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Research Article                                                                                                                                        Open Access

## The Use of Social Networking Sites by Adolescents with Psychiatric Illnesses: A Qualitative Study

Gerrit Ian van Schalkwyk 1 , Katherine Klingensmith 1 , Paige McLaughlin 1 , Zheala Qayyum 1,2

1 Yale University Department of Psychiatry, New Haven, CT, USA 2 Yale Child Study Center, New Haven, CT, USA

*Corresponding author: gerrit.vanschalkwyk@yale.edu

## Abstract

Background: Social networking sites (SNSs) are increasingly dominant platforms for communication among adolescents. Recently, concerns have been raised about the risks involved with SNS use, particularly among more vulnerable adolescents. Objective: Our goal was to explore the experience of SNS use by adolescents with psychiatric illnesses. We also sought to understand the ways in which these sites may be a useful way to communicate-as well as a potential source of increased stress-for this vulnerable population.

Methods: We performed a qualitative study by conducting in-depth, semi-structured interviews with 20 adolescents (mean age,  16  years;  15  female  and  5  male  participants)  attending  the  Yale  Adolescent  Intensive  Outpatient  Program,  which includes 3 hours of outpatient treatment 3 or 4 days per week.

Results: The  participants  in  our  study  described  multiple  ways  in  which  SNSs  possessed  unique  utility  as  platforms  for communication. Participants found that SNSs allowed them to reach out to a broader audience and to 'broadcast' feelings of distress without forcing any specific person into a supportive discussion. In addition, SNSs were described as lower-stress means of communication that allowed responses to be carefully formulated; this led to participants sharing information that they would not have shared during face-to-face interactions. However, participants also described anxiety surrounding the pressure to be active on SNSs, and they found it stressful to be exposed to pictures and posts involving former romantic partners.

Conclusion: SNSs provide a useful platform for adolescents with psychiatric illnesses to use to communicate, particularly with regard to communicating any feelings of distress. However, there are many ways in which SNSs can increase levels of anxiety, and this aspect may be an important focus of future clinical attention.

Keywords: Social networks; Facebook; Online communication

## Introduction

Social  networking  sites  (SNSs)  are  services  that allow users to construct online profiles and to form connections with other users. Users are then able to communicate with and explore the profiles of other users  according  to  sets  of  rules  that  vary  across different  sites  (1).  The  first  SNS  (SixDegrees.com) was launched in 1997; it consisted of user profiles, lists of friends, and messaging options. However, it was after the launch of Facebook in 2004 that these services entered a period of unprecedented growth and  significance  (1).   Facebook  currently  has  more than 1 billion users, 757 million of whom access the site  daily  (2).  Additional  SNSs  that  have  gained popularity include Twitter, Instagram, MySpace, and LinkedIn, and new services continue to be developed.

A significant amount of research has been conducted  to  explore  various  aspects  of  SNSs, including  the  patterns  in  which  they  are  used  and the  reasons  that  people  consider  them  to  be  of value  (3-5).  The  risks  associated  with  SNS  use  are also an increasing focus of investigation. A prominent example is the phenomenon of cyberbullying, which was found by a large study to be more damaging than traditional bullying because of  the  perceived  24/7  nature  of  SNS  interactions (6). Specifically, adolescents who were experiencing cyberbullying reported significantly more social difficulties and higher levels of anxiety and depression as compared with victims of traditional bullying (6). Another study found that cyberbullying is associated with increased substance use and mental  health  problems  (7). Less  overt  risks  have also been described, including the use of SNSs for people to engage in antisocial behavior (8) and the phenomenon of 'distorted perception' (9)   that may result from people comparing their own lives to the way  others'  lives  may  appear  on  Facebook.  (This most often leads people to conclude that their lives are  less  happy  than  the  lives  of  their  Facebook friends.)

A more nascent  discussion  involves  the  use  and consequences of SNS use among anxious adolescents. It  had  previously  been  predicted  that SNSs would prove to be of utility to this population by giving those with social inhibitions the ability to interact  in  an  environment  that  facilitated  greater anonymity,  required  less  interpretation of social cues, and provided time for the planning of interactions  (10,11). A  recent  study  by  Baker  and Oswald (12) found that individuals with high degrees  of  shyness  reported  a  stronger  association between Facebook use and friendship quality. Supporting this finding is  the  results of  a  study  of 80 female adolescents which found that participants with  unsatisfactory offline  social  lives  were  able  to compensate to some extent using online communication  (13).  However,  other  studies  have found that those who are socially anxious offline are also  less  successful  online;  this  is  a  phenomenon described as the 'rich get richer' and the 'poor get poorer' hypothesis (10).

