parental attitudes and responses among depressed parents and parents of depressed youth. Improving parental depression literacy and reducing depression stigma during treatment of adolescent depression may facilitate parental responsiveness.

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I did my research on the idea that one of the best things to do when parenting a depressed teenager is to say “I love you” and show it often. Although we know words of affirmation like “I love you“ can have positive effects, I was interested to know how effective they could be on a depressed teen. There is often conflict between parent and child during the teenage years and because of this children tend to push away their parents and spend more time with friends. We also see instances of children disregarding the words of their parents and giving their peers more power in their life. Through the research I wanted to break down the different ways parents can help a depressed teen aside from saying “I love you”, while understanding the most successful treatments for teenagers with depression.

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For my research I utilized google scholar and access to articles using Ohio State access. It was difficult to find articles on the saying “I love you” and connecting it to depression in teenagers. I used a variety of keywords and phrases to search including depression in teenagers, parents dealing with adolescent depression, and “I love you”.

I struggled to find articles that relate directly to parents, saying “I love you“ and how this affects adolescents with depression. I also struggled to find pseudoscience articles within the topic I was researching. This took a bit longer than expected. I decided to take the route on depression in adolescence and the most effective treatments found and what exactly parents can do to help. This process did not take long once I decided what type of articles I wanted to use. Once I found three empirical articles I linked them directly into a padlet and continued my research. The filled out the QALMRI on a separate Google doc and copied and paste to Padlet when I was done.

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Parental Support is Key to Supporting Teen Depression | Charlie Health

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What contributes to an adolescent's mental health? A teenager's life experiences, genetics, and family history certainly play a large role. But other factors are involved too.

Social determinants of health are conditions in the environment in which a teen is born, lives, works, plays, and ages. Examples include items like economic stability, transportation availability, education, food and health care access, and more. All of these significantly impact both physical and mental health.

This article will focus on one of the most important social determinants of health: family support systems.

Specifically, this post will discuss changing parent-teen relationships, how healthy and unhealthy relationships can contribute to adolescent depression, and what can change in order to create a healing environment and a reduction in depressive symptoms.

Changes in the Parent-Teen Relationship

In a book entitled Handbook of Parenting: Children and Parenting, psychology researchers analyzed the following potential sources of conflict and change throughout the teenage years:

Developmental changes of adolescence include the onset of puberty and an increase in sex hormones. This can change the parent-adolescent relationship by changing the way teens and parents view themselves and each other.

Cognitive changes, in addition to developmental changes, allow teenagers to not only start to look like adults but also to express themselves and think more like adults. Adolescents may also begin to question and think differently about morals, social conventions, and rules. These changes inevitably shake the previously-set balance between parent and child.

Self-definitional changes include the desire for a teenager to create an autonomous identity distinct from their parents or family.

Social changes push teenagers to spend less time with family and more time in new social structures with new friends or romantic partners. Living with these social changes, parents may find themselves renegotiating boundaries and worrying about their child driving, using alcohol or drugs, participating in sexual activity, and more.

Increase in unsupervised time results in greater autonomy of time over which parents may have little or no control.

Increase in expectations in autonomy in school as teens transition from elementary to middle to high school comes with its own challenges. While in elementary school, parents are often provided direct information about assignments and schoolwork from teachers. But come middle school and especially high school, parents must often rely primarily on their child to keep them informed about their academic endeavors.

Increased exposure to self-selected mass media may be particularly relevant in today's social-media obsessed world. Adolescents spend a considerable amount of time consuming media. This is a way for teens to privately talk, socialize, or experiment. Additionally, private social media accounts may create further distance between teens and their parents.

Although the above changes may feel overwhelming, simple positive parenting strategies can help ensure that parent-teen relationships remain healthy and intact.

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Healthy Parenting Practices

Research studies have shown that high quality parent-teen relationships can predict many health and behavioral outcomes, including a lower level of adolescent depression. So, what parenting practices best support teens?

One study published in the Journal of Research on Adolescence in 2008 reviewed data on the importance of quality parent-adolescent relationships. Although this is not an exhaustive list, researchers point to the following four qualities as signs of healthy parent-teen relationships:

Routine family activities

Routine family activities can mean different things to different families. Adolescents in this study were instructed to note the number of days a week that they ate dinner with their family, did a family faith-based activity, or did something fun with the family. Family rituals were found to promote adolescent sense of identity, create greater family cohesion, and helped families push through difficult times.

