Introduction
This chapter will look at using internet-based technology (IBT) within the context of mental health and children and young people (CYP).
The following acronyms will be used throughout the chapter:
IBT – Internet-based technology
CYP – children and young people
Background
Back in the early 1990s, when the internet first arrived, it was referred to as ‘Athens without slaves’ [Reference Robins and Webster1] in that the internet would provide society with an abundance of information, and a platform for them to openly express themselves. As the digital revolution took hold, so did the condemnation of the internet and its associations with social ills and threats, specifically to poor mental health [Reference Kiger2,Reference Young3].
Fast forward 30 years, and the Covid-19 pandemic hits, and as a result, society witness significant transformations to the digital landscape once again [Reference De’, Pandey and Pal4]. The speed and adoption of digital technologies during this time increased considerably, which was particularly evident in health care and education settings, where much of traditional in-person delivery was replaced with IBT [Reference Feger, Crump and Scott5]. Again, this fast-paced transformation was condemned and widely associated with its potential threats to society, with particular concern regarding a ‘digital divide’ [Reference Baker, Hutton, Christie and Wright6]. However, despite many of the pandemic-specific measures now returning to normal, some of the lessons learned during this time, particularly ones that resulted in successful digital transformations and improvement, are being held onto, and considered a change for the better [Reference Johns, Burhouse, Tan and John7,Reference Johns, Khalil and Ogonosky8], with additional reassurance that the digital divide isn’t that much of a problem either [Reference Johns, Khalil, Ogonosky and Ahuja9]. It is therefore important to understand these ongoing digital changes, and to become better familiar with both the benefits and risks of using IBT for the delivery of care and education.
Understanding Internet-Based Technology
The increasing emergence of IBT has transformed the way that people of all ages communicate with each other, particularly among CYP [Reference Kutty and Sreeramareddy10].
CYP’s use of IBT is increasing. The UK Council for Child Internet Safety state that now 94% of CYP aged 5 to 16 use IBT for a range of activities, many use it on a daily basis [11].
These activities may include searching the internet for homework/school project; reading a book/magazine on an e-Reader; online browsing or shopping; watching TV or online subscriptions, for example, Netflix, Disney Plus, YouTube; using social media platforms, for example, TikTok, Snapchat, Instagram, Twitter; and playing games interactively with peers via consoles, for example, Xbox or PlayStation or mobile devices or PCs and the use of ‘multi-playing’ for gaming and interacting with other players.
While the majority of CYP are using similar types of IBT for similar purposes, CYP can still have vastly different experiences and outcomes depending on the use, duration of use, content and impact of the IBT. Therefore, when considering the benefits and risks of IBT use, a good clinical knowledge base and understanding of its content, and impact specific to CYP is essential.
As a clinician, it is important to consider the benefits and risks of IBT in relation to both the ‘CYP’ and to your clinical role for the CYP. As a clinician, it is important that you:
(a) Have a good understanding and evidence base of IBT.
(b) Have a good understanding and evidence base of how IBT suits CYP.
(c) Understand how IBT fits into your clinical role.
(d) Base your clinical judgements and decisions on what the CYP want and need, rather than personal preference.
To do this, you will need to ensure that you understand:
(a) CYP preferences, attitudes, and purpose/use of IBT to understand what the CYP will want from IBT.
(b) Time spent on IBT.
(c) Websites and apps used.
(d) Impact of IBT on their sleep, mood, appetite, concentration, day-to-day life and schoolwork.
Understanding the Benefits and Risks of IBT
Benefits
IBT is an integral part of CYP lives, and for many, it can provide numerous benefits. For example:
Socialisation
It offers immediate contact and communication with family and friends.
It can be accessed at any time of the day, and any day of the year – making access/socialising a 24/7 space if needed.
It allows for CYP to develop and enhance social relationships.
It allows for CYP to socialise in a range of different environments, which extends their skills sets and encourages them to learn new cultures.
For some CYP with high levels of anxiety or poor social skills it can support socialisation.
During the Covid-19 pandemic, it helped reduced isolation for many CYP.
Development
Education and Knowledge
It presents unlimited access to high-quality information, which can lead to increased knowledge and improved educational outcomes.
Increase reading ability, due to fast access of eBooks.
