assistant professor in pediatrics-adolescent medicine head of the adolescent health unit (Α.h.u.)...
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Assistant Professor in Pediatrics-Adolescent Medicine
Head of the Adolescent Health Unit (Α.H.U.)Second Dpt of Pediatrics, University of Athens,
«P & Α Kyriakou» Children’s Hospital Athens-Greece.
Artemis K. Tsitsika MD, PhD
Internet risksInternet risks among amongEuropean AdolescentsEuropean Adolescents
International Seminar on International Seminar on Problematic Use of New MediaProblematic Use of New Media
May 7-9th, 2014May 7-9th, 2014LuxembourgLuxembourg
Technology offers youth Technology offers youth
unique possibilities of unique possibilities of
education, entertainment and education, entertainment and
progressprogress
Adolescent developmental Adolescent developmental characteristicscharacteristics
Curiosity-experimentation
Lack of objectivity and relative lack of good judgment
Fixation to present tense
High risk behavior
Challenge of parental authority
Brain DevelopmentBrain Development
Modern SocietiesModern Societies (1) (1)
Family crisis-divorce
Media pressure
Multicultural societies
Unemployment – parent over occupation
Youth-technology experts vs parents-limited technology knowledge (generation gap fortification)
Modern societiesModern societies (2) (2)
-Lack of social bonding (small families in large societies)
-Lack of places for physical activity and entertainment in large cities
-Lack of interesting activities in rural areas
New expressions of high risk behaviors
(new morbidity)
As in natural world risks develop in cyber world
Children and adolescents are not developmentally fully matured
The internet is an amazing tool that however needs use instructions
EU-NET ADB surveyEU-NET ADB survey
Seven European countriesSeven European countries
Safer Internet Programme Safer Internet Programme
Landeszentrale für Medien und Kommunikation Rheinland-PfalzUniversity of MainzGermany
The consortiumThe consortiumUniversity of Akureyi
Iceland
Protegeles
Spain Adolescent Health UnitUniversity of Athens
Greece
University ofMedicine and Pharmacy lasiRomania
Nobody’s Children FoundationPoland
IVO Addiction Research Institute
Netherlands
Purpose of StudyPurpose of Study• Prevalence and determinants of Internet Addictive Behavior (IAB)
•Development of internet addictive behaviors
•Increase awareness
•Knowledge base required for the development of strategies
Study designStudy design
N= 14.000[2.000 X
7]
N= 140[20 X 7]
Quantitative Quantitative MethodologyMethodology
Questionnaire – tool covering: 1. Internet use (Socio-demographic data, family, school
achievement, internet usage characteristics, parental control) 2. Addictive behaviour (IAT; Young, 1998), 3. Psychosocial status (YSR; Achenbach & Rescorla, 2001)
Representative sample from each country – up to 2000 questionnaires / country (final sample of 13300 questionnaires).
Adolescents 14-17 years old
Data collection: October 2011 – May 2012
Cyber bullyingCyber bullying
“Insults that lower our self-esteem
and affect us psychologically”.
Girl, 15, Portugal
“Be made ridicule by having personal
stuff written about you, and then
made public”.
Boy, 11, Greece
Cyber bullyingCyber bullyingHaving received disturbing or embarrassing or
fearful messagesDisturbing for me material has been sent to othersCreating a false profile for me with embarrassing
informationGiving out personal data without my permissionExcluding me from web activities
EU Kids Online Survey 2009
21.9% of total sample has experience bullying on-21.9% of total sample has experience bullying on-lineline
53.5% of those bullied state that this experience was 53.5% of those bullied state that this experience was harmful (11.2% of total sample)harmful (11.2% of total sample)
More girls than boys experience bullyingMore girls than boys experience bullying
Romania and Greece have the higher percentages, Romania and Greece have the higher percentages, while Iceland and Spain the lowerwhile Iceland and Spain the lower
EU NET ADB, 2012EU NET ADB, 2012
Cyber bullying Cyber bullying
Risk vs HarmRisk vs Harm
Although a significant number of adolescents may be exposed to internet risks,
a much lower number experiences harm.