In this study, we sought to explore these phenomena in a group of adolescents with psychiatric  illnesses.  This  represents  an  important area for study given the interactions between psychiatric  illnesses,  anxiety,  and  self-esteem  issues (14). There  is a limited  understanding  of  how individuals with these underlying vulnerabilities experience the use of SNSs  and  whether  this innovation  is  in  fact  providing  a  helpful  platform for  communication.  This  is  particularly  relevant given the likely need for these individuals to communicate  thoughts  or  feelings  of  distress.  In addition, there has been little investigation into how SNSs  may  in  fact  contribute  to  worsened  anxiety. Our  study  represents  a  preliminary  exploration  of these ideas.

## Methods

Over a 1-month period, we recruited a sample of 20 patients between the ages of 14 and 18 years (mean age,  16  years;  standard  deviation,  1.37)  who  were currently enrolled in the Yale Psychiatry Adolescent Intensive Outpatient Program. Of the 20

participants  in  our  study,  5  were  male  and  15 female. Twelve participants had a primary diagnosis of  major  depressive  disorder,  three  had  a  primary diagnosis of mood disorder not otherwise specified, two had a primary diagnosis of post-traumatic stress disorder, one had a primary diagnosis of psychosis not  otherwise  specified,  and  one  had  a  primary diagnosis of attention-deficit/hyperactivity disorder. See  Table  1  for  further  demographic  details.  The Intensive Outpatient Program comprised 3 hours of outpatient treatment 3 or 4 days  a  week  and included both group therapy and individual medication management from a psychiatrist. Informed consent was obtained through phone calls to  the  parents  of  the  participants,  after  which  the adolescents themselves were offered the opportunity to participate. Those who agreed took part in in-depth, semi-structured interviews in which  open-ended  questions  were  used  to  elicit narrative descriptions of their experiences with SNSs (15).  Sample  questions  are  listed  in  Table  2. Interviews  were  conducted  by  authors  GVS,  KK, and  PM,  all  of  who  have  extensive  experience conducting interviews with members of this population.  Author  GVS  had  extensive  experience conducting qualitative research interviews and thus provided the initial training and subsequent supervision of the co-authors throughout the study.

Table 1. Demographics

|   Parti- cipant |   Age | Gender   | Race            | Diagnosis                              |
|-----------------|-------|----------|-----------------|----------------------------------------|
|               1 |    16 | Male     | Caucasian       | ADHD, mood disorder NOS                |
|               2 |    19 | Female   | Caucasian       | MDD                                    |
|               3 |    16 | Male     | Caucasian       | MDD, anxiety disorder NOS              |
|               4 |    15 | Female   | Caucasian       | MDD, PTSD                              |
|               5 |    15 | Female   | Caucasian       | Psychosis NOS, PTSD                    |
|               6 |    18 | Female   | Caucasian       | MDD                                    |
|               7 |    15 | Female   | Hispanic        | PTSD                                   |
|               8 |    14 | Male     | Caucasian       | MDD, anxiety disorder NOS              |
|               9 |    14 | Female   | Caucasian       | Mood disorder NOS                      |
|              10 |    17 | Female   | Mixed ethnicity | Mood disorder NOS, learning disability |
|              11 |    14 | Female   | Caucasian       | Mood disorder NOS, ODD                 |
|              12 |    16 | Female   | Caucasian       | MDD                                    |
|              13 |    17 | Male     | Caucasian       | MDD                                    |
|              14 |    17 | Female   | Caucasian       | PTSD, mood disorder NOS                |
|              15 |    18 | Female   | Caucasian       | MDD, anxiety                           |
|              16 |    16 | Female   | Caucasian       | MDD                                    |
|              17 |    17 | Male     | Hispanic        | MDD                                    |
|              18 |    16 | Female   | Hispanic        | MDD                                    |
|              19 |    16 | Female   | Caucasian       | MDD, anxiety disorder NOS              |
|              20 |    16 | Female   | Caucasian       | MDD                                    |