It lends itself well to extending educational and occupational opportunities far and wide, for example, remote learning and remote working.
Linking with educational and occupational opportunities across the world.
Access to Health Care Services
It offers access to various online support for a range of health and well-being concerns, for example, online CBT, mindfulness and counselling.
It also presents the ability to obtain information and understand some common health care concerns, such as the RCPsych website or Mind website [12,13].
Remember: Some websites can provide unhelpful information or be harmful to a CYP, so carefully, and regularly, research and recommend trusted sites.
Websites can reduce anxiety and stress in some people, for example, virtual consultations may help some CYP with high levels of anxiety by providing a virtual platform, reducing the need for in-person contact, waiting rooms, travel and missed school/work.
Websites can sometimes be more accessible and potentially reduce waiting times, as virtual appointments are more readily available, which can impact positively on CYP clinical outcomes.
Online mental well-being communities can provide free, safe and anonymous support, for example, Kooth.
Risks
However, there is similar evidence to suggest that IBT may impact adversely on comparable themes for the CYP. For example:
Socialisation
The reliance of online socialisation may isolate or institutionalise CYP from in-person contact.
CYP may become lonely due to peers’ reliance on IBT.
Online bullying can be 24/7.
There is potential for exploitation/grooming in vulnerable CYP.
Online socialisation may reinforce anxiety/lack of socialisation in some CYP.
Education and Knowledge
Health Care Access
Take-Home Message
Based on the comparable evidence, it is unclear as to whether IBT benefits a CYP any more than it can put a CYP at risk. But after 30 years of controversy, all we can do as clinicians is to better understand IBT use in CYP so we can provide our patients with the best possible clinical advice that best suit them and their current IBT use.
Understanding Your Clinical Role in IBT
Digital History Taking
The evidence surrounding IBT is in its infancy and therefore we are still unable to reach a definitive conclusion on IBT and its contribution to mental health disorders and addictions. It is therefore, recommended that, when assessing a CYP, a digital history is included as part of history taking in every CYP seen in-clinic.
Digital History Screening
Using digital screening questions, the clinician can learn more about the CYP individual use of IBT, with specific targeting/individualised questions towards more relatable content and impacts specific to the CYP.
Remember: Keep digital history screening questions ‘balanced’ and refrain from assuming any causal direction of IBT and health outcomes.
Rather, seek to explore areas such as the use and purpose of the IBT used by the CYP, the duration of each use, preferences and interests, satisfaction level (e.g., an unhealthy habit versus a happy place), perceived attitudes on IBT (CYP and their peers/parents) and impacts on sleep, eating habits, well-being and so on.
It can also be helpful to engage the CYP in a more relatable discussion, utilising language and understanding that CYP are more familiar with. With the support of a Young Person Representative Group, Box 17.1 provides simple questions to help approach these areas of discussion.
If trying to establish a social media or Internet usage, you could ask the CYP:
Do you use social media platforms, such as TikTok, Snapchat, Instagram or Twitter?
Or
Do you have a YouTube channel?
And if so,
Do you make online content, or are you just a viewer?
What content do you make/view, e.g., images or videos?
Do you think your content builds a positive atmosphere?
Do you feel comfortable in the comments section of the content you share or view?
If trying to understand a privacy or risk concern, you could ask the CYP:
Do you have privacy options enabled on your social media/online account?
Do you have an extensive online following?
How much information do you generally share online?
Do you speak personally with your followers?
If trying to establish a gaming or gambling presence, you could ask the CYP:
Do you play video games?
If so,
Additional Assessment: If any problematic behaviour is identified at digital screening, it is important to understand and consider some following areas of assessment. Seek to understand the impact of presenting difficulties, such as:
family and friend relationships
intimate relationships/relationship status
identity and value systems of CYP and others around them
school attendance or educational performance
other responsibilities, for example, paid job, voluntary and caring role, chores
home life, home set-up and safeguarding implications
impact on sleep, eating, schoolwork and emotional well-being
Role of Parents/Guardians
Also, talk to parents/guardians about how they can safeguard CYP when using IBT, by:
(a) Engaging in relatable and balanced discussions with their CYP, taking about both the benefits and risks of IBT.