Key point Educate young people to deal with risks,
So that they do not experience harm
GroomingGrooming
GroomingGrooming
The most dangerous possibility for child The most dangerous possibility for child safetysafety
Influence or abuse after meeting in natural Influence or abuse after meeting in natural worldworld
30% of kids have met some stranger 30% of kids have met some stranger through the internet and through the internet and 8% have met in real world8% have met in real world
EU Kids Online 2009 EU Kids Online 2009
Between parents that their kids have met some Between parents that their kids have met some
stranger through the internet and have realized a stranger through the internet and have realized a
natural meeting: natural meeting:
-28%, know about this meeting-28%, know about this meeting
--61%, 61%, state that their kid has never met with state that their kid has never met with
somebody somebody
-11% -11% state that they are not aware of such an state that they are not aware of such an
eventevent
GroomingGrooming
63% of sample communicate with strangers online63% of sample communicate with strangers online
9.3% of those, state that this experience was 9.3% of those, state that this experience was perceived as harmful for them (5.4% of total sample)perceived as harmful for them (5.4% of total sample)
45.7% of those, have gone on to meet face to face 45.7% of those, have gone on to meet face to face someone who they first met on the internet (28.4% someone who they first met on the internet (28.4% of total sample) of total sample)
Risk of grooming is higher in Romania, Germany Risk of grooming is higher in Romania, Germany and Poland and lowest in Greeceand Poland and lowest in Greece
EU NET ADB, 2012EU NET ADB, 2012
GroomingGrooming
Harmful context
“What really affects me and my
psychology,
are the ones depicting rape and
sexual acts”.
Girl, 11, Turkey
“I was playing a game with my friend
online
and we bumped into something like sex
and it was all over the screen”.
Boy, 11, Belgium
Sexual images
Violence
High risk behaviors (eating disorders, suicidal behavior)
Harmful contextHarmful context
20% of teenagers state that they have used pornographic sites
Sexual Education ?
Frequent (> 3 times a week) use of pornographic material may influence adolescent psychosocial health
Tsitsika AK. et al. Cyberpsycol. Behavior 2009 Oct;12(5):545-50.
Sexual imagesSexual images
58.8% of sample are exposed to sexual 58.8% of sample are exposed to sexual imagesimages
32.8% of those, state that this experience 32.8% of those, state that this experience was harmful (18.4% of total sample)was harmful (18.4% of total sample)
More boys than girls have been exposed More boys than girls have been exposed to sexual images to sexual images
EU NET ADB, 2012EU NET ADB, 2012
Sexual imagesSexual images
Social NetworkingSocial Networking
A lot of people chat on Facebook and get together physically on a later stage. Otherwise, no one will come and say “hello, how are you? etc. [..]”. Boys are especially shy
and they can’t come to you “out of the blue” to have a conversation. While on facebook, they can always come up with something
e.g. commenting a photo… something like that. They grab an opportunity.
Girl, 16, Greece
“Yes, I stopped using Facebook because I came in state to have 1200 friends, of which I really knew only a few. It is also that I got into a lot of trouble, so, I decided
to let it go and focus on real life”.
Boy, 17, Greece
Social networking is the fastest growing
online activity among adolescents.
92% of European adolescents are members of at least one Social Networking Site (SNS)
39.4% of adolescents spend at least 2 hours on SNS on a normal school day
Using SNS more than 2 hours daily is associated with IAB
More girls than boys use SNSHaving more than 500 online friends is
associated with IAB
Tsitsika AK & the EU NET ADB Consortium,
Budapest, September 2012
Are SNS a new context for development?
Youth has always had the need and the habit to congregate, to form cliques and crowds
SNS are often compared to hangout places of previous generations (Muri, 2009)
What was previously done in the neighborhood or in the mall, today’s teens do online in social networking sites.
Age Restrictions: Are they Age Restrictions: Are they followed?followed?
Facebook has introduced in their Statement of Rights and Responsibilities an age restriction of 13 years for use
This restriction is frequently violated one quarter of European preadolescents 9-11 years old half of 11-12 years old,
have their own social networking profiles (Linvingston
et al., 2011).
