Social Networking and New Technologies 9781581107869

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Social Networking & New Technologies Megan A. Moreno, MD, MSED, MPH Victor C. Strasburger, MD Editors

December 2014 • Volume 25 • Number 3

ADOLESCENT MEDICINE: STATE OF THE ART REVIEWS Social Networking & New Technologies GUEST EDITORS

Megan A. Moreno, MD, MSED, MPH Victor C. Strasburger, MD

December 2014 • Volume 25 • Number 3

ADOLESCENT MEDICINE: STATE OF THE ART REVIEWS December 2014 Editor: Carrie Peters Marketing Manager: Marirose Russo Production Manager: Shannan Martin eBook Developer: Houston Adams

Volume 25, Number 3 ISBN 978-1-58110-786-9 ISSN 1934-4287 MA0667 SUB1006

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Statements and opinions expressed are those of the author and not necessarily those of the American Academy of Pediatrics. Products and Web sites are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics. The American Academy of Pediatrics is not responsible for the content of the resources mentioned in this publication. Web site addresses are as current as possible but may change at any time. Every effort has been made to ensure that the drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. It is the responsibility of the health care provider to check the package insert of each drug for any change in indications and dosage and for added warnings and precautions. Copyright © 2014 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information retrieval system, without written permission from the Publisher (fax the permissions editor at 847/4348780). Adolescent Medicine: State of the Art Reviews is published three times per year by the American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007-1019. Periodicals postage paid at Arlington Heights, IL. POSTMASTER: Send address changes to American Academy of Pediatrics, Department of Marketing and Publications, Attn: AM:STARs, 141 Northwest Point Blvd, Elk Grove Village, IL 60007-1019. Subscriptions: Subscriptions to Adolescent Medicine: State of the Art Reviews (AM:STARs) are provided to members of the American Academy of Pediatrics’ Section on Adolescent Health as part of annual section membership dues. All others, please contact the AAP Customer Service Center at 866/843-2271 (7:00 am–5:30 pm Central Time, Monday– Friday) for pricing and information.

Adolescent Medicine: State of the Art Reviews Official Journal of the American Academy of Pediatrics Section on Adolescent Health

EDITORS-IN-CHIEF Victor C. Strasburger, MD Distinguished Professor of Pediatrics Founding Chief, Division of Adolescent Medicine University of New Mexico School of Medicine Albuquerque, New Mexico

Donald E. Greydanus, MD, Dr HC (ATHENS) Professor & Founding Chair Department of Pediatric & Adolescent Medicine Western Michigan University Homer Stryker M.D. School of Medicine Kalamazoo, Michigan

ASSOCIATE EDITORS Robert T. Brown, MD Camden, New Jersey

Paula K. Braverman, MD Cincinnati, Ohio

Cynthia Holland-Hall, MD, MPH Columbus, Ohio

Sheryl Ryan, MD New Haven, Connecticut

Martin M. Fisher, MD Manhasset, New York

Alain Joffe, MD, MPH Baltimore, Maryland

SOCIAL NETWORKING & NEW TECHNOLOGIES

EDITORS-IN-CHIEF

VICTOR C. STRASBURGER, MD, Distinguished Professor of Pediatrics, Founding Chief, Division of Adolescent Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico DONALD E. GREYDANUS, MD, Dr HC (ATHENS), Professor & Founding Chair, Department of Pediatric & Adolescent Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan

GUEST EDITORS

VICTOR C. STRASBURGER, MD, Distinguished Professor of Pediatrics, Founding Chief, Division of Adolescent Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico MEGAN A. MORENO, MD, MSED, MPH, Associate Professor of Pediatrics, University of Washington and Principal Investigator of the Social Media and Adolescent Health Research Team (SMAHRT) Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington

CONTRIBUTORS

ALINA ARSENIEV-KOEHLER, BA, University of Washington Department of Sociology, Seattle, Washington; Seattle Children’s Research Institute, Center for Child Health Behavior and Development, Seattle, Washington SHEANA BULL, PHD, MPH, Colorado Schools of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado DIMITRI A. CHRISTAKIS, MD, MPH, Seattle Children’s Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington PAULA J. CODY, MD, MPH, Assistant Professor of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin KATIE DAVIS, PHD, Assistant Professor, University of Washington iSchool, Seattle, Washington EDWARD DONNERSTEIN, PHD, Department of Communication, University of Arizona, Tucson, Arizona v

DUSTIN D. DRENGUIS, JD, University of Washington School of Law, Seattle, Washington DANIEL EISENBERG, PHD, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan YOLANDA N. EVANS, MD, MPH, Associate Professor of Pediatrics, Division of Adolescent Medicine, Seattle Children’s Hospital and University of Washington, Seattle, Washington NNAMDI EZEANOCHIE, MD, MPH, Colorado Schools of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado ELIZABETH C. FALK, MS, WHNP-BC, Nurse Practitioner, The University of Wisconsin-Madison University Health Services, Madison, Wisconsin JULIE A. GORZKOWSKI, MSW, Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Elk Grove Village, Illinois PAUL M. GROSSBERG, MD, Clinical Professor Emeritus, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin SCOTT HARPIN, PHD, MPH, College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado SKYLER T. HAWK, MA, MS, PHD, Department of Educational Psychology, The Chinese University of Hong Kong, Hong Kong LAURA HOOPER, MS, Seattle Children’s Hospital, Nutrition Department and Division of Adolescent Medicine, Seattle, Washington LAUREN A. JELENCHICK, MPH, Medical Scientist Training Program, University of Minnesota Medical School, Minneapolis, Minnesota KRISTEN R. KASEESKA, BA, Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Elk Grove Village, Illinois JASON R. KILMER, PHD, Assistant Professor, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington; Assistant Director of Health & Wellness for Alcohol & Other Drug Education, Health and Wellness, Division of Student Life, University of Washington, Seattle, Washington RYAN P. KILMER, PHD, Professor of Psychology, Department of Psychology, Co-Director of the Community Psychology Research Laboratory, University of North Carolina at Charlotte, Charlotte, North Carolina JONATHAN D. KLEIN, MD, MPH, Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Elk Grove Village, Illinois RAJITHA KOTA, MPH, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

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CONTRIBUTORS

HEDWIG LEE, PHD, University of Washington Department of Sociology, Seattle, Washington SARAH KETCHEN LIPSON, MED, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan; Center for the Study of Postsecondary and Higher Education, University of Michigan, Ann Arbor, Michigan JOANNA MILLS, MS, Graduate student, University of Washington iSchool, Seattle, Washington PETER S. MORENO, JD, MS, University of Washington School of Law, Seattle, Washington MAUREEN NOVAK, MD, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida HEATHER R. ROYER, PHD, FNP, Nurse Scientist, Wm. S. Middleton Memorial Veterans Hospital, Madison, Wisconsin CHARLOTTE SANDY, MA, School of Social Work, University of Michigan, Ann Arbor, Michigan ANZEELA M. SCHENTRUP, PHARMD, PHD, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida ELLEN SELKIE, MD, MPH, Division of Adolescent Medicine, University of Washington/Seattle Children’s, Seattle, Washington VICTOR C. STRASBURGER, MD, Distinguished Professor of Pediatrics, Founding Chief, Division of Adolescent Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico LINDSAY A. THOMPSON, MD, MS, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida; Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida BLAKE WAGNER III, BA, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan PAUL J. WRIGHT, PHD, The Media School, Indiana University, Bloomington, Indiana SEAN YOUNG, PHD, MS, Assistant Professor of Family Medicine and Director, Center for Digital Behavior at UCLA, Los Angeles, California

CONTRIBUTORS

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SOCIAL NETWORKING & NEW TECHNOLOGIES CONTENTS Preface

Megan A. Moreno, Victor C. Strasburger

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Youth Perspectives on Social Media and Technology

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Cross-Cultural and Cross-Platform Differences in Youths’ Social Networking Site Behavior

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Megan A. Moreno, Katie Davis, Joanna Mills

Skyler T. Hawk

The increasing diversification of Social Networking Sites (SNS) available to adolescents and emerging adults presents challenges to intervention and education efforts aimed at encouraging healthy and socially responsible online behavior. The wide array of features, services, and privacy and ownership policies that characterize different SNS platforms suggests that users’ motives, “friends,” and shared content might vary considerably among the different sites. Complicating matters further, users likely connect to multiple SNS because the different platforms fulfill particular social needs. The different features and customs of particular SNS constitute specific subcultures within the larger social networking phenomenon, and youths may participate differently in several of these communities. This variety makes it difficult to generalize research findings and educational strategies across all available SNS. In order to assist continuing research and intervention efforts, the present review details the evolution of several structural and social aspects of current SNS. The present review places a special focus on China, which is perhaps the fastest growing market for these platforms because of the unavailability of popular western sites such as Facebook and Twitter. A closer examination of Chinese SNS provides important clues about emerging trends in youth social networking culture, and demonstrates how young people from individualistic and collectivistic cultures might approach their preferred SNS with substantially different mindsets. A better understanding of how their motives for use vary between platforms can aid educators and interventionists in mitigating potential harms and promoting the social benefits of these online environments. VOLUME 25 • NUMBER 3 • DECEMBER 2014

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Sex and Social Media: New Avenues for Hookups and New Opportunities for Interventions542

Heather R. Royer, Sean Young, Elizabeth C. Falk

Social media are interwoven into the lives of adolescents and may influence their sexual health in ways that are potentially harmful or health promoting. Understanding the risk and the opportunities of social media are imperative to understanding the adolescent patient and delivering innovative sexual health care. This article will describe the role of social media in adolescent sexual risk behavior and describe new opportunities for using social media that may improve the sexual health of this population. Online Pro-Eating Disorder (Pro-ED) Activity

Alina Arseniev-Koehler, Laura Hooper, Hedwig Lee

553

Pro-eating disorder (pro-ED) movements include pro-Ana (Anorexia) and, less commonly, pro-Mia (Bulimia). These online movements aim to support individuals with eating disorders to attain and maintain extreme weight loss. Eating disorder social expression and connection online are sources of social support and information exchange, but they also may reinforce deleterious attitudes, intentions, and health behaviors among adolescents who engage or intend to engage in disordered eating. This article describes viewership of pro-ED sites among adolescents, characteristics of pro-ED sites, and clinical implications for adolescents involved in pro-ED. This article also describes prevention and intervention efforts against pro-ED. Cyberbullying and Online Harassment in Adolescents

Ellen Selkie, Rajitha Kota

564

Cyberbullying, also known as online harassment, is a newly recognized problem in the age of increasing technology use. Cyberbullying shares some characteristics with traditional bullying, but other aspects of this digital phenomenon introduce unique challenges to adolescents and their parents. This article explores the definitions, causal theories, and epidemiology of cyberbullying, reviews the evidence for its adverse psychosocial consequences, and describes the effect of school programs and legal policies on cyberbullying. The article also provides recommendations for parents and pediatricians to help combat cyberbullying. x

CONTENTS

Sex Online: Pornography, Sexual Solicitation, and Sexting

Paul J. Wright, Edward Donnerstein

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Researchers have studied the effects of media portrayals on young people for decades. This research has given us insights into violence, obesity, sexuality, and many other areas of child and adolescent health. The platforms and devices available to children and adolescents today, however, are far beyond those we studied years ago. The media landscape is rapidly changing, and in this article we look at some of the effects of newer technologies on risk-related behaviors, focusing specifically on the exposure to online pornography and the concerns of sexting and sexual exploitation with respect to children and adolescents. This is emerging and ongoing research and offers both theoretical and empirical insights into child and adolescent health. Legal Risks of Online Adolescent Communication

Peter S. Moreno, Dustin D. Drenguis

590

The law regarding electronic communication is evolving rapidly as governments and schools seek to control potentially harmful online behavior such as cyberbullying and sexting. Nearly every state has passed laws that punish electronic harassment or cyberbullying, and many of these laws are broad enough to restrict a wide range of communication. Some states now have laws that address the distribution of sexually explicit images by minors, but in the remaining states, minors who self-produce or receive sexually explicit images or videos can be prosecuted under child pornography statutes, which carry severe penalties. Problematic Internet Use During Adolescence and Young Adulthood

Lauren A. Jelenchick, Dimitri A. Christakis

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Problematic Internet use (PIU) is an emerging health concern among adolescents. Defined as “Internet use that is risky, excessive or impulsive in nature leading to adverse life consequences,” the condition is estimated to affect approximately 4% to 6% of the US adolescent population. Adolescents with psychosocial or health risk factors, such as low parental involvement, school failure, depression, or engagement in other risk behaviors, may be at risk for PIU. Recent advances in the conceptualization of PIU among adolescents are providing new avenues for physicians in screening and intervention options, particularly among adolescents who may be high risk. CONTENTS

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Adolescent Social Media Use: The Role of the Pediatric Practitioner and the Healthy Internet Use Model

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Kristen R. Kaseeska, Julie A. Gorzkowski, Jonathan D. Klein

The rapid rise of social media (defined as media with an interactive component) has important implications for adolescent health. Pediatric practitioners such as physicians, physician assistants, and nurse practitioners are in a unique position to screen and counsel adolescents about social media use to ensure that adolescents balance their time, set appropriate boundaries, and communicate with trusted adults about their experiences online. Pediatricians should screen and counsel adolescents for safe and healthy media behavior at every well-child visit. One method for doing so is the “Healthy Internet Use Model,” described in this article. These clinical discussions should be tailored to the adolescent’s age and interests, and they should involve the adolescent and his/her parents/ guardians in developing a family media plan. Adolescent Mobile Phone Use and Mobile Phone-Based Health Promotion

Scott Harpin, Nnamdi Ezeanochie, Sheana Bull

631

Mobile phone use has become ubiquitous among adolescents in the United States, and worldwide, in the past 10 to 15 years. Mobile phone ownership among young people has changed interpersonal communications, as well as how young people access information. Adolescents increasingly use short messaging service (SMS) technologies and Web-based “apps” instead of traditional voice telecommunications. Youth with special needs and hard-to-reach adolescents (ie, homeless youth, highly mobile students) have found distinctive utility in mobile phones, especially as lifelines to others. Recently, physicians and health systems have leveraged mobile phone technology to expand health promotion efforts, tailored interventions, and social marketing for prevention and health care delivery. Media Matter: But “Old” Media May Matter More Than “New” Media

Victor C. Strasburger

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There has been an explosion of “new” media in the past decade—cell phones, iPads, iPods—in addition to the now almost-ubiquitous Internet. As a result, parents and clinicians have expressed considerable concern about teenagers’ media use and its effect. This article briefly reviews known media effects for both traditional media (eg, TV, movies, videos) and newer media (eg, Internet, social networking sites, cell phones). However, xii

CONTENTS

to date there has been very little research on the behavioral effects of newer media. In addition, media that tell stories—TV, movies, videos— will probably always have a greater behavioral effect on children and adolescents, although the harmful effect of cyberbullying in particular should not be underestimated. Social Media and Mental Health in Adolescent and Young Adult Populations 670

Blake Wagner III, Sarah Ketchen Lipson, Charlotte Sandy, Daniel Eisenberg

This article reviews research on the connection between social media use and mental health in adolescent and young adult populations. Social media, particularly social networking sites such as Facebook, have become an important aspect of young people’s self-identity and therefore have important implications for self-esteem and psychological well-being. Research to date indicates that social media use has a variety of effects on mental health, both positive and negative. Given the importance of social media in young people’s lives, there is significant potential for mental health interventions that operate through social media, but research evidence in this regard is limited. The Role of Media on Adolescent Substance Use: Implications for Patient Visits684

Jason R. Kilmer, Ryan P. Kilmer, Paul M. Grossberg

Youth are exposed to and engage in a tremendous amount of media, both “old” (eg, television, music) and “new” (eg, social media via the Internet). These various media outlets can be the source of exposure to portrayals of alcohol and other drug use, advertisements for alcohol or tobacco, and images or messages about substance use. In this article, we (1) highlight findings regarding the potential effect of media exposure on substance use by adolescents and young adults; (2) discuss implications and recommendations for health professionals, including strategies for messaging to parents; and (3) identify resources for clinicians and parents to provide concrete strategies for communicating about these issues. Adolescent Health and the Electronic Health Record: Can It Be a Social Media Tool for Quality Adolescent Care? 698

Lindsay A. Thompson, Maureen Novak, Anzeela M. Schentrup

This article presents the background to support the value of promoting the electronic health record in the adolescent population. Their facile use of social media can be garnered to engage this population with their own CONTENTS

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healthcare. The system and practice-based incentives through the Meaningful Use (MU) program are novel opportunities to assess usage. We highlight how each MU objective should be adapted to uphold quality adolescent health care, and exemplify this with the After Visit Sheet and the patient portal. Future directions will allow creation of adolescentfriendly portals and websites that increase health literacy and facilitate transition to adult health services. Physician Blogging for Parent Health Education

Yolanda N. Evans, Paula J. Cody

711

Parents and adolescents routinely use online social media and often seek information on health-related topics using these forums. Social media, including the use of blogs, are being used by some medical professionals as a way to spread accurate and up-to-date health information. Blogging has the potential to be a health education tool that can reach beyond hospital or clinic walls, yet few guidelines are in place to ensure they are presented in a preferred way to readers. This chapter will outline what a blog is, how they are being used by physicians, and some of the challenges to incorporating blogging and social media into practice. Index716

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CONTENTS

Adolesc Med 025 (2014) xv

Preface

Social Networking & New Technologies Today’s teens are often referred to as digital natives because of their upbringing immersed in technologic tools including smartphones and social media, while most of us who provide health care for this group remain, at best, digital immigrants. These technologies present both new opportunities and challenges to teens’ health as well as to their education and life experiences. Pediatricians can play a key role in helping teens and their families navigate critical issues, such as balancing their online and offline lives as well as understanding the links between media and health. This issue of AM:STARS is meant to provide pediatricians with knowledge and updates so that they feel prepared to have these conversations with patients and families in the busy clinical office setting. Several articles set the stage for understanding the digital landscape and adolescents’ immersion in media, both across diverse countries in an article describing social media from an international perspective, and understanding dimensions of both “new” and “old” media. Given the emergence of cell phones and smartphones as standard operating equipment for today’s teens, we provide an article exploring the epidemiology of cell phone use. Furthermore, as increasing numbers of physicians and health care systems begin to provide health education via blogs, we provide an article describing blogs, including a blog focused on teen health: “Teenology101.” Finally, teens’ access to, and facility with, the online environment provide new opportunities to engage them in their own health care via electronic health records and related tools. Several articles address links between media and specific health behaviors, including sex, eating disorders, mental health, and substance use. These issues remain salient to this generation of adolescents as they have for many previous generations. However, technology and social media provide new outlets for teens to express their views and experiences, as well as new venues to reach teens for prevention, education, and intervention. Some chapters investigate emergent adolescent health concerns that directly relate to technology. Problematic Internet use (PIU) is an emerging public health issue that includes risky Internet use, such as seeking inappropriate content, and Internet use that is characterized as compulsive or addictive. Cyberbullying is a frequent topic in news media, typically highlighting rare cases that involve devastating consequences such as suicide. The online environment also provides new venues for old behaviors; an article explores how teens use the Internet to seek pornography as well as to share intimate photographs with peers via sexting. In cases of cyberbullying and sexting, pediatricians may be asked to provide support and resources for teens who have experienced, perpetrated, or observed these behaviors. Thus, we provide an article on the legal risks of adolescent online communication to address these common issues.

Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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M. A. Moreno, V. C. Strasburger / Adolesc Med 025 (2014) xv–xvi

Finally, this issue would not be complete without the inclusion of voices from the digital natives themselves, so in the introduction we capture the voices and viewpoints of adolescents regarding their use of technology and social media. We would like to express our appreciation to Carrie Peters, who provided outstanding input and insights on editing these articles. Megan A. Moreno, MD, MSEd, MPH Associate Professor of Pediatrics University of Washington and Principal Investigator of the Social Media and Adolescent Health Research Team (SMAHRT) Center for Child Health, Behavior and Development Seattle Children’s Research Institute Seattle, Washington

Victor C. Strasburger, MD Distinguished Professor of Pediatrics Founding Chief, Division of Adolescent Medicine University of New Mexico, School of Medicine Albuquerque, New Mexico

Adolesc Med 025 (2014) xvii-xxi

Introduction Youth Perspectives on Social Media and Technology Megan A. Moreno, MD, MSEd, MPHa, Katie Davis, PhDb, Joanna Mills, MSc Associate Professor of Pediatrics, University of Washington and Principal Investigator of the Social Media and Adolescent Health Research Team (SMAHRT) Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington b Assistant Professor, University of Washington iSchool, Seattle, Washington c Graduate student, University of Washington iSchool, Seattle, Washington

a

YOUTH PERSPECTIVES ON SOCIAL MEDIA AND TECHNOLOGY

On October 16-17, 2014, the iSchool at the University of Washington hosted a conference called “Digital Youth Seattle Think Tank.” This 2-day event drew scholars from around the country for a discussion about new opportunities provided by digital media to advance youth education. A panel session included 8 youths from grades 9 to 11, 4 youths from an elite private school, and 4 from a public high school with a high proportion of immigrant youth. These youth voiced their own views on the challenges and opportunities provided to them by social media. This introduction includes excerpts of ideas and quotations from this session to illustrate key issues and perspectives of adolescents toward informing the larger discussions in this issue of AM:STARS. TECHNOLOGY PROVIDES A RICH COLLECTION OF TOOLS IN THE TOOLBOX

The first theme of the panel discussion was the multifaceted ways in which adolescents use social media and technology tools for their academic and social goals. Panelists raised several innovative ways that they incorporate technology tools into their day-to-day lives, including: “I use YouTube to help me with my homework, I can find videos on how to solve math problems.” “I use technology basically to resolve arguments with my sister by looking up facts to prove her wrong.” “I use online dictionaries during the day because English is not my first language.”

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M. A. Moreno, K. Davis, J. Mills / Adolesc Med 025 (2014) xvii–xxi

Given the creative ways in which teens utilize these tools, it may not be a surprise that some comments illustrated a near-constant immersion in media during the day. One quote described: “I live and breathe technology, I get up in the morning and check Twitter, I go to school, in the evening I watch YouTube or Vine, post on Facebook, and check Twitter the last thing before I go to bed.” Teens also discussed different sites that provide different types of entertainment and can be used either for immersive viewing or for a quick study break. In addition to its entertainment value, the importance of using technology to establish real and virtual connections was emphasized. Panelists commented that some sites are useful for keeping up with “real life” friends, while others provide a connection to celebrities or organizations. “I use Vine to follow people who are famous and funny.” “I use Tumblr for entertainment, I use it in the half hour before bed to  unwind so I don’t go to bed thinking about my homework.” “I like the sites to connect with my friends in real life, like Facebook, Insta gram, Twitter.” “Twitter is the site I consider most universal, you can connect to friends in  real life but also follow famous people, and people post links to Instagram or YouTube, so it’s probably most universal.” MICROCULTURES AND MAJOR STRATEGIES

A second theme of the discussions was the importance of understanding the rules and etiquette that each social media site presents. Teens described a complex set of unwritten rules for posting and self-presentation across different sites. Lessons on how to adhere to these rules were described as passed along verbally among peers or as learned by trial and error when followers on a site “unfollow” you when rules were broken. Some discussions highlighted examples of how teens may even teach parents these rules. “On Instagram there’s the basic rule that you shouldn’t post more than one photo  each day, but on Facebook you can post multiple times a day and that’s ok.” “At my house we have chickens and my mom is posting all these pictures of  chickens on Instagram. So I was like ‘Mom, nobody wants to see so many photos of chickens!’” “It’s like a science but it’s not written, you just know.” Threaded through these discussions was an emphasis on strategy. Teens need to understand the culture of a site in order to develop a strategy of how to post on that site in ways that are consistent with that site’s culture and with one’s own identity. Furthermore, there are rules about when one can join a site depending on the site’s popularity and how long it has been in existence. One teen described: “I don’t have an Instagram and I couldn’t make one now, I’m past that point where



M. A. Moreno, K. Davis, J. Mills / Adolesc Med 025 (2014) xvii–xxi xix

I could make one. Just like you can’t make a Facebook now if you don’t already have one, because only grandparents are making one now.” Teens discussed that some sites allow for “in the moment” posting, which can provide relief from the standard strategic posts on Facebook or Twitter. These sites, the most commonly discussed of which was Snapchat, provide them with a chance to connect to friends in a communication format that may feel more spontaneous or less like a high-stakes gamble because of the perception that the posts are not permanent. “For Instagram I have strategic posts, once a week, a really good photo where  I did filters and planned it out.” “Snapchat is more in the moment, I can take a picture and update my friends  on what I’m doing.” In addition to unwritten rules and strategies, teens described some rules that were clearly understood among their family or friends. Several teens mentioned “technology-free dinnertime” as a rule within their family. One youth described that he and his friends had decided to develop a rule for when they were together at a restaurant: “My friends and I came up with this rule when we go to dinner at a restaurant we all put our phones in the middle of the table. If someone reaches out to answer a call or text they have to hold the full stack of phones…so that they’ll be embarrassed holding this huge stack of phones.” This example of a self-imposed rule by a group of teens hints that some teens are devising ways to push back against the ubiquitousness of technology in their lives. TECHNOLOGY PROVIDES OPPORTUNITIES AND CHALLENGES

Adolescent panelists frequently referred to the benefits of technology use, including the capacity to “see other people’s opinions other than your parents” and for teens to “escape the bubble you live in.” Teens described using technology to learn about causes that were important to them, such as social justice issues. Thus, a distinctly positive aspect of technology was the ability to gain exposure to new ideas and perspectives. Teens also described frustration with the addition of technology in ways in which it wasn’t helpful to them. One teen described a program at her school: “My school gave us all iPads but we still had to have textbooks. The iPad didn’t help with anything; it was like having a big phone that couldn’t call. So now our backpacks were heavier but we didn’t really get any benefit.”

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Other teens mentioned that schools that were “totally wired” sometimes led to classes in which technology was not a helpful adjunct. “Technology in classrooms doesn’t work if the teacher doesn’t know how to use it.” “Technology doesn’t work in every classroom, like, you don’t need technology for math class….” The use of technology for technology’s sake was something that teens recognized and viewed as challenging, particularly in the school environment. WORRIES ABOUT TECHNOLOGY

Teens brought up several common worries about technology, 1 of which was cyberbullying. Teens discussed how media coverage of severe cyberbullying cases that led to suicide has skewed their view of this phenomenon. Some teens described too much emphasis on these severe cases and not enough information on how to handle the everyday cyberbullying they experience. Some thoughts included: “We hear stories about cyberbullying leading to suicide and that doesn’t reach us, we didn’t experience that. Don’t just tell us the worst case scenario, tell us what cyberbullying is.” “As teens our perception of cyberbullying is skewed right now, you hear things that could be bullying like ‘don’t hit people,’ but what about posting embarrassing photos?” “Cyberbullying is just…a huge thing that goes on for us.” “At my school someone set up a Twitter account just making fun of someone’s forehead. And, like, her friends were following it. And I was like, ‘really?’ ” It is interesting to note that in the above example of a Twitter account created for cyberbullying someone, further discussion revealed that a group of teen hackers ended up taking down this site to support the cyberbullying victim. Thus, teens can also use technology to respond to cyberbullying in proactive ways. Another area of concern was the perception that teens being constantly connected can lead to communication difficulties if those teens are offline for a time. A common discussion point was “read receipts,” which allow a recipient to view when a text message was received. Teens discussed that they need to be really clear with their friends when they won’t be answering a text message because failure to respond can lead peers to question whether there is a problem in their relationship with that person. “Texting comes with read receipts and if you send a text and someone read it and didn’t respond this can lead to lots of drama and miscommunication.”



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“Read receipts lead to miscommunication because that’s all the information you have to work with, you don’t have the person or their facial expression.” Teens also seemed to consider the downsides of having so much of their lives— homework, friends, and entertainment—in 1 place. One teen eloquently put this as: “When I do my homework I also go on Facebook. Having work and entertainment in one place has downsides, it makes entertainment feel kinda like work and work feel kinda not like work.” TEENS REFLECT ON WHAT LIFE WOULD BE LIKE WITHOUT TECHNOLOGY

Asking teens to reflect on life without technology may seem like asking teens to reflect on life without oxygen; however, panelists had a variety of responses to this question. Many of these responses led to head nods, and occasional giggles, from the other panelists and the audience. “Without technology I’d feel lonely because my close friends are apart from me in another area of the state, and my parents are not always home. Without technology I’d feel alone a lot of the time.” “Without technology I would not have as much connection to my friends. We as teens are much more scheduled nowadays. I have school and then sports practice and then hours of homework. My schedule doesn’t leave me much time for interacting with friends and my friends don’t live near me and I don’t have a driver’s license, so if I didn’t have this it would be harder to interact with them.” “If there was no technology…I’d probably be better at sports or something….” “Life without technology would definitely be boring. Technology opens doors, you can communicate. Like on Snapchat you can share what’s going on with friends really quickly and let them see what’s going on. You could just tell them…but it’s different when they can see it by sending them a photo. You can share more of your life…like…I can take a picture of being on this panel and send it to them.” In summary, reflections from the teens on this panel reflect the complex and nuanced world of technology that teens navigate every day. Adolescents must navigate a digital world of microcultures and strategic self-branding. Their comments illustrate that when technology is used with purpose and intention, it can be a tool for learning and self-growth. But if it is being used because it’s the newest, shiniest thing or as a tool to hurt others, it quite literally can be extra baggage weighing down a person. Adolescents’ views and experiences represented in this introduction illustrate that adolescents are worthy allies in pediatricians’ efforts to develop best practices and educational efforts about technology.

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Cross-Cultural and Cross-Platform Differences in Youths’ Social Networking Site Behavior Skyler T. Hawk, MA, MS, PhD* Department of Educational Psychology, The Chinese University of Hong Kong, Hong Kong

The explosion of social networking sites (SNSs) in the last decade has shown a great deal of variety in the services and features offered by various platforms. The increasing popularity of SNSs has also revealed the dynamic nature of this phenomenon, both in terms of how particular platforms have evolved over time and how new SNSs have emerged to meet specific demands. Although Facebook largely dominates both the international SNS market and related social and behavioral research, platforms continue to arise on both the national and global levels, and these new platforms remain relatively untapped contexts for understanding youths’ SNS activity.1 Physicians, educators, and researchers can easily become overwhelmed by the fast pace at which new SNSs appear and disappear and by the ways in which this rapid evolution complicates intervention efforts. As a result, it might be tempting to generalize research findings and concerns based on particular platforms to the broader context of all SNSs or to focus on 1 or 2 popular platforms at the expense of others. However, doing so ignores important distinctions between different sites that might contribute to youths’ SNS behaviors. Knowledge of the factors influencing SNS popularity, as well as the policy, structural, and feature differences that characterize particular SNSs, can assist in anticipating new online trends and their implications for youths’ well-being. It is important to recognize that most adolescents and young adults now use multiple SNSs, and a better understanding of how their motives for use vary between platforms can aid educators in mitigating potential harms and promoting the social benefits of these online environments. While previous works have provided a detailed history of the early days of SNSs and related research efforts,2 the present review focuses more on the structural and social aspects of several current platforms and their implications for continuing *Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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research in this field. In addition to SNSs that are popular internationally, it is important to consider SNSs that are largely unfamiliar to western users and researchers. In this regard, the present review places a special focus on China, perhaps the fastest growing but most politically complicated market for SNS platforms. Because others have suggested that aspects of predominant culture often translate to online interaction, it is important for researchers to have an in-depth knowledge of the features of indigenous SNSs as well as how differences in both culture and SNS platform structure might promote certain online behaviors.3,4 If research, social policy, and intervention efforts related to SNS behavior are to remain accurate and relevant, it is essential to consider how these potential issues might influence research questions, methodologies, and the generalizability of findings. Beyond Facebook: Indigenous SNSs and the Case of China

While SNSs such as Facebook, Twitter, and Instagram have gained large international followings, a number of indigenous platforms, such as Hyves (Netherlands), Biip (Norway), VK (originally VKontakte) (Russia), Orkut (India), CyWorld (Korea), and Mixi (Japan), have arisen to fill particular social and cultural niches. While Facebook and Twitter are available—and even widely used—in these countries, individuals might also opt for indigenous SNSs to nurture their local networks, more comfortably communicate in their own language, and share content that is highly pertinent to the local culture. Mainland China is particularly interesting in this respect because Facebook, Twitter, and YouTube all have been blocked in the country for several years. A number of homegrown SNSs have rushed in to fill this vacuum, including RenRen (translated as “everyone,” often called the Facebook of China), Sina Weibo (translated as “micro blog,” a platform similar to Twitter), Douban (a MySpace-like platform organized around various artistic and intellectual interests), and Weixin (“WeChat”). WeChat combines instant messaging with a personalized news feed and currently is the most dominant mobile SNS in China.5 All of these SNSs easily have more than 100 million subscriptions, thus demonstrating a more variable market than exists in countries dominated by Facebook and Twitter. Social media seem to be equally or even more important to Chinese users, with recent research suggesting that they actually spend more time on SNSs than do Americans.6 One recent study reported that 9.5% of sampled Chinese adolescents aged 12 to 17 years (which translates to more than 13 million youths) exhibited signs of problematic Internet use.7 With first-time Internet users in China still growing at a rate of 10% per year, the behaviors of Chinese young people present a highly dynamic context for SNS research and intervention efforts.8 In particular, the larger variety of Chinese SNSs can provide important clues regarding how particular structural, feature, and policy differences attract users and shape related behavior. Evolution of SNS Features, Policies, and Popularity

Numerous structural aspects of SNSs have changed over time. For example, commentators have noted a steep decline in popularity of sites that too slowly