Note. ADHD, Attention-deficit/hyperactivity disorder; MDD, major depressive disorder; NOS, not otherwise specified; PTSD, post-traumatic stress disorder

## Table 2. Sample questions

1. In what ways do you use online social networks like Facebook?
2. How is talking over Facebook or another social network different from talking to someone face to face?
3. In what ways have online social networks been helpful to you?
- a. Have you reached out to others in times of crisis?
- b. Do they represent a lower-stress way to communicate?
4. Have social networks like Facebook ever made you more stressed out?
- a. In what ways?
- b. Have you experienced any bullying?
- c. What's like having contact with your friends all the time?
- d. Do you ever feel like you need to monitor Facebook to stay up to date?

The interviews were transcribed and analyzed with the use of inductive thematic analysis, during which data  were  subjected  to  repeated  rounds  of  coding with  the  aid  of  QSR  International's  NVivo  data analysis software. Specifically, transcripts were read, and  specific  responses  were  labeled  descriptively according  to  their  content,  without  consideration for a specific theoretical framework. Responses that centered  on  similar  content  were  coded  together. After  this  process  was  complete  for  all  of  the transcribed  interviews,  the  codes  that  had  been generated  were  reviewed  to  ensure  that  data  were appropriately labeled. Redundant codes were merged, and codes that appeared to be related (e.g., those  that  referred  to  similar  issues  but  were  not clearly  the  same)  were  placed  in  hierarchies  or groups.  This  process  was  then  repeated  with  a refined set of codes.  The  coding  process was completed  by  author  GVS  and  reviewed  with  coauthor  KK  at  several  stages.  When  reporting  the data, preference is given to the themes that emerged most consistently across the sample (16). Approval for the study was obtained from the Yale University Human Investigation Committee.

## Results

Several prominent themes emerged during this study and are best organized around two main ideas (Table  3).  First,  participants  consistently  described the advantages of SNSs as including providing them with a context in which it was easier to communicate  and  open  up  about  their  problems, with  substantial  benefits  experienced  in  terms  of having access to a large support network. Seventeen participants described some way in which they had found SNSs to be helpful. However, equally prominent was the extent to which SNSs resulted in significant anxiety as a result of the perception that a  lack  of  engagement  or,  indeed,  less  successful engagement would lead to negative peer evaluation; such concerns were highlighted by 18 participants. Participants  also  shared  several  examples  of  how these  opposing  ideas  had  interacted  to  both  their benefit and their detriment at different times. Both female  and  male  participants  appeared  to  have similar ideas about the usefulness of SNSs and the associated potential for anxiety.

## Table 3. Summary of themes

- Unique features of communicating on social networking sites
- -Broader access to sources of support
- -Ability to 'broadcast' feelings to a large audience
- -Messages of support stored for future
- -Less stressful way to open up about problems
- -Allows time to formulate responses carefully
- Ways in which social networking sites make participants feel more anxious
- -Time to agonize about their responses
- -Fear about missing out if not engaged
- -Anxiety about posts being negatively perceived
- -Negative content may be posted by others
- -Exposure to the experiences of one's former romantic partners

## The Unique Usefulness of Communicating on a Social Networking Site

Participants spoke about the advantages of communicating via SNSs, particularly with regard to conveying feelings of distress or anxiety. A number of these advantages related to the practical benefits of  the  technology  for  broadening  their  access  to sources of support. When asked whether SNSs had ever been  helpful to them,  several participants described instances in which they had been able to reach out to people living far away:

'I mean, I had a really bad upbringing and stuff, so  it's  difficult  for  me  to,  um,  talk  to  people,  and then,  social  networks  just  help  me  because  of  the fact that I'm able to contact certain people…that I know will, like, support me in different things, when even  though  they  might  be  far  away  from  me,  or somewhere, they're still there.'

## -Participant 7, a 15-year-old female

Participants  further  described  the  advantages  of being  able  to  post  messages  on  their  SNS  walls, thereby  communicating  their  distress  to  a  broader audience and then being able to discuss their issues further with whoever was available to assist them:

'On the  wall,  I'll  post,  like,  'Having  a  bad  day,' and,  like,  my  friends,  they'll  private  chat  me,  and they'll be like, 'What's wrong?''

