title: Secret Society 123: Understanding the Language of Self-Harm on Instagram.
abstract: OBJECTIVE
  Nonsuicidal self-injury (NSSI) content is present on social media and may influence adolescents. Instagram is a popular site among adolescents in which NSSI-related terms are user-generated as hashtags (words preceded by a #). These hashtags may be ambiguous and thus challenging for those outside the NSSI community to understand. The purpose of this study was to evaluate the meaning, popularity, and content advisory warnings related to ambiguous NSSI hashtags on Instagram.
  
  
  METHODS
  This study used the search term "#selfharmmm" to identify public Instagram posts. Hashtag terms co-listed with #selfharmmm on each post were evaluated for inclusion criteria; selected hashtags were then assessed using a structured evaluation for meaning and consistency. We also investigated the total number of Instagram search hits for each hashtag at two time points and determined whether the hashtag prompted a Content Advisory warning.
  
  
  RESULTS
  Our sample of 201 Instagram posts led to identification of 10 ambiguous NSSI hashtags. NSSI terms included #blithe, #cat, and #selfinjuryy. We discovered a popular image that described the broader community of NSSI and mental illness, called "#MySecretFamily." The term #MySecretFamily had approximately 900,000 search results at Time 1 and >1.5 million at Time 2. Only one-third of the relevant hashtags generated Content Advisory warnings.
  
  
  CONCLUSIONS
  NSSI content is popular on Instagram and often veiled by ambiguous hashtags. Content Advisory warnings were not reliable; thus, parents and providers remain the cornerstone of prompting discussions about NSSI content on social media and providing resources for teens.
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington. Electronic address: megan.moreno@seattlechildrens.org.
authors.forename: Megan A
authors.initials: MA
authors.lastname: Moreno
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington.
authors.forename: Adrienne
authors.initials: A
authors.lastname: Ton
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Ellen
authors.initials: E
authors.lastname: Selkie
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Evans
mesh_terms: D000293:Adolescent; D005260:Female; D006801:Humans; D007802:Language; D008297:Male; D001523:Mental Disorders / Q000523:psychology; D016728:Self-Injurious Behavior / Q000523:psychology*; D061108:Social Media / Q000639:trends; D011795:Surveys and Questionnaires
keywords: Adolescent health; Content analysis; Instagram; Mental health; Nonsuicidal self-harm; Online safety; Self-harm; Social media