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embraced users’ moves from PC-based to mobile-based platforms. This has been viewed as a partial reason for Facebook’s domination over MySpace9 as well as an issue that has contributed to the waning interest in RenRen in China.10 In contrast, WeChat was specifically launched as a mobile platform in 2011 and acquired more than 300 million users in the first 2 years alone.8 Mobile Internet traffic in China surpassed desktop Internet use as of early 2014, suggesting that the shift toward mobile SNSs likely will continue.5 The ability of individuals to immediately connect with others and to share their experiences in real time, regardless of their location, is an especially dramatic example of how SNSs have become integrated into everyday life. The features offered both within and between particular SNSs have also undergone modifications. For example, Facebook has tried to cater to users and advertisers by continually increasing the number of available services. Similarly, WeChat quickly evolved beyond instant messaging and posting personal photos to include a variety of features in order to maintain its entertainment value. In contrast, other currently popular sites have settled into various niches, such as microblogging (Twitter, Tumblr, Weibo), instant messaging (WhatsApp), sharing photographs and videos (Instagram, Flickr, YouTube), and professional networking (LinkedIn). Many SNSs also differ in their privacy policies in order to strike a balance between profitability, accountability, and encouraging their members to share a large amount of content. Some SNSs allow pseudonyms (eg, MySpace, Twitter, and WeChat), while others require individuals to register their actual identities (eg, Facebook, RenRen, and Weibo). Some SNSs have become popular because the information shared by users is not permanent (eg, Snapchat). Additionally, the ability to have multiple accounts, the amount of control over who sees particular information, and the amount of ownership that companies claim over users’ posted content all vary between these sites. Thus, there has been considerable variety in how specific SNSs attempt to appeal to new users and retain existing ones. It is important to note that studies conducted several years apart on the same SNS might not be comparable if such policies and features change substantially over time. Political concerns and youth culture surrounding SNSs have also evolved and have been equally crucial in determining the success and failure of particular platforms. One notable issue surrounding Chinese SNSs is the censorship of user-generated content. Some have suggested that stricter institutional control over traditional media outlets has led social and political activists in China to consider SNSs more effective for disseminating information and fueling open discussions among large groups of people.11 While both Chinese and western SNS companies actively delete posts deemed to be inappropriate or depicting illegal activity, some have suggested that the government of mainland China takes a more active role in initiating such moves.12 This is particularly the case with regard to sensitive political issues, such as criticism of the Communist Party, separatist sentiments in Hong Kong and Taiwan, and commemoration of

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the anniversary of Tiananmen Square. Reports of deleted content on sites such as Weibo and Douban have increased steadily in recent years. Beyond deletions, the government has also instituted policies mandating account suspensions for those discussing potentially volatile topics and prison sentences for those intentionally distributing false information. These crackdowns have had an especially sanitizing effect on Chinese platforms such as Weibo, which typically experiences large spikes in activity after major disasters and social or political events. Users have now become more reluctant to pass along sensationalized information or unsubstantiated rumors to a large number of followers, but these constitute a large portion of Weibo’s entertainment value.12 This government involvement has been at least partially blamed for the steep declines in Weibo’s popularity and user activity.8,12 In contrast, WeChat focuses on being a venue for interactions with smaller networks and closer ties. This has allowed users a relatively higher level of freedom from censorship and monitoring because of a reduced potential for broadcasting opinions and rumors about sensitive topics to a large number of followers.12 Even so, anecdotally, individuals expressed concern that posts related to the July 1, 2014, election protests in Hong Kong could be censored from their WeChat newsfeeds and private conversations. Such censorship and monitoring policies present challenges for those interested in the role of SNS in Chinese youths’ development of self-expression, political identity, and civic engagement. Adolescents and emerging adults are the primary users of many popular SNSs, and for them novelty is an essential component. Once particular media have become popular in the larger culture, it is common for young people to seek out new trends. Social networking sites have been no exception to this pattern. For example, scholars and news outlets have suggested that younger users have begun to retreat from Facebook en masse and to migrate to more novel networks that are not yet populated by parents, teachers, and family members.13 Not surprisingly, youths apparently are reluctant to share all aspects of their lives with their entire social network. Similarly, RenRen in China faced complaints from university students in 2009 when it began allowing nonstudents to register for the site.14 Although RenRen continues to struggle, recent evidence suggests that the reports of Facebook’s demise were premature.15 Facebook remains the most popular SNS among young people; 88.6% of late adolescents and young adults in the United States had an account as of late 2013. However, sites such as Instagram (51.5%), Twitter (43.7%), and Tumblr (35.5%) certainly are competing for users’ attention. Likewise, while older SNSs such as Weibo and RenRen likely remain important to Chinese young people because such sites allow them to quickly acquire information from and communicate with a larger network of childhood friends and relatives, youths might currently prefer their WeChat accounts for staying in touch with more proximal contacts.16 In other words, users likely connect to multiple SNSs because the different platforms fulfill particular social needs.17

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Such information suggests that youths are not wholly abandoning more established sites, but rather that they are diversifying their SNS use. This poses a challenge to research and intervention efforts because it suggests that a single individual’s motives for use, the “friends” with whom the user interacts, and the content he/she shares might vary considerably among the different sites. In this sense, different SNSs even within the same host country constitute particular subcultures with their own communities, norms, and styles of interaction, and users of different platforms might participate differently in each of them.4 Even to the extent that information shared on a certain SNS can be considered an accurate depiction of a person’s offline life, it is not necessarily a complete portrayal.18,19 As such, sweeping generalizations about SNS behavior, as well as the predictors and consequences of such activity, must be made with caution.4,20 Understanding how youths’ motives for SNS use might differ between cultures, as well as how the same users’ behaviors might change when they switch between different SNSs, is essential for researchers using related evidence to develop sound policy and interventions. Cross-Cultural and Cross-Platform Differences in SNS Behavior

Jackson and Wang21 gathered self-reports from both Chinese and American students on motivations for general SNS use (with questions such as “How much time per week do you spend on social networking sites?”) as well as personality factors (eg, extraversion, agreeableness) that might predict such motives. Users in both countries reported motives such as keeping in touch with family members, friends, and long distance contacts, acquiring information, and making new friends. However, American students reported a larger number of SNS contacts than did Chinese students, and they endorsed all motivations for use more strongly. Furthermore, personality characteristics tended to be stronger predictors of American students’ SNS motivations compared to their Chinese counterparts. The researchers conjectured that orientations inherent in collectivistic cultures, including the emphases placed on face-to-face interaction, family duty, and group harmony, might account for these patterns. Members of individualist cultures, in contrast, are more motivated to engage in strategic self-presentation in order to project the best possible image of themselves.22 Comparisons of college students on Facebook in the United States and in Singapore (relatively individualistic and collectivistic cultures, respectively) have shown that American students tend to update their profiles more frequently and more actively manage unwanted photo tagging by others in their network.23 However, American students with a very large number of “loose” ties in their networks also seem to be more willing to forego positive self-presentation in exchange for attention. A study of Korean CyWorld users and American Facebook users also found that college students in each culture endorsed the same basic motivations for using their respective sites (seeking friends, social support, information, entertainment, and convenience) and used the SNSs at similar frequencies.24 However,

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Korean students had a substantially smaller number of friends, on average, and their networks consisted of a higher proportion of close friends and family members. These differences were also reflected in each group’s reports of motivations for use. While American students found greater entertainment in making new contacts through Facebook, Korean students were more likely to use CyWorld for maintaining close relationships and obtaining social support. Taken together, this collection of studies suggests that youths select particular SNSs with specific goals in mind and that young people from individualistic and collectivistic cultures might approach their preferred SNSs with substantially different mindsets. Research comparing particular platforms against one another has been invaluable for demonstrating the general notion that user motives and behaviors across different SNSs are not identical. As noted by Panek et al,20 for instance, the 140-character limit for Tweets might make Twitter a less ideal platform than Facebook for self-promotional behavior. The same might not be true for China’s Weibo because although it has a similar interface and an identical character limit to Twitter, substantially more information can be conveyed with 140 Chinese characters than with 140 Roman characters. How youths choose and interact with different SNSs based on these kinds of fundamental structural differences constitutes an interesting area for both intracultural and cross-cultural research. Few studies have strongly considered potential intrapersonal variation in user behavior (eg, honesty, self-presentation, and extent or content of self-disclosures) between different SNSs. Such research might be more difficult in a cross-cultural context because it requires obtaining samples of participants who have access to and are familiar with multiple SNSs. One such study to do so examined a group of Chinese international students’ use of both RenRen and Facebook while they were in the United States.25 Findings showed that students used both SNSs (but especially Facebook) in order to expand their networks while they were abroad so that they could acquire social information and resources. In contrast, they used only RenRen to maintain close ties in their home country. Another study examined Chinese students’ use of both RenRen and Facebook while they were abroad in Singapore (where Facebook is the dominant SNS).4 Not only did these participants view the RenRen community as more collectivistic (ie, oriented toward sharing and conformity) than Facebook, but their patterns of use on each SNS actually reflected these differences. Specifically, both self-reports and observations of actual SNS behavior revealed that individuals engaged in more benevolent in-group sharing on RenRen (eg, distributing travel information that other contacts might find valuable) than they did on Facebook. Interestingly, these differences reflected patterns of behavior observed in participants’ larger network of friends on each SNS, suggesting conformity to prevailing norms of particular online cultures. In contrast to the aforementioned research examining separate, culture-based groups, these studies more effectively demonstrated that even the same individual’s network composition and behaviors might vary substantially between different

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SNSs and can switch rather flexibly, depending on how these particular platforms meet specific needs and motives. Conclusions

This review highlights how diversity in SNS platforms, their features and architecture, and related social policy are linked to youths’ SNS behaviors and motivations for use. While research on Facebook and Twitter continues to proliferate, it is important to consider whether the findings of such studies can be generalized across all SNSs, especially those that are indigenous to other countries. The unavailability of Facebook and Twitter to most Chinese youths has been a contributing factor in allowing Chinese companies to develop a wide range of alternative SNSs. The variety of different sites available to Chinese young people, the rapid changes in the popularity of these sites, and the continued increase in novice users offer exciting avenues for understanding trends in youth culture and the ways that different SNS features both reflect and modify prevailing norms. However, blocked platforms (eg, Facebook, Twitter, and YouTube) and government/corporate censorship might complicate comparisons of western and Chinese youths’ behaviors, as well as investigations of the content posted to Chinese SNSs. The Chinese context provides an example of an issue that is rarely considered in either western or cross-cultural research, namely, that today’s youth likely use a variety of different SNSs simultaneously in order to meet particular psychosocial needs. The different features and customs of particular SNSs constitute specific subcultures within the larger social networking phenomenon, and youths may participate differently in several of these communities. While prior studies have compared the motives and behaviors related to using different SNSs, such comparisons run the risk of creating a false dichotomy if memberships to different platforms are not mutually exclusive. The relatively few examinations of how the same individuals use different SNSs have demonstrated how youths might alter their posting behaviors and communications in concert with differing motives and perceived norms. While most SNSs have the potential to provide teens with similar benefits (eg, obtaining social support, acquiring information, making new friends, and maintaining existing relationships) and might pose similar risks (eg, increased narcissism,26 decreased empathy and prosocial behavior,27 less conservative views and behaviors related to alcohol,28,29 and risky disclosures and loss of privacy30), it is fairly unlikely that all SNSs pose these consequences equally for a particular individual. Interventionists aiming to combat negative outcomes and promote positive SNS use must consider whether the problematic activities of target groups are widespread or confined to a particular SNS and must address the platform-specific motivations that might contribute to such behavior. Researchers and policymakers must carefully consider the SNS platforms and methodologies used to investigate such issues in both prior and prospective empirical studies in order to make accurate and contemporarily relevant decisions.

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References 1. Wilson RE, Gosling SD, Graham, LT. A review of Facebook research in the social sciences. Perspect Psychol Sci. 2012;7:203-220 2. Boyd DM, Ellison NB. Social network sites: definition, history, and scholarship. J Comput Mediat Commun. 2007;13:210-230 3. Kim H, Coyle JR, Gould SJ. Collectivist and individualist influences on website design in South Korea and the U.S.: a cross-cultural content analysis. J Comput Mediat Commun. 2009;14:81-601 4. Qiu L, Lin H, Leung KY. Cultural differences and switching of in-group sharing behavior between an American (Facebook) and a Chinese (Renren) social networking site. J Cross Cult Psychol. 2013;44:106-121 5. China Internet Watch. China’s top mobile social apps by time usage. May 13, 2014. Available at: www.chinainternetwatch.com/7481/chinas-top-mobile-social-apps-by-time-usage/. Accessed May 30, 2014 6. Ji YG, Hwan H, Yi JS, et al. The influence of cultural differences on the use of social network services and the formation of social capital. Int J Hum Comput Interact. 2011;26:1100-1121 7. Zhang Y, Yang Z, Duan W, Tang X, et al. A preliminary investigation on the relationship between virtues and pathological internet use among Chinese adolescents. Child Adolesc Psychiatry Ment Health. 2014;8:1-7 8. Custer, C. The demise of Sina Weibo: censorship or evolution? February 4, 2014. Available at: www.forbes.com/sites/ccuster/2014/02/04/the-demise-of-sina-weibo-censorship-or-evolution/. Accessed May 31, 2014 9. Baer J. 6 lessons learned from the demise of MySpace. September 8, 2010. Available at: www.convinceandconvert.com/social-media-strategy/6-lessons-learned-from-the-demise-of-myspace/. Accessed April 6, 2014 10. Mishkin S. Weibo and RenRen highlight troubles facing Chinese web groups. May 22, 2014. Available at: www.ft.com/cms/s/0/120c7f24-e181-11e3-9999-00144feabdc0.html#axzz35p6zZLvu. Accessed May 27, 2014 11. Harp D, Bachmann I, Guo L. The whole online world is watching: profiling social networking sites and activists in China, Latin America, and the United States. Int J Communic. 2012;6:298-321 12. Rudolph J. Censorship, innovation, and China’s changing social media. February 5, 2014. Available at: http://chinadigitaltimes.net/2014/02/censorship-innovation-chinas-changing-socialmedia/. Accessed June 15, 2014 13. Wiederhold BK. As parents invade Facebook, teens tweet more. Cyberpsychol Behav Soc Netw. 2012;15:385 14. China Internet Watch. RenRen released new version app to retarget students. December 3, 2013. Available at: www.chinainternetwatch.com/4953/renren-released-new-version-app-retargetstudents/. Accessed May 18, 2014 15. Elliott N, Fleming G, Parrish M, Colburn C. Facebook dominates teens’ social usage: why the sky isn’t falling on the world’s favorite social network. June 24, 2014. Available at: www.forrester.com/ Brief1Facebook1Dominates1Teens1Social1Usage/fulltext/-/E-RES116135. Accessed June 25, 2014 16. Kan M. China’s Facebook, Renren, faces stiff competition. May 4, 2011. Available at: www.pcworld. com/article/227052/article.html. Accessed May 18, 2014 17. Rubin AM. Media uses and effects: a uses-and-gratifications perspective. In: Bryant J, Zillimann D, eds. Media Effects: Advances in Theory and Research. Hillsdale, NJ: Erlbaum; 1994: 417-436 18. Waggoner AS, Smith ER, Collins EC. Person perception by active verses passive perceivers. J Exp Soc Psychol. 2009;45:1028-1031 19. Weisbuch M, Ivcevic Z, Ambady N. On being liked on the web and in the “real world”: consistency in first impressions across personal webpages and spontaneous behavior. J Exp Soc Psychol. 2009;45:573-576 20. Panek E, Nardis Y, Konrath SH. Mirror or megaphone? How relationships between narcissism and social networking site use differ on Facebook and Twitter. Comput Human Behav. 2013;29:20042012

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21. Jackson LA, Wang J. Cultural differences in social networking site use: a comparative study of China and the United States. Comput Human Behav. 2013;29:910-921 22. Gudykunst WB, Yang S, Nishida T. Cultural differences in self-consciousness and self-monitoring. Communic Res. 1987;14:7-34 23. Rui J, Stefanone MA. Strategic self-presentation online: a cross-cultural study. Comput Human Behav. 2013;29:110-118 24. Kim Y, Sohn D, Choi SM. Cultural difference in motivations for using social network sites: a comparative study of American and Korean college students. Comput Human Behav. 2011;27:365-372 25. Li X, Chen W. Facebook or RenRen? A comparative study of social networking site use and social capital among Chinese international students in the United States. Comput Human Behav. 2014;35:116-123 26. Gentile B, Twenge JM, Freeman EC, Campbell WK. The effect of social networking websites on positive self-views: an experimental investigation. Comput Human Behav. 2012;28:1929-1933 27. Chiou W, Chen S, Liao D. Does Facebook promote self-interest? Enactment of indiscriminant one-to-many communication on online social networking sites decreases pro-social behavior. Cyberpsychol Behav Soc Netw. 2014;17:68-73 28. Egan KG, Moreno MA. Alcohol references on undergraduate males’ Facebook profiles. Am J Mens Health. 2011;5:413-420 29. Litt DM, Stock ML. Adolescent alcohol-related cognitions: the roles of social norms and social networking sites. Psychol Addict Behav. 2011;25:708-713 30. Christofides E, Muise A, Desmarais S. Risky disclosures on Facebook: the effect of having a bad experience on online behavior. J Adolesc Res. 2012;27:714-731

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Sex and Social Media: New Avenues for Hookups and New Opportunities for Interventions Heather R. Royer, PhD, FNP*a; Sean Young, PhD, MSb; Elizabeth C. Falk, MS, WHNP-BCc a Nurse Scientist, Wm. S. Middleton Memorial Veterans Hospital, Madison, Wisconsin; Assistant Professor of Family Medicine and Director, Center for Digital Behavior at UCLA, Los Angeles, California; cNurse Practitioner, The University of Wisconsin-Madison University Health Services, Madison, Wisconsin

b

Disclaimer: “This material is the result of work supported with resources at the William S. Middleton Memorial Veterans Hospital, Madison, WI. The contents do not represent the view of the Department of Veterans Affairs or the United States Government.”

Introduction

Sexual risk behavior among adolescents is a serious public health concern. Half of the nearly 19 million new sexually transmitted infection (STI) cases diagnosed annually occur among 15- to 24-year olds,1 and nearly 800,000 young women between the ages of 15 and 19 years become pregnant each year, many unintentionally.2 The social, economic, and public health effect of the outcomes of sexual risk behavior are well documented.3 Although extensive efforts have been made to determine the factors that contribute to sexual risk behavior in this population, with the emergence of social media we are only now beginning to understand the potential risks and benefits of this new technology.4 Social media are a common avenue for social interactions among adolescents, and, for many people, social media are central to their daily lives.5 Social media facilitate social communication through sharing pictures, messages, locations, and other multimedia content.6 As such, social media provide adolescents with a new avenue for identity expression and peer interaction.7 According to the Pew Institute, in 2012, 95% of teens between the ages of 12 and 17 years were online, *Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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and 81% had used social media. The high prevalence of social media use extends to older adolescents as well.8 Among the numerous social media platforms available, the most commonly used are Facebook (95%), followed by Twitter (26%), Instagram (11%), MySpace (7%), YouTube (7%), and Tumblr (5%).8 Research is emerging that, for adolescents, social media play an important role in sexual identity experimentation, romantic relationships, and sexual behavior. Social media allow teens to publicly display references to a variety of health risk behaviors, including sexual behavior.9 In fact, 24% of older adolescents display sexual references on their social networking profiles, with females more likely than males to display sexual content.10 Examples of sexual references include sexually suggestive pictures and personally written statements about sexual behavior. Among older adolescents, sexual reference displays have been found to be associated with their intention to become sexually active, suggesting that displays of sexual reference are developmental markers of sexual being.7 Furthermore, social networking has been found to play a role in the development of adolescent romantic relationships. Both male and female adolescents use social networking sites (SNSs) such as Facebook to learn about potential dating partners.11,12 Adolescent sexual health and social media are interconnected.4 It is increasingly important for physicians, nurses, and other health care providers (hereafter referred to as clinicians) to understand this relationship, particularly given the high rates of STIs and unintended pregnancies in this population.2,3 The purpose of this review is to describe the role of social media in adolescent sexual risk behavior and to describe new opportunities for using social media to improve the sexual health of this population. This will be followed by a discussion of the clinical implications for adolescent clinicians. Social Media and Sexual Health: New Risks Use and Risks of Using Social Media to Find Partners

Social media facilitate social communication through a variety of ways, and social exchanges between individuals who meet on social media often lead to offline sexual encounters (Table 1).6,13 In fact, social media can increase the chances that people will find sexual partners because of features that help people connect to others with similar interests.14 For example, many men who have sex with men (MSM) are now using global positioning system (GPS)-based social networking smartphone applications to identify and meet sexual partners based on geographic proximity.15 For example, Grindr, which was released in 2009, is a GPS-based mobile application that allows users to identify other users within their immediate proximity. Grindr was the first geosocial networking mobile application targeting gay/bisexual men, and it currently has more than 5 million active users worldwide.16 Several other gay/bisexual dating/hookup geosocial networking apps have subsequently emerged, such as Scruff and MISTER.17,18

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Table 1 Social Media and Sexual Risk Means of Social Media Use

Example

Finding partners GPS to find sexual partners in close proximity Sending messages Sharing sexual references, sexually explicit materials, or discussions about sexual orientation or sexual behaviors, to solicit sexual inquiries through online profiles or dating sites Presenting oneself to attract partners Customizing profiles to reflect social and sexual identity to attract potential partners

Studies have consistently found that, among MSM, using social networking technologies/the Internet to find sexual partners is associated with sexual risk behaviors, such as unprotected anal intercourse, previous STI diagnosis, and more sexual partners.6,13,15,19 Although most studies have focused on sex seeking and social media among MSM, increasing evidence suggests that heterosexual men and women also are using social media to look for sexual partners and engage in sexual risk behaviors.20,21 Given the popularity of geosocial networking apps among gay/bisexual men, many other similar apps for heterosexual users have become available, such as Tinder, Down, and Pure.22-24 Use and Risks of Using Social Media to Send Messages

Many social media users have used their profiles and chat programs to share sexual references, sexually explicit materials (photographs, videos, texts), or discussions about sexual orientation or sexual behaviors, to solicit sexual inquiries.11,25 For example, an increasing number of youth are now using Snapchat for “sexting.” Snapchat, an app that began growing in use in 2012, allows users to share pictures and video messages with others that will only be available for viewing for a limited amount of time (up to 10 seconds as of April 2014).26 The fleeting nature of shared content has helped to make this a popular new technology that can be used for sexting. Moreover, many individuals have sent or received sexual propositions as private messages on Facebook. In a recent survey, 24% of users did not list their true relationship status to keep their “options” open for this purpose.27 In fact, online dating sites such as Match.com (with more than 2.8 million paid subscribers), POF.com (Plenty of Fish), eHarmony, and OkCupid have achieved immense popularity. Some dating sites, such as OkCupid, allow users to search for profiles of individuals who are interested in casual sexual encounters or hookups.28 Similarly, researchers have found that using social media/the Internet for sex seeking among heterosexual individuals is related to sexual risk behaviors, such as unprotected penetrative sex.20,21

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Use and Risks of Presenting Oneself Online to Attract Partners

Social media technologies are being used as tools for sex seeking by allowing users to browse and learn about potential partners’ profiles (walls) or by allowing users to directly communicate with potential partners. For example, social media users often customize their profiles to reflect their social and sexual identity, providing useful information to others who might be searching their profiles to gain information. A recent study found that sexual references altered viewers’ sexual expectations.11 Upon viewing sexual references on female students’ social media profiles, a group of male college students indicated increased sexual expectations such that sexual references fueled the belief that the profile owners were more prone to engage in sexual activity.11 These heightened sexual expectations might facilitate viewers to initiate sexual communication. Social media also have the potential to connect individuals who are specifically looking for stigmatized sexual behaviors, such as “bareback” (unprotected, typically anal, sex) or group sex29; however, little is known about the relationship between sexual references and expectations of sexual risk behaviors. Sexual communication allows individuals to manage their sexual risk and involves 2 processes: sexual negotiation and serostatus disclosure.30 Studies have found that individuals are more likely to engage in sexual negotiation online, discuss sexual preferences (eg, likes and dislikes) and safety boundaries (eg, condom use), and come to an agreement before meeting offline.30 While serostatus disclosure (a process for potential partners to mutually disclose their HIV status) is equally important, research found that MSM social media sex seekers often are unaware of their HIV risk and, therefore, inconsistently inquire about their potential partners’ HIV status.15,19,30 These individuals were more likely to have sex with partners of unknown or positive status and to increase their HIV risk.15,19,30 More studies are needed to gain further understanding of the mechanism of how social media sex seeking is related to sexual risk behavior in order to prevent STIs and HIV. Social Media and Sexual Health: New Opportunities

Clinicians and researchers have begun to recognize the immense potential of social media as an effective platform for delivery of sexual health interventions.4 Social media are particularly intriguing for sexual health intervention delivery because they provide a mechanism for circumventing the known culture of silence and stigma that surrounds sexual health, which often inhibits access to clinical service, hinders STI information seeking, and stifles open communication.31 Additional benefits include the potential to increase the reach and scalability of interventions, improve fidelity, facilitate data collection, and allow for individualization and interactivity between peers and interventionists. The latter 2 are critical to successful behavior change.4

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Social Media and Sexual Health Promotion

To understand how social media are being used to improve sexual health, it is important to first understand the extent to which SNSs have been used to deliver sexual health messages. In 2011, Gold and colleagues32 conducted a systematic review of 178 sexual health promotion activities identified from 3 sources: published scientific literature, electronic sources, and 2 SNSs (Facebook and MySpace). They found that health promotion activities were most commonly conducted by nonprofit organizations (43%), governmental agencies (16%), private sector organizations (12%), and academic institutions (11%). Thirty-two percent of the health promotion activities were conducted by clinical care delivery organizations. The most commonly used SNSs for health promotion activities were Facebook (71%), MySpace (46%), and Twitter (30.3%). The most common activities included having an organizational or program presence on an SNS (63%), delivering a campaign or intervention (29%), and connecting individuals who were similar (6%). The content of the health promotion activities focused largely on general sexual health (57%) but also included activities specific to HIV (25%) and STIs (7%). The audience of the activities included young people (30%), people living with HIV (7%), and individuals in the sexual minority (6%). Most of the health promotion activities (78%) involved providing sexual health information, while 49% provided direct referrals to clinical services. Gold and colleagues point out that few reports of social media interventions were published in the academic literature. Although there is evidence that social media are being used for sexual health promotion, little is known about the effect of these activities. Effect of Sexual Health Interventions Delivered via Social Media

In 2012, Guse and colleagues33 conducted a systematic review to determine the effect of digital media-based interventions on sexual health knowledge, attitudes, and behaviors of adolescents aged 13 to 24 years. New digital media were defined as user-driven interactive forms of communication, including text messaging, SNSs, Web sites, e-mail, chat rooms, videos, and virtual worlds. The authors found that few of the studies were designed to evaluate the effect on sexual health outcomes. Instead, many studies described the content, feasibility, or acceptability of interventions using new media. Of the 10 studies that met inclusion criteria and were reviewed, 8 described Web-based interventions, 1 used mobile phones, and only 1 empirically evaluated the effect of an intervention delivered via an SNS.25 Three of the interventions showed statistically significant effects on behavior, specifically, 2 delayed the initiation of sex, and 1 encouraged users to remove sexual references from their SNS profiles. Seven interventions influenced psychosocial outcomes like abstinence attitudes and condom self-efficacy, although the results were not always in the expected direction. Finally, 6 interventions increased knowledge of sexual health, including HIV, STIs, and pregnancy. We currently lack conclusive evidence about the actual effect of interventions delivered via SNSs.

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The 2009 SNS study led by Dr Megan Moreno included in the review by Guse and colleagues33 was the first to examine the effect of a sexual health intervention delivered via SNS.25 This was a randomized controlled pilot interventional trial to determine whether, among at-risk adolescents, an online intervention reduced references to sex and substance abuse on an SNS. Participants were individuals aged 18 to 20 years with a public MySpace profile that included 3 or more references to sexual behavior or substance abuse. The intervention group received an e-mail directly into their MySpace Web profile from Dr Meg, an adolescent medicine physician. The e-mails included information about the risks associated with online personal disclosures, as well as a link to a Web site about STIs and free chlamydia testing. The authors found that a brief e-mail intervention reduced the number of sexual references in the online profiles of at-risk adolescents.25 Since the review by Guse and colleagues in 2012, several other studies have examined the effect of social media-based interventions.34-37 In 2012, Bull and colleagues34 conducted a randomized controlled trial to determine whether STI prevention messages delivered via Facebook prevented increases in sexual risk behavior among youth. The “Just/Us” intervention page on Facebook contained content about 8 sexual health topics. One week was dedicated to each topic. Youth facilitators posted updates daily in the form of video links, quizzes, games, and discussions. Participants completed a follow-up behavioral risk assessment after 8 weeks of participation and again at 6 months. The Facebook-delivered “Just/Us” intervention prevented declines in condom use in the short term. The authors noted that the small to medium effect sizes of their current short-term outcomes were similar to the effect sizes found in a meta-analysis of Internet interventions, suggesting that use of an SNS for sexual health intervention delivery is at least equally as effective as other technology-based approaches.34 In 2013, Young and colleagues35,36 conducted a mixed-methods randomized controlled trial to determine whether black and Latino MSM were willing to use peer-led HIV prevention social networking groups for HIV prevention communication and to request a home-based HIV testing kit. The inclusion criteria were age 18 years or older, living in Los Angeles, had a Facebook account, and had sex with a man in the past year. The average age of the participants was 31.2 years (SD 10.6 years). Using Facebook, participants were randomly assigned to either a secret HIV prevention intervention group or a general health (control) group. During a 12-week period, trained peer leaders communicated with the intervention group about HIV prevention. Participants were encouraged to use Facebook as they normally would. Participants could request 1 free home-based HIV testing kit during the intervention. The authors found that, compared to those in the control groups, participants in the intervention groups were 24% more likely to request a home-based HIV test.36 They also found high engagement in social media, with more than 95% of intervention participants using the social media platform, and found that those who discussed HIV prevention with

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other group members had more than 9 times the odds of requesting an HIV testing kit.35 They concluded that Facebook can serve as an innovative forum to increase both HIV prevention discussions and HIV testing requests among MSM.35,36 Finally, the effect of an ongoing national social media-based campaign to encourage STI testing was evaluated.37 The Get Yourself Tested (GYT) campaign was launched to encourage STI testing among sexually active youth younger than 25 years. The campaign was developed through a partnership with MTV, the Kaiser Family Foundation, and Planned Parenthood Federation of America (PPFA). The hub of the campaign is the Web site GYTNOW.org, which has a presence on Facebook and Twitter. An evaluation was conducted to assess the first 2 years of campaign engagement and associations with STI testing among youth. Three data sources were used: event and media tracking metrics through Facebook and Twitter, STI patient data from PPFA health centers, and national trend data from clinics participating in national infertility prevention activities (specifically chlamydia testing). Although there are limitations to assessing the community-level effects of a national campaign, there was evidence that the GYT campaign reached youth and was associated with increased STI testing.37 As we consider the use of social media to improve sexual health, the benefits and the limitations to this approach must be considered. In 2013, Moorhead and colleagues38 conducted a systematic review of 98 articles to determine the benefits and limitations of using social media for health communication. The benefits of social media use for the general public, for patients, and for health professionals are numerous. Benefits include the ability to increase the quantity of interactions with others and consequently provide additional access to available, shared, and tailored information. Social media can improve access to health information for those who may not easily have such access through traditional means. Social media provide a platform to obtain social and emotional support from peers. Social media also can be used for public health surveillance, such as monitoring public response to health issues,39 identifying areas for intervention efforts, and circulating tailored health information to specific communities. Moorhead and colleagues38 concluded the discussion of the benefits by describing the potential role of social media in influencing health policy. The common limitations of social media for health communication cited by Moorhead and colleagues included concerns about the quality of social media-based health information as well as the lack of reliability, confidentiality, and privacy.39 Clinical Implications for Adolescent Medicine Clinicians

The purpose of this review was to describe the role of social media in adolescent sexual risk behavior and to describe new opportunities for social media use to improve the sexual health of this population. The following are our recommendations for adolescent medicine and pediatric clinicians.

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Talk to Adolescents about Their Social Media Use

Given the ubiquitous use of social media among adolescents, a discussion of social media use should be incorporated into clinical assessments. A key component to a developmentally appropriate psychosocial interview is a discussion of an adolescent’s environment. With the emergence of social media, environment now extends beyond structured buildings like homes and schools to online social networks. Therefore, the environmental assessment should include a detailed discussion of social media use, including the types social media sites visited, the types of content posted and viewed (with a particular emphasis on sexual references), privacy strategies, and the use of social media for relationships or sexual activity. The answers elicited from this assessment can provide rich information that can be used to enhance the clinician’s understanding of an adolescent’s risk profile beyond questions about whether or not someone is sexually active. This information can then be used to direct educational messages and clinical care, such as STI/HIV screening and contraception targeted to the specific risk profile of the adolescent. For example, if an adolescent indicates that he or she uses Tinder (social media site for hookups), the clinician can be alerted to the need for discussing STI/HIV screening and prevention and perhaps expanding the type of routine STI screening given the varied the geographic locations and frequent anonymity of their patient’s sexual partners. Furthermore, an assessment of social media use may provide a natural transition into a discussion of sexual health. Consider an adolescent who identifies as LGBT or is gender nonconforming but has not disclosed this information to the clinician. A discussion about social media use may disclose use of social networks specific to MSM, LGBT, or gender nonconforming youth, and can provide another avenue for the clinician to assess need in this area. This is of particular importance given the unique needs and clinical care necessary to address the added risks faced by this population (eg, sexual risk behavior, STI/ HIV, depression, substance abuse, suicide). Furthermore, a clinician who is able to demonstrate knowledge and understanding of the adolescent’s life experiences may foster more open communication with the patient.40 Talk to Parents about Adolescent Social Media Use

Parents play an integral role in the health of their adolescents. Clinicians should be encouraged to talk with parents about the role of social media in adolescent sexual health. This can include discussion of sexual reference display, privacy, and use of social media for relationships or sexual activity. Parents should be encouraged to have an open dialogue with their adolescents about social media use. Furthermore, because parents commonly have difficulty talking with their kids about sexual health, talking about social media use may provide an effective method for transitioning into a discussion about sexual risk and health. Clini-

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cians can direct parents to social media resources for parents. One such example is Sex, Drugs ‘n Facebook: A Parents Toolkit for Promoting Healthy Internet Use written by adolescent medicine physician and scientist Dr Megan Moreno, an expert on social media and adolescent health. Consider Use of Social Media for Intervention Delivery

Counter to the sexual health risks associated with social media is the potential benefit of interventions delivered using this highly accessible platform. The evidence suggests that social media-based sexual health interventions show promise; however, more programs and evaluations are needed before conclusions about efficacy can be reached with confidence.4,33 As it stands, clinicians can consider directing adolescents to established sexual health interventions delivered via social media as an extension of the care they provide their patients. Furthermore, clinicians may consider harnessing social media technologies to develop new social media-based sexual health interventions and expand the clinical care they currently provide. Clinicians should consider partnering with researchers to determine ways of tracking outcomes of social media-based interventions as a means to Table 2 Opportunities and Examples of Social Media-Delivered Sexual Health Interventions Opportunity

Example

Platform to obtain social and emotional Private, safe SNS feature for adolescents with an STI support from peers to share management experiences Public health surveillance Posting public health message recommending HPV vaccine to an SNS and monitoring public response Target areas for intervention efforts Syphilis prevention messages posted to MSM hookup SNS Increase access to care for those in Clinic-facilitated SNS with private chat feature that rural communities allows for communication between adolescents and physicians Reduce barriers to care seeking (eg, privacy, Virtual visits for pregnancy prevention education and embarrassment, transportation) contraception via SNS Tailor intervention delivery Tailored health promotion messages based on patient-selected sexual health goals Data collection Monitoring adherence to contraceptive regimen Health promotion and education Peer-delivered HIV prevention messages shared on SNS Extend reach and timeframe of SNS-delivered reinforcement activities after a condom intervention delivery use intervention for at-risk teens at 2 months and 6 months Partner notification Notify partners of the need for STI testing privately and anonymously using SNS, including clinic locators based on geographic location Directing to clinical care Include condom vendor (eg, pharmacy) location on geosocial networking app HPV, human papillomavirus.