- -Participant 7, a 15-year-old female

'They  might  not  be  ready  for  it  or  whatever, versus some people, they might see it, and it's just gonna  be  like,  'I  should  answer  it,  I  should  help,'

and other people might be like 'No, I'm not gonna do  that  right  now.'  'Cause  you  don't  know  what they're going through at that moment.'

## -Participant 8, a 14-year-old male

Other  practical  advantages  that  were  mentioned included being able to look back at previous messages  of  support  that  were  stored  online  and having constant access to supportive friends:

'I have a good friend of mine, who I talk to a lot, and she's been, too, in  like  a  very  similar  situation that I've been, so when I can't, like, go talk to her in person, I talk to her over Facebook, and she helps me a lot and vice versa. There's just one person that I  always talk to, which is her, which, when I can't, like, get hold of her, she's always on Facebook, so I can always reach her through Facebook.'

## -Participant 10, a 17-year-old female

In  addition  to  describing  the  mechanisms  by which SNSs broadened their access to support, the majority  of  participants  also  described  a  sense  in which it was more comfortable for them to open up about their problems online:

'It's  actually  helped  me  to  talk  to  people  and open up to people, because I've been able to, like, tell my  sister what's been  going on  with me, through, like, Facebook, [as] opposed to having to tell her face to face, where I'd be really overwhelmed  and  anxious  and  I  wouldn't  be  able to.'

## -Participant 20, a 16-year-old female

'Cause some people don't like things, like, straight to someone's face, they like saying it through,  like,  a  phone  or  something,  like,  so  they don't, like, they can't judge them or something. So I find it easier to just type it to them.'

## -Participant 17, a 17-year-old male

This sense of online interactions being less anxiety provoking  and  less  likely  to  result  in  perceived judgment  was  reiterated  by several participants. Three  participants  suggested  that  this  had  led  to their  being  able  to  communicate  in  a  way  that helped them to avoid self-injurious behavior:

'I have actually [reached out] to my best friend, I call her my sister. Um, when I've had the urge to cut or I've had suicidal thoughts, I've messaged her and told her, and she's talked, like, talked me through it and talked me out if it. And, like, it's helped me a lot.'

## -Participant 20, a 16-year-old male

An additional advantage mentioned was the ability afforded  by  the  medium  to  provide  the  necessary time to consider, formulate, and reformulate responses:

'Um, I think talking over Facebook or Instagram or stuff like that, it's, like, you feel more comfortable,  because  you're  not  in  front  of  the person, and you have, like, time to think about what you want to say, and if, like, you don't want to say it, you can just erase it and rewrite it. But if you just are talking to the person, you kinda can't take back what you said.'

## -Participant 10, a 17-year-old female

Although this additional response time was often described as an advantage, some participants framed it as a potential source of anxiety:

'I, like, over-analyze everything I've written. Like, if  I'm  commenting  on  something,  I,  like,  read  it over and over again before I post it. Like, I'm just like,  uh,  and  tweet,  like,  I'll  look  back  at  my  past tweets  and  be  like,  'Oh,  I  shouldn't  have  posted that.''

## -Participant 16, a 16-year-old female

This was one of many examples that our participants  provided  about  specific  ways  in  which SNSs  led  to  them  feeling  more  anxious.  More details about this phenomenon are provided in the next section.

## The  Use  of  Social  Networking  Sites  Made Participants Feel Anxious

Eighteen of the participants in our study described some  way  in  which  SNSs  contributed  to  their anxiety. Broadly, the sources of anxiety were divided into two areas: those surrounding the consequences of not being engaged on SNSs and those that arose during the course of participation in an SNS, while either  posting  or  viewing  content.  With  regard  to the issue of being engaged, some participants described their concern about missing out on things:

'I  remember,  I  didn't  have  my  phone,  so  I couldn't  see  what  was  going  on  with  everyone. Everyone around me was like, 'Oh my god, that's so funny,' and I was like, 'Oh, what's going on?''

## -Participant 7, a 15-year-old female

'Like, I mean, I guess it could be like you might feel like you might have to be on it all the time and always  be  checking  it,  because  who  knows  what's gonna  come  up,  like  somebody  could  be  doing something. I mean, I guess that could be stressful, because  you  feel  like  you  have  to  spend  all  your time on the computer or your phone checking it.'