(b) Focusing on the positive impacts of IBT, for example, having a healthy routine rather than any negative concerns.
(c) Encouraging discussions on IBT content that is viewed online, and how this makes them feel.
(d) Having discussions early in child development as healthy IBT habits are easier to establish when children are younger.
(e) Setting appropriate and balanced screentime boundaries and model this approach with all family members. In other words, be a good role model.
(f) Safeguarding CYP by setting/reviewing privacy and location settings [Reference Dubicka and Theodosiou14].
Understanding Social Media
Social media is defined as a ‘website and applications (apps) that enable users to create and share content or to participate in social networking’ [Reference Chandler and Munday15].
It is reported that 70% of 12–15-year-olds have a social media account, and 95% of CYP over 15-years-old use social media regularly in the UK [16].
To understand a CYP use of social media, it is important to keep on top of ‘current’ and ‘popular’ social media sites. These may include TikTok, Instagram, Snapchat, Twitter, Facebook, WhatsApp and other messaging services.
The rise in social media use, particularly among CYP has changed the way they communicate with friends and family, and how they showcase themselves as individuals.
Social media is now also used as a platform for immediate notifications and updates, such as daily news and public issues.
The benefits of social media for CYP can include its ability to motivate them to action; its ability to influence social, political and economic thinking and change; provide a platform for CYP to voice their opinions, and to be heard; and enables CYP voices to come together, providing a sense of shared identity and empowerment [17].
For example, climate activist Greta Thunberg has achieved significant social media following and positive reinforcement, impact and change due to her online ability to influence and lead.
In addition, social media enables CYP to communicate and socialise with friends and family across the world; find new friends and communities and network with people that share their own interests; join and promote groups and causes; raise awareness; seek or offer emotional support; seek out social connections when living in isolated or rural settings or marginalised groups; improve social anxiety in some CYP; improve creativity and self-expression; discover sources of information, support and learning; and seek out new opportunities, such as job adverts, educational sponsorships and more.
However, social media can also result in challenges and clinical risks for some CYP. For example, the immediate and ongoing notifications of social media, and the normalisation of sharing a filtered sense of their lives (showing only what the content sharer wants to share) can have significant implications on CYP mental health. These may include:
difficulties with development and identity formation
false sense of reality
unhealthy balance between real life and virtual reality and connections
self-esteem and worth issues
body image problems
As a CYP clinician, there are some things to look out for, such as:
low self-esteem and worth
low mood when viewing content
envy and comparison of others
excessive or compulsive social media viewing or content sharing
fear of missing out (FOMO)/not knowing about something ‘immediately’
avoidance of in-person contact
becoming self-absorbed or obsessed with content sharing
type of content being viewed or shared, for example, violent, sexual or graphic
cyberbullying
grooming and sexual exposure
Understanding Compulsive Use, Gaming, Gambling, Cyber Bullying and Grooming
Compulsive Use and Addiction
Compulsive use or addition has been associated with the use of many types of IBT in CYP, but two areas of particular interest tend to be in relation to social media use and gaming.
In social media, compulsion or addiction is often associated with the notification aspects of the platforms, such as the need for a post to receive a strong reaction of ‘likes’ or ‘shares’ to validate its public recognition. In gaming, competition, goal attainment and social gratification are common goals, but when used in excess, can lead to compulsive use and addictive behaviours in pursuit of winning.
For CYP, this behaviour can impact on restlessness, low mood, low self-esteem, depression, anxiety, impacts on sleep, body image, weight and diet, socialisation and interaction, academic, physical and social performance and self-harm and suicidal thoughts/actions.
What Does the Evidence Say?
IBT and compulsive behaviours and addictions are often associated [Reference Kutty and Sreeramareddy10]. However, the evidence of positive and negative associations is mixed.
Positive Associations
Research demonstrates that IBT provide positive associations with the mental health of CYP. For example, IBT is a means of creating connections with other individuals, which can reduce loneliness. A second benefit that was acknowledged included the improved self-esteem of CYP in that it is ‘boosted’ from presenting a positive version of themselves to the world and their networks [Reference Stephen and Edmonds18].
Please note: It is unknown whether this improvement is sustained over time, or if there are differing impacts associated with vulnerability or additive behaviours.