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contribute to the advancement of the emerging science of social media aimed at improving adolescent sexual health. Table 2 includes a description of the various opportunities for social media-based sexual health interventions. In conclusion, social media are interwoven into the lives of today’s adolescents. Social media can be used in ways that present sexual risks such as sending sexually explicit messages, locating casual sex partners, and presenting oneself to attract partners. Conversely, social media may present many opportunities for improving sexual health outcomes through increasing access to care, public health surveillance, data collection and social support. Adolescent sexual health outcomes have presented a long-standing challenge to clinicians for many reasons. Rather than viewing social media as solely another challenge to sexual health, clinicians should also be mindful of the many novel and innovative opportunities it affords. References 1. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36:6-10 2. Guttmacher Institute. U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity. New York: Guttmacher Institute; 2010 3. Maynard RA. Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy. Washington, DC: Urban Institute; 1997 4. Collins RL, Martino S, Shaw R. Influence of new media on adolescent sexual health: evidence and opportunities. WR 761 ed. Santa Monica, CA: RAND Health; 2010 5. Lenhart A, Madden M, Smith A, Macgill A. Teens and social media. Pew Research Internet Project. December 19, 2007. Available at: www.pewinternet.org/2007/12/19/teens-and-social-media/. Accessed February 26, 2014 6. Young SD, Szekeres G, Coates T. The Relationship between online social networking and sexual risk behaviors among men who have sex with men (MSM). PLoS One. 2013;8(5):e62271 7. Moreno MA, Brockman LN, Wasserhiet JN, Christakis DA. A pilot evaluation of older adolescents’ sexual reference displays on Facebook. J Sex Res. 2012;49(4):390-399 8. Social Networking Fact Sheet. Pew Research Internet Project. Available at: www.pewinternet.org/ fact-sheets/social-networking-fact-sheet/. Accessed February 26, 2014 9. Moreno MA, Parks M, Richardson LP. What are adolescents showing the world about their health risk behaviors on MySpace? MedGenMed. 2007;9(4):9 10. Moreno MA, Parks MR, Zimmerman FJ, Brito TE, Christakis DA. Display of health risk behaviors on MySpace by adolescents: prevalence and associations. Arch Pediatr Adolesc Med. 2009;163(1):27-34 11. Moreno MA, Swanson MJ, Royer H, Roberts LJ. Sexpectations: male college students’ views about displayed sexual references on females’ social networking web sites. J Pediatr Adolesc Gynecol. 2011;24(2):85-89 12. Moreno M, Royer H, Fernandez-Lambert, Stewart M, Krueger L. Young adult females’ responses to male “sexpectations” online. Presented at the University of Wisconsin-Madison Undergraduate Research Symposium; April 10, 2014, Madison, WI 13. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. J Am Med Assoc. 2000;284(4):443-446 14. Rietmeijer CA, Bull SS, McFarlane M. Sex and the Internet. AIDS. 2001;15(11):1433-1434 15. Landovitz RJ, Tseng C-H, Weissman M, et al. Epidemiology, sexual risk behavior, and HIV prevention practices of men who have sex with men using GRINDR in Los Angeles, California. J Urban Health. 2013;90(4):729-739 16. Grindr Los Angeles. Grindr Web site. Available at: grindr.com. Accessed December 30, 2013

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1 7. SCRUFF Web site. Available at: www.scruff.com/. Accessed May 12, 2014 18. MISTER Web site. Available at: www.misterapp.com/. Accessed May 12, 2014 19. Toomey KE, Rothenberg RB. Sex and cyberspace—virtual networks leading to high-risk sex. J Am Med Assoc. 2000;284(4):485-487 20. Mcfarlane M, Kachur R, Bull S, Rietmeijer C. Women, the Internet, and sexually transmitted infections. J Womens Health. 2004;13(6):689-694 21. Bolding G, Davis M, Hart G, Sherr L, Elford J. Heterosexual men and women who seek sex through the Internet. Int J STD AIDS. 2006;17(8):530-534 22. Tinder Web site. Available at: www.gotinder.com/. Accessed May 12, 2014 23. DOWN Web site. Available at: www.downapp.com/. Accessed May 12, 2014 24. Pure Web site. Available at: www.getpure.org/en/. Accessed May 12, 2014 25. Moreno MA, VanderStoep A, Parks MR, et al. Reducing at-risk adolescents’ display of risk behavior on a social networking web site: a randomized controlled pilot intervention trial. Arch Pediatr Adolesc Med. 2009;163(1):35-41 26. O’Brien J. Snapchat not sexting-safe, cops warn. Sun News. May 11, 2014. Available at: www.sunnewsnetwork.ca/sunnews/canada/archives/2014/05/20140511-170607.html. Accessed May 12, 2014 27. Kylstra C. How Facebook has changed sex. Available at: www.menshealth.com/mhlists/facebooksex/. Accessed May 12, 2014 28. OkCupid Web site. Available at: www.okcupid.com. Accessed May 12, 2014 29. Davis M, Hart G, Bolding G, Sherr L, Elford J. Sex and the internet: gay men, risk reduction and serostatus. Cult Health Sex. 2006;8(2):161-174 30. Carballo-Diéguez A, Miner M, Dolezal C, Rosser BS, Jacoby S. Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the Internet to seek sex with other men. Arch Sex Behav. 2006;35(4):473-481 31. Hood JE, Friedman AL. Unveiling the hidden epidemic: a review of stigma associated with sexually transmissible infections. Sex Health. 2011;8(2):159-170 32. Gold J, Pedrana AE, Sacks-Davis R, et al. A systematic examination of the use of online social networking sites for sexual health promotion. BMC Public Health. 2011;11(July):583 33. Guse K, Levine D, Martins S, et al. Interventions using new digital media to improve adolescent sexual health: a systematic review. J Adolesc Health. 2012;51(6):535-543 34. Bull SS, Levine DK, Black SR, Schmiege SJ, Santelli J. Social media-delivered sexual health intervention: a cluster randomized controlled trial. Am J Prev Med. 2012;43(5):467-474 35. Young SD, Jaganath D. Online social networking for HIV education and prevention: a mixedmethods analysis. Sex Transm Dis. 2013;40(2):162-167 36. Young SD, Cumberland WG, Lee S, et al. Social networking technologies as an emerging tool for HIV prevention: a cluster randomized trial. Ann Intern Med. 2013;159:318-324 37. Friedman AL, Brookmeyer KA, Kachur RE, et al. An assessment of the GYT: Get Yourself Tested campaign: an integrated approach to sexually transmitted disease prevention communication. Sex Transm Dis. 2014;41(3):151-157 38. Moorhead SA, Hazlett DE, Harrison L, et al. A new dimension of health care: a systematic review of the uses, benefits and limitations of social media for health communication. J Med Internet Res. 2013;15(4):e85 39. Young SD, Rivers C, Lewis B. Methods of using real-time social media technology for detection and remote monitoring of HIV outcomes. Prev Med. 2014;63(June):112-115 40. Thorne SE, Kuo M, Armstrong EA, et al. “Being known”: patients’ perspectives of the dynamics of human connection in cancer care. Psychooncology. 2005;14:887-898

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Online Pro-Eating Disorder (Pro-ED) Activity Alina Arseniev-Koehler, BA*a,b; Laura Hooper, MSc; Hedwig Lee, PhDa a University of Washington Department of Sociology, Seattle, Washington; bSeattle Children’s Research Institute, Center for Child Health Behavior and Development, Seattle, Washington; cSeattle Children’s Hospital, Nutrition Department and Division of Adolescent Medicine, Seattle, Washington

INTRODUCTION

Eating disorders (EDs) are psychological disorders with physical consequences characterized by a preoccupation with food and weight, body image distortion, use of harmful methods for weight control, and denial of the seriousness of the disorder. These disorders are particularly prevalent among adolescents and young adults.1 In the United States (US), an estimated 2.7% of adolescents have been diagnosed with a clinical ED.2 Disordered eating behaviors in adolescents are even more common; 28% of adolescent boys and 61% of adolescent girls report that they use unhealthy weight control behaviors, such as skipping meals, taking diet pills, and smoking more cigarettes to control their weight.3 Eating disorders and disordered eating behaviors impose a heavy burden on the overall health and well-being of adolescents.1,4 Eating disorders are also associated with high mortality rates.5 The growth of the Internet has resulted in proliferation of expression and connection via online social sites, especially among adolescents for whom social media use is the most prevalent and frequent.6 It also has resulted in the exchange of health information. Information seeking and socialization online may serve a specific purpose for individuals whose health condition is socially isolating, such as those suffering from an ED. Pro-eating disorder (pro-ED) movements first emerged in the 1990s, along with the Internet. The re-emergence of the Internet-based social pro-ED movement is not surprising considering the social

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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isolation commonly experienced by adolescents with EDs and the anonymous connections instantaneously accessible online, most often with little to no parental oversight. Pro-ED

Pro-eating disorder movements include pro-Ana (Anorexia) and pro-Mia (Bulimia), and their online rhetoric aims to provide support to maintain disordered eating behaviors.7,8 This activity and content are decentralized and freely migrate between emergent online social sites, such as forums and blogs, and social media sites such as YouTube, Tumblr, and Facebook. Numerous content analyses of pro-ED online sites have found common elements. First, most include thinspiration, a term used for images, clips, and quotes that are used to create the illusion that emaciated bodies are beautiful and desirable.9-11 Second, they are sources of information exchange, providing tips and tricks for weight loss and concealment of ED symptoms.11-14 Finally, pro-ED sites contain interactive elements such as message boards, which may be sources of social expression and connection.10 Moreover, because the adolescents who are most at risk for EDs also are the most frequent and prevalent users of social media, it is critical that caregivers and physicians be aware of the pro-ED movement online and its clinical relevance to disordered eating. Scope of Pro-ED Content and Users Access and Accessibility of Pro-ED Among Adolescents

Pro-eating disorder content is both easily accessible to and widely accessed by a variety of adolescents and young adults. One study reported more than 13.2 million searches annually for pro-ED Web sites on Google.15 In a survey study of 1218 adult pro-ED users, 17% maintained their own pro-ED sites, while about 6% maintained a pro-recovery site.16 It also has been estimated that these sites may outnumber pro-recovery sites by a ratio of 5:1.12 Social networking sites such as MySpace and Facebook contain groups dedicated to pro-ED content. For example, 1 study found over 421 groups on MySpace and over 500 on Facebook using pro-ED search terms in the fall of 2008.11 Previous research identified numerous pro-ED sites using key terms in search engines16,17; thus, for adolescents, pro-ED content may be simply a few search terms away. Specifically, in a survey study of ED patients, just under half found pro-ED sites through chance searches.12 Pro-eating disorder content also is accessible because it is primarily public; an examination of 180 active pro-ED sites found that 91% were freely open to the public.10 Indeed, viewing ED-related information is relatively common among these age groups. A study of 1575 undergraduate females in the United States found that 13% had viewed either a

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pro-ED site, a pro-recovery site, or a site with professional information on EDs, and about 2% had only ever viewed pro-ED sites.18 A study in Belgium of 711 adolescents enrolled in a secondary school found that 12% of girls and nearly 6% of boys had ever visited a pro-ED Web site. Notably, one-third viewed the existence of these Web sites as “somewhat good, good, or very good,” with the remaining viewing them as “somewhat bad, bad, or very bad.”19 These sites can be enticing to adolescent users given that most of the sites include interactive features such as personalized diet-related tools.10 Users Include Diagnosed and Undiagnosed Individuals

Regular users of these sites include individuals with diagnosed and undiagnosed EDs but also wannabe anorexics (wannarexics).14,20 Figure 1 illustrates the overlap between diagnosed ED patients and pro-ED users. A study of pro-ED site users older than 18 years found that by self-report about 40% of the users had been formally diagnosed with an ED, and about two-thirds had never been in treatment. Despite the lack of professional diagnoses and treatment, users had high levels of ED pathology and impaired quality of life on clinically validated tests.16 Another study of 50 pro-ED users aged 14 to 30 years similarly found that users had a wide range of weight but tended to be normal weight. Nearly all reported currently engaging in disordered eating behaviors: 90% restricted food intake and 43% purged or vomited, and they scored significantly higher than age-matched controls on clinically validated tests for ED pathology. Only 40% of participants reported having received formal ED diagnoses, but all had previously undergone treatment.13 While based on self-report, the prevalence of clinically significant ED pathology and the low rates of diagnoses are not surprising. Studies of ED pathology indicate that most patients who display clinically significant symptoms of EDs do not seek treatment.21

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Fig 1. Pro-eating disorder (pro-ED) site users and overlap with eating disorder (ED) patients.

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Perhaps unsurprisingly, among those with diagnosed EDs, use of pro-ED and ED-related online social sites is even more prevalent. For example, 1 study found that among 76 adolescent and young adult ED patients, just over half visited either nonprofessional pro-recovery or pro-ED sites, with 35% of all patients visiting pro-ED sites and 25% of all patients visiting both site types.12 However, the amount of time spent on pro-ED sites varied widely. Mean site usage was 2.8 hours per week (SD 4.5), with some patients using the sites up to 20 hours per week.12 This finding suggests that while patients are commonly aware of such sites, the frequency and duration of visitation are variable. Age and Gender Demographics

There is evidence that pro-ED site usage is more common in females, which likely reflects the female preponderance for EDs.7,10,13,16 In a study of 711 Belgian adolescents, girls were 3.1 times more likely than boys to have visited pro-Ana Web sites.19 It is evident that users range from adolescents to young adults.10,13,16 Pro-eating disorder exposure is common among adolescents, and social media is an exchange of information. Thus, intervention and media literacy efforts should be directed at all age groups potentially involved in pro-ED activity. Spectrum of Ideologies: Pro-ED to Pro-Recovery

Across sites and even within each site, ideologies fall on a spectrum from proED to pro-recovery.10,13,14 Despite the presence of informal pro-recovery sites and links, ED patients also report seeking, learning, and utilizing weight loss tips and tricks on both pro-recovery as well as pro-ED sites,12 producing concern that clinical implications must be directed at the spectrum of such resources. In a survey of adult pro-ED users solicited on 296 sites, less than 33% of respondents saw their ED as a choice, 25% saw themselves as sick, 13% were recovering or trying to do so, just 11% saw themselves as “healthy,” and the remaining 20% were a combination of the other categories. Furthermore, 44% of respondents reported that they completely or very much supported the pro-ED movement, 40% supported it only a little bit or somewhat, and the remaining 16% did not support it at all.16 Another study found that almost 1 in 5 pro-ED users reported that the sites harmed them.7 Additionally, of 20 pro-ED sites examined in 1 study, 42% included links to resources, such as general information on EDs and recovery.9 The ambivalence of content regarding pro-ED and pro-recovery is consistent with the ambivalence toward recovery commonly seen in patients being treated for EDs.22,23 What Are the Clinical Implications of Pro-ED?

In a position statement, the Academy for Eating Disorders, which is the world’s largest professional organization for those who work with individuals suffering from EDs, announced it was “extremely concerned about the proliferation of

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‘pro-anorexia’ Web sites” and that “the Web sites pose a danger in that they promote anorexia nervosa as a lifestyle, provide support and encouragement to engage in health threatening behaviors, and neglect the serious consequences of starvation.”24 There is a large body of theoretical and empirically grounded research that underlies the concerns that involvement in pro-ED cyberspaces poses a risk with regard to disordered eating pathology. Social Support and Anonymity

Numerous analyses of pro-ED Web sites indicate that they are sources of social support for site users.10,13,25-27 In particular, 1 study found that users of ED forums reported lower levels of social support than age-matched controls, and that they used these sites to fill this deficit.13 This is consistent with knowledge that ED patients commonly lack in-person social support,28-30 in part because of the covert nature of the illness and because EDs are recognized as stigmatizing and alienating illnesses.22,31,32 Online ED interaction provides the opportunity to gain lacking social support anonymously without repercussion from concerned offline relationships. However, the clinical implications of support received from pro-ED social networks warrant concern. Like membership in other social groups, pro-ED group membership generates solidarity and emotional energy, which serve to cultivate users’ identity as “pro-Ana” individuals in an established pro-ED network.9,14,17 Indeed, within many pro-ED online social sites, individuals openly identify with “Ana” or “Mia,” which are anthropomorphic representations of the idealized anorexic and bulimic, respectively.33 This cultivates an ED identity,14,17 which can entrench a patient further into the distorted thought process. Many physicians and parents are unaware that the adolescents interact with these sites. A survey study of adolescent ED patients and their parents/caregivers found that over half (52%) were aware of pro-ED sites. However, over half (52%) also were unsure of whether their child visited these sites, and less than one-third (27%) discussed these sites with their child.12 This finding suggests that physicians need to make efforts to increase caregiver awareness of pro-ED activity. It also warrants research into improved dialogue between physicians, adolescents, and caregivers regarding pro-ED interactions. Competition Among Users and Group Membership

Competition among individuals with EDs exists in various in-person settings, such as inpatient treatment and group therapy.34 This phenomenon also occurs in the online pro-ED setting. There is a need to regularly display one’s “authenticity” as an ED sufferer, which is thought to solidify membership in the pro-ED movement or a specific network of pro-ED users.14,17,20 The negative consequences of a competitive environment may be more explicit and are even recog-

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nized by some pro-ED users.7 From a physician’s perspective, this competition is extremely harmful. As patients become increasingly competitive with their online peers, they are essentially competing to see who can engage in the most destructive behavior. Physicians who work with eating disordered patients should be familiar with such pro-ED online competitions. Exchange of Weight Loss and Concealment Information

Pro-eating disorder sites commonly include tips and tricks for weight loss and purging, including concealment of ED symptoms from physicians and friends/ family.10,11,35 Specifically, a survey study of adolescent ED patients found that nearly all of the pro-ED site users learned new weight loss or purging methods, most learned of diet pills, laxatives, or supplements, and most actually used new weight loss or purging methods as a result of visiting pro-ED sites.12 Learning, but additionally, utilizing information on weight loss and purging methods from pro-ED sites was also found to be prevalent among pro-ED users.7,13,16 The prevalent exchange of information on concealment also is grave. A study of pro-ED sites found that of 180 sites examined, 43% included advice specifically on concealing ED symptoms.10 Users also commonly discuss ED treatment programs and offer advice on how to satisfy discharge criteria within the program while maintaining anorexic behaviors.14 Exchange of information for weight loss may lead to serious consequences for any at-risk individual, but advice on unhealthy weight control methods and concealment is especially serious for ED patients. Physicians and caregivers of ED patients, as well as any physicians working with adolescents, should be aware of information and tips exchanged on such sites so that they are better able to recognize signs of incidence and maintenance of ED pathology.35 Reinforcement of the ED Identity

Ultimately, online ED and pro-ED socialization and expression may serve to normalize, reinforce, or even cultivate an ED identity.14,17,20 As a patient becomes more entrenched in the ED mindset and more malnourished, this process can derail treatment efforts to nourish the body and show the adolescent that he/she has a life worth living outside of the ED identity. It is important that physicians be aware of pro-ED sites given consensus that separation from the ED identity plays a critical role in recovery from an ED.23,36,37 Empirical Studies of Site Use and Disordered Eating Pathology

Three major case control studies have contributed evidence that pro-ED site viewership results in negative ED-related outcomes, even among healthy viewers.38-40 Additionally, numerous other studies have established an associative relationship between views of pro-ED sites and such outcomes.12,16,18,19 A pilot

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study of college women found that after viewing pro-Ana sites, participants experienced a decrease in perceived attractiveness and an increased perception of being overweight.38,39 Another study of 235 college women found that after modest viewing of pro-ED Web sites, participants significantly reduced calorie consumption and expressed disordered eating symptoms for 3 weeks after the study’s end.40 Neither the control set exposed to healthy eating/exercise Web sites nor the control set exposed to unrelated Web sites displayed significant changes in eating habits. Other studies have also found associations between ED pathology and site visitation12,16,18,19 among both adolescent ED populations12 and a population of college women.18 A few studies specifically found a positive association between the frequency of visitation of sites and ED-related outcomes,16,19 including among adolescents.19 This finding underscores that the intensity of involvement, not only prevalence, factors into the clinical implications of pro-ED usage. Intervention Efforts

There has been significant activism against pro-ED online content since its emergence. In 2001, many sites went underground after several national health professional associations asked Yahoo and MSN to shut down pro-ED Web sites.41 When the pro-ED movement regained popularity, there was outcry from health professional associations once again. Many popular corporate sites,42-45 such as Instagram,43 Facebook,44 and Yahoo,41 have implemented guidelines to reduce such content. The National Eating Disorders Association now advises Facebook and Tumblr on how to manage this content.46 It is apparent that pro-Ana activity, when identified or censored, often migrates to other Web sites, contributing to the high turnover rate of pro-ED sites.10,35,47 This high turnover rate makes it impractical to consider banning or targeting specific sites. More importantly, this action might marginalize those with disordered eating and may make sites and users more inaccessible to researchers, concerned caregivers, and physicians.47 A promising area of possible intervention or prevention is through media literacy education. While media literacy related to pro-ED rhetoric has not specifically been investigated, 1 study showed that media-literate individuals are less likely to have body dissatisfaction and to compare themselves to others.48 Another study demonstrated that media literacy can help decrease risk factors for EDs and increase healthy body image among persons of different ages, from young adolescence to young adulthood.49 Bobbie Eisenstock, PhD, an expert in media literacy, developed an interactive toolkit about body image as part of a community engagement collaboration between her university students and the National Eating Disorders Association.50 Targeting specific pro-ED Web sites seems to be ineffective, but media literacy is a promising avenue for prevention.

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Clinical Recommendations Patients in Active Treatment for an ED

Within the ED treatment community, although not formally stated, the consensus seems to be that during treatment (inpatient, residential, outpatient treatment involving families), it is important to restrict access to pro-ED online rhetoric and to educate patients and families about the harmful effects of this content. Just as families or treatment facility staff are trained to renourish an adolescent and to restrict access to opportunities to exercise, vomit, and use laxatives and diet pills, families and treatment staff are encouraged to restrict access to pro-ED rhetoric that aims to maintain the ED identity and thus obstructs the treatment process. Practice regarding restricting access to pro-ED rhetoric likely varies considering the range of settings in which adolescents are treated for their EDs and the greater understanding of adolescents compared to their older caregivers or physicians regarding technological advances in social media. Additional dialogue, collaboration, and research are needed. Patients at Risk for Developing an ED

In addition to treating adolescents with an acute ED, many physicians work with adolescents who are in recovery from an ED or who are at risk for developing an ED. These physicians have a tremendous opportunity to gain insight and understanding into their patients’ self-image, attitudes about food and body, and the lens with which they filter nutrition and health information by screening for use of online pro-ED messages during clinic visits. Recommendations for working with patients presenting with body image concerns include the following: 1. Adopt a practice for screening patients for pro-ED online activity, the same way one would screen for vomiting, laxative and diet pill use, compensatory exercise, calorie counting, and other disordered eating behaviors. 2. Develop a toolkit of strategies to discuss positive body image messages with your patients, including, but not limited to, strategies that improve selfesteem and encourage adolescents to pursue their interests and long-term goals. The National Eating Disorders Association (NEDA) is an excellent online resource for reliable information for both physicians and the general public. NEDA also has information for responsible media coverage of proED rhetoric and is involved in legislative advocacy. It has Twitter and Facebook accounts and provides information on YouTube. Some Internet resources are provided in Table 1. 3. Maintain a posture of curiosity and humility when asking adolescents about their social media usage. Your patient is the expert in social media. Be excited to learn from him or her. However, you are the expert in adolescent health, providing accurate information about body image, expected discomfort or self-consciousness that accompanies pubertal changes, and

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Table 1 Internet Resources for Eating Disorders • General information about eating disorders and body image: www.nationaleatingdisorders.org/ general-information • Get REAL! Digital Media Literacy Toolkit: www.nationaleatingdisorders.org/sites/default/files/ Toolkits/getrealmedialliteracytoolkit/index.html • Proud2BMe online community: http://proud2bme.org/

the life-threatening consequences of EDs. Do not be afraid to let your patient know where you stand regarding the negative health effects of EDs, but also make an effort to develop and maintain rapport. 4. Participate in dialogue and coalition building across health care dis­ ciplines, but also with youth organizations, schools, parent groups, and policymakers. Conclusions

Many adolescents (and young adults) with diagnosed or undiagnosed disordered eating use pro-ED sites. These sites are sources of information exchange and social support, but expression and connection over EDs in those with an underlying pro-ED attitude may lead to deleterious outcomes, such as development of poor body image, learning of unhealthy tips and tricks for weight loss, and concealment of symptoms. Ambivalent characteristics of EDs that are apparent offline also seem to be highly salient online among users and content, which is promising for online and offline intervention efforts for these users. The high prevalence of public ED expression online offers a view for physicians and researchers into ED-related thoughts and practices. Such expression might offer access and intervention to diagnosed and, in particular, undiagnosed ED populations, which are difficult to reach given the covert nature of these disorders. Adolescents are the most at risk for EDs, and this is the same population with the most access and usage of online social networking and information seeking. Those treating and caring for adolescents need to be aware of the pro-ED phenomenon. Many adolescents with and without diagnosed EDs may use such sites for support and information, but use of these sites has been clearly linked to negative ED-related outcomes. References 1. Anorexia Nervosa and Related Eating Disorders, Inc. ANRED. Available at: www.anred.com/. Accessed February 15, 2014 2. Merikangas KR, He J, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Study–Adolescent Supplement (NCS-A). J Acad Child Adolesc Psychiatry. 2010;49(10):980-989

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3. Neumark-Sztainer D, Wall M, Larson NI, Eisenberg ME, Loth K. Dieting and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study. J Am Diet Assoc. 2011;111(7):1004-1011 4. Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2003;33:496-503 5. Klump KL, Bulik CM, Kaye WH, Treasure J, Tyson E. Academy for Eating Disorders Position Paper: eating disorders are serious mental illnesses. Int J Eat Disord. 2009;42(2):97-103 6. Duggan M, Brenner J. Demographics of social media users–2012. Available at: www.pewinternet .org/2013/02/14/the-demographics-of-social-media-users-2012/. Accessed December 15, 2013 7. Csipke E, Horne O. Pro-eating disorder websites: users’ opinions. Eur Eat Disord Rev. 2007;15(3):196-206 8. Casilli A, Tubaro P, Araya P. Ten years of Ana: lessons from a transdisciplinary body of literature on line pro-eating disorder websites. Soc Sci Inf. 2012;51(1):120-139 9. Norris ML, Boydell KM, Pinhas L, Katzman DK. Ana and the Internet: a review of pro-anorexia websites. Int J Eat Disord. 2006;39(6):443-447 10. Borzekowski DL, Schenk S, Wilson JL, Peebles R. E-Ana and E-Mia: a content analysis of proeating disorder web sites. Am J Public Health. 2010;100(8):1526-1534 11. Juarascio A, Shoaib A, Timko A. Pro-eating disorder communities on social networking sites: a content analysis. Eat Disord. 2010;18(5):393-407 12. Wilson JL, Peebles R, Hardy K, Litt K, Litt I. Surfing for thinness: a pilot study of pro-eating disorder web site usage in adolescents with eating disorders. Pediatrics. 2006;118(6):1635-1643 13. Ransom D, La Guardia J, Woody E, Boyd J. Interpersonal interactions on online forums addressing eating concerns. Int J Eat Disord. 2010;43(2):161-170 14. Boero N, Pascoe CJ. Pro-anorexia communities and online interaction: bringing the pro-ana body online. Body Soc. 2012;18(2):27-57 15. Lewis SP, Arbuthnott AE. Searching for thinspiration: the nature of internet searches for proeating disorder websites. Cyberspsychol Behav Soc Netw. 2012;15(4):200-204 16. Peebles R, Wilson J, Litt I, et al. Disordered eating in a digital age: eating behaviors, health, and quality of life in users of websites with pro-eating disorder content. J Med Internet Res 2012;14(5): e148 17. Maloney P. Online networks and emotional energy. Inf Commun Soc. 2013;16(1):105-124 18. Harper K, Sperry S, Thomson K. Viewership of pro-eating disorder websites: association with body image and eating disturbances. Int J Eat Disord. 2008;41:92-95 19. Custers K, Van den Bulck J. Viewership of pro-anorexia websites in seventh, ninth and eleventh graders. Eur Eat Disord Rev. 2009;17(3):214-219 20. Giles D. Constructing identities in cyberspace: the case of eating disorders. Br J Soc Psychol. 2006;45:463-477 21. Noordenbos G, Oldenhave A, Muschter J, Terpstra N. Characteristics and treatment of patients with chronic eating disorders. Eat Disord. 2010;10(1):15-29 22. Ison J, Kent S. Social identity in eating disorders. Eur Eat Disord Rev. 2010;18(6):475-85 23. Nordbø RH, Espeset EM. Gulliksen KS, et al. Reluctance to recover in anorexia nervosa. Eur Eat Disord Rev. 2012;20(1):60-67 24. Academy for Eating Disorders. Position statement: pro-anorexia web sites. Available at: www .aedweb.org/web/index.php/23-get-involved/position-statements/96-aed-statement-on-bodyshaming-and-weight-prejudice-in-public-endeavors-to-reduce-obesity-10. Accessed July 22, 2014 25. Yeshua-Katz D, Martins D. Communicating stigma: the pro-ana paradox. Health Commun. 2013;28(5):499-508 26. Tierney S. Creating communities in cyberspace: pro-anorexia web sites and social capital. J Psychiatr Ment Health Nurs. 2008;15(4):340-343 27. Tong ST, Heinemann-Lafave D, Jeon J, Kolodziej-Smith R, Warshay N. The use of pro-ana blogs for online social support. Eat Disord. 2013;21(5):408-422

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28. Tiller JM, Sloane G, Schmidt U, et al. Social support in patients with anorexia nervosa and bulimia nervosa. Int J Eat Disord. 1997;21(1):31-38 29. Shaw H, Stice E, Becker CB. Preventing eating disorders. Child Adolesc Psychiatr Clin N Am. 2009;18(1):199-207 30. Levine MP. Loneliness and eating disorders. J Psychol. 2012;146(1-2):243-257 31. Rich E. Anorexic dis(connection): managing anorexia as an illness and an identity. Sociol Health Illn. 2006;28(3):284-305 32. Roehrig J, McLean J, McLean C. A comparison of stigma towards eating disorders versus depression. Int J Eat Disord. 2010;43:671-674 33. Haas S, Irr M, Jennings N, Wagner L. Communicating thin: a grounded model of online negative enabling support groups in the pro-anorexia movement. New Media Soc. 2011;13(1):40-57 34. Colton A, Pistrang N. Adolescents’ experiences of inpatient treatment for anorexia nervosa. Eur Eat Disord Rev. 2004;12(5):307-316 35. Harshbarger J, Ahlers-Schmidt C, Mayans L, Layans D, Hawkins J. Pro-anorexia websites: what a clinician should know. Int J Eat Disord. 2009;42:367-370 36. Vandereycken W, Van Humbeek I. Denial and concealment of eating disorders: a retrospective survey. Eur Eat Disord Rev.2008;16(2):109-114 37. Lamoureux MM, Bottorff JL. “Becoming the real me”: recovering from anorexia nervosa. Health Care Women Int. 2005;26(2):170-188 38. Bardone-Cone AM, Cass KM. Investigating the impact of pro-anorexia websites: a pilot study. Eur Eat Disord Rev. 2006;14:256-262 39. Bardone-Cone AM, Cass KM. What does viewing a pro-anorexia website do? An experimental examination of website exposure and moderating effects. Int J Eat Disord. 2007;40:537-548 40. Jett S, LaPorte DJ, Wanchisn J. Impact of exposure to pro-eating disorder websites on eating behavior in college women. Eur Eat Disord Rev. 2010;18:410-416 41. Reaves J. Anorexia goes high tech. Time Magazine. July 31, 2001. Available at: content.time.com/ time/health/article/0,8599,169660,00.html. Accessed December 15, 2013 42. Tumblr. A new policy against self-harm blogs. February 23, 2012. Available at: staff.tumblr.com/ post/18132624829/self-harm-blogs. Accessed December 15, 2013 43. Instagram. Instagram’s new guidelines against self-harm images & accounts. Available at: blog .instagram.com/post/21454597658/instagrams-new-guidelines-against-self-harm-images. Accessed December 15, 2013 44. Facebook. Community standards. Available at: www.facebook.com/communitystandards. Accessed December 15, 2013 45. Pinterest. Pinterest: terms & privacy. Available at: about.pinterest.com/use/. Accessed December 15, 2013 46. Shalby C. Fighting social media “thinspiration” with messages of self-acceptance. PBS News Hour. March 1, 2014. Available at: www.pbs.org/newshour/updates/thinspiration-ban-social-media -doesnt-prevent-eating-disorders/. Accessed June 20, 2014 47. Casilli A, Paillier F, Tubaro P. Survival and turnover in ana-mia online networks. An in vivo study of the effects of moral panic surrounding eating disorder websites. Paper presented at the First International Workshop JITSO—Just-in-Time Sociology. Understanding Social Phenomena As They Unfold. December 4, 2012. EPFL, Lausanne, Switzerland 48. Yager Z, O’Dea J. Prevention programs for body image and eating disorders on university campuses: a review of large controlled interventions. Health Promot Int. 2008;23(2):173-189 49. McLean S, Paxton S, Wertheim E. Mediators of the relationship between media literacy and body dissatisfaction in early adolescent girls: implications for prevention. Body Image. 2013;10:282-289 50. Eisenstock B. Get REAL! Digital media literacy toolkit. Available at: namle.net/2014/06/18/ national-eating-disorders-association-digital-media-literacy-toolkit/. Accessed June 20, 2014

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Cyberbullying and Online Harassment in Adolescents Ellen Selkie, MD, MPH*a, Rajitha Kota, MPHb Division of Adolescent Medicine, University of Washington/Seattle Children’s, Seattle, Washington b University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

a

Introduction What Is Cyberbullying?