Excessive social networking use may lead to social competence dysfunction
• Lack of personal contacts may lead to limited interpretation of body language, loss of ability to handle true relationships and real life situations etc
Individuals with low self esteem may present themselves with a different-desired profile
Desired personality traits
Difficulty in real life self identity support and self improvement
Internet GamblingInternet Gambling
5.9% of total sample gamble online, while 10.6% gamble in real life
Romania and Greece have the higher gambling percentages (online and real life)
Adolescents who gamble have 3 times higher risk of exhibiting IAB
Tsitsika AK & the EU NET ADB Consortium,
Budapest, September 2012
GamingGaming
61.8% of total sample play games
6.7% of total sample were abusing or were addicted to games (10.7% of gamers)
Adolescents who play games have 2 times higher risk of exhibiting IAB
Gaming more than 2.6 hours / day is associated with IAB
This trend was higher in boys
EU NET ADB, 2012
GamingGamingAICA-S; Wölfling, Müller & Beutel, 2010
Presented odds ratios (OR) for the effect Presented odds ratios (OR) for the effect of internet activities on having IABof internet activities on having IAB
Internet Addictive Behaviour Internet Addictive Behaviour (IAB)(IAB)
“Lack of sleep,
you don’t do your homework
if you are too much on the
computer
and can’t concentrate to study”.
Boy, 14, Finland
Internet Addictive Internet Addictive BehaviorBehavior
Internet Addictive Behaviour (IAB) is defined as a behavioural pattern
characterized by a loss of control over internet use.
This behaviour potentially leads to isolation
and neglect of social, academic and recreational
activities or personal hygiene and health
EU NET ADB, 2012
1.2% of the total sample presents with IAB, while 12.7% with at risk IAB
There are no significant differences between countries, however Romania, Greece and Spain seem to have higher scores, when compared to Iceland, The Netherlands and Germany
There is a higher trend of IAB for boys, older adolescents and lower parental educational level
There is psychosocial negative impact in the group of IAB
EU NET ADB, 2012
Internet Addictive Internet Addictive BehaviourBehaviour
Psychosocial statusPsychosocial status ((YSRYSR; Achenbach & ; Achenbach &
Rescorla, 2001)Rescorla, 2001)
Functional Internet
Behaviour (%)
Dysfunctional Internet
Behaviour (%)
p
Social problems Normal 93.4 76 <0,001
Borderline / Clinical 6.6 24
Thought problems
Normal 88.9 70.3 <0,001
Borderline / Clinical 11.1 29.7
Attention problems
Normal 91.5 70.8 <0,001
Borderline / Clinical 8.5 29.2
Aggressive Behaviour
Normal 93.8 71.8 <0,001
Borderline / Clinical 6.2 28.2
Total problems
Normal 92.3 63.9 <0,001
Borderline / Clinical 7.7 36.1
Presented odds ratios (OR) for the effect Presented odds ratios (OR) for the effect of internet activities on having IABof internet activities on having IAB
Guidelines for daily screen time :Guidelines for daily screen time :
twotwo hourshours (2 (2 h h))
Bright Features, Guidelines for Health Supervision of Infants, Children and Adolescents. American Academy of Pediatrics 2008, p:
539-557.
CoCo--morbiditymorbidity with other with other psychosocial conditionspsychosocial conditions ( (toto 60%) 60%)
Attention deficit-Hyperactivity disorder
(ADHD)
Depression
Anxiety
Social phobia
Compulsive disorder
Autistic Behavior
Drug use
Ha JH et al., J Clin Psychiatry, 2006 May; 67/5: 821-6Ha JH et al., J Clin Psychiatry, 2006 May; 67/5: 821-6
ΒΒai et al , 2000ai et al , 2000
Causative factorsCausative factorsComplex and multifunctional phenomenon
Causative factorsCausative factors : :* Genetics* Genetics ( (coco--morbiditymorbidity))* Personality traits* Personality traits* Life events* Life events* Family factors* Family factors* Cultural factors* Cultural factors* Adolescence* Adolescence
QuaQuallitative itative MethodologyMethodology
Interviews of adolescents showing signs of IAB (IAT score > 30).
Up to 20 interviews/ country (124 final interviews).
Full-stepwise approach of Grounded Theory (Strauss & Corbin, 1990).