Awareness or monitoring of the adolescent

Researchers say that parents with more negative attitudes toward their children are less likely to engage in the appropriate amount of parental monitoring. But parental monitoring and awareness is crucial. Adolescents in this study coded parent awareness by answering if their parents knew about their friends, friends' parents, who the adolescent was with when they weren't at home, and about the adolescents' teachers and school activities. According to researchers, this kind of knowledge can predict healthy preteen psychology and a lower incidence of internalizing and externalizing problems. On the flip side, a lack of parental monitoring can lead to negative behavior, substance abuse, and other "delinquent" behaviors. A review of more than 140 articles found that parent monitoring protects against youth depression, as does supportiveness and autonomy-granting.

Support and affirmations

Praise for when your teen does something well is one example of a supportive behavior that can assist in reducing levels of depression, psychological disorders, externalizing behaviors, and behavioral problems among youth. Supportive relationships can help address youth isolation.

Autonomy-granting balanced with adequate parental strictness

While very low and very high levels of parental strictness can predict behavioral problems, researchers found that a moderate amount of parental strictness- giving youth chances to make their own decisions while also keeping the adolescent accountable for doing what they're supposed to do-promoted a protective influence regarding depression.

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Parent-Teen Therapy Works for Teen Depression

For children and youth with depression, mental health treatment is especially effective if parents are involved. Two research teams have reviewed dozens of studies of depression treatments for youth, finding that children and teens had greater symptom improvement in treatments where their families were involved.

One recent study shows that family therapy may be particularly beneficial for those experiencing difficulties with communication or a breakdown in positive family functioning.

In 2019, researchers from the University of Delaware and Drexel University recruited depressed and suicidal adolescent participants for a study. Before the study began, teens who agreed to participate and a parent or guardian filled out forms describing their relationship. They were also observed in a 10-min video recorded conflict discussion rated by independent observers. The forms and observed conflict discussion helped researchers categorize the type of relationship the adolescent and parent had.

After providing this information, parents and teens were then randomly assigned to receive four months of one of two forms of therapy: attachment-based family therapy (AFBT) or a more standard form of therapy as the control group called family-enhanced non-directive supportive therapy (FE-NST).

While participating in therapy, monthly assessment scales were given to the adolescents to determine if their depressive symptoms had improved.

Participants who were noted to have more difficulty maintaining cooperative communication with parents at the beginning of the study were more likely to benefit from family-directed therapy and treatment. These participants had greater improvement in depressive symptoms. Both styles of family-directed therapy (attachment-based family therapy and family-enhanced nondirective supportive therapy) helped these participants equally.

Unlike depressive symptoms, suicidal symptoms did not appear to be directly tied to family function in this study. In addition, more research is needed to further study other factors and social determinants of health - including race, income level, and gender - that may have contributed to the study's outcomes.

What is Attachment-Based Family Therapy (AFBT)?

ABFT is one of the treatment courses used in the study. Even before this publication in particular, ABFT had been shown to be successful in treating suicidal and depressed teens. It is grounded in attachment theory and the understanding of the biological desire for meaningful and secure relationships.

The idea behind this form of therapy is as follows: breakdowns in the parent or guardian-teen relationship make adolescents feel that they do not have support.

Examples of relationship breakdowns include:

1. A reframing session helps move the family focus less on solely the patient's symptoms and more on the parent-teen relationship.

2. Adolescent alliance-building is formed with sessions between the teen and therapist. Therapists do not blame the parent for ruptures in the parent-teen relationship. Rather, they help the teen articulate feelings of disappointment or injustice.

3. Parent alliance-building is formed with sessions between the parent and therapist. Explorations of the parent's own history of attachment help parents understand their background in an empathetic setting. These sessions eventually focus on the parent's desire to improve and learn more about attachment-promoting parent skills.

4. Sessions with both parents and teens allow teens to express grievances in a more mature manner while receiving empathy and understanding from parents.

5. Families consolidate newly formed skills to discuss personal ways in which to promote the adolescent's autonomy or work through other causes of depression.

When teens feel that they do not have a parent or guardian available to help, attachment-based family therapy theorizes that teens instead turn to feelings of depression or suicidal ideation.

Protocol for ABFT

The protocol involves teens and parents working with a professional to complete 5 steps:

Multidimensional Family Therapy Works Too

The treatment described above specifically involved teenagers and a parent. But multidimensional family therapy-therapy that expands beyond the teen and guardian-can also greatly benefit adolescents who are struggling with their mental health.