The Centers for Disease Control and Prevention (CDC) has defined the term bullying as “any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated.”1 While traditional “schoolyard” bullying still exists, in recent years, the advent of the Internet has provided a new platform on which bullying can occur. This phenomenon has come to be known as cyberbullying, commonly defined as “an aggressive, intentional act or behavior that is carried out by a group or an individual, using electronic forms of contact, repeatedly and over time against a victim who cannot easily defend him or herself.”2 “Electronic forms of contact” compose a broad category that may include e-mail, blogs, social networking Web sites (eg, Facebook, Twitter, Instagram), online games, chat rooms, forums, instant messaging, Skype, text messaging, and mobile phone pictures. Cyberbullying may take the form of mean or nasty messages or comments, rumor spreading through posts or creation of groups, and exclusion by groups of peers online. Other terms on the spectrum of negative online interactions include “online harassment” and “electronic aggression.” While some studies have distinguished an overlap between cyberbullying and online harassment, there may be a subset of electronic aggression that is not necessarily cyberbullying.3 *Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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How Is Cyberbullying Different from Other Forms of Bullying?

Currently there is some debate as to whether cyberbullying is an entity distinct from in-person or traditional bullying. Clearly many of the behaviors that occur in traditional bullying can take place online (eg, name calling and rumor spreading), but some aspects of the CDC definition may not apply to cyberbullying in a straightforward way. For example, a person can post online a single picture of a peer with a negative caption, which can then be viewed by many people, multiple times. The “power imbalance” that may be characterized by physical strength differences in traditional bullying becomes blurrier online, where theoretically both the aggressor and target have the same “strength.” Can Cyberbullying Be More Harmful than Traditional Bullying?

Cyberbullying has the potential to be as harmful, if not more so, than traditional bullying that happens in the schoolyard. Traditional bullying occurs face to face, whereas online bullying allows perpetrators the powerful advantage of anonymity. When afforded the ability to hide behind a computer screen, perpetrators may act without regard for the consequences and feel less accountability and guilt for their actions.4 Anonymity can also be distressing to the targets of cyberbullying. Not knowing the identity of the perpetrator can lead to increased anxiety, especially if they fear encountering this person in their offline life.5 In addition to anonymity, the Internet allows bullies to bother their targets 24 hours a day, in contrast to traditional bullying, which generally only occurs at a specific time and place. Targets can feel constantly harassed, and even if they remain offline, they may constantly worry about what is being posted without their knowledge. Additionally, since the Internet is a rapid communication tool, it allows embarrassing information to be spread quickly and widely.6 Figure 1 further elucidates the differences and similarities between traditional bullying and cyberbullying.

dƌĂĚŝƟŽŶĂůďƵůůLJŝŶŐ Ͳ&ĂĐĞƚŽĨĂĐĞ ͲWŚLJƐŝĐĂůĐŽŵƉŽŶĞŶƚ ͲdĂƌŐĞƚĂďůĞƚŽƌĞŵŽǀĞ ƐĞůĨĨƌŽŵůŽĐĂƟŽŶŽĨ ĂŐŐƌĞƐƐŽƌ ͲŐŐƌĞƐƐŽƌŝƐ ŝĚĞŶƟĮĂďůĞ

^ŚĂƌĞĚ ͲZĞƉĞƟƟǀĞĂŐŐƌĞƐƐŝŽŶ ͲƵůůLJĂĐƚƐǁŝƚŚŽƵƚ ƌĞŐĂƌĚĨŽƌ ĐŽŶƐĞƋƵĞŶĐĞƐŽƌ ƉƵŶŝƐŚŵĞŶƚ Ͳ,ĂƌŵĨƵů ƉƐLJĐŚŽƐŽĐŝĂůͬŚĞĂůƚŚ ĞīĞĐƚƐ

LJďĞƌďƵůůLJŝŶŐ ͲĂŶŚĂƉƉĞŶϮϰͬϳ ͲŶLJůŽĐĂƟŽŶ ͲZĂƉŝĚĚŝƐƐĞŵŝŶĂƟŽŶŽĨ ŝŶĨŽƌŵĂƟŽŶ;ƌƵŵŽƌƐͬƉŝĐƐͿ Ͳ>ĂƌŐĞĂƵĚŝĞŶĐĞ Ͳ>ĞƐƐĚŝƌĞĐƚĨĞĞĚďĂĐŬͬŐƵŝůƚLJ ĨĞĞůŝŶŐƐƚŽĂŐŐƌĞƐƐŽƌ ͲŶĨŽƌĐĞŵĞŶƚĚŝĸĐƵůƚ;ĨƌĞĞ ƐƉĞĞĐŚƌŝŐŚƚƐ͕ĂŶŽŶLJŵŝƚLJͿ ͲŐŐƌĞƐƐŽƌĂŶŽŶLJŵŝƚLJ ͲŶdžŝĞƚLJͬĨĞĂƌŽĨƐĞĞŝŶŐ ďƵůůLJ͞ŝŶƌĞĂůůŝĨĞ͟

Fig 1. Comparison of traditional and cyberbullying characteristics.

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Scope and Epidemiology of the Problem Early and Middle Adolescents

Cyberbullying, like other bullying behaviors, tends to develop in late elementary school and tends to peak in middle school and early high school.7 In middle and high school, cyberbullying affects around 20% to 40% of students.8-11 However, prevalence rates have large variability, likely because of differences in the definitions of cyberbullying between prevalence studies and surveys, as well as differences in the questions that are asked. A Problem of Definition

Currently, there is no consistency in the use of a single definition of cyberbullying among researchers. A number of conceptual definitions have been used to assess the prevalence of cyberbullying, but the lack of consensus on a definition has resulted in reported prevalence rates ranging from 7% to 72%.7 For example, 1 study, which defined cyberbullying as “harassing using technology such as e-mail, computer, cell phone, video cameras, etc.,” found the prevalence rate of being cyberbullied among Canadian adolescents aged 12 to 15 years to be 25%.9 A second study that defined cyberbullying as “mean things” or “anything that someone does that upsets or offends someone else” found that 72% of a sample of 12- to 17-year-olds reported that they had experienced cyberbullying.12 A third study, which defined cyberbullying as “bullying through text messaging, e-mail, mobile phone calls or picture/video clip,” found the prevalence rate among 12- to 20-year-olds to be 17.6%.13 A fourth study found a prevalence rate of 7% among 10- to 17-year-olds who were asked if they had engaged in online harassment behaviors, which were defined as “making rude or nasty comments to someone on the Internet or using the Internet to harass or embarrass someone with whom [they were] mad.”14 One study even showed that using the word bully in comparison to using a description of bullying behaviors (without using the actual word bully) led to differential prevalence rates in the same population.15 Without a single definition or clear understanding of what exactly cyberbullying entails, estimating the magnitude of the problem among adolescents is very difficult. Varied interpretations of the definition may lead individuals to report the behaviors they see differently. Cyberbullying in Older Adolescents and College Students

Although studies indicate that cyberbullying seems to decline in college compared to middle and high school, it is evident that a significant minority still experiences cyberbullying.16 To date, few studies have examined cyberbullying among college students. One study surveyed college students about how often they had experienced electronic bullying behaviors and found that 38% knew someone who had been cyberbullied, 21.9% had been cyberbullied, and 8.6%

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had acted as a cyberbully.17 A second study surveyed college students and found that 7% reported that they had been cyberbullied while at college and that 34% considered it to be a serious issue.18,19 Risk Factors for Cyberbullying

In early studies, increased use of the Internet was associated with increased risk for being cyberbullied,19 although given the steady increase in adolescents’ use of the Internet, this may no longer hold true. Other risk factors for being targeted by cyberbullying include being a target of traditional bullying,3,20,21 loneliness and social anxiety,22 and depressive symptoms.19 However, higher levels of self-control and parental control may mitigate the risk for depression in those who are targeted.23 Several behavioral theories have been proposed as underlying mechanisms for perpetration of cyberbullying in adolescents. Those who cyberbully have been found to have lower empathy24,25 and higher moral disengagement,26 and are more likely to view cyberbullying as acceptable than their noncyberbully peers.27 Adolescents likely to perpetrate cyberbullying are also those who have been targets8 as well as those who have had low self-esteem and problem behavior in other areas.28 One study among high school students also suggested that cyberbullying may be an avenue to maintain popularity and social capital in an established peer hierarchy.29 Why Is Cyberbullying Important? Peer Interactions Online

As is apparent throughout this issue of AM:STARs, technology use is widespread and pervasive among adolescents. In fact, because of the amount of time spent with technology, tools like social media have become part of the fabric of the experience of adolescence. Social media provides a sense of connectedness, and the distinction between face-to-face and online issues has become blurred. Studies have shown that peer interactions online can be just as important as those expressed offline in relation to self-esteem and friendships.30 Developmentally, adolescents in middle and high school are using peer input to determine their identity and self-worth, and online interactions with peers play a significant role. The connectedness that adolescents can form through social media can be positive and should not be understated. On the other hand, as with negative peer interactions in person, the same can occur online in the forms of cyberbullying and online harassment, leading to distress and emotional dysregulation. Several high media profile cases have illustrated this concept by implicating cyberbullying as a cause of adolescent suicide. For example, Amanda Todd was a Canadian teenager who posted a video on YouTube detailing her experiences with years of bullying both online and in school.31

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She suffered from depression and anxiety, and she changed schools multiple times but continued to be a target of bullying. Shortly after posting the video, she committed suicide, prompting international media coverage. This brought the issue of cyberbullying to the forefront of public consciousness. Negative Effect of Cyberbullying

Multiple studies have examined the substantial psychological effects that cyberbullying can have on both bullies and targets of bullying. Perpetration of cyberbullying in adolescence has been found to be associated with depression, anxiety, low self-esteem, and suicidal ideation.32,33 Children and adolescents who have been cyberbullied report higher levels of depression and lower self-esteem,20 and the severity of depression has been shown to be associated with the degree and severity of cyberbullying.34 Furthermore, emotional distress, anger, sadness, detachment, externalized hostility, and delinquency have also been shown to be more common in targets of cyberbullying than in the general population.11 Many of these effects are also seen in targets of traditional bullying, suggesting that cyberbullying may have similar negative consequences.13 There is some evidence that engaging in cyberbullying as well as being cyberbullied may contribute to depression and suicidality independently of traditional bullying.35 Adolescents who are cyberbullied are less likely to be prosocial, and more likely to internalize their problems as well as display their unhappiness; these behaviors can prevent adolescents from making friends and adjusting properly.36 In addition, cyberbullied adolescents consistently report lower grades and other academic problems.10 These effects may be attributable to the target’s poorer concentration, along with preoccupation and frustration with the bully and the situation.37 Lastly, absence and truancy rates of cyberbullied adolescents often are higher, and many of these adolescents report that they do not feel safe at school.38 Addressing Cyberbullying in Communities and Families

Cyberbullying is a multifaceted problem that requires attention from various sectors of the community. While cyberbullying shares many characteristics with traditional bullying, few evidence-based programs exist for prevention and intervention. Because cyberbullying is a comparatively new phenomenon, few traditional bullying prevention programs have been evaluated as to their effect on cyberbullying. Still, schools are becoming more involved in cyberbullying prevention and intervention efforts, and parents may seek guidance from physicians about how to address cyberbullying, either generally or with their own child. The Role of Schools

Most research and program development on bullying prevention has focused on schools, given that traditional bullying tends to occur at school. Most states have laws mandating anti-bullying policies in schools, which individual school districts

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in turn implement in various ways, including programming for students to prevent bullying as well as consequences such as suspension for bullies. However, the role of schools in addressing cyberbullying is complex. Because many cyberbullying incidents occur outside of school hours and off school premises, schools may not perceive it to be in their jurisdiction to include cyberbullying in their antibullying policies, even though most cyberbullying incidents happen between peers from the same school.39 Yet there is evidence that school climate and perception of teachers’ ability to intervene in bullying can affect rates of cyberbullying, so it is important to include cyberbullying in school prevention efforts.40 The limited research evaluating school-based programs’ effect on cyberbullying has been performed primarily in Europe. The KiVa program is a school-based anti-bullying curriculum that teaches students conflict resolution skills and peer support tools, including motivating students to intervene if they see a classmate being bullied. A recent study showed that after implementation of this program, rates of cyberbullying decreased, indicating that a change in school climate can affect cyberbullying rates.41 The ConRed program addresses cyberbullying specifically; it is a 3-month program with classroom activities that promotes schoolcommunity collaboration. When evaluated in Spain, it was found to significantly reduce rates of cyberbullying.42 Both of these programs show that improving school-level attitudes toward cyberbullying can help to reduce it. Legal Implications

Multiple cases of cyberbullying have been brought to legal attention, and media coverage of these cases has shown the legal complexities surrounding cyberbullying. In the United States, cases of cyberbullying are being prosecuted as harassment or defamation when coming to legal attention. In particular, if the content of cyberbullying interactions is deemed to be focused on race, ethnicity, disability, or sexual orientation, it may fall under the category of “discrimination” and be subject to prosecution under federal antidiscrimination law.43 While no research has examined the effect of legal action on cyberbullying rates, the potential for legal involvement is often not understood by youth who may be involved in cyberbullying,44 and parents and youth may be held accountable for actions online. In some extreme cases, youth who have cyberbullied someone who commits suicide have been charged in relation to the target’s death; however, to date, these cases have largely resulted in charges being dropped against the adolescent perpetrator.45 It is important to remember when discussing such cases with youth and parents that suicide is complex and multifactorial—cyberbullying likely contributes but may not be the sole cause in all cases. In addition, prosecution of a minor for cyberbullying may result in a missed opportunity to explore why the youth perpetrated the bullying in the first place. While it is important to establish consequences for bullying behavior and poor online conduct, there is no evidence to support legal action as the most effective punishment.

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The Importance of Parents

While schools can play an important role in cyberbullying prevention, parents’ contributions should not be underestimated. Studies have shown that authoritative, supportive parenting is protective against cyberbullying,46,47 and given that cyberbullying may often be experienced at home, it is necessary to involve parents in cyberbullying prevention. Parents should have a basic knowledge of social media and related technology; they can even learn about these things from their child as a bonding experience. Discussing online etiquette with children should start early, and witnessing things like negative comments online can be used as teachable moments for children. A common discussion might be to ask a child whether a negative online comment would be appropriate for a faceto-face interaction, and emphasizing that one should never say something online or via text message that he or she would not be comfortable saying in person. Along these lines, it is appropriate and necessary for parents to discuss consequences, such as loss of privileges, should an adolescent cyberbully a peer. Some youth may not report being cyberbullied to their parents, often because of a fear of having technology taken away from them.48 If these youth are forbidden to use social media or a cell phone, this sudden cutoff from their social life can create isolation and result in more harm than good; thus, creating an atmosphere of open communication without automatic punishment is important for parents to keep in mind when discussing cyberbullying and online safety with their children. Software to monitor adolescents’ online activity is not recommended as a strategy for parents to address cyberbullying.49 If a youth is the target of cyberbullying, important strategies for parents should include unconditional support for the child and listening to his or her side of the story. Discussion of whether to report cyberbullying to the school and/or service provider should involve the youth’s opinion, but if there appears to be a threat to safety, police can and should be notified. Keeping records of e-mails and text messages as well as screenshots of online posts can be used as evidence of the cyberbullying if needed. Immediate actions from the youth’s standpoint might include blocking the bully if possible, but it is important that the youth not retaliate and perpetuate the cycle of cyberbullying. Role of the Pediatrician

There are multiple ways that physicians and other health care professionals can help address cyberbullying. First, anticipatory guidance about appropriate online conduct should start as soon as the child begins using the Internet and cell phones, or even before then. Counseling parents about supporting their child can be incorporated into general anticipatory guidance about creating a nurturing environment in the home. Physicians can also screen for cyberbullying in the office; the most efficient way would be to ask about all types of bullying

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in order to assess for both traditional bullying and cyberbullying. If a child does endorse bullying (either as a perpetrator or a target), physicians should explore how the bullying has affected the child’s life, particularly assessing mood, anxiety, and school performance. Further information for parents can be accessed at www.cyberbullying.us and www.stopbullying.gov. Finally, advocating for inclusion of cyberbullying in antibullying policies can be a powerful way for physicians to help address cyberbullying at the community level. Conclusion

Cyberbullying is common in adolescents and typically goes hand in hand with other forms of bullying. Research about cyberbullying has raised multiple concerns about the adverse mental health and educational outcomes among both cyberbullies and those who are cyberbullied. Because technology is rapidly changing, there is wide variance in the way that schools and laws address cyberbullying. However, physicians can and should partner with parents and communities to create a supportive environment for youth, both online and offline, in order to prevent cyberbullying and its negative consequences. References 1. Gladden R, Vivolo-Kantor A, Hamburger M, Lumpkin C. Bullying Surveillance Among Youths: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, and US Department of Education; 2013 2. Smith PK, Mahdavi J, Carvalho M, et al. Cyberbullying: its nature and impact in secondary school pupils. J Child Psychol Psychiatry. 2008;49(4):376-385 3. Ybarra ML, Espelage DL, Mitchell KJ. Differentiating youth who are bullied from other victims of peer-aggression: the importance of differential power and repetition. J Adolesc Health. 2014;55(2): 293-300 4. Li Q. New bottle but old wine: a research of cyberbullying in schools. Comput Human Behav. 2007;23(4):1777-1791 5. Shariff S, Gouin R. Cyber-dilemmas: gendered hierarchies, new technologies and cybersafety in schools. Atlantis. 2006;31(1):26-36 6. Raskauskas J, Stoltz AD. Involvement in traditional and electronic bullying among adolescents. Dev Psychol. 2007;43(3):564-575 7. Tokunaga RS. Following you home from school: a critical review and synthesis of research on cyberbullying victimization. Comput Human Behav. 2010;26(3):277-287 8. Dehue F, Bolman C, Vollink T. Cyberbullying: youngsters’ experiences and parental perception. Cyberpsychol Behav. 2008;11(2):217-223 9. Li Q. Cyberbullying in schools: a research of gender differences. School Psychol Int. 2006;27(2):157170 10. Kessel Schneider S, O’Donnell L, Stueve A, Coulter RWS. Cyberbullying, school bullying, and psychological distress: a regional census of high school students. Am J Public Health. 2012;102(1):171-177 11. Patchin JW, Hinduja S. Bullies move beyond the schoolyard: a preliminary look at cyberbullying. Youth Violence Juv Justice. 2006;4(2):148-169 12. Juvonen J, Gross E. Extending the school grounds? Bullying experiences in cyberspace. J School Health. 2008;78(9):496-505

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13. Slonje R, Smith P. Cyberbullying: another main type of bullying? Scand J Psychol. 2008;49(2):147154 14. Smith A, Rainie L, Zickuhr K. College Students and Technology. Washington, DC: Pew Internet and American Life Project; 2011 15. Ybarra ML, Boyd D, Korchmaros JD, Oppenheim JK. Defining and measuring cyberbullying within the larger context of bullying victimization. J Adolesc Health. 2012;51(1):53-58 16. Beran TN, Rinaldi C, Bickham DS, Rich M. Evidence for the need to support adolescents dealing with harassment and cyber-harassment: prevalence, progression, and impact. School Psychol Int. 2012;33(5):562-576 17. MacDonald CD, Roberts-Pittman B. Cyberbullying among college students: prevalence and demographic differences. Procedia Soc Behav Sci. 2010;9:2003-2009 18. Molluzzo JC, Lawler J. A study of the perceptions of college students on cyberbullying. Inf Syst Educ J. 2012;10(4):84 19. Ybarra ML. Linkages between depressive symptomatology and Internet harassment among young regular Internet users. Cyberpsychol Behav. 2004;7(2):247-257 20. Ybarra ML, Mitchell KJ, Wolak J, Finkelhor D. Examining characteristics and associated distress related to Internet harassment: findings from the Second Youth Internet Safety Survey. Pediatrics. 2006;118(4):e1169-e1177 21. Mitchell KJ, Ybarra M, Finkelhor D. The relative importance of online victimization in understanding depression, delinquency, and substance use. Child Maltreat. 2007;12(4):314-324 22. van den Eijnden R, Vermulst A, van Rooij AJ, Scholte R, van de Mheen D. The bidirectional relationships between online victimization and psychosocial problems in adolescents: a comparison with real-life victimization. J Youth Adolesc. 2014;43(5):790-802 23. Hay C, Meldrum R. Bullying victimization and adolescent self-harm: testing hypotheses from general strain theory. J Youth Adolesc. 2010;39(5):446-459 24. Ang RP, Goh DH. Cyberbullying among adolescents: the role of affective and cognitive empathy, and gender. Child Psychiatry Hum Dev. 2010;41(4):387-397 25. Steffgen G, Konig A, Pfetsch J, Melzer A. Are cyberbullies less empathic? Adolescents’ cyberbullying behavior and empathic responsiveness. Cyberpsychol Behav Soc Netw. 2011;14(11):643-648 26. Pornari CD, Wood J. Peer and cyber aggression in secondary school students: the role of moral disengagement, hostile attribution bias, and outcome expectancies. Aggress Behav. 2010;36(2):81-94 27. Barlett CP, Gentile DA. Attacking others online: the formation of cyberbullying in late adolescence. Psychol Pop Media Cult. 2012;1(2):123-135 28. Modecki KL, Barber BL, Vernon L. Mapping developmental precursors of cyber-aggression: trajectories of risk predict perpetration and victimization. J Youth Adolesc. 2013;42(5):651-661 29. Badaly D, Kelly BM, Schwartz D, Dabney-Lieras K. Longitudinal associations of electronic aggression and victimization with social standing during adolescence. J Youth Adolesc. 2013;42(6):891-904 30. Valkenburg PM, Peter J. Online communication among adolescents: an integrated model of its attraction, opportunities, and risks. J Adolesc Health. 2011;48(2):121-127 31. Ng C. Bullied teen Amanda Todd’s death under investigation. October 16, 2012. Available at: abcnews.go.com/US/bullied-teen-amanda-todds-death-investigation/story?id517489034. Accessed May 8, 2014 32. Hinduja S, Patchin JW. Bullying, cyberbullying, and suicide. Arch Suicide Res. 2010;14(3):206-221 33. Yang SJ, Stewart R, Kim JM, et al. Differences in predictors of traditional and cyber-bullying: a 2-year longitudinal study in Korean school children. Eur Child Adolesc Psychiatry. 2013;22(5):309318 34. Didden R, Scholte RH, Korzilius H, et al. Cyberbullying among students with intellectual and developmental disability in special education settings. Dev Neurorehabil. 2009;12(3):146-151 35. Bonanno RA, Hymel S. Cyber bullying and internalizing difficulties: above and beyond the impact of traditional forms of bullying. J Youth Adolesc. 2013;42(5):685-697 36. Arseneault L, Walsh E, Trzesniewski K, et al. Bullying victimization uniquely contributes to adjustment problems in young children: a nationally representative cohort study. Pediatrics. 2006; 118(1):130-138

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37. Beran T, Li Q. The relationship between cyberbullying and school bullying. J Stud Well Being. 2007;1(2):15-33 38. Varjas K, Henrich CC, Meyers J. Urban middle school students’ perceptions of bullying, cyberbullying, and school safety. J Sch Violence. 2009;8(2):159-176 39. Freeman BW, Thompson C, Jaques C. Forensic aspects and assessment of school bullying. Psychiatr Clin N Am. 2012;35(4):877-900 40. Elledge LC, Williford A, Boulton AJ, et al. Individual and contextual predictors of cyberbullying: the influence of children’s provictim attitudes and teachers’ ability to intervene. J Youth Adolesc. 2013;42(5):698-710 41. Williford A, Elledge LC, Boulton AJ, et al. Effects of the KiVa antibullying program on cyberbullying and cybervictimization frequency among Finnish youth. J Clin Child Adolesc Psychol. 2013;42(6):820-33 42. Ortega-Ruiz R, Del Rey R, Casas JA. Knowing, building and living together on internet and social networks: the ConRed cyberbullying prevention program. Int J Conflict Violence. 2012;6(2):303312 43. Federal law. 2014. Available at: www.stopbullying.gov/laws/federal/. Accessed May 28, 2014 44. Paul S, Smith PK, Blumberg HH. Investigating legal aspects of cyberbullying. Psicothema. 2012;24(4):640-645 45. Alvarez L. Charges dropped in cyberbullying death, but sheriff isn’t backing down. November 21, 2013. Available at: www.nytimes.com/2013/11/22/us/charges-dropped-against-florida-girls -accused-in-cyberbullying-death.html. Accessed May 27, 2014 46. Hinduja S, Patchin JW. Social influences on cyberbullying behaviors among middle and high school students. J Youth Adolesc. 2013;42(5):711-722 47. Wang J, Iannotti RJ, Nansel TR. School bullying among adolescents in the United States: physical, verbal, relational, and cyber. J Adolesc Health. 2009;45(4):368-375 48. Agatston PW, Kowalski R, Limber S. Students’ perspectives on cyber bullying. J Adolesc Health. 2007;41(6 Suppl 1):S59-S60 49. Law DM, Shapka JD, Olson BF. To control or not to control? Parenting behaviours and adolescent online aggression. Comput Human Behav. 2010;26(6):1651-1656

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Sex Online: Pornography, Sexual Solicitation, and Sexting Paul J. Wright, PhD*a; Edward Donnerstein, PhDb a The Media School, Indiana University, Bloomington, Indiana; Department of Communication, University of Arizona, Tucson, Arizona

b

The articles in this volume of AM:STARs are intended to examine the influences of new media technologies (which really are current media technologies) on child and adolescent health issues. Newer technologies, such as the Internet and mobile devices, have drastically changed the availability of media to, and consequently the influences of media on, children and adolescents. One of the areas of concern has been their exposure to sexual materials, particularly pornography, as well as the advent of a newer sexual issue, sexting. Unlike traditional media such as TV and film, fewer studies have been conducted on the effect of exposure to potentially harmful materials, like risky sexual acts, on the Internet. In a recent review focusing on more traditional sexual media (TV, film), researchers noted the commentary scholars have made about the potential and far-reaching influences of this “newer” technology (the Internet, mobile devices) on sexual socialization1: “Mass media play an important role in the sexual socialization of American youth and given its expanding nature and accessibility, the Internet may be at the forefront of this education.”2 “Adolescents’ increasing access to, and use of, sexually explicit Internet material—material that is not meant for minors—has led to concerns about whether youth are able to make sense of the reality depicted in that material.”3 Unlike traditional media, such as TV, the Internet and related new technologies (eg, mobile devices) give children and adolescents access to just about any form of content they can find.4 Often with little effort they are able to view almost any type of sexual behavior, which has the potential of producing negative effects.5-7

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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Of further concern is the fact that this can occur in the privacy of their own rooms with little supervision from their parents. Why might we expect that these newer technologies will have different effects than traditional media? Theoretically it has been noted that the Internet provides motivational, disinhibitory, and opportunity aspects that make it somewhat different than traditional media in terms of its potential effect.8 With regard to motivation, the Internet is ubiquitous in that it is always on and can easily be accessed, potentially leading to overexposure. In the world of new technology, there is no “family viewing hour.” Online content can be interactive and more engaging, so there is increased learning and certainly exposure time. It is portable, allowing access to materials anytime and anyplace. In thinking about exposure to sexual materials, this is far different than the world in which one’s parents first started searching for information about sex. From a disinhibitory aspect the content is unregulated. Studies suggest that extreme forms of violent or sexual content are more prevalent on the Internet than in other popular media.7 Participation is private and anonymous, which allows children and adolescents to search for materials in ways they could not with traditional media. There is the suggestion that finding such materials could increase social support for these images and messages through online chat rooms and blogs. Finally, online media exposure is much more difficult for parents to monitor than media exposure in traditional venues. The ability to access sexual materials can now be done “virtually” anywhere. Opportunity aspects play a more important role in the areas of sexual solicitation and sexting. Potential targets, or recipients, are readily available and reachable, and the identities of the “aggressors” often are disguised (as is often the case with pedophiles). The person an individual wants to “sext” or sexually exploit is always there, often in an anonymous environment. The areas we are going to discuss are relatively new in terms of research. For obvious reasons, researching child and adolescent sexual behavior and media exposure is not easy. However, significant advances in recent years give us a better understanding of the implications of new technology within this area. We will examine 3 concerns: online pornography, sexting, and sexual solicitation. They each have limitations in what we can conclude, but the new and significant research in these areas opens the door for further exploration and certainly educational and intervention discussions. The issue of exposure to online pornography is the most researched of these topics. A long history of research on traditional access to pornography (film, magazines) has given us a sound footing to examine the concerns of child and adolescent exposure to online pornography.

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Online Pornography

The term pornography refers to sexually explicit media designed to arouse and excite the consumer.1 Studies on pornography that sample youth aged 17 years or younger are a new phenomenon. In a major review of this literature a few years ago by the current authors, only a few such studies were available.1 Accordingly, we primarily referenced studies of young adults (ie, individuals 18 years or older) and extrapolated to children and adolescents. The field has changed. More studies of children and adolescents are now available. Synthesizing the findings from these studies is the focus of this section. Exposure to Pornography

National and international studies both indicate that exposure to pornography is quite common among boys and not uncommon among girls. Illustrative findings from US studies are highlighted below and summarized in Table 1. Boys Most boys report that they have viewed pornography. In a study of middle school students conducted in the early 2000s, two-thirds of boys reported exposure to pornography in the prior year.13 In a recently published study of adolescents from 45 different states, more than half of the boys reported that they had viewed pornography.16 Girls Boys are not alone in their exploration of pornography. A study of 7th- and 8thgrade students conducted in the early 1990s found that slightly fewer than onethird of girls reported regular exposure to R- and X-rated films.9 A study of attendees at an urban clinic in 2006 found that slightly more than one-third of girls reported exposure to pornography in the prior month.14 Predictors of Exposure A number of factors have been found to predict children and adolescents’ exposure to pornography (see Table 1). Demographically, male youth and youth who are of lower socioeconomic status are more likely to be exposed to pornography. Family factors also are important. Pornography exposure is more likely when youth reside in single-parent families, have caregivers who monitor them less, and have poor emotional bonds with their caregivers. Common psychosocial risk factors also are predictive. Youth who are sensation seekers, engage in delinquent and rule-breaking behavior, and have low self-control are more likely to view pornography. Traumatic life events also are significant. Exposure is more likely among youth who have been victimized physically or sexually or who have had a recent negative life experience, such as a death in the family. Opportunity factors also are correlative. The likelihood of exposure increases if youth have Internet access on their phone or a computer in their bedroom. Social control

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Table 1 Illustrative Examples of Peer-Reviewed Studies of Child and Adolescent Exposure to Pornography (National) Year and author

Exposure summary

Important predictors of exposure

1994. Strouse et al9

31% of girls and 54% of boys reported •  Male gender regular exposure to R- and X-rated films. • Residing in a single-parent 2001. Wingood et al10 30% of girls reported pornography exposure in the last 3 months household (all-female sample). •  Mother is not primary monitor 2005. Ybarra 15% of participants reported • Male gender and Mitchell11 intentional exposure to pornography •  Poor emotional bond with in the prior year.   caregiver • Lack of caregiver monitoring • Physical or sexual victimization • Recent negative life experiences • Delinquent behavior 2007. Wolak et al12 42% of participants reported exposure Predictors of intentional to pornography in the prior year. exposure: • Male gender • Internet access on cell phone • Computer in bedroom • Physical or sexual victimization • Rule-breaking behavior • Depression 2009. Braun-Courville 55% of participants reported lifetime •  Male gender and Rojas2 exposure to pornography. 2009. Brown 66% of boys and 39% of girls reported •  Male gender and L’Engle13 exposure to pornography in the • Black ethnicity prior year. • Lower socioeconomic status • Lower parent education • Sensation-seeking personality 2012. Rothman et al14 34.1% of girls reported pornography [Predicting pornography exposure in the prior month exposure not focus of study] (all-female sample). 19% of participants reported [Predicting pornography 2011. Ybarra et al15 pornography exposure in the prior exposure not focus of study] year at first data collection, 27% at second data collection, and 22% at third data collection (3-wave panel study). 2013. Hardy et al16 54% of boys and 17% of girls reported •  Male gender lifetime intentional pornography • Lower religiosity exposure. • Lower self-control •  Lower perceived social condemnation for exposure Note: Sex offender studies, retrospective studies (ie, adults reflecting back on their youth), and studies with adolescents and adults in which most the sample were adults (ie, 18 years or older) were excluded.

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dynamics also are relevant. Youth who are less religiously involved and who perceive they would receive less social condemnation if their pornography viewing was discovered also have a higher likelihood of exposure. Sexual Script Theory

Through what mechanisms might viewing pornography affect children and adolescents’ sexual attitudes and behaviors? Wright’s acquisition, activation, application model (3AM) offers a theoretical rationale for the socializing effect of sexual media.1,17 According to the 3AM, sexual media present consumers with scripts for sexual behavior. Scripts can inform abstract perspectives on sexual behavior (eg, scripts for aggressive behavior in the context of sex, in general) or perspectives on specific sexual behaviors (eg, scripts for particular aggressive behaviors in the context of sex, such as hair pulling or spanking). Sexual media can present consumers with scripts they were unaware of (acquisition), prime scripts they were already aware of (activation), and encourage the perceptual and behavioral utilization of scripts by portraying behaviors as normative, appropriate, and rewarding (application). Sexual Scripts in Pornography

Content analyses indicate that pornographic media recurrently present scripts supportive of aggressive and gender-stereotypic behavior, alternative sexual behaviors, and sex that is associated with a higher likelihood of outcomes such as unintended pregnancy and sexually transmitted infection (STI) transmission. Table 2 provides a summary of recent content analytic findings related to these scripts. Aggressive and Gender-Stereotypic Scripts Scripts for aggressive behavior are common in pornography.19,21,24 Men are usually the perpetrators. Women are most often the targets. A wide variety of aggressive behaviors have been observed: pushing/shoving, biting, pinching, hair pulling, spanking, slapping, gagging, choking, kicking, use of weapons, smothering, whipping, and name calling. Depictions of rape have been noted but are uncommon. Of course, individuals so predisposed can simply use an Internet search engine to find pornographic depictions of rape to fuel their fantasies or reinforce/enhance their rape supportive scripts.28 Scripts supportive of gender-stereotypic behaviors and roles also regularly appear.18,19,25 Women are depicted as subordinate to men in institutional relationships more so than the converse (eg, male boss, female secretary). Women are more likely to be shown submitting to men’s sexual demands than men are to be shown submitting to women’s sexual demands. Often this submission manifests as enthusiastic eagerness on the part of women to sexually please men. The sexual exploitation of women has also been observed (eg, women exchanging sex for food, shelter, or employment).