Adolescents 14-17 years old
Data collection: October 2011 – May 2012
The Model of Four
A. “Stuck Online”“Well, I used to go out more.
Being outside, going swimming, or stuff like that. I haven’t being swimming for about 2 years. I haven’t been
out with my friend in the evening for over 4 months
now, such things you neglect.” (Boy, 16 years)
“Because I am busy and next to that I
spend a lot of time on the internet. Then it’s hard to
manage everything. But I get everything
done.” (Girl, 15 years)
B. “Juggling it all”
“I started visiting social networks like Facebook, saying ‘’ah, here there are many people, I meet
new people, that’s nice”, staying [online] for more and more time,
making comments, uploading stuff and creating a new life in
there. Like a virtual reality. Um… I think that happened. After a while though, you come full
cycle, you start saying “what am I doing now?”, you get tired of it, you shut it down, you go out and
you start cutting down on the time you spend on it. Just like
that; it comes full cycle.” (Girl, 17 years)
C. “Coming Full Cycle”
D. “Killing Boredom”
“Well, I really don’t care.
I just kill time. I feel so bored…”
(Boy, 17 years)
Despite common ground concerning internet use in Europe, there are substantial differences across countries
Internet addictive behaviour (IAB) incidence ranges widely among adolescents in European countries (from 1% to 18% !!!!!!!!)
Young S, American Behavioral Scientist, 2004 Tsitsika et al., European Journal of Pediatrics, 2009
Johansson A et al, Scand J Psychol, 2004
Why adopt a cross-cultural perspective
A cross-national comparison allows for:
Detection of similarities, thus more valid generalizations
Detection of differences, thus identification of culture/country-specific patterns
A more thorough study of cross-cultural differences in problematic behaviors, such as IAB, may allow the development of culture-
sensitive and, thus, more effective prevention and intervention strategies.
Percentage of adolescents at risk for IAB or with IAB by country
Source: EU NET ADB D6.2 Final Report (2013).
Socio-cultural factors that result to country related IAB differences – “The list of Ten (10)”
1. Information and Communication Technologies (ICTs) in Education *
2. Duration of Use *3. Education of Parents *4. Legislation5. Values and Attitudes6. Technology Literacy7. Religion8. Way of life, weather etc.9. Cultural, age and sex differences*10.Socio-economical crisis
* EU NET ADB D6.2 Final Report (2013)
1. Information and Communication Technologies (ICTs) in Education
Τhe classification of the six European countries (Romania not included) concerning the average proportion of computers with internet connection in schools was as follows:
1. Iceland 95%
2. The Netherlands 84,8%
3. Poland 82,7%
4. Germany 70,7%
5. Spain 79,3%
6. Greece 69,2%
Organization for Economic Co-operation and Development (OECD)
Programme for International Student Assessment (PISA, 2003)
Using the internet in an educational setting may be beneficial for students to learn how to use it in functional and not excessive ways
Adolescents who used the internet at school had lower percentages and low possibility for developing DIB (protective factor) *
* Tsitsika et al, European Journal of Pediatrics, 2008
In some European countries (eg. Germany, Belgium, France) there is a specific government organization for ICT implementation in schools
In Iceland, media education is deeply
integrated in curricula
These progresses are still in their first steps in southern and mostly eastern (new entries) European countries
Hasebrink, U., Livingstone, S., Haddon, L. (2008) Comparing children’s online opportunities and risks across Europe: Cross-
national comparisons for EU Kids Online.
2. Duration of Use
Possible interpretation of findings:
Living in a country in which the internet diffusion has reached an advanced stage earlier in time, leads to a mild process that gives the state parents and adolescents the opportunity to adapt to the new medium and develop protective policies and behaviors
In countries where the internet is relatively new, higher rates of DIB are probably related to the initial novelty value and can be expected to “wear off” with increased familiarity
For those who started internet use near adolescence, developmental characteristics of this period have also a contribution to DIB emergence *
* The Model of Four, EU NET ADB, 2013
Countries where the prevalence of DIB is lower (northern countries), are those where the internet use became widespread earlier, before 2006
In the eastern and southern European countries of our sample, adolescents seem to have been using regularly the internet for a shorter period of time
Percentage of adolescents who spend at least 2 hours using the internet on a school day and
on a non-school day by country
Differentiated country pattern of internet use > 2 hours daily on school and non-school days
In countries with high DIB prevalence (eg. Romania), adolescents show higher prevalence of >2 hours daily internet use in non-school days
In countries with lower DIB prevalence (eg. Iceland, Germany) adolescents show higher prevalence of >2 hours daily internet use in school days
Especially in Spain and Greece the difference in the two percentages is almost double !