Furthermore, IBT can encourage social connections with others and the ability to share experiences. This is particularly important for CYP suffering from poor mental health whereby online engagement is a critical tool [Reference Stephen and Edmonds18].
Negative Associations
The compulsive use of IBT has negative associations with mental health. For example, its associations between screen-time duration. Cross-sectional and longitudinal studies have documented negative associations of excessive screen-time with increased anxiety and depressive symptoms. There is also an association with screen-time and internalising problems, which is a common symptom of both anxiety and depression [Reference Stiglic and Viner19].
When Gaming Becomes a Disorder
Gaming Disorder
Gaming disorder is now considered a mental health condition and is part of ICD-11. Gaming disorder is defined by the WHO as a
pattern of gaming behavior (‘digital-gaming’ or ‘video-gaming’) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences [20].
However, for gaming disorder to be diagnosed, the behaviour pattern must be:
(a) Of sufficient severity to result in significant impairment in personal, family, social, educational/occupational areas of functioning.
(b) Typically evident for at least 12 months [20].
When attempting to understand the disorders associated with gaming, it is essential to understand where the problem stems from.
Think of it like this …
Online gaming is associated to the notion that players create and build relationships with online characters or other online players that ultimately develop into virtual relationships and social interactions, similar to real life [Reference Singh21]. If, however, these relationships break down, or present a negative connotation, reactions may become apparent, such as aggression, irritability and restlessness.
For example, if a CYP in real life was ‘denied or unable to play’ with a friend, there would be a negative reaction felt to that CYP, such as social exclusion or loneliness. It is just as important to consider this feeling online as you would do in real life. Nevertheless, other studies investigating gaming addiction and mental health highlight a direct relationship with negative symptoms of depression, anxiety and stress [Reference Loton, Borkoles, Lubman and Polman22].
Please note: It is therefore important to encourage a balance of gaming behaviours to CYP, by keeping an open mind to the benefits, but also weighing up the risks when used in excess.
Online Gaming to Online Gambling
According to the National Audit Office, there are 55 000 problem gamblers aged 11–16 in the UK [23]. For CYP, online gambling and gaming disorder are often closely linked, in that online gaming can encourage gambling or ‘gambling-like’ behaviour, for example, in-game incentives and additional in-play purchases.
The clinical concern is that by the time a CYP reaches the legal gambling area, they may have ‘normalised’ their gambling behaviour (as part of the gaming experience) and may fail to see the risks at later life. There are however clinics and interventions (both in-person and virtual) available to support CYP with this condition.
An additional concern is that CYP are more susceptible to online gambling as access to the internet increases the convenience of doing so. It is therefore recommended to ensure ‘gambling blocks’ are activated on IBT devices that are used by CYP.
What Does the Evidence Say?
The mental health association with online gambling can be problematic for CYP. For example, the number of CYP internet gamblers increased greatly during the Covid-19 pandemic lockdowns, which in turn matched the higher rates of mental health problems reported during this time, such as an increase in depression and stress [Reference Emond, Nairn, Collard and Hollén24], which is a common association with online gambling [Reference Benson, Hand and Hartshorne25].
While multifaceted, the association between online gambling and mental health can be explained by either neurological factors associated with brain activation and structural changes or explained by social factors, such as financial hardship from monetary losses often leading to poor mental health conditions, such as depression and stress. A systematic literature review of neuroimaging studies identified that areas of the brain associated with reward, addiction, craving and emotion are increasingly activated when individuals are playing games, and even more prominent in individuals who are addicted to the internet [Reference Kuss and Griffiths26].
Neuroimaging research highlighted how structural changes are often observed in the brains of those who are online gamers. Changes in the brain are regularly seen in the meso-corticolimbic system, which is the part of the brain associated with reward and addiction. This evidence supports the claim that online gaming and gambling can be addictive and associated to the neurological factors of the CYP. The meso-corticolimbic system mediates depression-like symptoms and therefore, changes that can occur in the brains of gaming addicts are linked to mental health disorders such as depression [Reference Nestler and Carlezon27].
Gaming addicts have been found to have decreased gray matter in areas of the brain that are associated with motor control, cognition, motivation and processing emotion, such as the inferior parietal cortex convexity [Reference Kuss and Griffiths26]. Reduced gray matter is commonly observed in patients with major depressive disorder [Reference Webb, Weber, Mundy and Killgore28].