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Year and author

Sample

1993. Brosius et al

Random sample of pornographic videos • Women depicted as subordinate to men more than men depicted as subordinate to women. released in Germany between 1979 and 1988 •  Group sex in approximately one-fourth of scenes. (majority of videos originated in the • Affection/love central motivation for sex in 6% of scenes; pleasure central motivation United States)   in 77% of scenes. • 5% of scenes featured committed partners. • Contraception mentioned in 1% of scenes. Interracial pornographic videos obtained • Example of aggressive acts observed included hitting, hair pulling, holding down, pinching, from independent and national-chain   name calling, and racial insults. retailers in the United States •  Men perpetrated more aggressive acts than women; women were targets of aggressive acts more than men. • Female submission was more common than male submission. • Anal sex performed by 53% of characters. Random sample of pornographic videos • Approximately 90% of scenes featured casual sex. available from national retailer in the • Approximately 40% of scenes featured women subordinating themselves to men. United States • Approximately 1 in 5 scenes featured aggression against women. Random sample of pornographic videos • 25% of scenes in magazines featured aggression. and magazines available in the eastern • 27% of scenes in videos featured aggression. United States • 42% of scenes in Usenet stories featured aggression. Random sample of pornographic stories • Women were targets of aggression more than men in all 3 genres. available on Usenet Random sample of images obtained from • More than 1 in 10 pictures depicted group sex. 32 sexual online newsgroups • More than 1 in 10 pictures depicted intercourse. • Approximately 2 in 10 pictures depicted oral sex.

18

1994. Cowan and Campbell19

1999. Monk-Turner and Purcell20 2000. Barron and Kimmel21

2001. Mehta22

Key findings

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Table 2 Illustrative Examples of Peer-Reviewed Content Analyses of Pornography

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Year and author

Key findings

2009. Grudzen et al

Random sample of heterosexual and gay targeted pornographic videos selected from   the largest distributor in the United States

2010. Bridges et al24

Random sample of best-selling or most- rented pornographic videos in the   United States

2010. Gorman et al25

Random sample of videos on popular free pornography Web sites  

2013. Peters et al26

Random sample of “teen” videos on popular free pornography Web sites Teen videos highlight the teenage status of at least 1 female participant Random sample of “teen” and “MILF” (“Mother I’d like to f**k”) videos on popular free pornography Web sites Teen videos highlight the teenage status of at least 1 female participant

• Penile-anal contact depicted in 42% of heterosexual-targeted video scenes and 80% of gay-targeted video scenes. •  Oral-genital or oral-anal contact depicted in 94% of heterosexual-targeted video scenes and 100% of gay-targeted video scenes. • A condom was used in 3% of penile-vaginal scenes in heterosexual-targeted videos. • A condom was used in 78% of penile-anal scenes in gay-targeted videos. • Approximately 90% of scenes depicted aggressive acts; targets of aggression were women about 95% of the time. • Less than 1% of scenes featured discussion of pregnancy or sexually transmitted infections. • Condoms were used in 11% of scenes. •  Fellatio was performed in 90% of scenes, vaginal intercourse in 86%, anal intercourse in 56%, and group sex in 12%. • Fellatio was performed in 79% of videos with at least 2 individuals, vaginal intercourse in 68%, anal intercourse 32%. • A condom was used in 1 of 45 videos. • About one-third of videos featured men sexually dominating women. •  Approximately 50% of videos depicted women as enthusiastically eager to sexually accommodate men. •  Fellatio was performed in 78% of videos. •  Vaginal intercourse was depicted in 73% of videos. •  Anal intercourse was depicted in 19% of videos. •  Coercion depicted in 7% of videos. • Vaginal intercourse was depicted in 88% of videos. •  Fellatio was performed in 86% of videos. • Spanking was depicted in 27% of videos. • Anal sex was depicted in 15% of videos. • Condom use was depicted in 2% of videos. • Female sexual exploitation was more common than male sexual exploitation.

2014. Vannier et al27

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Sample 23

580

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Table 2 Illustrative Examples of Peer-Reviewed Content Analyses of Pornography—cont’d

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Alternative Sexual Scripts The traditional sexual script stipulates that sex should take place only between married, monogamous, adult couples who are relationally or procreationally motivated.* Sexual scripts in pornography deviate from each component of the traditional sexual script.18,20,24,26,29 Depictions of committed partners are almost nonexistent. Extrarelational sex is a common theme. “Teen” pornography is a popular genre (teen pornography highlights the teenage status of at least 1 female participant). Sex is much more likely to be driven by pleasure seeking than love or affection. The prevalence of anal sex and extravaginal ejaculation suggests that procreation is not a goal. Epidemiologically Risky Sexual Scripts From a public health perspective, sex is risky if it is associated with a higher likelihood of unintended pregnancy or STIs. Two behaviors that are associated with higher sexual risk are sex without a condom and having multiple sexual partners. Condomless sex is the norm in pornography featuring men and women.23 Pornographic actors and actresses have sex with different partners within and across performances. Simultaneous sex with at least 3 participants has been observed in several studies.18,22,24 Attitudinal and Behavioral Correlates Related to Pornographic Scripts

Pornography experiments with individuals younger than 18 years would be illegal in the United States and many other countries. Surveys that confidentially ask children and adolescents about their pornography exposure and their attitudes and behaviors related to scripts in pornography have been conducted, however. Table 3 summarizes recent studies that have correlated exposure to pornography among children and adolescents with theoretically related cognitions and behaviors. Aggression and Gender Stereotypes Pornography exposure has been a significant correlate of sexually aggressive behavior in several surveys. In a cross-sectional study of Italian adolescents, pornography exposure was associated with a higher likelihood of having sexually harassed a peer and having forced somebody to have sex.32 Longitudinal studies have also found associations between youths’ exposure to pornography and sexually aggressive behavior. In a 2-wave panel study with US middle school students, boys who consumed more pornography at the first wave were more likely to have engaged in sexual harassment perpetration at the second wave.13 In *It should be noted that while most adults are opposed to aggression, unintended pregnancy, and STIs, adults’ views on alternative sexual behaviors are quite varied. In other words, while there is relative consensus among adults that pornography’s scripts for aggression and epidemiologically risky behaviors are negative, there is much less consensus among adults regarding the positivity or negativity of alternative sexual behaviors.

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Method

Year and author

Country

Criteriona

Cross-sectional survey

1994. Strouse et al

United States

Cross-sectional survey

1999. Lo et al30

Taiwan

Cross-sectional survey

2001. Wingood et al10

United States

Cross-sectional survey

2005. Lo and Wei31

Taiwan

Cross-sectional survey

2006. Bonino et al32

Italy

Cross-sectional survey

2006. Peter and Valkenburg33

Netherlands

Cross-sectional survey

Sweden

Cross-sectional survey

2007. Johansson and Hammarén34 2007. Peter and Valkenburg35

Cross-sectional survey

2008. Peter and Valkenburg3

Netherlands

2 Among boys and girls, exposure to R- and X-rated films was associated with more acceptance of sexual harassment. 2, 3 Controlling for gender, pornography exposure was associated with more positive attitudes toward premarital sex and extrarelational sex, frequency of casual sex, and number of sexual partners. 1, 3 Exposure to pornography was associated with belief that partners would become upset if asked to use a condom, testing positive for chlamydia, not using contraception, and having multiple sexual partners (all-female sample). 2, 3 Controlling for gender, pornography exposure was associated with more positive attitudes toward premarital and extramarital sex and frequency of casual sex. 3 Among boys and girls, exposure to pornography was associated with having engaged in sexual harassment and sexual coercion. 2 Boys perceive pornography as more realistic than girls; perceiving pornography as realistic associated with more recreational attitudes toward sex. 3 Among boys and girls, exposure to pornography was associated with having had oral and anal sex. 1, 2 Among boys and girls, exposure to pornography was associated with the notion that women are sex objects (criterion measure contained both belief and attitude items). 2 Controlling for gender, exposure to pornography was associated with more positive attitudes toward uncommitted sexual exploration.

9

Netherlands

Major findings

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Table 3 Illustrative Examples of Peer-Reviewed Studies Correlating Exposure to Pornography among Children and Adolescents with Theoretically Related Beliefs, Attitudes, and Behaviors (National and International)

2009. Braun-Courville and Rojas2

United States

Cross-sectional survey

2011. Luder et al36

Switzerland

Cross-sectional survey

2012. Rothman et al14

United States

Cross-sectional survey

2012. Weber et al37

Germany

Longitudinal survey

2008. Peter and Valkenburg38

Netherlands

Longitudinal survey

2009. Brown and L’Engle13

United States

Longitudinal survey

2009. Peter and Valkenburg39

Netherlands

Longitudinal survey

2009. Peter and Valkenburg40

Netherlands

Longitudinal survey

2010. Peter and Valkenburg41

Netherlands

Longitudinal survey

2010. Peter and Valkenburg42

Netherlands

Longitudinal survey

2011. Ybarra et al15

United States

2, 3

Controlling for gender, exposure to pornography was associated with having  multiple partners, anal sex, and using alcohol or drugs at last sexual encounter. Pornography exposure also associated with permissive sexual attitudes. 3 Exposure to pornography was associated with noncondom use among boys (only 1% of girls reported intentional exposure to pornography). 3 Exposure to pornography was associated with having engaged in group sex (all-female sample). 1 Among both boys and girls, exposure to pornography was associated with higher estimates of peers’ sexual activity. 1 Among boys and girls, exposure to pornography predicted more preoccupation with sex 1 year later. 2, 3 Pornography exposure predicted oral sex and intercourse initiation 2 years later among boys and girls. Baseline pornography exposure also prospectively predicted girls’ regressive gender role attitudes and boys’ permissive sexual attitudes and sexual harassment perpetration. 1, 2 Among boys and girls, exposure to pornography predicted the notion that women are sex objects 1 year later (criterion measure contained both belief and attitude items). 2 Among boys and girls, exposure to pornography predicted lower sexual satisfaction 6 months later. 2 Among boys and girls, exposure to pornography predicted more recreational attitudes toward sex 6 months later. 1 Among boys and girls, exposure to pornography predicted a more disjointed sexual identity 1 year later. 3 Among boys and girls, exposure to violent pornography was associated with sexually coercive behavior over a 3-wave, 36-month data collection period.

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Cross-sectional survey

Note: Sex offender studies, retrospective studies (ie, adults reflecting back on their youth), and studies with adolescents and adults in which most the sample were adults (ie, 18 years or older) were excluded. a For criterion: 1 5 belief (cognition without valence), 2 5 attitude (valenced cognition), 3 5 behavior. 583

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a 3-wave panel study with children and early adolescents in the United States, exposure to violent pornography was associated with an increased probability of having engaged in sexually coercive behavior.15 A gender stereotype commonly associated with pornography is that women are objects whose purpose is to sexually gratify men. In both cross-sectional and longitudinal research conducted with Dutch adolescents, pornography exposure has been correlated with more agreement that women are sex objects.35,39 Alternative Sex Exposure to pornography has correlated with more alternative sexual attitudes and behaviors in cross-sectional and longitudinal surveys conducted in several countries (eg, United States, Netherlands, Sweden, Taiwan). Alternative behaviors associated with pornography exposure in cross-sectional studies include having casual sex, anal sex, and group sex.14,30,34 In longitudinal research, pornography exposure has been prospectively predictive of initiating oral sex, initiating intercourse, and having more recreational attitudes toward sex.13,41 Epidemiologically Risky Sex Pornography exposure has been associated with having more sexual partners in cross-sectional surveys. In a study of Taiwanese adolescents, youth who consumed more pornography also had more sexual partners.30 Another study with young girls found that those who consumed pornography were more likely to have had multiple sexual partners.10 Pornography exposure has also correlated with the number of sexual partners in US studies with both boys and girls.2 Pornography exposure has correlated with a lower likelihood of contraceptive use in a few cross-sectional surveys. Exposure to pornography has been correlated with a lack of contraceptive use as well as testing positive for chlamydia.10 In a study conducted in Switzerland, exposure to pornography was correlated with a reduced likelihood of condom use among boys.36 Sexting

The topic of sexting is relatively recent with respect to other Internet concerns. Although definitions vary, it is generally considered to be the electronic transmission of nude or seminude images as well as sexually explicit text messages.43 The prevalence of this activity among adolescents has been a topic of considerable debate. Prevalence data, in terms of both sending and receiving sexts, vary from 2% to 50%. An excellent and recent review of the literature on the sending of sexual photos estimated a prevalence of 12% for those in the age range from 10 to 19 years.44 Given that many of these studies represent large-scale samples, this represents a significant number of children/adolescents engaged in what some states would consider illegal activities.

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Researchers in the last few years have begun the process of trying to determine the “why” and “who” of sexting. The data to date suggest a number of fairly consistent trends. With respect to why adolescents sext, the following seem to be strongly suggestive44,45: 1. 2. 3. 4. 5.

They want to be sexy or initiate sexual activity. They want to gain attention from a partner. They want to be fun and flirtatious. They succumb to pressure from friends/dating partner. They sext as a form of self-expression.

The peer pressure aspect seems to be especially strong. In a survey of adolescent and mobile phone use, it is noted, “From an adolescent frame of reference, sext­ ing and mobile porn use may be associated mostly with benefits (in terms of peer acceptance) rather than risks.”45(p29) As we will note later, there are risks, particularly from a legal perspective, but they seem rather innocuous with respect to peers. With respect to who sexts, much of the research seems somewhat similar to the data on who views online pornography. Risk taking, particularly sexual risk taking, plays a strong role. In a recent comprehensive review some of the following are noted44: 1. Sexting (particularly the sending of a photo) is associated with higher rates of engaging in a variety of sexual behaviors. 2. Teens who sexted were 7 times more likely to be sexually active and nearly twice as likely to engage in unprotected sex than their peers. 3. Girls who had sent naked photos of themselves had a higher chance of engaging in risky sex and using substances before sex. The recent appearance of sexting naturally limits our ability to draw firm conclusions on prevalence and effects. A number of issues need to be considered. First are the definitional issues. There is a significant difference between sending a photo and sending a text message. There is also the degree of explicitness associated with the transmission. This current lack of consistent definitions probably accounts for the large discrepancies in the prevalence data. Second, much of the current research is based within the United States. While studies have been conducted abroad, we need more cross-cultural research in this area. Third, we need to move beyond cross-sectional studies. As in many areas, longitudinal panel studies will give us much more information on behavioral patterns and effects. Fourth, when does sexting turn to “bullying” (eg, sending explicit pictures of someone else to others, known as revenge porn)? Finally, researchers noted that while a small percentage of sent messages could be considered child pornography, the occurrences were widespread enough that education is needed about

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the legal consequences of possessing or sending such images.46 Laws differ between states, but consequences still exist, and education for adolescents is needed in this area. Education also is needed for parents and other adults in supervisory positions. Sexual Exploitation

The disinhibitory and opportunistic nature of the Internet opens up a new potential for the sexual exploitation of children and adolescents. The sending of sexual information via e-mail or postings on virtual bulletin boards by those targeting children has been a subject of ongoing research. There are number of reasons to expect that the Internet plays a role in sexual exploitation. As researchers have noted, children are more accessible to offenders through social networking sites, e-mail, and texting because these behaviors are largely anonymous and normally outside the supervision of parents.47 Children also may find the privacy and anonymity of this type of communication much more conducive for them to have discussions of intimate relationships than face-to-face meetings. Potential offenders have easy access to Web sites and other Internet groups that encourage and legitimize these types of behavior with children and adolescents. Perhaps the most comprehensive series of studies on these issues has come from the Crimes Against Children Research Center at the University of New Hampshire. These studies involved 3 different random national samples of 1500 children aged 10 to 17 years interviewed in 2000, 2005, and 2010.47 This procedure allowed the researchers to look at changes in youths’ experiences with the Internet. The major findings from this study can be summarized as follows: 1. In the year 2000, about 19% of youth reported sexual solicitation. This was reduced to about 10% by 2010. One explanation for this decrease was extensive news coverage of sexual predators and perhaps better filtering software. 2. Perhaps more important, about 3% of these encounters were considered “aggressive” in that the solicitor attempted to contact the user offline. These episodes are the most likely to result in actual victimizations. 3. Most solicitations were among older youth (aged 16 to 17 years), yet the distressing situations were more common among younger youth (aged 13 to 15 years), as might be expected. 4. Females were more likely than males to be solicited. While these percentages might seem small, we must remember that these are national samples, and this represents a significant number of children. In their research, the authors identified some potential risk factors for online solicitation: a high degree of parent/child conflict, which leads to less supervision of children; and children who have survived sexual abuse or assault.

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Conclusions

The topics we discussed in this article are fairly new with respect to research and are an obvious outgrowth of new technology. There is much more we need to know in these areas, but the research to date suggests that there are significant risks to children and adolescents from online interactions. We agree that the prevalence data for pornography exposure, sexting, and online solicitation are small, but the data represent a substantial amount of youth. In thinking about potential solutions to these issues, we do not believe that governmental regulation (eg, censoring specific Internet sites, prosecuting pornography Web site developers) would be an answer, particularly in a media platform that is global in nature. Rating systems, if handled adequately, might help somewhat, but such systems are rarely utilized by parents and have not been effective even with simple technologies like television. We strongly believe that various forms of education and media literacy are reasonable solutions. They can include 1. Professionals such as pediatricians and teachers taking a more active role in discussing the effect of new media. 2. Empowering parents in their roles as monitors of children’s media viewing (including the Internet). 3. Media literacy and critical viewing skills that, taught as part of school curriculum, may be strong interventions for mitigating the effects of many negative media depictions. 4. The mass media itself being part of the solution. For example, movies and Web sites about sex education that are professionally produced and also are entertaining have great potential for informing the public and influencing risk-related attitudes and behaviors. In summary, this article was intended to provide a brief overview of some of the concerns we have about new media platforms. In reflecting on this brief review, it would be safe to conclude that the mass media, in all its domains, is a contributor to a number of risk behaviors and health-related problems in children and adolescents, which are discussed throughout this volume. We must keep in mind, however, that the mass media is but one of a multitude of factors that contribute but, in many cases, is not always the most significant. Nevertheless, it is one of the factors for which proper interventions, as we suggested, can mitigate its effect and a factor that can be controlled with reasonable insight.7,48 References 1. Wright PJ, Malamuth N, Donnerstein E. Research on sex in the media: what do we know about effects on children and adolescents? In: Singer DG, Singer L, eds. Handbook of Children and the Media. Thousand Oaks, CA: Sage; 2012 2. Braun-Courville D, Rojas M. Exposure to sexually explicit web sites and adolescent sexual attitudes and behaviors. J Adolesc Health. 2009;45:156-162

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3. Peter J, Valkenburg P. Adolescents’ exposure to sexually explicit Internet material, sexual uncertainty, and attitudes toward uncommitted sexual exploration: is there a link? Communic Res. 2008;35(5):579-601 4. Livingstone S, Haddon L. EU Kids Online: Final Report. London, England: EU Kids Online; 2009 5. Donnerstein E. The Internet as “fast and furious” content. In: Warburton W, Braunstein D, eds. Growing up Fast and Furious. Sydney, Australia: The Federation Press; 2012 6. Donnerstein E. Children, adolescents, and the Internet: are there risks online? In: Dill K, ed. The Oxford Handbook of Media Psychology. New York: Oxford University Press; 2013:373-381 7. Strasburger V, Jordan A, Donnerstein E. Children, adolescents, and the media: health effects. Pediatr Clin North Am. 2012;59(3):533-587 8. Malamuth N, Linz D, Yao M. The Internet and aggression: motivation, disinhibitory and opportunity aspects. In: Amichai-Hamburger Y, ed. The Social Net: Human Behavior in Cyberspace. New York: Oxford University Press; 2005:163-191 9. Strouse J, Goodwin M, Roscoe B. Correlates of attitudes toward sexual harassment among early adolescents. Sex Roles. 1994;31:559-577 10. Wingood G, DiClemente R, Harrington K, Davies S, Hook E, Oh M. Exposure to x-rated movies and adolescents’ sexual and contraceptive-related attitudes and behaviors. Pediatrics. 2001;107(5): 1116-1119 11. Ybarra M, Mitchell K. Exposure to Internet pornography among children and adolescents: a national survey. Cyberpsychol Behav. 2005;8(5):473-486 12. Wolak J, Mitchell K, Finkelhor D. Unwanted and wanted exposure to online pornography in a national sample of youth internet users. Pediatrics. 2007;119(2):247-257 13. Brown J, L’Engle K. X-rated: sexual attitudes and behaviors associated with U.S. early adolescents’ exposure to sexually explicit media. Commun Res. 2009;36(1):129-151 14. Rothman E, Decker M, Miller E, et al. Multi-person sex among a sample of adolescent female urban health clinic patients. J Urban Health. 2012;89(1):129-137 15. Ybarra M, Mitchell K, Hamburger M, Diener-West M, Leaf P. X-rated material and perpetration of sexually aggressive behavior among children and adolescents: is there a link? Aggress Behav. 2011;37(1):1-18 16. Hardy S, Steelman M, Coyne S, Ridge R. Adolescent religiousness as a protective factor against pornography use. J Appl Dev Psychol. 2013;34(3):131-139 17. Wright PJ. Mass media effects on youth sexual behavior. Commun Yearbook. 2011;35:343-386 18. Brosius H, Weaver III J, Staab J. Exploring the social and sexual “reality” of contemporary pornography. J Sex Res. 1993;30(2):161-170 19. Cowan G, Campbell R. Racism and sexism in interracial pornography: a content analysis. Psychol Women Q. 1994;18(3):323-338 20. Monk-Turner E, Purcell H. Sexual violence in pornography: how prevalent is it? Gender Issues. 1999;17(2):58-67 21. Barron M, Kimmel M. Sexual violence in three pornographic media: toward a sociological explanation. J Sex Res. 2000;37(2):161-168 22. Mehta M. Pornography in Usenet: a study of 9,800 randomly selected images. Cyberpsychol Behav. 2001;4(6):695-703 23. Grudzen C, Elliott M, Kerndt P, et al. Condom use and high-risk sexual acts in adult films: a comparison of heterosexual and homosexual films. Am J Public Health. 2009;99(Suppl 1):S152-S156 24. Bridges A, Wosnitzer R, Sun C, Scharrer E, Liberman R. Aggression and sexual behavior in bestselling pornography videos: a content analysis update. Violence Against Women. 2010;16(10):10651085 25. Gorman S, Monk-Turner E, Fish J. Free adult Internet web sites: how prevalent are degrading acts? Gender Issues. 2010;27(3-4):131-145 26. Peters E, Morrison T, Bishop C, Kiss M, McDermott D. Age is in the eye of the beholder: examining the cues employed to construct the illusion of youth in teen pornography. Sex Cult. 2014;18(3): 527-546

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Legal Risks of Online Adolescent Communication Peter S. Moreno, JD, MS*, Dustin D. Drenguis, JD University of Washington School of Law, Seattle, Washington

INTRODUCTION

As the power and reach of electronic media increase, so do the risks of using such media. Among adolescents, social media postings have been associated with a range of potentially negative health consequences.1,2 To a certain extent, such consequences are foreseeable, and some adolescents have begun to recognize and minimize those health risks as they use electronic media. Less obvious, but growing in importance, is the legal liability adolescents can incur when communicating online or by phone. Driven in part by news reports regarding tragic consequences of online harassment, governments across the country have raced to pass laws to address electronic safety.3 Forty-eight states now have laws that explicitly prohibit cyberbullying or electronic harassment, and 17 states have laws related to sexting, the practice of texting nude or seminude images of a person younger than 18 years (Figure 1).4,5 Adolescents who create or possess nude images of people younger than 18 years are also subject to criminal prosecution under existing child pornography laws, which are ubiquitous and impose severe penalties, including sex offender registration.6 An adolescent—or his or her parents—might also be subject to civil lawsuits for money damages from people who claimed to be wronged by the adolescent’s communications, such as victims of alleged harassment. In many cases, adolescents may be surprised that their online actions (eg, sending a nude photo of oneself to a friend) not only could be punished by school administrators but also could be prosecuted as a criminal offense.6 To an extent, such surprise is justified because much of the law in this area is unsettled and

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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U.S. states with electronic harassment and sexting laws ϱϬ ϰϱ ϰϬ ϯϱ ϯϬ Ϯϱ ϮϬ ϭϱ ϭϬ ϱ Ϭ

States with laws regarding electronic States with laws regarding sexting harassment Fig 1. States with electronic harassment and sexting laws.

inconsistently applied. Prosecutions and other punishments for hurtful communications vary widely by jurisdiction and circumstance, and the outcomes of such cases often are unpredictable. Many of the statutes governing online communications are new and vague, and some of the broadest statutes have been challenged as violations of free speech. Life in such an unsettled legal world presents dangerous uncertainty, both for victims of online abuse and for those accused of wrongdoing. This is particularly true for adolescents who might lack the foresight and experience to recognize that their online actions could be hurtful or even illegal. The law regarding online behavior is changing, but adolescents still must be aware of the laws as they currently stand to avoid potential problems and to take advantage of remedies offered to victims. The most notable developments in this area have been the emergence of cyberbullying and sexting statutes, and the courts’ views of online privacy generally. These new laws provide a glimpse of how governments will regulate online speech now and in the future. CYBERBULLYING LAWS

Cyberbullying, or harassment through electronic means, has been the subject of intense recent debate, because of both its perceived effects on health and the efforts of lawmakers and school administrators to curb the practice. A growing body of research demonstrates the risk of cyberbullying. Among adolescents, targets of cyberbullying seem to be at higher risk for suicide, depression, and academic problems.1 Researchers suspect that the prevalence of cyberbullying is increasing, but prevalence rates are difficult to determine because the definition of cyberbullying varies between different studies and states.7

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State Cyberbullying Statutes

Almost all states have specifically prohibited cyberbullying or electronic harassment, and every state that has an anti-bullying statute also requires its schools to implement anti-bullying policies.4 There is no federal statute on the topic, but statutes have been proposed. Figure 2 contains excerpts of Arkansas’s bullying statutes, which provide an example of a broad state cyberbullying law, including definitions of key terms.8 Like other states with bullying statutes, Arkansas requires its schools to adopt policies to combat bullying on- and off-campus. In practice, the contents of these school policies are important because they are enforced far more frequently than are criminal statutes.9 School punishments for policy violations typically involve suspension or expulsion. Scope and Constitutionality of Cyberbullying Statutes

As schools have sought to define and prohibit cyberbullying, legal concerns have arisen regarding the extent to which schools can limit student speech.10 Public Excerpts of Arkansas Statutes Regarding Bullying A.C.A. § 5-71-217. Cyberbullying (b) A person commits the offense of cyberbullying if: (1) He or she transmits, sends, or posts a communication by electronic means with the purpose to frighten, coerce, intimidate, threaten, abuse, or harass, another person; and (2) The transmission was in furtherance of severe, repeated, or hostile behavior toward the other person. .... A.C.A. § 6-18-514. School antibullying policies (b)(2) “Bullying” means the intentional harassment, intimidation, humiliation, ridicule, defamation, or threat or incitement of violence by a student against another student or public school employee by a written, verbal, electronic, or physical act that may address an attribute of the other student, public school employee, or person with whom the other student or public school employee is associated and that causes or creates actual or reasonably foreseeable: .... (b)(2)(D) Substantial disruption of the orderly operation of the school or educational environment; .... (b)(5) “Substantial disruption” means without limitation that any one (1) or more of the following occur as a result of the bullying: (A) Necessary cessation of instruction or educational activities; (B) Inability of students or educational staff to focus on learning or function as an educational unit because of a hostile environment; (C) Severe or repetitive disciplinary measures are needed in the classroom or during educational activities; or (D) Exhibition of other behaviors by students or educational staff that substantially interfere with the learning environment. Excerpts of Arkansas Code §§ 5-71-217 and 6-18-514 relating to cyberbullying and bullying generally. Source: West’s Arkansas Code Annotated, current through 2014.

Fig 2. Excerpts of Arkansas Code relating to cyberbullying and bullying generally.

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schools are government actors, and, as such, they may not limit speech in a way that conflicts with free speech rights under the First Amendment of the US Constitution or similar provisions in state constitutions. Also, school policies must define the prohibited behavior well enough so that students are aware when their actions constitute a punishable offense. Section 6-18-514(b) of the Arkansas statutes shown in Figure 2 defines the terms that schools in that state must use when forming anti-bullying policies, including the term bullying itself. Similar to the bullying statutes of other states, Arkansas’s definition of bullying is very broad, presumably reflecting the reality that harassment can occur in a multitude of forms and giving great flexibility to schools to punish bullying behavior however it may arise, now or in the future. The problem with such broad authority is that it can lead to unpredictable enforcement and potential conflict with longstanding civil liberties law. For example, the Arkansas definition categorically prohibits ridicule of any student or employee by virtually any means if the act results in a substantial disruption of the school. The statute lists categories of substantial disruption, but categories such as “exhibition of other behaviors by students or educational staff that substantially interfere with the learning environment” and “inability of students or educational staff to focus on learning…” are exceedingly vague and could punish types of student speech that have been constitutionally protected in the past.11 For example, a high school student who criticizes an incompetent teacher on social media, inadvertently causing a disruption of class, could be subject to punishment or even criminal charges under such a policy. The same liability exists even if the student used his or her home computer to post the criticism, and the criticism was not part of a pattern of harassment. The statutes of other states, such as Virginia and Indiana, criminalize an even broader range of electronic communication, including things as vague as “indecent language.”12 The constitutionality of such laws has been called into question, and courts are divided as to the power schools should be afforded to curb bullying. These cases are most often brought by students punished for cyberbullying who are challenging their punishments in court, often arguing that the punishment violates his or her free speech rights.13 Ultimately, constitutionality is an issue for the US Supreme Court, which defines the extent to which the government, including public schools, can regulate speech under the First Amendment. The Supreme Court has not yet ruled on the constitutionality of any state bullying policies specifically, so lower federal and state courts hearing challenges to cyberbullying punishments apply the law of older Supreme Court decisions regarding student speech to the facts of the case before them to determine whether the punishment was permissible.13 The Supreme Court decision most often cited by courts regarding student speech generally is Tinker v. Des Moines Independent School District (1969).14 In Tinker, the Court held that a school was unjustified in banning students from wearing

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black arm bands to school to protest the Vietnam War. If the school cannot show that the speech threatens safety or “materially and substantially interfere(s) with the requirements of appropriate discipline in the operation of the school,” it may not limit it. The fact that speech is offensive or causes an emotional effect does not, in itself, justify a restriction.15 Most courts hearing challenges to cyberbullying policies will in some fashion consider whether the punished speech “substantially interferes” with school operation, a standard created by Tinker and restated in subsequent Supreme Court opinions.16 Similarly, many state bullying policies require schools to find “substantial interference” before punishing the bully, presumably to account for the Tinker requirement. Unfortunately, the Supreme Court has not defined “substantial interference” in the bullying context, and lower courts are divided as to what it means. At least 1 federal court of appeals has struck down a school’s antiharassment policy as unconstitutionally overbroad, noting the general principle that “the mere fact that someone might take offense at the content of speech is not sufficient justification for prohibiting it.”11 The author of that opinion was Third Circuit Judge Samuel Alito, now on the Supreme Court, suggesting that at least part of the Supreme Court will have the same view regarding other antibullying laws. Other Supreme Court cases have clarified that there are instances in which a student’s speech can be restricted. Student speech that contains lewd comments, threatens physical harm, or advocates for illegal drug use receive no First Amendment protection.17 Speech in a school-sponsored publication is subject to more control than other student speech.18 In general, courts have found that schools tend to be more justified in restricting speech when the speech is oncampus or otherwise bears some clear connection to campus.10 However, a few courts do not recognize a distinction between on-campus and off-campus speech, or do not view the distinction as important, especially in the cyberbullying context.13 Some legal commentators and courts have noted that Tinker and subsequent Supreme Court case law are not easily applicable to the cyberbullying arena.10,19 First, cyberbullying is not the kind of speech considered in these cases, and there is some question as to whether a type of harassment should enjoy the same type of protection afforded political advocacy or nonmalicious lewd speech. Furthermore, cyberbullying often involves personal interactions that do not amount to physical threats and are not obvious disruptions to the school as a whole under Tinker but nonetheless are profoundly hurtful to the victim. Finally, cyberbullying routinely involves postings or texts that are created or viewed off-campus, where school authority probably is weakest.10 Regardless of constitutionality concerns, cyberbullying laws and policies likely are here to stay in one form or another, and those students (or parents) wishing

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to challenge a punishment will face uncertain outcomes in the courts. A cautious student should take care to limit malicious online expression, especially if it focuses on a single person, and targets of bullying should be aware that schools can punish the behavior only when it creates a serious problem. Despite the overbreadth of some cyberbullying laws, egregious bullying that includes severe, repeated harassment or physical threats is very likely to be punished, either under bullying statutes or other laws that prohibit harassment, defamation, or assault. The outcomes of these cases are very fact-specific, so it is important for all parties to record as much information about the bullying as possible, including the times and locations of the bullying behavior, the people involved, electronic and physical evidence of bullying, and the effects to the victim, both short and long term.12 These facts will help schools and courts determine whether punishment is warranted.20 Anonymous Bullying

Cyberbullying through anonymous texts or Web site postings has become common and is particularly difficult for schools and governments to address. The Internet provides users some degree of anonymity generally, and social media Web sites typically allow users to adopt screen names that can hide the user’s true identity.21 Cyberbullies tend to find such anonymity attractive because it allows them to avoid detection.21 Anonymity does not make bullying less hurtful; in fact, the opposite may be true. Victims of anonymous cyberbullying can find school life extremely difficult and isolating because they must deal not only with the pain of being bullied but also the fear of an unknown perpetrator.21 Clearly, if the source of the bullying cannot be identified, it is difficult or impossible for school officials to link the bullying to the school and punish the bully. Courts may breach the anonymity of a Web site user if a person presents enough evidence that he or she has suffered harm, but such a showing would require substantial effort and court involvement.22 A more effective strategy might be to expose the bully’s identity through peer pressure, research, or other means. When physicians encounter reports of cyberbullying, they must be aware of the limits of school intervention and the importance of educating patients and parents about the health and potential legal risks of such harassment. Researchers have begun to stress that schools are necessarily limited in their ability to deter cyberbullying through punishment.23 Education and a school climate that encourages responsible Internet use might be preferred means of deterrence.24 SEXTING LAWS

Sexting is the sending of sexually explicit messages or images (sexts) by cell phone.25 It is increasing in popularity and is closely associated with the growing use of smartphones, which allow users to photograph themselves and distribute the image easily.26 Estimates of teen sexting rates vary, with 1 survey reporting

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20% of teens are sending or posting nude or seminude images of themselves,27 and another study placing the number at 4%.28 Even if the lower rate is more accurate, this finding suggests that thousands or even millions of teens have sent sexts at some point in their lives, and many more teens have received them. Sexting by people younger than 18 years can have severe and unintended consequences, some of which are predictable and some of which are not. Teens who take and send sexually explicit photos of themselves risk the recipient posting those images online or forwarding them to others, which can lead to embarrassment, harassment, and bullying.29 This also means that the recipient who distributed the image might face penalties under cyberbullying laws or might be sued for damages by the victim. Another risk for children who send texts and for the people who receive them is prosecution under child pornography statutes, a potentially catastrophic consequence. Convictions under these laws can result in incarceration, a felony record, and lifelong sex offender registration.6 Although child pornography prosecutions for sexting seem to be uncommon, the liability and risk of prosecution remain. Some states have adopted sexting exceptions or created alternative sexting crimes so that sexting teens are not liable under child pornography statutes, but most states have not followed suit.5 Child Pornography Statutes

Most child pornography statutes were created in the mid-1970s to combat sexual abuse and exploitation of children by adults.29,30 Under the federal statute, which can apply in interstate cases, criminal charges may be brought against anyone who creates, possesses, or transfers images of anyone younger than 18 years engaging in sexually explicit conduct.31 “Sexually explicit conduct” includes actual or simulated sexual intercourse, masturbation, or “lascivious exhibition of the genitals or pubic area of any person.”32 The definitions of child pornography in state statutes vary somewhat by state but typically mirror the federal statute. For example, Virginia’s statute (Figure 3) makes it a felony to create or possess “sexually explicit visual material” depicting someone younger than 18 years.33 Prohibited material includes “lewd exhibition of nudity,” and nudity in turn can include depiction of genitals, breasts, or buttocks with “less than a full opaque covering.”34 Anyone who possesses such images in Virginia is guilty of a felony, and anyone who produces or asks someone to produce such images also must serve a mandatory prison sentence.35 Under the federal statute and many state statutes, at least some violators must register as sex offenders.36 Additionally, those convicted of creating, distributing, or possessing child pornography are often required to pay restitution.37 Child pornography statutes typically provide no exceptions for teens who produce or receive sexts, and the statutes are broad enough to apply to self-produced child pornography.6 The laws criminalize the creation and possession of images, generally regardless of intent. Hypothetically, a minor teen may take an

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Excerpts of Virginia Statutes Regarding Child Pornography V.C.A. § 18.2-374.1. Production, publication, sale, financing, etc., of child pornography. A. For purposes of this article…, “child pornography” means sexually explicit visual material which utilizes or has as a subject an identifiable minor.... For the purposes of this article…, the term “sexually explicit visual material” means a picture, photograph, drawing, sculpture, motion picture film, digital image, including such material stored in a computer's temporary Internet cache when 3 or more images or streaming videos are present, or similar visual representation which depicts sexual bestiality, a lewd exhibition of nudity, as nudity is defined in § 18.2-390, or sexual excitement, sexual conduct or sadomasochistic abuse, as also defined in § 18.2-390, or a book, magazine or pamphlet which contains such a visual representation. V.C.A. § 18.2-390. Definitions. (2) “Nudity” means a state of undress so as to expose the human male or female genitals, pubic area or buttocks with less than a full opaque covering, or the showing of the female breast with less than a fully opaque covering of any portion thereof below the top of the nipple, or the depiction of covered or uncovered male genitals in a discernibly turgid state. V.C.A. § 18.2–374.1:1. Possession, reproduction, distribution, solicitation, and facilitation of child pornography; penalty. A. Any person who knowingly possesses child pornography is guilty of a Class 6 felony. B. Any person who commits a second or subsequent violation of subsection A is guilty of a Class 5 felony. C. Any person who (i) reproduces by any means, including by computer, sells, gives away, distributes, electronically transmits, displays with lascivious intent, purchases, or possesses with intent to sell, give away, distribute, transmit, or display child pornography with lascivious intent …shall be punished by not less than five years nor more than 20 years in a state correctional facility.... Excerpts of Virginia Code §§ 18.2-374.1, 18.2-374.1:1, and 18.2-390 relating to child pornography. Source: West’s Annotated Code of Virginia, current through 2014.