Possible interpretation of findings: In Mediterranean countries, adolescents follow a
schedule of after-school educational and recreational activities, which can minimize their free time
In northern countries, as mentioned, there are a lot of internet activities at school and so this contributes to higher school day internet use levels
• The educational level of parents was significantly related (p=0,028) to the presence of DIB
• In Greece and Spain a high percentage of the population has attained only primary education (29% and 24% respectively)
while
• in Iceland and Germany it is 3% and in the Netherlands 8%
• On the contrary, northern and central European countries (e.g. Iceland and the Netherlands) stand out as being above average concerning the attainment of tertiary education (31% both)
Education of Parents
EU NET ADB D6.2 Final Report (2013)
Organization for Economic Co-operation and Development (OECD), 2007
% Dysfunctional Internet Behavior
Low/Middle educ. level
High educ. level P
Greece 14,8 9,9 0,002
Spain 24,1 22 0,309
Romania 18,8 17,1 0,394
Poland 13 13,6 0,72
Germany 12,4 9,5 0,061
Netherlands 16,9 11,7 0,061
Iceland 11,6 7,3 0,012
DIB and education of parents
9. Cultural, age and sex differences
Adolescents aged 16-17 years old with DIB are more than their younger peers (except Germany)
Age differences in DIB
14-15 years old
16-17 years old
P
Greece 12,7% 12,8% 0,93
Spain 21,1% 26% 0,013
Romania 17,1% 17,9% 0,689
Poland 12,5% 15,4% 0,102
Germany 11,9% 8,9% 0,022
Netherlands 11,2% 12,8% 0,408
Iceland 7,8% 8,5% 0,718
DIB is higher in males, at least during the first years of DIB emergence
This finding is associated to gaming
Internet use and misuse is dynamic, changing in short intervals of time
In the last AHU study in 2010, DIB was higher in females using the internet mainly for social networking
Tsitsika et al, European Journal of Pediatrics, 2008
Tsitsika et al, abstract in the16th European IAAH Meeting, Copenhagen, 2011
Gender differences in DIB
Female Male P
Greece 11,8% 13,7% 0,22
Spain 24,6% 20,8% 0,05
Romania 14,5% 21,7% <0,001
Poland 12% 14,6% 0,103
Germany 7,7% 14,2% <0,001
Netherlands 11,2% 13,1% 0,316
Iceland 7,4% 8,5% 0,358
The prevalence of DIB is also higher among males than females adolescents (except Spain)
Gender differences in DIB
EU NET ADB, 2013
Gender differences in DIB may be attributed to more subtle gender differences in country online practices and experiences
Eg. In Romania the significant gender differences in DIB could be explained by with males’ greater computer self efficacy, lower computer anxiety, more positive attitudes towards the Internet and longer use of the Internet in this country
Durndell, A., Haag, Z., Computers in Human Behavior, 2009
Psychosocial status (YSR) of total population per country
YSR;Achenbach & Rescorla, 2001
Despite the fact that DIB prevalence rates vary widely across countries reflecting key differences in cultural and contextual properties, the relation of DIB with psychological problems among adolescents seems to be global
This finding is important for two reasons:The same criteria could be used for the screening of
adolescents with severe problems in internet use across countries
The interventions developed for the prevention and treatment of DIB could target the same specific psychological processes and manifestations (both internalizing and externalizing)
Food for thought Psychosocial problems are 5 times more prevalent
in youth with DIB
As socio-economical crisis is a factor that may influence psychosocial status of youth, could this lead to a higher prevalence of DIB in relevant countries?
EU NET ADB, 2013
FamilyFamily
SchoolSchool
MediaMedia
State policy makingState policy making
ChloeChloe, 16 , 16 yrsyrs
«Children are never responsible for what they do to themselves.
There will always be reasons.However, gradually they take control
of how they want to live. As long as there is support».
Thank you !Thank you !
Adolescent Health Unit (A.H.U.)Adolescent Health Unit (A.H.U.)University of Athens – GreeceUniversity of Athens – Greece
www.youth-health.grinfo@youth-health.gr
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