## -Participant 19, a 16-year-old female

Another participant framed it as follows:

'[I]t's just kinda like addicting to look through it [SNS], so during like homework or something, then I will resort to my social networks, but when I really should  be  doing  my  homework,  so  then  I  end  up being much more stressed out.'

## -Participant 4, a 15-year-old female

When participants were engaged with SNSs, they described  concerns  about  how  the  content  they were posting was being perceived:

'Like  I  said,  I  over-analyze  everything.  If  I  see, like,  really  pretty  girls  in  pictures  or  something  or, like,  if  I'm  not  getting  as  many  'likes'  as  someone else, like, it definitely causes a lot of stress actually. Like, if you have a picture, if I post a picture of, like, me and two of my friends, but  then,  like,  another girl  does  the  same  thing  and  she  gets  the  more 'likes' than I do, I'll take it very personally.'

## -Participant 16, a 16-year-old female

Participant  15,  an  18-year-old  female,  described these concerns as follows:

Participant 15: ''Cause, like, if you don't post good statuses or whatever, then people are gonna be like, 'You're  not  cool,  because  you  can't  do  this'  or whatever, and how  many  likes you get on a photo…'

Interviewer: 'That stuff matters?'

Participant 15: 'Yeah.'

This type of anxiety extended to content that was posted about these individuals by other users:

'When people put, like, embarrassing pictures of me, like, there's a thing that people do on Instagram called 'Women Crush Wednesday,' and, like, a lot of my  friends,  they  usually  put, like,  embarrassing pictures of, like, their friends. And, like, I hate when they put me up there. It's really embarrassing.'

## -Participant 2, a 19-year-old male

Participants  also  described  distress  when  seeing content  about  people  with  whom  they  no  longer had relationships. A prominent example was being exposed  to  the  lives  of  former  boyfriends  and girlfriends:

''Cause it's like my ex-boyfriend, I know we were, we were together for like a year or so, and then I realized that, um, we had broken up, and it's been a while, but we still, like, decided that we were gonna be friends, and so we were okay with it. And then, like,  eventually,  on  his  wall,  he  would  post,  you know, 'Just went out on my date with my girlfriend,' and I'd be really upset, because, you know, like, he would take her to places that we used to go.'

## -Participant 7, a 15-year-old female

In some  isolated cases, participants described instances  in  which  they  had  been  bullied  online, either by friends or, in some cases, people they had never met, although overall this was a less prominent theme.

## Discussion

The  findings  related  to  the  utility  of  SNSs  in  our sample  are  consistent  with  those  found  in  the existing literature, which suggests that this form of communication has several advantages for individuals who are socially anxious (10,11). However,  our  study  raises  several  new  points  of interest in this regard. First, there was the idea that SNSs allowed people to communicate their distress in a non-specific  manner  to  a  broad  audience through the use of mechanisms such as the Facebook  wall.  This  appeared  to  be  of  value  for 'broadcasting' distress without pushing anyone into a conversation for which they might not have the capacity or desire at a specific time. As a result, the user could be assured that whoever replied was someone who had declared his or her willingness to engage in a supportive discussion. This is of particular value for a population in which concerns about  self-esteem  may  be  of  significance  and  in which  fear  may  exist  that  one  is  being  'overburdensome'  to  his  or  her  support  network  (13). The utility of this feature of SNSs was enhanced by the  fact  that  participants  reported  being  able  to maintain contact with friends and family who lived further  away  and  who  may  perhaps  otherwise  not have been potential sources of support.

Our  study  provides  further  support  for  existing ideas  that  communication  via  SNSs  may  in  some ways be less stressful than other forms of communication (3,10,11). In particular, participants described being able to  'open up'; in some cases, they even stated that this had led to them discussing things  that  they  previously  had  not  been  able  to discuss.  This  is  consistent  with  a  well-articulated theory  by  Schouten  and  colleagues  (17),  which describes  the  concept  of  enhanced  self-disclosure and  suggests  that  people  are  more  willing  to  open up about significant details of their lives within the context  of  online  interactions.  It  is  also  suggested that  this  phenomenon  could  lead  to  improved relationships,  because  self-disclosure  is  thought  to be of value in this regard (17). Our findings further support  this  idea  by  suggesting  that  an  increased willingness  to  disclose  via  SNSs  could  be  of  value for preventing negative behaviors among adolescents with mental illnesses.