Fig 3. Excerpts of Virginia Code relating to child pornography.

explicit image of him or herself but keep that image and not share it with anyone else. Under the typical state statute, that teen still is guilty of producing and possessing child pornography. Similarly, a teen who receives an explicit image of another teen without requesting it also is guilty of possessing child pornography.29 Teens may be surprised to learn this behavior is illegal, given state laws regarding consent for sexual activity. In most states, the age of consent for sexual activity is 17 years or younger, and “Romeo and Juliet” statutes allow teens similar in age but under the age of consent to engage in sexual activity. These laws suggest that expressions of teen sexuality are not punishable. Clearly, this is not an accurate perception. Criminal charges have been brought against adolescents for sexting even though they were carrying out a legal sexual relationship.25 It is difficult to evaluate whether prosecutions for teen sexting under child pornography statutes are rising or falling because only a small percentage of these cases result in reported appellate court decisions. Several news articles in the past few years have lamented the absurdity of these criminal charges, and many states passed sexting statutes in response, which classify teen sexting as a lesser

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crime than possessing or creating child pornography. However, in jurisdictions that have not passed new laws, child pornography charges continue to be threatened and brought against sexting teens.25 The outcomes of these cases vary. Often, teens initially charged with manufacturing or possessing child pornography see the charges reduced later and addressed with a diversion program.38 Prosecutors and judges generally have the power to offer such leniency.6 In sentencing the offending teen, judges may consider whether the teen is a first-time offender or a potential pedophile, and the nature and number of the sexual images, and many judges are inclined to impose lengthy probation terms rather than jail sentences.25,39 However, because of statutory restrictions and mandatory minimum sentences, judges often have no discretion over whether a teen is incarcerated or will be required to register as a sex offender. As with cyberbullying, some teens punished under child pornography statutes have challenged the punishment as a First Amendment violation, with varying degrees of success. According to the Supreme Court, the First Amendment generally protects sexually explicit expression, but it still allows states to enforce child pornography laws because of the states’ compelling interest in protecting children from abuse and exploitation.40 As legal commentators have noted, this rationale supporting enforcement does not seem to apply when minor teens consensually self-produce images.6 Production of such images typically is not the product of exploitation, and many teens never intend to share the images with third parties. The Supreme Court has not decided the constitutionality of child pornography statutes as applied in this context, and lower courts are split. A Florida court upheld the child pornography conviction of a 16-year-old girl who along with her 17-year-old boyfriend took photos of themselves engaged in sexual behavior.41 Although they never showed the images to a third party, the court clearly viewed the images as child pornography and recognized that the state of Florida had “a compelling interest in seeing that the videotape or picture including ‘sexual conduct by a child of less than 18 years of age’ is never produced.”42 In Washington State, a court upheld a 16-year-old boy’s conviction for production and possession of child pornography; in this case, he had taken sexually explicit photos of his 16-year-old girlfriend and then showed them to classmates at school after the couple broke up.43 The court found the child pornography statute clearly applied to juvenile offenders.43 In both the Florida and Washington cases, the prosecutors sought charges under statutes with the most severe penalties.44 In another case, a Pennsylvania district attorney threatened to charge 3 teenage girls with the production of child pornography—felonies carrying prison time and mandatory sex offender registration—unless their parents agreed to probation terms that included drug testing and a 5-week, 10-hour education program

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discussing “what it means to be a girl in today’s society.”44 At issue were 2 sexted images, 1 showing 2 of the girls at age 13 years wearing white opaque bras, and a second photo showing a girl outside the shower with a towel below her chest, exposing her breasts.45 When the teens and their parents refused to participate in the educational program, the district attorney threatened to pursue the child pornography charges. A reviewing court found that the district attorney’s threats likely violated the constitutionally protected rights of the teens and parents to refuse participation in the program, but the court did not address the issue of whether the images constituted child pornography.45 New Sexting Statutes

Seventeen states have passed statutes that make sexting a lesser crime than child pornography, or decriminalize sexting altogether.5 Other states currently are considering such legislation. To date, the federal government has not addressed the issue. Vermont was one of the first states to enact a statute that exempts minors from prosecution under state child pornography laws and any applicable sex offender registration requirements.46 First-time offenders may be referred to the state’s juvenile diversion program. For subsequent sexting offenses, juveniles may be prosecuted for sexual exploitation of children but do not have to register as sex offenders, and all records of the violations are expunged when the minor turns 18. The same year Vermont passed this law, state prosecutors dropped criminal charges against an 18-year-old boy who allegedly directed 2 teenage girls to record themselves performing sex acts and then send him the material. Their decision was influenced in part by the state legislature’s action to reduce the penalties associated with sexting.44 Nebraska passed a statute that takes a similarly lenient approach to teenage sext­ ing by providing older teens a legal defense to the possession of child pornography.47 Under the Nebraska law, individuals who are 18 years or younger cannot be convicted under the state child pornography statute if they received a sexually explicit image of a minor who is at least at 15 years old, provided (1) the image was voluntarily created and provided by the minor, (2) the image only depicts the 1 minor, (3) the defendant did not distribute the image to another person, and (4) the defendant did not pressure the minor to transmit or generate the image. Nebraska has similar protections for teens who produce and send such images.47 Some states, like North Dakota, have recognized that one of the real dangers of sexting is the distribution of sexted images without the consent of the person depicted in the image. North Dakota’s sexting law provides that a person who knowingly acquires and distributes any sexually expressive image created without the consent of the person depicted is guilty of a class B misdemeanor. A

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more serious class A misdemeanor applies when a person distributes or publishes such an image “with the intent to cause emotional harm or humiliation” and the person depicted has a reasonable expectation of privacy in the image, or after the person depicted informs the distributor that he or she does not consent to distribution of the image.48 CIVIL LIABILITY AND ONLINE PRIVACY LAW

Some victims of online harassment, perhaps seeking satisfaction outside the criminal justice realm, have taken their aggressors to court to claim injury and demand compensation. Courts hearing civil cases still must grapple with many of the same problems encountered in criminal cases, specifically issues of causation and the defendant’s intent. Furthermore, courts must consider the bounds of privacy in electronic communication and when that privacy is forfeited. Civil Liability for Cyberbullying and Unauthorized Forwarding of Sexts

Malicious electronic communications, even if they are not criminal, may make the speaker liable to victims for money damages. If the speaker is a minor, sometimes the minor’s parents also can be held liable. It is difficult for plaintiffs to succeed in such claims, especially when the primary harm to the victim is emotional, but they can provide an avenue for relief in certain circumstances.44 Adolescents who bully others online, or forward without permission self-produced sexual images they have received from peers, should be aware of this as a potential penalty. As with criminal charges, the accusation alone can have substantial and lasting effects for the accused. In the bullying and harassment context, a victim could make many civil claims of harm (ie, tort claims), depending on the case. Examples include public disclosure of private facts and intentional infliction of emotional distress, both of which can entitle the plaintiff to compensation if the claim is proven. Public disclosure of private facts generally requires proof that (1) private information was publicly divulged (2) to persons who had no legitimate interest in the information and (3) in a manner that was coercive and oppressive, and (4) such information would be highly offensive and objectionable to a reasonable person of ordinary sensibilities.49 In a case that predates the phenomenon of unauthorized sexting but invokes the same issues, an Indiana court recognized a woman’s claim for public disclosure of private facts after her ex-husband publicly distributed sexually explicit photos of the woman. The court determined that even though the woman voluntarily posed for the photos and that she failed to take action to obtain the photos after her former husband’s threat to make them public, these actions did not mean she consented to their distribution. Intentional infliction of emotional distress claims may provide another vehicle for victims of cyberbullying or unauthorized distribution of sexual images.

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Under this theory, emotional distress includes reactions such as extreme grief, shame, humiliation, embarrassment, anger, and worry.50 To prove intentional infliction of emotional distress, a plaintiff must show that the defendant intentionally or recklessly took outrageous action that caused him or her severe emotional distress.51 Tort claims against an online aggressor would likely involve several challenges. In unauthorized sexting cases, it is sometimes difficult to identify the parties at fault because text messages are widely transmitted, and some individual transmitters might not possess the requisite intent for liability.44 For example, it may be difficult to establish that forwarding a sext constitutes “extreme and outrageous” conduct to support a claim of emotional distress.44 Similar challenges would exist in cyberbullying cases, especially when bullies are anonymous or the bullying is subtle. Online Privacy Law

Much online bullying or harassment involves the dissemination of private or embarrassing information, so courts deciding these cases must consider what constitutes private information. Under the Fourth Amendment, individuals are protected from governmental searches when and where they have a reasonable expectation of privacy. This expectation is limited by what society recognizes as reasonable, given the circumstances of the individual at the time of the search. The Supreme Court has held that an individual generally does not have a reasonable expectation of privacy in things the individual knowingly exposes to the public.52 The right to privacy is construed similarly in civil cases between nongovernmental parties. For example, a defendant can be liable when he or she makes public disclosures of private facts about the plaintiff. Courts deciding such cases often apply a “reasonable expectation of privacy” analysis to the alleged disclosure, typically finding that a fact is private when a reasonable person in the plaintiff ’s position would expect the fact to be private. When determining whether a fact is private, it is important to determine whether the victim had previously shared the fact with others. Federal and state courts have generally held that a person has no reasonable expectation of privacy in any material they post on social media or send to others electronically. For example, in the New York case Romano v. Steelcase Inc., the plaintiff Romano sued the Steelcase company, claiming Steelcase caused her permanent injury and suffering.53 Steelcase requested information from Romano’s current and historical Facebook accounts, including deleted pages, to defend against these claims. The court granted Steelcase’s request to access the information on these pages, holding that Romano did not have a reasonable expectation of privacy in information that she published on social networking sites. The court noted that Facebook privacy policies plainly state that information users post may be shared with others, notwithstanding the users’ privacy settings, and that information sharing

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is the “very nature and purpose of these social networking sites else they would cease to exist.”53 Other courts have similarly concluded that a person has no reasonable expectation of privacy in writings that the person makes available to the public on a social networking site or, more generally, in materials shared with others.54 At least 1 court has held that a user’s privacy settings could create a reasonable expectation of privacy in certain circumstances, but the majority view is that privacy settings do not give rise to such an expectation even when the user restricts access to his or her postings.55 Courts have held the same rule typically applies to information sent to another by e-mail; once the e-mail is sent, the sender cannot reasonably expect the content of the message to remain private because the sender cannot control the recipient’s actions.56 One would expect the same rationale to apply to the forwarding of text messages. Although unauthorized dissemination of sexts or other material initially disclosed by the victim may be punishable under other theories, there is little to suggest that such dissemination is a violation of the victim’s privacy.41 CONCLUSIONS

The law as it applies to electronic communication is new and changing rapidly. Courts and legislatures are still determining how government regulation should apply to online users as a whole and have only begun to consider whether children and adults should be treated differently. Meanwhile, freedom-of-speech and fairness concerns abound as the new statutes are crafted and as old laws such as those banning child pornography are applied to communications using new technology. As baffling as the law may be at times, adolescents and parents must do their best to keep abreast of the current prohibitions and to express their reactions to policymakers who may be in a position to change the law. Adolescents who stay informed are better equipped to avoid legal troubles and may be more sensitive to the effects that online behavior can have. References 1. Patchin JW, Hinduja S. Cyberbullying among adolescents: implications for empirical research. J Adolesc Health. 2013;53(4):431-432 2. Moreno MA, Christakis DA, Egan KG, Brockman LN, Becker T. Associations between displayed alcohol references on Facebook and problem drinking among college students. Arch Pediatr Adolesc Med. 2012;166:157-63 3. Finnegan M. Carson mayor and city council move to outlaw bullying. Los Angeles Times, May 3, 2014. Available at: www.latimes.com/local/lanow/la-me-ln-carson-bullying-20140503-story.html. Accessed June 1, 2014 4. Cyberbullying Research Center. The state cyberbullying laws page. Available at: www.cyberbullying .us/Bullying_and_Cyberbullying_Laws.pdf. Accessed June 1, 2014 5. Cyberbullying Research Center. The state sexting laws page. Available at: www.cyberbullying.us/ state_sexting_laws.pdf. Accessed June 1, 2014

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6. Smith S. Jail for juvenile child pornographers?: a reply to Professor Leary. Va J Soc Policy Law. 2008;15:505-544 7. Congressional Research Service. The bullying: overview of research, federal initiatives, and legal issues page. Available at: www.fas.org/sgp/crs/misc/R43254.pdf. Accessed June 1, 2014 8. A.C.A. §§ 5-71-217, 6-18-514 9. Patchin JW. Most cases aren’t criminal. New York Times, September 30, 2010. Available at: www.nytimes.com/roomfordebate/2010/09/30/cyberbullying-and-a-students-suicide/most -bullying-cases-arent-criminal. Accessed June 1, 2014 10. Hostetler D. Off-campus cyberbullying: first amendment problems, parameters, and proposal. BYU Educ & LJ. 2014;2014:1-24 11. Saxe v. State College Area School District, 240 F3d 200 (3d Cir 2001) 12. Newby T. Developments in cyberstalking and cyberharassment law: what attorneys need to know. Aspatore. 2014;WL 1600592 13. Kowalski v. Berkeley County Schools, 652 F3d 565 (4th Cir 2011) 14. Tinker v. Des Moines Independent Community School District, 393 US 503 (1969) 15. Davis v. Monroe County Board of Education, 526 US 629, 633 (1999); Boos v. Barry, 485 US 312 (1988) 16. Morse v. Frederick, 551 US 393, 408 (2007); Hazelwood School Dist. v. Kuhlmeier, 484 US 260 (1988); Bethel School District No. 403 v. Fraser, 478 US 675 (1986) 17. Morse v. Frederick, 551 US 393, 408 (2007); Bethel School District No. 403 v. Fraser, 478 US 675 (1986); Watts v. United States, 394 US 705, 706 (1969) 18. Hazelwood School Dist. v. Kuhlmeier, 484 US 260 (1988) 19. J.S. ex rel. H.S. v. Bethlehem Area Sch. Dist., 807 A2d 847 (Pa 2002) 20. J.C. ex rel. R.C. v. Beverly Hills Unified School District, 711 F Supp 2d 1094 (CD 2010) 21. McQuade SC, Colt JP, Meyer N. Cyber Bullying: Protecting Kids and Adults from Online Bullies. Westport, CT: Praeger Publishers; 2009 22. Kissinger A, Larsen K. Protections for anonymous online speech. Commun Law Digital Age (PLI). 2013;8:721-876 23. Grant N. Mean girls and boys: the intersection of cyberbullying and privacy law and its socialpolitical implications. Howard Law J. 2012;56:169-206 24. Patchin JW, Hinduja S. School-based efforts to prevent cyberbullying. Prev Res. 2012;19(3):7-9 25. U.S. v. Nash, 2014 WL 868628 (ND Alabama 2014) 26. Pew Research Internet Project. The couples, the internet, and social media page. Available at: www.pewinternet.org/2014/02/11/couples-the-internet-and-social-media/. Accessed June 1, 2014 27. The National Campaign to Prevent Teen and Unplanned Pregnancy. The sex and tech: results from a survey of teens and young adults page. Available at: www.thenationalcampaign.org/resource/ sex-and-tech. Accessed June 1, 2014 28. Pew Research Internet Project. The teens and sexting page. Available at: www.pewinternet. org/2009/12/15/teens-and-sexting/. Accessed June 1, 2014 29. Sweeny J. Sexting and freedom of expression: a comparative approach. KY Law J. 2014;102:103146 30. Mazzone A. United States v. Knox: protecting children from sexual exploitation through the federal child pornography laws. Fordham Intellect Property Media Entertain Law J. 1994;5(1):174 31. 18 U.S.C. §§ 2251; 2252 32. 18 U.S.C. § 2256 33. V.C.A. §§ 18.2-374.1(a), (b)(2); 18.2-374.1:1 34. V.C.A. § 18.2-390(2) 35. V.C.A. §§ 18.2-374.1(a)-(c)(2); 18.2-374.1:1 36. 42 U.S.C. §§ 16911-16913 37. 18 U.S.C. § 2259 38. Jouvenal J. Teen ‘sexting’ case goes to trial in Fairfax County. Washington Post. April 17, 2013. Available at: www.washingtonpost.com/local/teen-sexting-case-goes-to-trial-in-fairfax-county/ 2013/04/17/4936b768-a6b7-11e2-b029-8fb7e977ef71_story.html. Accessed June 1, 2014 39. U.S. v. Autery, 555 F3d 864 (9th Cir 2009); U.S. v. Duhon, 541 F3d 391 (5th Cir 2008)

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40. United States v. Williams, 553 US 285, 288 (2008); Ashcroft v. Free Speech Coal., 535 US 234 (2002); New York v. Ferber, 458 US 747 (1982) 41. A.H. v. State, 949 So2d 234 (Fla Dist Ct App 2007) 42. A.H. v. State, 949 So2d 234 (Fla Dist Ct App 2007) (quoting Florida statute) 43. State v. Vezzoni, 127 Wash App 1012 (Wash Ct App 2005) (unpublished) 44. Eraker E. Stemming sexting: sensible legal approaches to teenagers’ exchange of self-produced pornography. Berkeley Technol Law J. 2010;25:555-596 45. Miller v. Mitchell, 598 F3d 139 (3rd Cir 2010) 46. 13 V.S.A. § 2802(b) 47. N.R.S. §§ 28-1463.03, 28-1463.04, 28-1463.05, 28-813.01 48. N.D.C.C. §§ 12.1-27.1-03.3 49. Pohle v. Cheatham, 724 NE2d 655 (Ind Ct App 2000); see also Restatement (Second) of Torts §652A 50. Restatement (Second) of Torts § 46, cmt. J 51. Restatement (Second) of Torts §46 52. Katz v. United States, 389 US 347 (1967) 53. Romano v. Steelcase, 30 Misc 3d 426 (NY Sup Ct 2010) 54. Moreno v. Hanford Sentinel Inc., 172 Cal App 4th 1125 (Cal Ct App 2009); Guest v. Leis, 255 F.3d 325 (6th Cir 2001) 55. 88 A.L.R.6th 319, §§4-13 56. 92 A.L.R.5th 15, §3

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Problematic Internet Use During Adolescence and Young Adulthood Lauren A. Jelenchick, MPH,a* Dimitri A. Christakis, MD, MPHb,c Medical Scientist Training Program, University of Minnesota Medical School, Minneapolis, Minnesota; b Seattle Children’s Research Institute, Seattle, Washington; cDepartment of Pediatrics, University of Washington, Seattle, Washington

a

Overview

Internet use begins in preadolescence and continues at high levels into adulthood. More than 93% of adolescents go online regularly, and most report rates of daily Internet use substantially higher than that of the adult population.1 Pathologic use of the Internet, most commonly called problematic Internet use (PIU), has been a growing public health concern among adolescents and young adults over the past decade.2,3 Problematic Internet use in adolescents and young adults can be described as “Internet use that is risky, excessive or impulsive in nature leading to adverse life consequences, specifically physical, emotional, social or functional impairment.”4 Although definitive diagnostic criteria for PIU do not currently exist, a citation for “Internet Use Addiction Disorder” is currently included in the appendix of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) as a disorder requiring further study. Regardless of whether or not it is an officially recognized disorder, the general consensus is that there are youth for whom Internet usage is both compulsive and counterproductive. Given that Internet usage patterns begin during childhood, primary care pediatric physicians are uniquely positioned to help prevent the development of PIU. In much the same way as smoking and problematic drinking begin in adolescence and young adulthood, so too does PIU. This review summarizes the existing literature on PIU among adolescents and young adults, including prevalence and risk factors, describes the current

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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conceptualization of the condition and available assessment tools, and discusses potential screening practices and intervention options. The article concludes by offering a set of suggested guidelines for physicians practicing in adolescent and young adult health care settings. Prevalence

Estimates for prevalence of PIU during adolescence vary widely. Prevalence in Europe is reported as between 1% and 9%,5-9 in the Middle East between 1% and 12%,10-12 and in Asia between 2% and 18%.13-20 Older adolescents, particularly those engaged in postsecondary education, often report the highest levels of Internet use and may be at higher risk for PIU.21,22 Prevalence within this group is estimated to be between 6% and 19% internationally.23-25 In 2011, a systemic review of the literature on PIU in adolescents in the United States (US) cited 8 studies reporting prevalence data for PIU published before July 2010 and estimated a range in prevalence between 1% and 25%. This variation in estimates was attributed to the disparity in measurement approaches across studies and, in some cases, lack of robust study design and reporting. Since then, several additional studies have been published reporting prevalence estimates for US adolescents and young adults (Table 1). A study of younger adolescents between the ages of 14 and 18 years set in high schools throughout Connecticut estimated prevalence at 4%.26 Moreover, 3 recent studies within diverse populations of adolescents and young adult university students estimated the prevalence between 4% and 6%,27-29 making PIU as frequent a health concern as other conditions common to this age group, such as asthma30 or depression.31 Risk Factors and Associated Conditions

Screening for pathologic Internet use has primarily been limited to how much time an adolescent spends online. Studies conducted in Asian countries suggest a cutoff of at least 6 hours a day of daily recreational hours as the most highly discriminating for detecting adolescent and young adult PIU.32 However, how an adolescent chooses to interact with the online world may play as significant a role in determining his or her relative risk for PIU. In particular, online gaming and social networking site use have been strongly associated with PIU.33-38 Both of these activities involve highly interactive, socially based Internet applications. While a smaller proportion of adolescents regularly engages in online gaming,39 use of social networking sites has reached nearly ubiquitous levels.40 Rates of PIU have been shown to vary significantly across demographic groups. In particular, those who self-identify their race or ethnicity as nonwhite have consistently been reported to be at higher risk for PIU.26,28 In a study of racially and ethnically diverse older adolescent and young adult US college students, PIU was more prevalent among those identifying as Asian/

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Reference

Setting

Participants (N)

Age Group (M, SD or Range)

Liu et al 2011

Connecticut high schools

3560

Christakis et al27 2011

2 Public universities located in Midwest and Northwest Midwest university Geographically unspecified US university

26

Derbyshire et al28 2013 Yates et al29 2012

PIU Scale

Prevalence

15.9, SD 5 1.27

Criteria modeled after MN Impulsive Disorder Inventory

4.0%

224 2108

18.9, Range 5 18-20 22.6, SD 5 5.07

IAT IAT

4.0% 5.3%

1470

19.13, SD 5 1.49

IAT

6.0%

IAT 5 Internet Addiction Test; M 5 mean; SD 5 standard deviation.

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Table 1 Studies Published after 2010 Reporting Prevalence of Problematic Internet Use (PIU) in US Adolescents and Young Adults

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Pacific Islander participants compared to black/African American, Hispanic/ Latino, white, or multiracial.29 Other factors that may increase risk for PIU include living in a urban setting, low parental involvement, and parental unemployment.41 Similar to other mental conditions, gender differences may also affect the presentation and course of PIU. On average, males spend more time online than do females, and they use the Internet more frequently for entertainment purposes, checking sports scores, and downloading or streaming music and videos.21,42 In comparison, females are more likely to use the Internet to communicate socially and to maintain, renew, or form relationships.36,42 However, findings related to PIU in US adolescents and young adults have been inconclusive, with support for greater risk among both males26 and females,27 and, in other cases, no gender differences at all.29 Furthermore, the relationships between PIU and other mental health conditions have demonstrated variability across gender.43,44 Thus, additional research is needed in order to produce generalizable conclusions regarding gender that would be useful to physicians. Other risk factors for PIU include mental health conditions such as major depressive disorder, social anxiety, and attention-deficit/hyperactivity disorder (ADHD), and behavioral problems such as hostility and aggression.45 The presence of PIU has also been shown to place adolescents at higher risk for future mental health symptoms.46 Numerous cross-sectional studies have also shown correlations between PIU and other health conditions such as dysthymia, insomnia, excessive daytime sleepiness, problematic alcohol use, and personal injury.47-51 Adverse effects in psychosocial adjustment and academic achievement, such as missed classes, lower grades, and even academic dismissal, have also been reported.52-54 Conceptual Approach

Initial efforts towards conceptualizing the nature of PIU during adolescence and young adulthood focused on adapting clinical guidelines for other conditions, such as substance abuse/dependency and pathologic gambling.55,56 Later approaches defined the condition as a behavioral addiction57,58 or an impulse control disorder.59 Others described PIU within the scope of a cognitive behavioral model60 or existing theories explaining adolescent risk behavior, namely, problem behavior theory, with mixed results.48,61,62 A recent study used a concept mapping approach to gain insights and perspectives from both adolescents and young adults, in addition to physicians, in order to rigorously describe the characteristics of PIU. This work represents the first data-driven, conceptual framework for PIU in adolescents and young adults. Along with providing an operational definition of PIU, the framework describes 7 core constructs of PIU.

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609

The first construct, psychosocial risk factors, includes emotional and social traits or states, such as depression or isolation, which may place an adolescent at risk for PIU. The next 3 constructs describe forms of impairment, specifically physical, emotional, and social/functional impairment, which may be present in adolescents affected by PIU. Finally, 3 constructs describe behaviors and perceptions related to Internet use. Risky use depicts behaviors that increase risk for adverse consequences, including both activities (eg, cyberbullying or illegal online activities) and actions (eg, prioritizing Internet use over other aspects of life). The impulsive use construct describes an inability to maintain balance or control over Internet use in relation to everyday life. The final construct, dependent use, describes the more severe symptoms that typically are associated with behavioral addictions, such as withdrawal. Working from the PIU concept map described, we include a model describing potential mechanisms of PIU among adolescents and young adults (Figure 1). Central to this model is a cycle of impairment and dependence that perpetuates PIU over time. Youth may enter a cycle of PIU through 2 main pathways:, either risky or impulsive Internet use, as described earlier. When risky or impulsive behaviors occur concomitantly in adolescents with psychosocial risk factors, the probability of developing PIU is increased. Similarly, the presence of strong resilience factors may prevent or mitigate the progression of PIU. The cyclical nature of this model allows for continual reinforcement and diversification of both impairment and dependence symptoms. Thus, while an adolescent or young adult with PIU may present initially with mild symptoms, over time, particularly in the presence of significant risk factors or problem behaviors that continue unchecked, they may develop more severe pathology. Continuing investigation into the nature of PIU through adolescence and young adulthood is needed to further validate this model. Assessment Tools

There has been considerable variability in measurement approaches and diagnostic criteria used by researchers and physicians to assess PIU. During the past 2 decades, at least 13 instruments were introduced for PIU (Figure 2). Most were adapted from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria for substance abuse and dependency criteria63,64 or pathologic gambling.56,65-67 However, little is known regarding the translation of these criteria to PIU. Others have been based on a behavioral addiction68 or cognitive behavioral models,69,70 but their psychometric properties have been incompletely described or lack support from primary data.69,70 Finally, there has been a notable lack of instruments designed with content domains specific to the experiences of adolescents and young adults. The Internet Addiction Test (IAT) has been the most commonly used assessment for PIU. The IAT was developed using the DSM-IV criteria for pathologic

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Fig 1. Proposed model for mechanism of problematic Internet use (PIU) during adolescence and young adulthood. Youth may enter a cycle of PIU through 2 main pathways, either risky or impulsive Internet use. When psychosocial risk factors are present, the risk for developing PIU through either pathway is heightened. Problematic Internet use then progresses over time through cycles of impairment and dependence.

gambling and substance abuse and dependency.65 The IAT contains 20 items, and its overall score is used to categorize the respondent as either an “average,” “problematic,” or “severely problematic” Internet user. Several assessments of the IAT’s psychometric properties have been reported,64,71-76 but the scale has performed inconsistently across adolescent populations.77 Furthermore, significant concerns regarding its content validity and its ability to discriminate clinically between nonsymptomatic and symptomatic groups have been reported.78-80

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Kim and Haridakis Internet Addiction Scale, 2009: - 31 items: 20 item IAT, 11 items taken from Horvath’s Television Addiction Scale (adapted from DSM-IV psychological addiction criteria) - Responses given on a 5-point scale (“Never” – “Very Often”) - Score interpretation: none given

Anderson Internet Dependence Scale, 2001: - 7 items - Binary responses - Score interpretation: Dependent if “yes” to 3+ items Fortson et al. Internet Dependence Scale, 2007: - 9 items - Responses given on a 1-5 scale (“never”–“very frequently”) or 1-3 scale (“definitely not” – “yes, definitely”) - Score interpretation: Provide criteria for liberal (LC) and conservative (CC) interpretations LC: Dependent if scoring 3+/5 or 2+/3 on 3+ items CC: Dependent if scoring 5/5 or 3/3 on 3+ items

Young Internet Addiction Test (IAT), 1998: - 20 items - Responses given on a 5-point scale (“Not at All” – “Always”) - Score interpretation: 20-39 = average use 40-69 = frequent problematic use 70+ = significant problematic use

Lavin and Yuen Internet Dependence Scale, 2004: - 7 items - Responses given on a 1-5 scale (“Not at All” – “Always”) - Score interpretation: Dependent if scoring 4+/5 on 3+ items Scherer Internet Dependence Scale, 1997: - 10 items - Response scale not specified - Score interpretation: Dependent if 3+ items positively endorsed

DSM-IV Criteria for Substance Dependence

Kim and Davis Problematic Internet Use Scales, 2009: - 30 items total: 16 from the IAT, 14 from the GPIUS - Responses given on a 1-5 scale (“Strongly Disagree” – “Strongly Agree”) - Score interpretation: none given

Caplan Generalized Pathological Internet Use Scale (GPIUS), 2002: - 29 items - 7 subscales: mood alteration, social benefit, negative outcomes, compulsivity, excessive use, withdrawal, interpersonal control - Responses given on a 1-5 scale (“Strongly Disagree” – “Strongly Agree”) - Score interpretation: none given

Davis Online Cognition Scale (OCS), 2002: - 36 items - 4 subscales: social comfort, loneliness/depression, distraction, diminished impulse control - Responses given on a 7-point Likert scale - Score interpretation: none given Index of Problematic Online Experiences (I-POE), 2009: - 26 items - 4 subscales: overuse, family and friends, daily obligations, online interactions, concerns over use, concerns about online behavior - Binary, positive responses weighted as 1-2 points - Score interpretation: Total score out of 38, no cut-offs

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DSM-IV Criteria for Pathological Gambling

Davis Cognitive-Behavioral Model of Pathological Internet Use

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Fig 2. Scales for problematic Internet use developed before 2010 and used in studies of US adolescents and young adults. Scales are categorized into 3 areas of primary developmental influence. Arrows connecting scales represent either direct adaptation from 1 scale into another (black) or a more moderate influence on design (gray).