The assessment phase allows therapists to understand the adolescent by assessing each area of an adolescent's life. This is completed by gathering information from multiple sources and establishing trusting relationships between the therapist and adolescent, parents, and family members.

The middle phase starts to address the areas of improvement and objectives outlined in the first month using problem-solving techniques to promote new areas of functioning. Everyone - adolescents, parents, and family members - is asked to grow, change, and reflect on their attitudes.

The final phase starts to bridge new ideas, skills, and behaviors learned by all parties in therapy into real-world environments

Multidimensional family therapy was initially designed and studied in adolescents with substance abuse and its associated mental health and behavioral problems. It has also been studied in those with antisocial behavior, a clinical term for behavior that shows no regard for the rights or feelings of others. This type of therapy involves adolescents, parents, other family members, and other influential adult figures such as extended family or school personnel. Therapy sessions involve the adolescent alone as well as combinations of the adolescent with family members or others.

Phases of Multidimensional Family Therapy

This style of therapy often involve three basic phases:

The purpose of treatment is to allow teens to build social competence and prosocial behaviors, create a supportive peer network, and rely on more helpful and healthy family relationships.

There are many other evidence-based family therapies to help youth, including brief Strategic family therapy (BSFT), family-focused or parent-adolescent cognitive behavioral therapy (CBT), functional family therapy (FFT), multi-dimensional family therapy (MDFT), multi-systemic therapy (MST), and parent management training. Other treatments that are individually-focused often add sessions designed to include families, such as family-enhanced non-directive supportive therapy (FE-NST).

Other Ways for Depressed Teens to Seek Help

Although the types of therapies listed above have been proven to help depressed adolescents and their parents heal, not all teenagers have access to this kind of treatment. Involving an adult requires asking parents for their time, energy, and their buy-in. This is something many parents may not be willing to pursue, especially in a family where the parent-teen relationship is already strained. Furthermore, it's often hard to find a treatment program that accommodates a wide variety of families from varying financial backgrounds.

In situations like this, what are ways for depressed teens to access the help they need?

Solo therapy‍

If involving a parent or guardian in therapy is not possible, there are many individual forms of therapy available to teenagers that reduce depressive symptoms. Cognitive behavioral therapy and dialectical behavior therapy, just to name two, are further detailed on this website.

Medication

Several large studies on psychopharmacology in childhood and adolescence completed by the National Institute of Mental Health have proven the safety and efficacy of newer generation antidepressants in teens, especially when used in conjunction with therapy. However, no medication is perfect. The use of medication, including all benefits and risks, should be weighed carefully by the teen, their prescribing physician, and the parent.

Improving sleep

Insomnia has been shown to contribute to depression and interfere with depression treatment. Therapies directly targeting improvement of sleep and sleep quality may help improve depressive symptoms and keep depression in remission.

Nutrition

Nutritional deficiencies and malnutrition can impact both physical and mental health in children and adolescents. In one large research review, healthy foods like olive oil, fish, nuts, legumes, dairy products, fruits and vegetables were associated with lower risks of depression. In contrast, Western dietary patterns of sweetened beverages, fried food, processed meats, and baked products were associated with an increased risk of depression. Further research is required in this developing field.

Physical activity‍

Adolescents who are more active have been proven to have reduced odds of developing depressive symptoms. And for those who already have depressive symptoms, vigorous physical activity (as little as 15 minutes several times a week) has been shown to be associated with reductions in depressive symptoms and anxiety as well as an improvement in body esteem.

Knowledge of support and crisis resources‍

Asking for support and knowing how to give support are difficult tasks that can make a big difference in the lives of depressed or suicidal teens. As always, teens should be made aware of the suicide and crisis lifeline: 988. In addition, creating a safety plan with trusted adults or professionals should include basic steps that a teen knows to take in the midst of a mental health crisis.

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Parenting Resources at Charlie Health

While none of the above is a one-stop shop solution, it is important to recognize that different resources are accessible or available to different adolescents. If you're a teen or family member interested in personalized support for mental health issues, our team at Charlie Health can help. Contact us to get started today.

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Parental Support is Key to Supporting Teen Depression | Charlie Health

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What contributes to an adolescent's mental health? A teenager's life experiences, genetics, and family history certainly play a large role. But other factors are involved too. Social determinants of health are conditions in the environment in which a teen is born, lives, works, plays, and ages.

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Parenting a Teenager with Depression - Outside the Norm Counseling - 92591

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Being a parent is the hardest job on the planet, particularly when you have a teenager. But being a parent of a child or teen with a mental illness can feel unbearable at times.