Cyberbullying
Cyberbullying is a form of bullying and harassment that is conducted using digital forums and mediums.
It is therefore important to remember that anyone with an online presence is vulnerable to cyberbullying.
Traditional Bullying Versus Cyberbullying
Research by Landstedt and Persson [Reference Landstedt and Persson29] explored the mental health impacts of traditional in-person bullying and cyberbullying. Interestingly, both present similar outcomes. However, a combination of the two at the same time lead to much poorer mental health, such as depression. This study also discovered that both types of bullying can contribute to psychosomatic problems in females (more than males).
Despite the commonalities of the two, cyberbullying can present additional challenges to the CYP [Reference Betts and Spenser30,Reference Slonje and Smith31,Reference Vandebosch and Van Cleemput32]. For example, cyberbullying can:
(a) Extend traditional bullying, for example, in-person at school, and continues to follow CYP into their home, often invading their safe space.
(b) Present an opportunity to save and store content, and therefore a single cyber-bullying episode can be permanently recorded.
(c) Present an opportunity to use content such as social media feeds, pictures or videos to target victims, such as name calling, insults and threats.
(d) Present an opportunity for ‘anonymity’ thus protecting the bully from disclosing themselves, and therefore increasing the chances and capacity to do so.
Cyberbullying and Mental Health
Although there are many ways in which IBT can be used for good, there are many negative influences such as cyberbullying [33].
Cyberbullying can have a significant impact on CYP and their mental health. There are strong links reported between cyberbullying and mental health. For example, a systematic mapping review investigated the association between cyberbullying and mental health in CYP [Reference Kwan, Dickson and Richardson34]. This review concluded that cyberbullying is only increasing as the availability, accessibility and functionality of internet-enabled technologies continue to develop and expand [Reference Kwan, Dickson and Richardson34].
With this, the expansion of IBT and accessibility of cyberbullying is an increase in the negative impact on CYP’s mental health [Reference Kwan, Dickson and Richardson34].
The review additionally identified the negative outcomes that have been found to accompany cyberbullying such as depression, suicidality, anxiety, hostility/aggression, substance misuse/use, self-harm, ADHD/hyperactivity, low self-esteem, peer problems, stress/distress, loneliness and life dissatisfaction.
However, it was acknowledged that none of the 19 reviews included longitudinal evidence therefore, it is difficult to establish to what extent these poor mental health outcomes are a result of cyberbullying [Reference Kwan, Dickson and Richardson34].
Cyberbullying and Trauma/PTSD
In some cases, the CYP may become traumatised by cyberbullying which may cause physiological stress responses and for some, PTSD. This is often caused when the CYP relives the stressful event over and over, and the CYP has trouble dealing with the negative thoughts and difficulty controlling emotions.
Grooming Risks
In addition to the increase of IBT, CYP are now more vulnerable to online grooming and sexual exploitation as a result [33].
Grooming has been universally defined as ‘a technique to help turn a sex offender’s fantasy into reality, whether online of offline’ [Reference Whittle, Hamilton-Giachritsis, Beech and Collings35].
IBT is rapidly developing and expanding, therefore, the opportunity for sexual offenders to access and build relationships with CYP online is on the rise [Reference Whittle, Hamilton-Giachritsis, Beech and Collings35]. For example, in the UK there were 5 441 Sexual Communication with a Child offences recorded between April 2021 and March 2021, which depicted a 70% increase from previous years [36]. Online groomers are increasing using social media sites to groom CYP. It is reported to have increased significantly in recent years, with the National Society for the Prevention of Cruelty to Children reporting that 34% of sexual grooming offences involve social media sites such as Facebook-owned apps such as Messenger, Instagram and WhatsApp, with Instagram being the most commonly reported [36].
There is work currently being done by the UK government, to introduce Artificial Intelligence technology that can identify and block grooming conversations, which therefore places a legal duty of care on social media companies. However, in the meantime, it is therefore important to ‘educate’ CYP about these risks.
Online Copycat Behaviour in CYP
CYP can have enormously different experiences of IBT depending on what content they are utilising and accessing [Reference Dubicka and Theodosiou14].
