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