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A newly available scale, the Problematic and Risky Internet Use Screening Scale (PRIUSS), was designed specifically for use in adolescents and young adults. The scale’s development was informed by the PIU concept map described earlier,4 and thus far it has demonstrated strong reliability, face validity, and content validity.81 The PRIUSS is made up of 18 items that assess different symptoms of PIU. Respondents reply to each item of a 5-point frequency scale (where 0 5 never, 1 5 rarely, 2 5 sometimes, 3 5 often, and 4 5 very often). Items are summed to create a total scale score between 0 and 72. The PRIUSS items can be categorized into 3 core symptom groups, each of which is represented by a discrete subscale.81 The first subscale, Social Impairment (SI), items 1 to 6, assesses the effect of Internet use on both offline and online social interaction. Example questions include “How often do you skip out on social events to spend time online?,” and “How often do your offline relationships suffer due to your Internet use?” The second subscale, Emotional Impairment (EI), items 7 to 11, assesses emotional attachment and dysregulation related to Internet use. Example questions include “How often do you feel angry because you are away from the Internet?,” and “How often do you feel vulnerable because the Internet isn’t available?” The third subscale, Risky/Impulsive Internet Use (RIU), items 12 to 18, assesses salient problematic behaviors regarding Internet use. Example questions include “How often do you put the Internet in front of important, everyday activities?,” and “How often does time on the Internet negatively affect your school performance?” Summing all response to items within a subscale and then dividing by the total number of subscale items produces a standardized total score for each subscale. Validation studies have also supported the PRIUSS’ performance in adolescent and young adult populations and have provided guidelines for its use in screening settings.82 In particular, the PRIUSS has been shown to correlate with hours of recreational Internet use but not hours of use for school or work. The subscales have also demonstrated good reliability in adolescent and young adult populations (Cronbach alpha: SI 5 0.89, EI 5 0.90, RIU5 0.88).82 Scoring guidelines suggest that total scores greater than 25 on the PRIUSS best identify adolescents who may be at risk for PIU (sensitivity 5 0.80, specificity 5 0.79).82 Furthermore, adolescents who screen as at risk for PIU on the PRIUSS have also been found to be at higher reciprocal risk for depression, ADHD, and social anxiety. Figure 3 presents the PRIUSS, including directions for respondents regarding completion and a guide for providers for scoring. Opportunities for Screening

Although universal screening for PIU among adolescents and young adults may not yet be warranted, developing best practices for screening among at-risk groups is a critical objective for physicians and researchers. Insights from focus groups with adolescents and their physicians suggest multiple avenues for PIU

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PROBLEMATIC AND RISKY INTERNET USE SCREENING SCALE (PRIUSS) Please answer the questions below based on how you have felt and conducted yourself regarding your Internet use over the past 6 months. Please do your best to interpret these questions as they apply to your own experiences and feelings.

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When considering your Internet use time, think about any time you spend online, whether you are using a computer or a mobile device. Do not include time you spend texting unless you are using text messages to interact with an online application such as Facebook or Twitter.

1. do you choose to socialize online instead of in-person?

0

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2. do you have problems with face to face communication due to your internet use?

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3. do you experience increased social anxiety due to your internet use?

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4. do you fail to create real-life relationships because of the internet?

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5. do you skip out on social events to spend time online?

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6. do your offline relationships suffer due to your internet use?

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7. do you feel irritated when you’re not able to use the internet?

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8. do you feel angry because you are away from the internet?

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9. do you feel anxious because you are away from the internet?

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10. do you feel vulnerable when the internet isn't available?

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11. do you experience feelings of withdrawal from not using the internet?

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12. do you put internet use in front of important, everyday activities?

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13. do you avoid other activities in order to stay online?

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14. do you neglect your responsibilities because of the internet?

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15. do you lose motivation to do other things that need to get done because of the internet?

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16. do you lose sleep due to nighttime internet use?

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17. does time on the internet negatively affect your school performance?

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18. do you feel you use the internet excessively?

0 Total Score SI subscale

1 +

2 +

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EI subscale

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Originally published: Jelenchick LA, Eickhoff J, Christakis DA, et al. The Problematic and Risky Internet Use Screening Scale (PRIUSS) for adolescents and young adults: Scale development and refinement. Computers in Human Behavior. 2014;35(0):171-178.

Fig 3. A screening scale for problematic Internet use developed specifically for use in adolescents and young adults.

screening.81 Physicians primarily considered the option of screening during office visits, with 1 pediatrician stating: “I think in a physical when someone is coming in for guidance on their health, I think a scale could slip in quite easily, if the clinician is aware of the issues we are talking about.” This idea was also sup-

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ported in discussions with adolescents and young adults; as 1 older adolescent male elaborated: “I think this is definitely something you could ask at yearly checkup. It could be grouped with alcohol, tobacco, or even seatbelt use questions.” Alternatively, mental health resources, including self-screening for common disorders, are increasingly being made available to patients in online formats, particularly among adolescents and young adults in academic settings (see www. mentalhealth.umn.edu/screening). The idea of allowing patients to initiate selfscreening was endorsed by physicians, with 1 suggesting: “If they could score it and see what it meant—and just like we have with alcohol, if they’re at that level [their score would tell them] ‘this may be something you need to talk to a physician about.’” However, adolescents provided a different perspective, namely, that there may be significance to the setting in which screening is introduced, as 1 female adolescent explained: “If I found [a PIU assessment] on the Internet, then I wouldn’t really think of it too much as an issue, but if in a doctor’s office setting, then I’d think about it more.” Finally, the idea of jointly approaching parents and adolescents for screening during yearly health maintenance visits was raised, with 1 nurse commenting: “One interesting thought about this is that if you gave it to the majority of parents and asked them to fill it out, they may have the same problematic internet use as their kids. So, it’d be interesting if you gave it to parents and children, even if you’re gearing at the children.” Parental media use is strongly associated with adolescents’ use and may be a target for intervention.83,84 Although research in this area has primarily focused on television viewing, given the high rates of smartphone and other Internet-enabled device use by adults, this approach may be adaptable to PIU. Prevention and Treatment

Current recommendations by the American Academy of Pediatrics focus on a limitation of no more than 2 hours of recreational screen time per day.85 These guidelines may be challenging to apply among adolescents because most report substantially higher levels of media exposure.40,86 In particular, while rates of television viewing have decreased over the past decade (from 42.8% reporting 3 or more hours on an average school day in 1999 to 32.5% in 2013), computer use has risen (from 22.1% reporting 3 or more hours on an average school day in 2003 to 41.3% in 2013).87 Furthermore, the preponderance of the existing literature predates the smartphone era in which most adolescents have full access to the Internet virtually at all times. Interventions for media overuse have traditionally focused on television viewing and have been nested within larger interventions for health behaviors such as obesity or physical activity.88-90 Nevertheless, evidence supports a positive effect resulting from such interventions. Translation of these intervention approaches to PIU has yet to be reported in the literature.

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A recent meta-analysis of available treatment studies found positive effects for both psychological and pharmacologic approaches in reducing PIU and associated symptoms among those with severe pathology.91 The most common psychological approaches assessed include either cognitive behavioral therapy92-95 or multilevel counseling approaches96-100 incorporating additional elements such as motivational interviewing or parental and family involvement. Drug therapy options explored have included escitalopram,101 bupropion,102 and methylphenidate.103 However, these findings should be interpreted with caution because many of the randomized controlled trials published thus far have been significantly limited by inconsistencies in PIU diagnosis, methodologic challenges such as inadequate randomization, or insufficient reporting of trial methodologies and outcomes.104 Therefore, while a variety of intervention options show promise for helping adolescents and young adults to cope with symptoms of PIU, additional research is needed to determine the efficacy and effectiveness of these practices. Conclusions and Recommendations

PIU is a common and consequential condition during adolescence and young adulthood. Although no formal guidelines exist for screening or prevention by pediatricians, several strategies may be synthesized from the literature. As suggested by the AAP social media report, pediatricians are in a unique position to help educate both parents and adolescents about both the risks and benefits of Internet use.105 Given prevalence consistent with other diseases in which screening—or at least attention to—is routinely recommended, discussions regarding healthy Internet use are an important part of overall health promotion. Furthermore, primary prevention strategies require a conversation before a problem has arisen. Thus, the promotion and development of healthy Internet usage patterns should be targeted early in adolescence. Physicians should consider discussing how much time their patients spend online, as well as the activities they choose to pursue, and the overall importance that is placed on online time within the context of daily life and normal development. Among adolescents at high risk, screening may be warranted; however, only appropriately designed and validated instruments should be used in clinical settings. Finally, if intervention is indicated, conventional counseling approaches such as cognitive behavioral therapy or motivational interviewing may be useful. References 1. Lenhart A, Purcell K, Smith A, Zickhur K. Social Media and Young Adults. Washington, DC: Pew Internet and American Life Project; 2010 2. Christakis DA, Moreno MA. Trapped in the net: will internet addiction become a 21st-century epidemic? Arch Pediatr Adolesc Med. 2009;163(10):959-960 3. Dell’Osso B, Altamura AC, Allen A, Marazziti D, Hollander E. Epidemiologic and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiatry Clin Neurosci. 2006;256(8):464475

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4. Moreno MA, Jelenchick LA, Christakis DA. Problematic Internet use among older adolescents: a conceptual framework. Comput Human Behav. 2013;29(4):1879-1887 5. Kaltiala-Heino R, Lintonen T, Rimpela A. Internet addiction? Potentially problematic use of the Internet in a population of 12-18 year-old adolescents. Addict Res Theory. 2004;12(1):89-96 6. Pallanti S, Bernardi S, Quercioli L. The Shorter PROMIS Questionnaire and the Internet Addiction Scale in the assessment of multiple addictions in a high-school population: prevalence and related disability. CNS Spectr. 2006;11(12):966-974 7. Siomos KE, Dafouli ED, Braimiotis DA, Mouzas OD, Angelopoulos NV. Internet addiction among Greek adolescent students. Cyberpsychol Behav. 2008;11(6):653-657 8. Villella C, Martinotti G, Di Nicola M, et al. Behavioural addictions in adolescents and young adults: results from a prevalence study. J Gambl Stud. 2010:27(2):203-214 9. Zboralski K, Orzechowska A, Talarowska M, et al. The prevalence of computer and Internet addiction among pupils. Postepy Hig Med Dosw (Online). 2009;63:8-12 10. Ghassemzadeh L, Shahraray M, Moradi A. Prevalence of internet addiction and comparison of internet addicts and non-addicts in Iranian high schools. Cyberpsychol Behav. 2008;11(6):731-733 11. Canbaz S, Sunter AT, Peksen Y, Canbaz MA. Prevalence of the pathological Internet use in a sample of Turkish school adolescents. Iran J Public Health. 2009;38(4):64-71 12. Canan F, Ataoglu A, Nichols LA, Yildirim T, Ozturk O. Evaluation of psychometric properties of the internet addiction scale in a sample of Turkish high school students. Cyberpsychol Behav. 2010;13(3):317-320 13. Cao F, Su L. Internet addiction among Chinese adolescents: prevalence and psychological features. Child Care Health Dev. 2007;33(3):275-281 14. Deng Y-X, Hu M, Hu G-Q, Wang L-S, Sun Z-Q. [An investigation on the prevalence of internet addiction disorder in middle school students of Hunan province]. Zhonghua Liu Xing Bing Xue Za Zhi. 2007;28(5):445-448 15. Ko CH, Yen JY, Yen CF, Lin HC, Yang MJ. Factors predictive for incidence and remission of internet addiction in young adolescents: a prospective study. Cyberpsychol Behav. 2007;10(4):545-551 16. Park SK, Kim JY, Cho CB. Prevalence of Internet addiction and correlations with family factors among South Korean adolescents. Adolescence. 2008;43(172):895-909 17. Song XQ, Zheng L, Li Y, Yu DX, Wang ZZ. [Status of ‘internet addiction disorder’ (IAD) and its risk factors among first-grade junior students in Wuhan.]. Zhonghua Liu Xing Bing Xue Za Zhi. 2010;31(1):14-17 18. Wu J, Lin G, Lin L. Analysis of the situation of internet use and the related health-risky behaviors among the youngsters in Guangzhou City. J Trop Med (Guangzhou). 2007;7(8):816-818 19. Xu J, Shen L-X, Yan C-H, et al. Internet addiction among Shanghai adolescents: prevalence and epidemiological features. Zhonghua Yufang Yixue Zazhi. 2008;42(10):735-738 20. Wang Y-L, Wang J-P, Fu D-D. Epidemiological investigation on Internet addiction among Internet users in elementary and middle school students. Chin Ment Health J. 2008;22(9):678-682 21. Jones S, Johnson-Yale C, Millermaier S, Pérez FS. U.S. college students’ Internet use: race, gender and digital divides. J Comput Mediat Commun. 2009;14(2):244-264 22. Kandell JJ. Internet addiction on campus: the vulnerability of college students. Cyberpsychology Behav. 1998;1(1):11-17 23. Niemz K, Griffiths M, Banyard P. Prevalence of pathological Internet use among university students and correlations with self-esteem, the General Health Questionnaire (GHQ), and disinhibition. Cyberpsychol Behav. 2005;8(6):562-570 24. Zhu K, Wu H. Psychosocial factors of Internet addiction disorder in college students. Chin Ment Health J. 2004;18(11):796-798 25. Ni XL, Yan H, Chen SL, Liu ZW. Factors influencing Internet addiction in a sample of freshmen university students in China. Cyberpsychol Behav. 2009;12(3):327-330 26. Liu TC, Desai RA, Krishnan-Sarin S, Cavallo DA, Potenza MN. Problematic internet use and health in adolescents: data from a high school survey in Connecticut. J Clin Psychiatry. 2011;72(6):836-845 27. Christakis DA, Moreno MM, Jelenchick L, Myaing MT, Zhou C. Problematic Internet usage in US college students: a pilot study. BMC Med. 2011;9(1):77

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28. Derbyshire KL, Lust KA, Schreiber LR, et al. Problematic Internet use and associated risks in a college sample. Compr Psychiatry. 2013;54(5):415-422 29. Yates TM, Gregor MA, Haviland MG. Child maltreatment, alexithymia, and problematic internet use in young adulthood. Cyberpsychol Behav Soc Netw. 2012;15(4):219-225 30. Settipane GA, Greisner WA 3rd, Settipane RJ. Natural history of asthma: a 23-year followup of college students. Ann Allergy Asthma Immunol. 2000;84(5):499-503 31. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clin Psychol Rev. 1998;18(7):765-794 32. Tao R, Huang XQ, Wang JN, et al. Proposed diagnostic criteria for internet addiction. Addiction. 2010;105(3):556-564 33. van Rooij AJ, Schoenmakers TM, van de Eijnden RJ, van de Mheen D. Compulsive Internet use: the role of online gaming and other internet applications. J Adolesc Health. 2010;47(1):51-57 34. Morrison CM, Gore H. The relationship between excessive Internet use and depression: a questionnaire-based study of 1,319 young people and adults. Psychopathology. 2010;43(2):121-126 35. Kim HK, Davis KE. Toward a comprehensive theory of problematic Internet use: evaluating the role of self-esteem, anxiety, flow, and the self-rated importance of Internet activities. Comput Human Behav. 2009;25(2):490-500 36. Pempek TA, Yermolayeva YA, Calvert SL. College students’ social networking experiences on Facebook. J Appl Dev Psychol. 2009;30(3):227-238 37. Ross C, Orr ES, Sisic M, et al. Personality and motivations associated with Facebook use. Comput Human Behav. 2009;25(2):578-586 38. Lewis K, Kaufman J, Christakis N. The taste for privacy: an analysis of college student privacy settings in an online social network. J Comput Mediat Commun. 2008;14(1):79-100 39. Desai RA, Krishnan-Sarin S, Cavallo D, Potenza MN. Video-gaming among high school students: health correlates, gender differences, and problematic gaming. Pediatrics. 2010;126(6):E1414-E1424 40. Lenhart A, Purcell K, Smith A, Zickhur K. Social Media & Mobile Internet Use Among Teens and Young Adults. Washington, DC: Pew Internet & American Life Project; 2010 41. Durkee T, Kaess M, Carli V, et al. Prevalence of pathological internet use among adolescents in Europe: demographic and social factors. Addiction. 2012;107(12):2210-2222 42. Colley A, Maltby J. Impact of the internet on our lives: male and female personal perspectives. Comput Human Behav. 2008;24(5):2005-2013 43. Yen JY, Yen CF, Chen CS, Tang TC, Ko CH. The association between adult ADHD symptoms and internet addiction among college students: the gender difference. Cyberpsychol Behav. 2009;12(2): 187-191 44. Sun P, Johnson CA, Palmer P, et al. Concurrent and predictive relationships between compulsive internet use and substance use: findings from vocational high school students in China and the USA. Int J Environ Res Public Health. 2012;9(3):660-673 45. Ko CH, Yen JY, Chen CS, Yeh YC, Yen CF. Predictive values of psychiatric symptoms for internet addiction in adolescents: a 2-year prospective study. Arch Pediatr Adolesc Med. 2009;163(10):937-943 46. Lam LT, Peng ZW. Effect of pathological use of the internet on adolescent mental health: a prospective study. Arch Pediatr Adolesc Med. 2010;164(10):901-906 47. Ko CH, Yen JY, Chen CS, Chen CC, Yen CF. Psychiatric comorbidity of internet addiction in college students: an interview study. CNS Spectr. 2008;13(2):147-153 48. Ko CH, Yen JY, Yen CF, et al. The association between Internet addiction and problematic alcohol use in adolescents: the problem behavior model. Cyberpsychol Behav. 2008;11(5):571-576 49. Yoo HJ, Cho SC, Ha JY, et al. Attention deficit hyperactivity symptoms and Internet addiction. Psychiatry Clin Neurosci. 2004;58(5):487-494 50. Choi K, Son H, Park M, et al. Internet overuse and excessive daytime sleepiness in adolescents. Psychiatry Clin Neurosci. 2009;63(4):455-462 51. Lam LT, Peng Z, Mai J, Jing J. The association between internet addiction and self-injurious behaviour among adolescents. Inj Prev. 2009;15(6):403-408 52. Young KS. Internet addiction: symptoms, evaluation, and treatment. In: Van de Creek L, Jackson X, eds. Innovations in Clinical Practice: A Source Book. Vol 17. Sarasota, FL: Professional Resource Press; 1999

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53. Kubey RW, Lavin MJ, Barrows JR. Internet use and collegiate academic performance decrements: early findings. J Commun. 2001;51(2):366-382 54. Chen SY, Tzeng JY. College female and male heavy internet users’ profiles of practices and their academic grades and psychosocial adjustment. Cyberpsychol Behav Soc Netw. 2010;13(3):257-262 55. Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype. Psychol Rep. 1996;79(3 Pt 1):899-902 56. Young KS. Internet addiction: the emergence of a new clinical disorder. Cyberpsychol Behav. 1998;1(3):237-244 57. Griffiths M. Internet addiction: fact or fiction? Psychologist. 1999;12(5):246-250 58. Grant JE, Potenza MN, Weinstein A, Gorelick DA. Introduction to behavioral addictions. Am J Drug Alcohol Abuse. 2010;36(5):233-241 59. Shapira NA, Lessig MC, Goldsmith TD, et al. Problematic Internet use: proposed classification and diagnostic criteria. Depress Anxiety. 2003;17(4):207-216 60. Davis RA. A cognitive-behavioral model of pathological Internet use. Comput Human Behav. 2001;17(2):187-195 61. Yen JY, Ko CH, Yen CF, et al. Psychiatric symptoms in adolescents with Internet addiction: comparison with substance use. Psychiatry Clin Neurosci. 2008;62(1):9-16 62. De Leo JA, Wulfert E. Problematic Internet use and other risky behaviors in college students: an application of problem-behavior theory. Psychol Addict Behav. 2013;27(1):133-141 63. Goldberg I. Internet addiction disorder (IAD): diagnostic criteria. 1995. Available at: www-usr. rider.edu/,suler/psycyber/supportgp.html. Accessed October 29, 2014 64. Chang MK, Law SPM. Factor structure for Young’s Internet Addiction Test: a confirmatory study. Comput Human Behav. 2008;24(6):2597-2619 65. Young K. Caught in the Net: How to Recognize the Signs of Internet Addiction—And a Winning Strategy for Recovery. New York: John Wiley & Sons; 1998 66. Chen S-H, Weng L-J, Su Y-J, Wu H-M, Yang P-F. Development of a Chinese Internet addiction scale and its psychometric study. Chin J Psychol. 2003;45(3):279-294 67. Jia R, Jia HH. Factorial validity of problematic Internet use scales. Comput Human Behav. 2009;25(6):1335-1342 68. Griffiths M. Internet addiction: time to be taken seriously? Addict Res. 2000;8(5):413-418 69. Davis RA, Flett GL, Besser A. Validation of a new scale for measuring problematic internet use: implications for pre-employment screening. Cyberpsychol Behav. 2002;5(4):331-345 70. Caplan SE. Problematic Internet use and psychosocial well-being: development of a theory-based cognitive-behavioral measurement instrument. Comput Human Behav. 2002;18(5):553-575 71. Khazaal Y, Billieux J, Thorens G, et al. French validation of the internet addiction test. Cyberpsychol Behav. 2008;11(6):703-706 72. Widyanto L, Griffiths MD, Brunsden V. A psychometric comparison of the Internet addiction test, the Internet-related problem scale, and self-diagnosis. Cyberpsychol Behav Soc Netw. 2011;14(3): 141-149 73. Widyanto L, McMurran M. The psychometric properties of the internet addiction test. Cyberpsychol Behav. 2004;7(4):443-450 74. Korkeila J, Kaarlas S, Jaaskelainen M, Vahlberg T, Taiminen T. Attached to the web: harmful use of the Internet and its correlates. Eur Psychiatry. 2010;25(4):236-241 75. Milani L, Osualdella D, Di Blasio P. Quality of interpersonal relationships and problematic Internet use in adolescence. Cyberpsychol Behav. 2009;12(6):681-684 76. Yang CK, Choe BM, Baity M, Lee JH, Cho JS. SCL-90-R and 16PF profiles of senior high school students with excessive internet use. Can J Psychiatry. 2005;50(7):407-414 77. Jelenchick LA, Becker T, Moreno MA. The psychometric properties of the Internet addiction test (IAT) in US college study. Psychiatry Res. 2012;196(2-3):296-301 78. Zhang J, Xin T. Measurement of internet addiction: an item response analysis approach. Cyberpsychol Behav Soc Netw. 2013;16(6):464-468 79. Kim SJ, Park DH, Ryu SH, Yu J, Ha JH. Usefulness of Young’s Internet addiction test for clinical populations. Nord J Psychiatry. 2013;67(6):393-399

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80. Tonioni F, D’Alessandris L, Lai C, et al. Internet addiction: hours spent online, behaviors and psychological symptoms. Gen Hosp Psychiatry. 2012;34(1):80-87 81. Jelenchick LA, Eickhoff J, Christakis DA, et al. The Problematic and Risky Internet Use Screening Scale (PRIUSS) for adolescents and young adults: scale development and refinement. Comput Human Behav. 2014;35(0):171-178 82. Jelenchick L, Moreno M. 104. The Problematic and Risky Internet Use Screening Scale (PRIUSS): a new tool for assessing problematic Internet use in adolescents and young adults. J Adolesc Health. 2013;52(2):S71-S71 83. Hume C, van der Horst K, Brug J, Salmon J, Oenema A. Understanding the correlates of adolescents’ TV viewing: a social ecological approach. Int J Pediatr Obes. 2010;5(2):161-168 84. Barr-Anderson DJ, Fulkerson JA, Smyth M, et al. Associations of American Indian children’s screen-time behavior with parental television behavior, parental perceptions of children’s screen time, and media-related resources in the home. Prev Chronic Dis. 2011;8(5):A105 85. American Academy of Pediatrics Council on Communications and Media. Children, adolescents, and the media. Pediatrics. 2013;132(5):958-961 86. Rideout V, Foehr U, Roberts D. Generation M2: Media in the Lives of 8 to 18 Year Olds. Menlo Park, California: Henry J. Kaiser Family Foundation; 2010 87. Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior surveillance—United States, 2013. MMWR Surveill Summ. 2014;63(Suppl 4):1-168 88. Aragon Neely J, Hudnut-Beumler J, White Webb M, et al. The effect of primary care interventions on children’s media viewing habits and exposure to violence. Acad Pediatr. 2013;13(6):531-539 89. Friedrich RR, Polet JP, Schuch I, Wagner MB. Effect of intervention programs in schools to reduce screen time: a meta-analysis. J Pediatr (Rio J). 2014;90(3):232-241 90. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008;122(1):e15-e25 91. Winkler A, Dorsing B, Rief W, Shen Y, Glombiewski JA. Treatment of internet addiction: a metaanalysis. Clin Psychol Rev. 2013;33(2):317-329 92. Zhu TM, Jin RJ, Zhong XM. [Clinical effect of electroacupuncture combined with psychologic interference on patient with Internet addiction disorder]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2009;29(3):212-214 93. Zhou Y, Lin FC, Du YS, et al. Gray matter abnormalities in Internet addiction: a voxel-based morphometry study. Eur J Radiol. 2009;79(1):92-95 94. Young KS. Cognitive behavior therapy with Internet addicts: treatment outcomes and implications. Cyberpsychol Behav. 2007;10(5):671-679 95. King DL, Delfabbro PH, Griffiths MD, Gradisar M. Cognitive-behavioral approaches to outpatient treatment of internet addiction in children and adolescents. J Clin Psychol. 2012;68(11):1185-1195 96. Du Y-S, Huang L-L, Jiang W-Q, Wang Y-F. Research on group intervention process of Internet overuse youngsters. Chin J Clin Psychol. 2006;14(5):465-467 97. Du YS, Jiang WQ, Vance A. Longer term effect of randomized, controlled group cognitive behavioural therapy for Internet addiction in adolescent students in Shanghai. Aust N Z J Psychiatry. 2010;44(2):129-134 98. Orzack MH, Voluse AC, Wolf D, Hennen J. An ongoing study of group treatment for men involved in problematic Internet-enabled sexual behavior. Cyberpsychol Behav. 2006;9(3):348-360 99. Rong Y, Zhi S, Yong Z. Comprehensive intervention on Internet addiction of middle school students. Chin Ment Health J. 2005;19(7):457-459 100. Fang-ru Y, Wei H. The effect of integrated psychosocial intervention on 52 adolescents with Internet addiction disorder. Chin J Clin Psychol. 2005;13(3):343-345 101. Dell’Osso B, Hadley S, Allen A, et al. Escitalopram in the treatment of impulsive-compulsive Internet usage disorder: an open-label trial followed by a double-blind discontinuation phase. J Clin Psychiatry. 2008;69(3):452-456 102. Han DH, Hwang JW, Renshaw PF. Bupropion sustained release treatment decreases craving for video games and cue-induced brain activity in patients with internet video game addiction. Exp Clin Psychopharmacol. 2010;18(4):297-304

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103. Han DH, Lee YS, Na C, et al. The effect of methylphenidate on Internet video game play in children with attention-deficit/hyperactivity disorder. Compr Psychiatry. 2009;50(3):251-256 104. King DL, Delfabbro PH, Griffiths MD, Gradisar M. Assessing clinical trials of Internet addiction treatment: a systematic review and CONSORT evaluation. Clin Psychol Rev. 2011;31(7):1110-1116 105. O’Keeffe GS, Clarke-Pearson K; American Academy of Pediatrics Council on Communications and Media. The impact of social media on children, adolescents, and families. Pediatrics. 2011; 127(4):800-804

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Adolescent Social Media Use: The Role of the Pediatric Practitioner and the Healthy Internet Use Model Kristen R. Kaseeska, BAa*; Julie A. Gorzkowski, MSWa; Jonathan D. Klein, MD, MPHa Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Elk Grove Village, Illinois

a

Introduction

Ebony, an 18-year-old high school senior, was referred to Dr Smith for stomachaches that were keeping her out of school. Up to this point she had perfect attendance and excellent grades. However, her recent stomachaches were causing her to miss school 2 to 3 times a week. She described the stomachaches as starting when she woke up for school and lasting until she got home. When Dr Smith inquired about the start of her stomachaches, Ebony replied, “They started the day that my so-called friends posted a bunch of drunk photos of me on Facebook.” She went on to explain that 2 months before, she’d had her first experience with alcohol at a friend’s house. She drank too much and passed out, and her friends took embarrassing photos of her and then posted them on Facebook. As a result, Ebony experienced physical consequences in addition to emotional ones.1 Stories like this demonstrate the pervasive effect of social media on the lives of today’s adolescents. Social media describe interactive social forms of on-screen entertainment. Examples of social media include social networks, text messaging, and blogs. Social media build on “traditional media” (eg, television, video games) by providing an interactive component that transforms spectators into active participants, facilitating opportunities to collaborate, access information, create new content, and connect with others.2 These interactions provide a host

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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of opportunities and challenges for young users.1 While pediatric preventive service guidelines promoting healthy use of traditional media (eg, limiting screen time to 2 hours per day) are well established, these guidelines are insufficient to address social media.3 In this article, we discuss the integral role that social media play in the lives of today’s adolescents, describe a 3-part screening tool for pediatric practitioners such as physicians, physician assistants, and nurse practitioners, called the Healthy Internet Use Model to assess social media use with adolescent patients, and describe the process of creating a family media plan with the adolescents and parents in your care. Social Media and Adolescents

The interactive nature of social media provides many positive opportunities for today’s adolescents: the Internet is an avenue for academic enrichment and creative expression, enhancing personal growth.1 Electronic connections to friends and family help provide adolescents with increased social support regardless of location, while networking sites and interactive video games provide opportunities to interact with peers across the street or across an ocean.1 These benefits have caused the popularity and influence of the Internet to grow exponentially: nearly 90% of all 8- to 18-year-olds report having home Internet access,4 and nearly 74% of adolescents access the Internet through a mobile device, such as a cell phone or tablet.4 Adolescents are also spending an increasing amount of time on the Internet. Between 2009 and 2011, 18-year-olds reported logging roughly 40 hours online per week.5,6 Recent growth has coincided with the decreasing cost of mobile devices, including smartphones, laptops, and tablets. This drop in price has had 2 major effects on the way individuals use technology: (1) it has expanded access to the Internet for individuals across income levels; and (2) it has removed geographic restrictions on media use: users can connect anytime, anywhere.4 As use of social media has increased, social networking has become an integral component of adolescent life and social structure. Most adolescents (95%) report accessing the Internet at least occasionally, while 36% report access several times each day.4 This increased time spent on social media has created a social norm in which relationships and conversations include an element of online communication and texting. Take, for example, Travis’ story. Travis is a 16-year-old who had been fighting a lot more with his dad since he was caught drinking at a friend’s house. In the middle of a yelling match, Travis stormed into his room. Sometime later, Travis’ dad received a text from his son, saying, “I’m sorry. I really am. I just need u to lighten up a little.” His dad paused and then texted back, “I’m sorry too. It’s just that I’ve been worried about you.”1 This shift from in-person communication to maintaining relationships online is important for pediatric practitioners to understand and acknowledge, as this norm has both positive and negative consequences for adolescents.1 In Travis’

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case, social media fostered healthy communication between him and his father. However, this norm also has the potential to be detrimental to adolescents, as they may feel compelled to be constantly connected to their peers, especially during after-school and weekend hours.1 When access to social media is denied or obstructed, so is an adolescent’s access to vital social connections. Social consequences are likely to meet an adolescent back at school the next day. The obligation to stay constantly connected may make it challenging for adolescents to unplug from social media to finish their homework, go to sleep, or focus on tasks that require their attention.1 Constant media use can lead to both physical and emotional consequences, including weight gain, irritability, and feelings of withdrawal.1 Social media may also compound problems for adolescents dealing with bullying or peer-group problems at school. Because their social network has become virtual, these types of issues may follow them home. As a result, adolescents may skip class or avoid social situations, leading to poor grades or problems within their peer group.1 These potential areas of concern are important to address with adolescents in practice. Social Media and the Family Dynamic

Parents report the same frequency of daily Internet use as adolescents, but they connect for different reasons, including work-related tasks and keeping in contact with their child’s school administrators.7 Parents tend to report feeling less knowledgeable about social media than their adolescent children, and many families report that adolescents are the household’s most knowledgeable media user.8 However, adolescents may not be as media savvy as they’re perceived to be. Many adolescents have trouble distinguishing appropriate Internet content and focusing on online tasks. In a Pew Research Internet Project Report, nearly two-thirds (64%) of teachers reported that current digital technologies do more to distract adolescents than to help them academically, and many have difficulty judging the quality of online content.9 Furthermore, many teachers report a connection between an overexposure to technology and a resulting lack of focus and diminished ability to retain knowledge.9 This disconnect between parental perception of an adolescent’s media savvy and their actual abilities is concerning. If parents overestimate their adolescent’s media abilities, they may not feel compelled to discuss media use habits, or they may avoid doing so out of perceived incompetence. Alternatively, when parents are familiar with social media, they may feel more capable of addressing their child’s media use.10 Household discussions and agreed-upon guidelines for media use can be protective for youth. Adolescents are less likely to participate in risky online behaviors, including sexting, cyberbullying, and communications with strangers if they have discussed media guidelines with their parents or guardians.11 To protect adolescents’ safety, it’s important that families establish open communication about media use and exposure. Pediatric practitioners have an important role to play in helping families facilitate these conversations.

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Talking with Adolescents about Social Media

Pediatric practitioners are in a unique position to discuss media use during adolescent preventive service visits. This discussion should include screening for risk factors and working with patients and parents to ensure that social media are used positively and safely in the home. It’s important to include media questions in preventive service visits early in adolescence. Introducing this topic when preteens first begin using the Internet regularly sends an effective and consistent message about appropriate online behaviors and actions.1 Involving the family early on is especially beneficial. Working together on these issues in early adolescence can guide adolescents toward healthy online behaviors later in life, when their parents may not be as closely involved in their media use.1 The Healthy Internet Use Model outlined in this article provides a framework for conversations between pediatric practitioners and their adolescent patients.1 The Healthy Internet Use Model was developed in 2011 by American Academy of Pediatrics (AAP) content experts, based on current literature and existing AAP guidelines.12 After development, the model was brought to a group of practicing pediatricians from the AAP Pediatric Research in Office Settings (PROS) practice-based research network to determine utility in practice. The model is currently being tested in a national randomized controlled trial. Preliminary results indicate practitioners find the Healthy Internet Use Model both feasible and acceptable for use in pediatric practice. The Healthy Internet Use Model focuses on 3 key areas of social media behavior: balance, boundaries, and communication.1 A healthy adolescent media user maintains a healthy balance between his or her online and offline lives, protects him or herself online with safe boundaries, and regularly communicates with his or her parents or another trusted adult about media use. The Healthy Internet Use Model expands on existing adolescent media policies,12,13 which may become outdated as media norms and technology evolve. Existing recommendations about limiting screen time have become difficult to interpret. What is encompassed in the definition of a “screen”? Does it include a smartphone, a tablet, or a global positioning system (GPS) device? Do screentime policies apply only to leisure time, or do they include computer use for school and work? As media continue to evolve, new questions will be raised; thus, it’s important that practitioners focus on health and safety issues that cut across technologic changes. Pediatric practitioners may not be experts in social media, but they are experts in child health and they are able to draw from clinical training and experience to effectively screen and counsel teens for healthy Internet behavior. The Healthy Internet Use Model focuses the conversation on balance, boundaries, and communication, allowing pediatric practitioners to quickly screen for unhealthy media behavior and focus on the areas in which intervention is most needed.