For example, video sharing sites such as YouTube score highly in self-expression, awareness, self-identity and community building measures, which has contributed to high scores in positive impacts on mental health and well-being. On the other hand, social media sites such as Instagram have high scores in negative impacts on mental health and well-being due to scoring highly on body image, FOMO and bullying measures [Reference Stephen and Edmonds18].
In a similar way, IBT can encourage a wide range of ‘learning’ opportunities. However, in the same way that a CYP can share and learn a positive experience online, they can do so with a negative one.
Negative experiences and lessons learned can often be encouraged by poor online messages or trends.
Clinical areas to look out for are body image, disordered eating, low self-esteem, self-harm, suicide and/or involuntary body movements, such as tics.
For example, it is important to be made aware of social media and internet sites that promote terms such as ‘Thinspiration’ and ‘Fitspiration’, and even illegal sites such as Pro-Anorexia (Pro-Ana) content [Reference Turner and Lefevre37,Reference Jennings, LeBlanc, Kisch, Lancaster and Allen38].
There are many social media sites where this content is available such as, Instagram (where images are depicted) or Facebook and Twitter (where written content is favoured), however, TikTok utilises short duration videos [Reference Logrieco, Marchili, Roversi and Villani39].
Another clinical concern with social media sites is the ‘algorithm of the app’ that creates a personalised page for each user that suggests content and videos that the user may be interested in. However, for themes such as eating disorders and self-harming behaviour, the poor content filtering and privacy protection can lead to an overload of content delivered to the CYP.
For example, if a user views one video with Pro-Ana content and searches for similar content, the algorithm will keep suggesting similar content that contributes to the obsessive behaviour that is regularly seen in eating disorders [Reference Logrieco, Marchili, Roversi and Villani39].
Harmful content on social media and the internet does not just extend to eating disorders or self-harm, it can impact all types of mental illnesses [Reference Jadayel, Medlej and Jadayel40]. There have been many attempts to normalise mental health disorders and spread awareness in the last decade. However, this openness on social media has contributed to the glamorisation of mental health disorders and as a result have led to more complex disorders [Reference Jadayel, Medlej and Jadayel40]. A prominent example of this was in 2019 when the streaming service Netflix was forced to delete a graphic suicide scene from the 2017 show 13 Reasons Why. Although the aim of this scene was to capture the horrific consequences of suicide, others saw this concept as a ‘revenge fantasy’ and made it seem like it is something that is methodical and premediated, which it rarely is in real life [Reference Cabral41]. Furthermore, Euphoria a 2019 TV series addresses many issues such as mental health, sex and drug use. Experts believe this show additionally affects CYP due to how it glamorises problematic behaviour such as drug use, physical violence and promiscuity [Reference Cabral41].
Previous research has investigated young adults whose mental health issues as teenagers were exacerbated by social media. A 19-year-old who was clinically diagnosed with depression at the age of 15 highlighted how pictures that depicted depression and self-harm drove him to suicidal thoughts and aggravated his mental health problem [Reference Jadayel, Medlej and Jadayel40]. Therefore, many CYP are predisposed to thinking that they may be suffering a mental health disorder due to how relatable, normal and desirable they are seen to be online [Reference Jadayel, Medlej and Jadayel40].
Conclusion
Since its inception in the 1990s, IBT has often been associated with mental health and well-being outcomes. However, as research and clinical evaluation has demonstrated over the past 30 years, there is very little evidence to suggest a definitive association or direction between IBT and mental health and well-being outcomes. In other words, the positive and negative association between IBT and mental health tend to be comparable.
This chapter highlights that for CYP in particular, IBT offers many benefits for their mental health and well-being, and therefore this should be considered thoroughly when weighing up CYPs ‘wants and needs’. However, it is important to also consider the potential risks and challenges that IBT can present for some CYP. It is however recommended that, as a clinician, it is of good practice to better understand IBT in the context of CYP, and to keep updated on the ever-changing landscape of digital transformation. It is also essential that a clinician keeps a balanced clinical opinion on IBT and its associations with mental health among CYP, as at present, the evidence is not strong enough to support either direction (positive or negative impacts), and therefore no clinical decision should be made without clear and consistent evidence.
