Assistant Professor in Pediatrics-Adolescent Medicine

1. Internet risks amongEuropean Adolescents International Seminar on Problematic Use of New Media May 7-9th, 2014 Luxembourg 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

2. Technology offers youth unique possibilities of education, entertainment and progress

3. Adolescent developmental characteristics Curiosity-experimentation Lack of objectivity and relative lack of good judgment Fixation to present tense High risk behavior Challenge of parental authority

4. Brain Development

6. Modern Societies (1) Family crisis-divorce Media pressure Multicultural societies Unemployment – parent over occupation Youth-technology experts vs parents-limited technology knowledge (generation gap fortification)

7. Modern societies (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

8. New expressions of high risk behaviors (new morbidity)

9. 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

10. EU-NET ADB survey Seven European countries Safer Internet Programme

11. The consortium University of Akureyi Iceland Landeszentrale für Medien und KommunikationRheinland-Pfalz University of Mainz Germany Nobody’sChildren Foundation Poland IVO AddictionResearchInstitute Netherlands University of Medicine and Pharmacy lasi Romania Protegeles Spain Adolescent Health Unit University of Athens Greece

12. Purpose 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

13. Study design N= 140 [20 X 7] N= 14.000 [2.000 X 7]

14. Quantitative Methodology • 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

15. Cyber bullying

16. “Be made ridicule by having personal stuff written about you, and then made public”. • Boy, 11, Greece • “Insults that lower our self-esteem and affect us psychologically”. • Girl, 15, Portugal

17. Cyber bullying Having received disturbing or embarrassing or fearful messages Disturbing for me material has been sent to others Creating a false profile for me with embarrassing information Giving out personal data without my permission Excluding me from web activities EU Kids Online Survey 2009

18. Cyber bullying • 21.9% of total sample has experience bullying on-line • 53.5% of those bullied state that this experience was harmful (11.2% of total sample) • More girls than boys experience bullying • Romania and Greece have the higher percentages, while Iceland and Spain the lower EU NET ADB, 2012

19. Risk 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

20. Grooming

21. Grooming The most dangerous possibility for child safety Influence or abuse after meeting in natural world 30% of kids have met some stranger through the internet and 8% have met in real world EU Kids Online 2009

22. Grooming Between parents that their kids have met some stranger through the internet and have realized a natural meeting: -28%, know about this meeting -61%, state that their kid has never met with somebody -11% state that they are not aware of such an event

23. Grooming • 63% of sample communicate with strangers online • 9.3% of those, state that this experience was perceived as harmful for them (5.4% of total sample) • 45.7% of those, have gone on to meet face to face someone who they first met on the internet (28.4% of total sample) • Risk of grooming is higher in Romania, Germany and Poland and lowest in Greece EU NET ADB, 2012

24. Harmful context

25. “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 • “What really affects me and my psychology, • are the ones depicting rape and sexual acts”. • Girl, 11, Turkey

26. Harmful context • Sexual images • Violence • High risk behaviors (eating disorders, suicidal behavior)

27. Sexual images 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.

28. Sexual images • 58.8% of sample are exposed to sexual images • 32.8% of those, state that this experience was harmful (18.4% of total sample) • More boys than girls have been exposed to sexual images EU NET ADB, 2012

29. Social Networking

30. “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 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

31. Social networking is the fastest growing online activity among adolescents.

32. 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 SNS Having more than 500 online friends is associated with IAB Tsitsika AK & the EU NET ADB Consortium, Budapest, September 2012

33. Are SNS a new context for development?

34. 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.

35. Age Restrictions: Are they 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).

36. 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

37. 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

38. Internet Gambling

39. Tsitsika AK & the EU NET ADB Consortium, Budapest, September 2012 • 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

40. Gaming

41. 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 Gaming AICA-S; Wölfling, Müller & Beutel, 2010

42. Presented odds ratios (OR) for the effect of internet activities on having IAB

43. Internet Addictive Behaviour (IAB)

44. “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

45. Internet Addictive Behavior 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

46. 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 Behaviour

47. Psychosocial status(YSR; Achenbach & Rescorla, 2001)

48. Presented odds ratios (OR) for the effect of internet activities on having IAB

49. Guidelines for daily screen time : twohours (2 h) Bright Features, Guidelines for Health Supervision of Infants, Children and Adolescents. American Academy of Pediatrics 2008, p: 539-557.

50. Co-morbiditywith other psychosocial conditions (to 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: 821-6 Βai et al , 2000