Your friends are all rolling their eyes as they talk about the latest antic their teenager pulled. But sometimes it feels like what you're going through is even harder. You want to help your teen, but it's exhausting!

All parents want to do what's right for their kids, but when your child is sick, either physically or mentally, the desire to "get it right" becomes even more intense.

If you are the parent of a child or teen with depression, know there's isn't one "right way" to parent them. There's no magic wand that will help them feel better. Having said that, here are some ways you can support and show you love your child on their way back toward the light.

Accept Your Teen's Depression

Well meaning parents every day insist that their child is just "feeling a little down." They think they're helping by reminding their teen of everything they have in their life to feel happy about or grateful for. Maybe they even buy their teenager the latest video game or something else they've been wanting. Surely a teen can't be depressed if they have their basic needs met and people who care about them, right?

I wish it worked that way. Unfortunately, depression changes the way your teenager sees their world. Their depression isn't about you. In most cases, parents of depressed teens haven't done anything to cause the illness. It's just that: an illness that changes the way their teen thinks and sees the world around them.

For many parents, accepting that your child has a mental illness is extremely difficult. It is natural to want to deny the truth and pretend that everything is the way it was before the diagnosis. But invalidating reality will only make your child feel shame. Accepting the truth will help your family take the necessary steps to getting the right help.

Communicate Openly About Your Teen's Depression

Your teen needs you now more than ever. Teenagers need to feel that they can talk to parents or other trusted adults when their world feels dark. Often they talk to other depressed teenagers whose brains are also impacted by this illness. It is so important that you instead develop the trust it will take for your teenager to feel like they can speak to you about their problems.

Sit your child down and tell them they can come to you at any time for any reason. Let them know you could never be angry at them for how they feel. Be clear that you want to understand how they feel and won't judge them for their thoughts and feelings. When they are ready to talk, listen closely and with an open mind and heart. Try not to get defensive-they're depression isn't caused by you even if in the moment they say things that sounds like they are blaming you. Instead, focus on listening deeply and understand. You can't help them until you truly understand what they are going through.

Encourage Healthy Habits to Promote Mental Health

Mental health and physical health are very related. It's a fact that an unhealthy body effects the mind, especially with a mental illness in play. Help your child's recovery by encouraging healthy eating habits. Limit sugar, bad fats, and caffeine intake. Make sure they get plenty of exercise. This can be hard for depressed teenagers to find the motivation to exercise. Perhaps invite them to go for a hike or bike ride with you. And finally, help them get enough sleep each night by encouraging positive sleep habits by helping them find meditation to listen to at night, encouraging a consistent bedtime, etc. Remember that when it comes to healthy habits, leading by example is really important, so take care of your own body as well! Additionally, know that positive reinforcement (praising them for healthy habits) works better than nagging or punishments.

Talk to Them About Suicide

We get it, talking about suicide with your teenager isn't easy. It's a conversation no parent ever imagines they'll have to have. But for the parent of a depressed child, the risk of suicide is a sad reality. Start the conversation with your child. Ask if they've ever thought about suicide. Asking these questions in an objective way allows your child to speak candidly with you and share their true thoughts and feelings with you. Don't panic if they say they are thinking of suicide. Instead, assure them that you will do whatever it takes to get them help. Make it clear that you believe people who have suicidal thoughts get better with treatment whether that means an antidepressant or talk therapy.

And understand that there is no danger of a person planting a thought of suicide in someone else's mind if it's not already there.

*When in doubt, take your child to the emergency room or even call 911 if they are in immediate mental health evaluation. While suicidal thoughts can often be managed without emergency services, it is always better to error on the side of caution.*

Begin Counseling for Depression in Temecula, CA

Though you can be a big support in your child's life, you'll need the help and guidance of a trained mental health therapist. If your teenager finds a therapist they can trust, teen counseling is very, very effective for teen depression. As a Temecula, CA counseling clinic, we can help you connect with a therapist who works with teenagers.

If you or a loved one has a child or teenager suffering with depression, you are not alone. Please contact Outside The Norm Counseling to discuss treatment options.

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Parenting a Teenager with Depression - Outside the Norm Counseling - 92591

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Being a parent is the hardest job on the planet, particularly when you have a teenager. But being a parent of a child or teen with a mental illness can feel unbearable at times. Your friends are all rolling their eyes as they talk about the latest antic their teenager pulled.