2. 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 risks among European Adolescents International Seminar on Problematic Use of New Media May 7-9th, 2014 Luxembourg

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

4. Adolescent developmental characteristics 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

5. Brain Development

7. 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)

8. 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

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

10. 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

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

12. Landeszentrale für Medien und Kommunikation Rheinland-Pfalz University of Mainz Germany The consortium University of Akureyi Iceland Protegeles Spain Adolescent Health Unit University of Athens Greece University of Medicine and Pharmacy lasi Romania Nobody’s Children Foundation Poland IVO Addiction Research Institute Netherlands

13. 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

14. Study design EU-NET-ADB study Quantitative protocol 2.000 Questionnaires in each country Qualitative protocol 20 in-depth interviews in each country N= 14.000 [2.000 X 7] N= 140 [20 X 7]

15. 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

16. Cyber bullying

17. “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

18. 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

19. 21.9% of total sample has experience bullying on-line 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) 53.5% of those bullied state that this experience was harmful (11.2% of total sample) More girls than boys experience bullying More girls than boys experience bullying Romania and Greece have the higher percentages, while Iceland and Spain the lower Romania and Greece have the higher percentages, while Iceland and Spain the lower EU NET ADB, 2012 Cyber bullying

20. 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

21. Grooming

22. Grooming The most dangerous possibility for child safety The most dangerous possibility for child safety Influence or abuse after meeting in natural world Influence or abuse after meeting in natural world 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 world 8% have met in real world EU Kids Online 2009 EU Kids Online 2009

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

24. 63% of sample communicate with strangers online 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) 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) 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 Risk of grooming is higher in Romania, Germany and Poland and lowest in Greece EU NET ADB, 2012 EU NET ADB, 2012Grooming

25. Harmful context

26. “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

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

28. 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 images

29. 58.8% of sample are exposed to 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) 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 More boys than girls have been exposed to sexual images EU NET ADB, 2012 EU NET ADB, 2012 Sexual images

30. Social Networking

31. 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

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

33. 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

34. Are SNS a new context for development ?

35. 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.

36. 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).

37. 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

38. 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

39. Internet Gambling

40. 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

41. Gaming

42. 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

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

44. Internet Addictive Behaviour (IAB)

45. “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

46. 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

47. 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

48. Psychosocial status (YSR; Achenbach & Rescorla, 2001) Functional Internet Behaviour (%) Dysfunctional Internet Behaviour (%) p Social problems Normal 93.476<0,001 Borderline / Clinical 6.624 Thought problems Normal 88.970.3<0,001 Borderline / Clinical 11.129.7 Attention problems Normal 91.570.8<0,001 Borderline / Clinical 8.529.2 Aggressive Behaviour Normal 93.871.8<0,001 Borderline / Clinical 6.228.2 Total problems Normal 92.363.9<0,001 Borderline / Clinical 7.736.1

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

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

51. Co-morbidity with 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

52. Causative factors Complex and multifunctional phenomenon Causative factors : Causative factors : * Genetics (co-morbidity) * Personality traits * Life events * Family factors * Cultural factors * Adolescence

53. Qualitative Methodology  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

54. The Model of Four

55. 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)

56. “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”

57. “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”

58. D. “Killing Boredom” “Well, I really don’t care. I just kill time. I feel so bored…” (Boy, 17 years)

59. 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

60. A cross-national comparison allows for: Detection of similarities, thus more valid generalizations Detection of differences, thus identification of culture/country-specific patterns

61. 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.

62. Percentage of adolescents at risk for IAB or with IAB by country Source: EU NET ADB D6.2 Final Report (2013).

63. 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. Legislation 5. Values and Attitudes 6. Technology Literacy 7. Religion 8. Way of life, weather etc. 9. Cultural, age and sex differences* 10. Socio-economical crisis * EU NET ADB D6.2 Final Report (2013)

64. 1. Information and Communication Technologies (ICTs) in Education

65. Τ he classification of the six European countries (Romania not included) concerning the average proportion of computers with internet connection in schools was as follows: 1. Iceland95% 2. The Netherlands84,8% 3. Poland82,7% 4. Germany70,7% 5. Spain 79,3% 6. Greece69,2% Organization for Economic Co-operation and Development (OECD) Programme for International Student Assessment (PISA, 2003)

66. 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

67. 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.

68. 2. Duration of Use

70. 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

71.  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

72. Percentage of adolescents who spend at least 2 hours using the internet on a school day and on a non- school day by country

73. 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 !

74. 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

75. 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

76. % Dysfunctional Internet Behavior Low/Middle educ. level High educ. levelP Greece14,89,90,002 Spain24,1220,309 Romania18,817,10,394 Poland1313,60,72 Germany12,49,50,061 Netherlands16,911,70,061 Iceland11,67,30,012 DIB and education of parents

77. 9. Cultural, age and sex differences

78. Adolescents aged 16-17 years old with DIB are more than their younger peers (except Germany) Age differences in DIB 14-15 years old16-17 years oldP 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

79. 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 the16 th European IAAH Meeting, Copenhagen, 2011 Gender differences in DIB

80. FemaleMaleP 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

81. 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

82. Psychosocial status (YSR) of total population per country YSR;Achenbach & Rescorla, 2001

83. 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)

84. 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

85. Family Family School School Media Media State policy making State policy making

87. Chloe, 16 yrs «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».

88. Thank you ! Adolescent Health Unit (A.H.U.) University of Athens – Greece www.youth-health.gr info@youth-health.gr