The  concept  of  SNSs  allowing  people  to  have time  to prepare  their  responses  was  previously described by Arkin and Grove (11). This was clearly a significant theme in our study, although it was not always considered to be beneficial. Some participants  did  consider  being  able  to  type,  read, and edit a response to be an advantage, but it was clear that, in other instances, this led to participants becoming  obsessive  about  how  they  were  posting and how their posts were perceived by others. The overall consequence of this feature of SNS communication therefore remains unclear, although our  results  suggest  that  it  is  not  of  benefit  in  all cases.

A  second  significant  cluster  of  findings  in  our study  related  to  ways  in  which  the  use  of  SNSs contributed to increased stress or anxiety in the lives of our participants. The bulk of existing literature in this area describes the phenomenon of cyberbullying.  However,  in  our  study,  participants emphasized the ways in which a lack of engagement with SNSs contributed to their anxiety, because they felt that they were missing out on important developments going on within their peer networks. Participants described feeling pressure to constantly monitor  the  various  SNSs  in  which  they  were engaged, and this resulted in them having difficulty engaging in other activities, such as doing homework. To our knowledge, this finding has not been discussed in existing literature, but it is consistent  with  the  previously  mentioned  theory described by Valkenburg (10) whereby the 'rich get richer'  and  the  'poor  get  poorer,'  which  suggests that  those  who  are  most  effective  at  managing offline relationships are also most effective at managing online relationships (and vice versa). This finding points toward an extension of that idea by suggesting that individuals who have difficulty with their offline interactions may feel a particular pressure  to  be  effectively  engaged  online,  which potentially leads to a more stressful online experience.

Consistent with this idea were the vivid descriptions that multiple participants gave of being very  anxious  about  the  content  they  posted  on SNSs. They often found themselves agonizing about the wording of their posts or how they might appear  in  images.  Participants  appeared  to  believe that  posting  content  that  would  be  literally  'liked' could  be  of  benefit  to  their  social  status,  thereby leading  to  them  to  attribute  high  stakes  to  every online  interaction.  However,  it  is  unclear  whether this ever truly led to significant improvements in the quality  of  their  relationships  or  their  self-esteem, although  the  immediate  effect  on  their  levels  of stress and anxiety was apparent. Further research is needed to determine the extent to which the ability to  think  and  plan  responses  is  in  fact  of  value  to SNS users with anxiety.

A final idea of interest found by this study relates to the stress that our participants described feeling when browsing SNSs. Specifically, participants discussed  how  seeing  the  pictures  and  posts  of individuals  with  whom  they  had  largely  suspended offline contact could lead to negative feelings. Most often,  this  involved  seeing  the  posts  of  former boyfriends or girlfriends with whom they continued to  be  friends  on  SNSs.  Participants  described  a range  of  reactions  from  simply  being  upset  to feelings  of  jealousy,  particularly  in  cases  in  which the  former  romantic  partner  was  posting  about engaging  in  activities  with  a  new  significant  other. This finding resonates most closely with the reports of Chou and Edge (9), who found that people have a  tendency  to  feel  that  their  lives  are  worse  than those of their online friends; this finding is thought to  be  related  to  a  form  of  posting  bias.  It  appears that the participants in our study who had maintained only online contact with former partners would, over time, be exposed to positive events and new relationships  in  that  person's  life  but  perhaps be  less  aware  of  negative  experiences  that  person may have gone through, thus leading to a sense that the ex-partner had more successfully navigated the breakup.

## Clinical Significance

The  results  of  our  study  represent  a  preliminary exploration  of  the  experience  of  SNS  use  among adolescents  with  psychiatric  illnesses.  Our  data  are consistent  with  existing  descriptions  of  ways  in which  SNSs  may  facilitate  communication  in  the socially  anxious  population  through  a  number  of mechanisms.  However,  we  also  found  significant evidence  to  suggest  that  there  are  many  ways  in which  the  use  of  SNSs  can  increase  anxiety.  In particular,  being  able  to  painstakingly  formulate responses  in  addition  to  feeling  pressure  to  be constantly and successfully engaged create potential sources of stress for our especially vulnerable participants. Our study suggests that the experience of  SNSs  may  be  an  important  focus  for  clinical attention in this vulnerable population. This consideration will continue to increase in relevance as SNSs become the primary communicative platforms for adolescents.

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