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When appropriate, the elements of the Healthy Internet Use Model should extend past the clinical visit with the adolescent. Pediatric practitioners can work with adolescents and their parents to create a family media plan. Family media plans are household media-use guidelines made by adolescents and their parents. Parents have an invaluable role to play in enforcing healthy media behavior at home. Adolescents name their parents as the biggest influence on their Internet behaviors—over peers and teachers—and report that they remember what their parents say about Internet safety.14 Family media plans can incorporate household behavior changes, such as implementing a policy in which adolescents must “friend” their parents on a social networking site or keeping media devices in a communal area of the home so that adolescents are less likely to be exposed to negative online content.11 Anecdotal experience suggests that some pediatric practitioners have concerns about this advice because of the access that adolescents have to smartphones, tablets, laptops, and other screens that are mobile in nature and not restricted to 1 communal area. To account for this portability of mobile devices, parents can encourage appropriate programs and Web sites for viewing and view these programs with their adolescents to teach critical viewing skills. Conversations about family media plans often begin in the examination room, but they are intended to extend past the clinical visit to ensure that an adolescent’s media behavior is monitored at home, throughout the year. As these conversations continue over the course of adolescence, youth are equipped with the information and skills necessary to be successful Internet users at all stages of their lives, even when an adult is not present to offer advice. Healthy Media Use Balance

One important indicator of healthy media behavior is the balance between an adolescent’s online and offline life. Adolescents who strike a healthy balance actively participate in offline activities (sports, community involvement, extracurricular activities, in-person socialization with friends and family) and don’t experience feelings of withdrawal or loneliness when they are away from online access.1 Adolescents who do not strike a healthy balance between online and offline life may find that the time they spend online negatively affects their school performance, sleep, and personal relationships.1 Extensive time spent on social media may also increase the likelihood that adolescents will engage in risky online behaviors, including sexting and cyberbullying.11 In contrast, adolescents who strike an appropriate balance between online and offline life tend to counterbalance the information and emotions they experience online with the information and emotions from their offline life. This leaves them better able to identify and avoid online risks.1 To screen adolescents for healthy media-use balance, pediatric practitioners can ask questions about time spent online and the areas of an adolescent’s

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life that are affected by media use. Potential questions include the following: (1) Do you and your friends spend time together in person? How often? (2) Does your online time affect your school work? Do you ever find it takes more time to finish your homework because you’re spending time on social media? (3) Are you losing sleep because you’re using the Internet late at night? Although specific interactions will vary by individual, conversations about balance should reflect the patient’s developmental stage. Young adolescents who are just beginning to use social media often require counseling on the authenticity of online content; older adolescents may benefit more from discussions on the amount of time spent on social media and its effects on school work and quality of sleep.1 If an adolescent reports that media use is interfering with offline life, work with the adolescent to identify practical, realistic strategies for a more balanced lifestyle. You can find examples of these strategies in Table 1. Once you’ve identified a few strategies, ask the adolescent if he or she would like to include the parent in the conversation. Then the strategies can be included in a family media plan that’s adopted by the whole household. With this plan, the entire family can strike a healthy balance between online and offline activities, thus improving sleep, social relationships, and work/school performance. Boundaries

Another important indicator of healthy media use is an adolescent’s ability to set appropriate boundaries online. Online boundaries reflect an adolescent’s ability to identify and avoid online risk behavior, such as befriending strangers, not protecting one’s personal information, or posting pictures of illicit behavior on a social networking site. The risk level associated with these activities may be different based on adolescent maturity and changing social norms within peer groups. However, it is important that these types of online behaviors be monitored so that potential problems are identified. While such risky actions can have damaging consequences for adolescents (college admissions boards may be influenced by an adolescent’s online persona or an adolescent’s reputation at school can be tarnished1), pediatric practitioners are in a unique position to discuss social media boundaries with their adolescent patients and emphasize the importance of maintaining online boundaries that are appropriate to the personality and maturity level. Some questions to engage an adolescent in a conversation about their online boundaries include the following. (1) Are privacy settings in place on your social networking sites? (2) Are you “friends” with people on social networking sites whom you don’t know in your offline life? (3) “How are you making sure that embarrassing information about you does not end up online?” Pediatric practitioners should be prepared to discuss risky behaviors and address the reasoning for such behaviors. Questions such as “Why do you have online friends whom you don’t know in your offline life?” provide an opportunity to understand an adolescent’s choices while allowing the practitioner to emphasize the importance of setting safe boundaries.

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The Health Internet Model Use Themes Age Early adolescence (aged 11-13 years)

Middle adolescence (aged 14-16 years)

Balance

Boundaries

Communication

If an adolescent reports…

“Well, I saw it online so it must be true.”

“There are a few Web sites that I really like to spend time on.”

You may suggest…

“What about the Web site makes the content true?” “What are some trustworthy Web sites that your parents or teachers recommend?”

If an adolescent reports…

“It takes a little longer to do my homework because I’m usually texting my friends.” “Do you think it would be helpful to put your cell phone in the kitchen for an hour or 2 each night so that you can finish your home- work without being interrupted?”

“I don’t really restrict the stuff that I post online or that is posted about me.” “Have you ever known of a friend who got in trouble at school for something they posted online?” “What if you only posted comments and pictures that a future college admissions officer or your favorite teacher would want to see?” “I sometimes ‘friend’ people whom I don’t really know in real life.” “What are the good things about making online “friends” whom you don’t know in real life?” “What are the bad things?” “Do you think that you could implement a rule that you only friend people whom you and your family know in real life?” “There are a few of my friends who bully or embarrass other people online, and I feel pressure to do it too.” “How would you handle that situation if it happened at school?” “What would you say if it were you or your friends being bullied?”

“What good things might happen if your family had rules for media use?”

You may suggest…

Late adolescence (ages 17-20 years)

If an adolescent reports… “Sometimes I’m tired during class because I was up late using the Internet the night before.” You may suggest…

“My parents don’t set any rules for what I do online.”

“I don’t talk to my parents about what I do online.” “How might your parents be able to help you with things that happen to you online?”

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“What if you (and your family) implemented a no-media-after 10 pm rule on weeknights? Would that help you get enough sleep?”

“What are the Web sites?” “What do you like about them?” “What would you do if something happened on this Web site that made you feel uncomfortable?”

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Table 1 Media Screening Questions Based on Adolescent Age

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Clinical discussions about online boundaries should vary based on the adolescent’s age. Younger adolescents are likely to be joining social networking sites for the first time, so discussions about protecting personal information are a priority. Older adolescents may be experiencing pressure to participate in online risk behaviors, so discussions about posting appropriate content or not befriending strangers online may be more appropriate.1 If an adolescent reports any risky behavior, work with him or her to identify strategies for staying safe online; you can find sample strategies in Table 1. Once you and the adolescent have identified a few strategies, ask if he or she would like to include the parents in the conversation. These strategies can become part of the family media plan. With this media plan, the whole family is able to protect themselves and their personal information online. Communication

The third important indicator of healthy media behavior is whether an adolescent communicates with the parents (or other influential adults) about his or her media use. Open communication between adolescents and their parents is a protective factor for offline risk behaviors, such as alcohol use.15-17 In the same way, open communication can mitigate online risk behaviors. Regular conversations between parents and adolescents that involve open discussion of media use and incorporate specific rules decrease the chances that adolescents will engage in risky online behaviors.11 This open communication also strengthens the healthy balance and boundary goals discussed previously. Regular communication about media use gives parents and adolescents an opportunity to identify and address risky situations as they arise, preventing them from becoming larger problems. When assessing an adolescent’s level of communication with their parents about media behavior, pediatric practitioners may want to ask the following: (1) How often do you and your parents discuss your media use? (2) What rules do your parents set for your media use? Adolescents who report little or no media discussions should be encouraged to talk with their parents about the things they do online and to brainstorm some family rules or guidelines that might help keep their family safe online. Clinical discussions about a family’s media-related communication will vary over the course of adolescence. With younger patients, pediatric practitioners may choose to inquire about household communication patterns and directly involve the parents in the discussion. Older adolescents may respond better to a more inquisitive approach that respects their autonomy and encourages them to identify a trusted adult (eg, parent, coach, or teacher) they can talk with if a risky situation arises.1 If adolescents state that they do not talk with their parents about their online behavior or state that their family does not have any rules surrounding media use, work with them to identify strategies for starting the conversation with their parents. If the adolescents do not feel that they can safely

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discuss these behaviors at home, work with them to find a trusted adult (eg, coach or teacher) they can talk with if they are unsure about how to handle an interaction online. You can find sample strategies in Table 1. Once you and the adolescent have identified a few strategies, ask if he or she would like to include the parents in the conversation. These strategies can become part of the family media plan. With this media plan, the whole family can benefit from open communication and household rules about media use. Next Steps and Future Directions

The changing nature of social media and the devices on which the media can be accessed outline some key clinical areas about adolescent media use that require additional attention, including (1) the need for an updated media screener and (2) research on best practices for pediatric practitioners to use when interacting with adolescents and families. Becoming actively involved in networks that focus on adolescents and social media is 1 way for pediatric practitioners to remain updated on social media recommendations. The Council on Communications and Media (COCM), the Pediatric Research in Office Settings (PROS) research-based network, and the Section on Adolescent Health (SOAH) all are sources within the AAP that enable pediatric practitioners to become actively involved in improving the quality of preventive services for adolescents related to social media. Conclusions

Media use is the largest leisure-time activity among adolescents, second only to sleeping.13 Changes in media platforms and use patterns have created a host of new challenges and opportunities for adolescents. Pediatric practitioners, as experts in child and adolescent development and health, play an integral role in counseling their patients and families about safe and healthy online behaviors. The Healthy Internet Use Model provides an adaptable and useful framework that practitioners can use to screen for the 3 most important elements of adolescent online behavior, regardless of current technology trends: balance, boundaries, and communication. Based on the results of this screening, pediatric practitioners can work with adolescents and parents to create a family media plan to maintain healthy online behavior after the family returns home. Discussing media use over the course of adolescence and adapting conversations to the adolescent’s developmental stage allows for meaningful, personal conversations that have the potential to change adolescent behavior. Involving the entire family, including younger siblings, provides a healthy foundation for future family media use. To learn more, The American Academy of Pediatrics’ Media Matters campaign offers a variety of resources and materials on media education and tools for pediatric practitioners, including a media history form for parents to complete

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before a regularly scheduled visit.13 Implementing media education tools and counseling address the adolescent’s media use and provides the opportunity to involve the entire family. References 1. Moreno MA, ed. Sex, Drugs ‘n Facebook: A Parent’s Toolkit for Promoting Healthy Internet Use. Alameda, CA: Hunter House Publishers; 2013 2. Gilliam M, Allison S, Boyar R, et al. New media and research: considering next steps. Sex Res Soc Policy. 2011;8:67-72 3. American Academy of Pediatrics Council on Communications and Media. Children, adolescents, and the media. Pediatrics. 2013;132(5):958-961 4. Lenhart A. Digital divides and bridges: technology use among youth. Pew Res Internet Project. Available at: www.pewinternet.org/2012/04/13/digital-divides-and-bridges-technology-useamong-youth/. Published 2012. Accessed May 3, 2014 5. Madden M, Lenhart A, Duggan M, et al. Teens and technology 2013. Pew Res Internet Project. Available at: www.pewinternet.org/files/old-media/Files/Reports/2013/PIP_TeensandTechnology2013 .pdf. Published 2013. Accessed May 2, 2014 6. The Nielson Company. State of the media: TV usage trends: Q3 and Q4 2010. Available at: www .nielsen.com/us/en/insights/reports/2011/state-of-the-media-tv-usage-trends-q3-and-q4-2010 .html. Published 2011. Accessed May 15, 2014 7. Dowdell EB. Use of the internet by parents of middle school students: internet rules, risky behaviors and online concerns. J Psychiatr Ment Health Nurs. 2013;20:9-16 8. Kiesler S, Zdaniuk B, Lundmark R. Troubles with the internet: the dynamics of help at home. Hum Comput Interact. 2000;15(4):323-351 9. Purcell K, Rainie L, Heaps A, et al. How teens do research in the digital world. Pew Res Internet Project. Available at: www.pewinternet.org/files/old-media/Files/Reports/2012/PIP_Teacher SurveyReportWithMethodology110112.pdf. Published 2012. Accessed May 22, 2014 10. Livingstone S, Helsper EJ. Parental mediation of children’s internet use. J Broadcast Electron Media. 2008;52(4):581-599 11. Cho CH, Cheon HJ. Children’s exposure to negative internet content: effects of family context. J Broadcast Electron Media. 2005;49(4):488-509 12. American Academy of Pediatrics Council on Communications and Media. Children, adolescents, obesity, and the media. Pediatrics. 2011;128(1):201-208 13. Strasburger VC. Children, adolescent, and media. In: Tanski S, Garfunkel LC, Duncan PM, Weitzman M, eds. Performing Preventive Services: A Bright Futures Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2010:159-162 14. Lenhart A, Madden M, Smith A, et al. Teens, kindness and cruelty on social network sites. Pew Res Internet Project. Available at: www.pewinternet.org/files/old-media/Files/Reports/2011/PIP_Teens_ Kindness_Cruelty_SNS_Report_Nov_2011_FINAL_110711.pdf. Published 2011. Accessed May 15, 2014 15. Patock-Peckham J, Morgan-Lopez A. College drinking behaviors: mediational links between parenting styles, impulse control, and alcohol-related outcomes. Psychol Addict Behav. 2006;20(2):117125 16. Walls T, Fairlie A, Wood M. Parents do matter: a longitudinal two-part mixed model of early college alcohol participation and intensity. J Stud Alcohol Drugs. 2009;70(6):908-918 17. Windle M, Spear LP, Fuligni AJ, et al. Transitions into underage and problem drinking: developmental processes and mechanisms between 10 and 15 years of age. Pediatrics. 2008;121:S273-S289

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Adolescent Mobile Phone Use and Mobile Phone-Based Health Promotion Scott Harpin, PhD, MPHa*; Nnamdi Ezeanochie, MD, MPHb; Sheana Bull, PhD, MPHb College of Nursing and bColorado Schools of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado

a

Like many technologies before it, the mobile phone has become ubiquitous in the hands and back pockets of American adolescents in this generation since the first commercial “1G cell phone” in 1983. At the same time many people remember seeing a phone call being placed on the street using the first brick-like mobile handheld devices in the early 1990s, “smartphone” technologies were being tested and brought into commercial production. Personal digital assistants (PDAs) were integrated into mobile technologies in the late 1990s and predecessor to what are common-use telecommunications technologies of today—fully functional handheld computers in the form of smartphones. These advances in technology have affected the ways in which adolescents around the world communicate and how they interact with health care systems. Epidemiology of Adolescent Mobile Phone Use

The most current trend data for American adolescent technology use are presented by the Pew Research Center’s Internet and American Life Project (www. pewInternet.org). In the most recent Pew report on mobile technology use, 90% of American adults 18 years or older reported owning a mobile phone.1 In the 18- to 29-year-old group specifically, 98% owned a mobile phone. Mobile phone ownership among adolescents and young adults has lagged behind that of older adult age groups because of the costs of devices and cellular plans.1 Still, youth have quickly adopted mobile technology in a single generation, in essence changing the face of adolescent interpersonal communication. In an adolescentspecific technology use report, Pew researchers found in their nationally repre*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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sentative survey that more than three-quarters of all teens aged 12 to 17 years had a mobile phone, and nearly half of those mobile phones were smartphones.2 This was a 14% increase of smartphone ownership from just a year before, although standard mobile phone (voice and text only) ownership rates remained flat. Unique in these recent findings is that youth use their phones as their primary Internet portal: a quarter of respondents said they are “cell-mostly” Internet users. Ownership crosses socioeconomic strata as well. While there is an increase in mobile phone ownership by parent household income, more than two-thirds of youth from the poorest households reported owning a mobile phone.2 Rates of smartphone ownership among youths in households earning less than $30,000 per year are statistically no different than those from families with incomes greater than $75,000 per year. The same exploding trends of mobile phone ownership and use exist globally. In some developing regions, most notably sub-Saharan Africa, easy access to cellular technology allowed populations to literally skip the digital divide of haves and have-nots. Studies have projected that by 2017, 67% of the world’s population will own a phone, and 8 billion mobile phones with “short messaging service” (SMS) or text messaging, functions will be in use.3-5 Since one-fifth of the world’s population are adolescents and 85% of them live in the developing world,6 it is particularly salient to understand on an individual level how mobile phone technologies can be used to improve adolescent health. Developmental Considerations

Global mobile phone use has shifted how young people communicate and access peer networks. Before mobile technologies, youth relied on wired (aka landline) phones to call a single peer. At best, this was done by using a phone tree or numerous 1:1 calls for social planning. Short messaging service technologies have made synchronous communication and social planning easy. With the 2008 advent of Android and iPhone devices, the next generation of mobile phone social networking has moved to mobile application-based (apps) innovations to organize youth for simultaneous communication and computing. Young people can virtually organize communications and social events via a variety of Web-based options accessible on the latest generation of mobile phones. The need for a hard-wired telephone and a home/desktop computer for such activities is no longer required. Social learning theory provides a framework for how young people integrate and adapt their personal use of mobile technologies among peer networks.7 The current generation of adolescents (born the late 1990s and early 2000s) was the first to integrate the mobile phone as an essential element of identity formation.8 A number of studies have noted the element of fashion and trendiness in owning a mobile phone; youth accessorize and personalize phones as an expression of both interests and self.9,10 Indeed, the age of first mobile phone ownership in the

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United States coincides with the coming of age in early adolescence,11 averaging 12 to 13 years old.2 Just as parents had concerns about mobile phone use by their children, many grew to appreciate the positive aspects of their children having mobile phones. This included viewing the mobile phone as a safety mechanism and as a source for increasing parent-child communication.8,12 Campbell13 outlined the various aspects of family safety, particularly the “double-edged sword” of extending freedoms to a youth while also extending parental authority. In one study in Britain, youth described their mobile phone as a psychological protector.14 Youth in that study reported an increased probability of their traveling to “risky” places and feeling safer having their mobile phone with them. Williams and Williams15 explained how parental authority has moved beyond the private sphere of the home to the child’s real-time social space with the addition of mobile phones in the parenting mix. Risks of Mobile Phone Use

There were, and continue to be, a number of societal concerns about mobile phone use among young people. Some wondered if youth would detach from interpersonal communication,16 lose the ability to write narrative prose,17 or increase risk of brain tumors from mobile phone radio waves.18,19 Parents have experienced anxiety about youth impulsivity in communication. Might their child be more apt to press “send” on a text message or post on a social networking site without thinking through the ramifications of nonverbal interactions? This concern was somewhat confirmed with the first reports of “sexting” (sending/receiving of sexually explicit text messages) in the lay media.20 Mobile communication use during nighttime hours has been shown to exacerbate an already pressing issue of lack of sleep and fatigue among young people.21 Physiologically, adolescents require about 9 hours of sleep per night, although in reality they are averaging far less than that amount. Lack of sleep is exacerbated by technology in the bedroom at night.22 Two separate studies in the United Kingdom evaluated mobile phone use after bedtime hours compared to never use.23,24 More than 60% of youth used their phone after hours, increasing their odds of being “somewhat” to “very tired” or having difficulty falling asleep. Mobile phonerelated sleep disturbances have also been linked to stress and symptoms of depression in 20- to 24-year-olds.25 Distracted Driving However, the biggest apprehension was, and still remains, the lethal outcomes of distracted driving.26-28 Lay media, advocacy organizations, and public health officials raised the clarion call about the potential risk of injury to teen drivers from distracted driving because of talking, texting, or “posting” while driving. Distracted driving includes other behaviors and impulses such as vehicle control adjustment, grooming, and eating/drinking, any of which can be particularly

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harmful to the adolescent who tends to have little driving experience. The Youth Risk Behavior Surveillance Study did not begin asking about texting while driving until the 2013 iteration of the survey.29 In these recent findings, among the nearly two-thirds of all US young people who had driven in the past 30 days, 41.4% reported texting or sending an e-mail message while driving. Innovative clinical trials have been implemented to study specific distractions among adolescent drivers. These include use of driving simulators to measure time required to text,30 naturalistic studies using onboard cameras to track driving distractions by youth,31 and cognitive studies analyzing the link between attitudes and perceptions of risk and those correlations with driving behaviors.32 Mobile Phone Use in Unique Adolescent Populations

Recent studies have examined the role of mobile phone use among street youth. In 2009, Rice and colleagues33 documented prevalence rates showing that 3 of 5 youth owned a mobile phone and 2 of 5 had a working mobile phone (one that had an active contract with a service provider). They found few differences between owners of phones (either working or with expired minutes) and nonowners of phones, and even described the potential for phone-based health interventions in this hard-to-reach population when those technologies were still in their infancy. Phones also offered increased peer and parent connectedness that is not always inherent with runaway youth, the latter a unique finding in a population in which parent connections suffer. Homeless youth have been shown to be very resourceful when it comes to telecommunications as well as day-to-day challenges. They were well versed in where to go for free Wi-Fi Internet access, known as “hotspots.” Those hotspots include libraries, mobile phone carrier stores, and other public spaces where Internet access is available. The utility of mobile phones has a different significance for youth living with disabilities and chronic health conditions. Having a mobile phone means a lifeline to the people they rely on for day-to-day safety.34 For youth living with cognitive disabilities, adding frequent check-ins by phone increases independence and emotional stability.35 Those with chronic disease benefit from text messages from their physicians reminding them about blood glucose monitoring and diabetes management,36-38 medication for asthma control,39,40 and human immunodeficiency virus (HIV) prophylaxis.41 Mobile Phone Use in Health Promotion

While a generation of adolescent health promotion research has been tested in a variety of settings and formats for youth, technology-based health promotion interventions are still in the first generation of development and testing.42 Mobile phone-based interventions are being developed concurrently with the revolution of these technologies and is happening with populations across the lifespan, including younger adolescents.

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Adolescent mHealth

Mobile health (mHealth) technology refers to the application of phone-based functions in health promotion and systems-level activities. Health promotion and disease self-management can be facilitated by the use of text messaging, sending messages via phone directly to consumers or patients. Physicians and systems are recognizing the utility of and efficiency in using mobile phones to improve surveillance and care delivery by community health workers in remote settings. There is growing evidence that text messages, used either as a stand-alone intervention or in combination with traditional health promotion and disease selfmanagement efforts, can be effective with young people. There is evidence supporting the use of text messages to deliver health messages to youth and evidence demonstrating the suitability of using young adults as subjects of SMSbased interventions.43 Preliminary results from an efficacy trial of the Teen Outreach Program with Media Enhancement (TOP4ME) study demonstrates the potential for hybrid face-to-face programs combined with SMS.44 Participants who received the TOP intervention with supplemental text messages had comparatively lower rates of risky sexual activity at 9-month follow up compared to those receiving TOP alone. Additionally, there is evidence that using mobile phones can enhance health care delivery. Internationally, UNICEF has outlined how SMS can allow rapid tracking of supplies and data for vaccines to ensure vaccine coverage rates that can reduce the incidence of pneumococcal disease and rotavirus.45 This has the potential to reduce the under-5 mortality rate, contributing to the achievement of the 4th Millennium Development Goal.46 Another example of current efforts is an efficacy trial of using SMS reminders to facilitate initiation and completion of the human papillomavirus (HPV) vaccine series for youth and their parents.47 While these adolescent mHealth findings are promising, studies on the effectiveness of SMS-based interventions have varied results. Although multiple interventions demonstrate success with SMS, a major critique of these interventions is the lack of reproducibility in different settings or for different populations.48,49 Head and colleagues4 have offered explanations for limited reproducibility by identifying critical factors that influence and increase the efficacy of SMS-based interventions. These factors include use of targeted and tailored messages, scheduled approach to message texting (rather than constant message sending), and decreasing frequency of texting intervention once the individual begins to practice the desired behavior. Improving SMS efficacy by combining it with other interventions remains an unresolved issue. While some have suggested a multifaceted approach should be more effective (ie, combining SMS with material delivered via a Web site, e-mail, or print publication),50 there is a growing

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body of evidence that there is no significant difference in outcome when SMS is used alone or in combination with other approaches.4 Health Behavior Change Theory and mHealth Promotion

The limited reproducibility of SMS-related success can be related to inconsistent application of behavior change theory in the design of SMS intervention content. There is abundant literature demonstrating theoretical constructs from Social Cognitive Theory, Health Belief Model, Theory of Reasons Action and Planned Behavior, and Diffusion of Innovation Theory, which can be used to frame health promotion and self-management content to effectively improve healthy behaviors.51-54 These theories and constructs take into consideration the different nature of the intended behaviors (long-term behavior change; one-off screening behavior change; and short-term behavioral modification) and develop appropriate measurable constructs that help predict the intended behavior (Table 1).55-59 Limitations of Adolescent mHealth

With advances in mobile technology, there is a growing concern of SMS tech­ nology obsolescence. It is estimated that more than 300 million apps were downloaded between 2009 and 2010 in the United States,60 and that now at least 10,000 apps are dedicated to some type of health promotion or selfmanagement.61 Smartphones tend to have traditional SMS function but also provide computing and communication capability, which includes Internet access and GPS. Studies have yet to strongly demonstrate the efficacy of using apps for health promotion or disease management. An adolescent and young adult exemplar includes Muessig’s intervention with a sample of young black men who have sex with men (MSM).62 Participants were willing to accept app-based interventions targeted at providing information about sexually transmitted infection (STI) education, relationship counseling, testing site locations, disease symptoms, and connection to other gay HIV1 men for support services. Additionally, Guy2Guy (G2G) is another app-based intervention tailored to adolescent MSM in the United States, utilizing both SMS and peer social support to reduce sexual risk behavior.63 Such behavior change interventions innovatively tie the strength of social capital to social networking to improve health outcomes. While promising, we can anticipate several challenges in using mHealth apps for health promotion. Mobile platforms and apps have to be seamless and simple in order to be usable, especially to target those “hard to reach groups” who may have highly variable familiarity with technology.60 Additionally, there is a relatively higher cost for implementing apps instead of interventions that rely on SMS alone, especially in resource-poor regions. This includes the cost of purchasing apps, especially among adolescents with limited financial means. The

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Table 1 Key Theories and Constructs with Demonstrated Utility in Health Promotion and Health Communication Programs55 Construct(s)

Definition

Examples of Use in mHealth

Theory of Planned Behavior51

Outcome Expectancies, Norms, and Intentions

Social Cognitive Theory52,56

Self-Efficacy

Health Belief Model57

Cues to Action

Elaboration Likelihood Model58

Peripheral and Central Messaging

Gain and Loss Framing59

Gain and Loss Framing

Outcome Expectancies: The outcome anticipated if Messages that one enacts a behavior (a) offer reminders of the benefits of a behavior Norms: The perception of what behaviors others (eg, “Walking is an easy and simple way to improve similar to you engage in heart health.”) Intentions: Plans to enact a behavior (b) reinforce that the behavior is normative (eg, “Walking remains one of the most popular activities for people your age.”) (c) help increase intentions (eg, “Make a date in your calendar to walk with your neighbor tonight.”) The confidence and skills needed to perform Messages that offer specific strategies to enhance skills a behavior (eg, “Parking your car farther away from a store is an easy way to get some physical activity.”) Triggers from the environment, setting, and Messages that serve as reminders to take medications personal interactions that can motivate or or to make an appointment. encourage people to enact a behavior Messages that are peripheral operate like cues An alarm reminder to get out and walk is a peripheral to action but are not processed in a way that message. increases value of the behavior; messages that are A message such as “You met your weight loss goal last central reinforce a value or belief and therefore week in part because of walking, keep it up!” is an prompt a behavior example of a central message. Messages that are gain framed emphasize benefits “Walking will make you feel energized and refreshed to adopting a healthy behavior; loss framed NOW and healthier LATER” is an example of a gain messages emphasize what one avoids by enacting framed message. a behavior “Walking helps hold off the long term effects of diabetes” is an example of a loss framed message.

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Theory

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costs of acquiring Internet access and a smartphone with sufficient computing power and battery life can be critical barriers, especially with low-income young people. Finally, the use of a cloud computing resource external to the mobile device may be restrictive and will require speed and memory updates in the future as data accumulate and technology evolves. The mHealth apps have substantial promise in large part because they can reach so many more people than could be reached by traditional health promotion/ disease prevention efforts. In reality, they likely will realize only small-tomoderate effects on behaviors and health outcomes at an individual level. Therefore, in order to generate full benefit, mHealth apps must be scaled for use on a population level. Achieving small- to-medium effects on behavior within a large population can result in greater effects on health. To date, no studies have shown scalability, and potential threats to achieving this promise have been identified. In developing countries, street youth identified as at risk for negative health outcomes still face challenges in access to mobile phones. Shared phones may be common but limit the capacity to share private or sensitive information over the phone, thus restricting interventions to general health care information rather than more personalized targeted and tailored programming that can be more effective.4 Clinical Recommendations

Anticipatory guidance and education for adolescent mobile phone use align with prevention messages for other emerging technologies, akin to social network sites and general Internet use. Moreno’s recent parent guidebook on healthy Internet use has parallel recommendations and implications applicable to mobile phone use.64 The American Academy of Pediatrics has released 3 policy statements addressing aspects of adolescent mobile phone use. A synopsis of those key recommendations related to mobile phone use is as follows:

• • •

Physicians should ask at least 2 media-related questions at each well-child/ well-teen visit, which could include mobile phone use, risky texting, and social media use during night hours.65,66 Anticipatory guidance should include information on safe driving, specific to the perils of texting while driving and distracted driving while using mobile phones.67 Schools and communities should implement media education, which could include mobile technology-specific content, tailored to adolescent learners.65

The Society for Adolescent Health and Medicine’s Position Paper, Adolescents and Driving, further advocates regulations to limit distracted driving, as well as role-modeling of safe driving by parents (to include mobile phone use).68 Beyond

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this medical professional organization’s position paper, mobile phone use prevention advocacy efforts tend not to be adolescent specific and are geared primarily toward safe driving for all persons on the road. Summary

The past 20 years of mobile technology has shifted the ways in which young people communicate and network with one another. Mobile phone use is prevalent among adolescents and therefore is an ideal form of communication for tailored health care. This is especially so given the dramatic uptake in use of mobile technologies in this age group. Technology developments have also altered how physicians and public health interventionists communicate with adolescents for prevention messages. Rapidly changing technology has made the study of how best to communicate with youth a challenge because research can scarcely keep up with advances in the technology. However, best practices from behavior change and communication theories remain a foundation for future intervention directions and how we might best meet the health promotion needs of adolescents. References 1. Pew Research Center. Pew Research Center Internet Project Survey. Washington, DC: Pew Research Center; 2014 2. Madden M, Lenhart A, Duggan M, Cortesi S, Gasser U. Teens and Technology: 2013. Washington, DC: Pew Research Center; 2013 3. Portio Research. Mobile Messaging Futures 2012-2016: Analysis and Growth Forecast for Mobile Messaging Markets Worldwide. 6th ed. Chippenham, Wilts, UK: Portio Research Limited; 2012 4. Head KJ, Noar S, Iannarino NT, Harrington N. Efficacy of text messaging-based interventions for health promotion: a meta-analysis. Soc Sci Med. 2013;97:41-48 5. Eurostat. Telecommunication statistics 2013. Available at: epp.eurostat.ec.europa.eu/statistics_ explained/index.php/Telecommunication_statistics. Accessed November 12, 2013 6. Chinsembu KC. Sexually transmitted infection in the adolescent. Open Infect Dis J. 2009;3:107117 7. Bandura A. Health Promotion by Social Cognitive Means. Health Educ Behav. 2004;32(2):143-164 8. Srivastava L. Mobile phones and the evolution of social behaviour. Behav Inf Technol. 2005;24(2):111-129 9. Katz JE, Sugiyama S. Mobile phones as fashion statements: evidence from student surveys in the US and Japan. New Media Soc. 2006;8(2):321-337 10. Walsh SP, White KM, Young RM. Over-connected? A qualitative exploration of the relationship between Australian youth and their mobile phones. J Adolesc. 2008;31(1):77-92 11. Oksman V, Turtiainen J. Mobile communication as a social stage meanings of mobile communication in everyday life among teenagers in Finland. New Media Soc. 2004;6(3):319-339 12. Geser H. Towards a Sociological Theory of The Mobile Phone. Published May 2004. Available at: www.geser.net/mobile/t_geser1.pdf. Accessed November 5, 2014 13. Campbell MA. The impact of the mobile phone on young people’s social life. 2005. Available at: eprints.qut.edu.au/3492/1/3492.pdf?q5on-the-mobile-the-effects. Accessed February 12, 2014 14. Pain R, Grundy S, Gill S, et al. “So long as I take my mobile”: mobile phones, Urban life and geographies of young people’s safety. Int J Urban Reg Res. 2005;29(4):814-830 15. Williams S, Williams L. Space invaders: the negotiation of teenage boundaries through the mobile phone. Soc Rev. 2005;53(2):314-331

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16. Durkin K, Conti‐Ramsden G, Walker AJ. Txt lang: texting, textism use and literacy abilities in adolescents with and without specific language impairment. J Comput Assist Learn. 2011;27(1): 49-57 17. Plester B, Wood C, Bell V. Txt msg n school literacy: does texting and knowledge of text abbreviations adversely affect children’s literacy attainment? Literacy. 2008;42(3):137-144 18. Aydin D, Feychting M, Schüz J, et al. Mobile phone use and brain tumors in children and adolescents: a multicenter case–control study. J Natl Cancer Inst. 2011;103(16):1264-1276 19. Kheifets L, Repacholi M, Saunders R, Van Deventer E. The sensitivity of children to electromagnetic fields. Pediatrics. 2005;116(2):e303-e313 20. Rice E, Rhoades H, Winetrobe H, et al. Sexually explicit cell phone messaging associated with sexual risk among adolescents. Pediatrics. 2012;130(4):667-673 21. Zimmerman FJ. Children’s media use and sleep problems: issues and unanswered questions: research brief. Henry J. Kaiser Family Foundation. May 2008. Available at: kff.org/other/issuebrief/childrens-media-use-and-sleep-problems-issues. Accessed August 8, 2014 22. Calamaro CJ, Yang K, Ratcliffe S, Chasens ER. Wired at a young age: the effect of caffeine and technology on sleep duration and body mass index in school-aged children. J Pediatr Health Care. 2012;26(4):276-282 23. Van den Bulck J. Adolescent use of mobile phones for calling and for sending text messages after lights out: results from a prospective cohort study with a one-year follow-up. Sleep. 2007;30(9):12201223 24. Arora T, Broglia E, Thomas GN, Taheri S. Associations between specific technologies and adolescent sleep quantity, sleep quality, and parasomnias. Sleep Med. 2013;15(2):240-247 25. Thomée S, Härenstam A, Hagberg M. Mobile phone use and stress, sleep disturbances, and symptoms of depression among young adults—a prospective cohort study. BMC Public Health. 2011;11(1):66 26. Bingham CR. Driver distraction: a perennial but preventable public health threat to adolescents. J Adolesc Health. 2014;54(5S):S3-S5 27. Tison J, Chaudhary N, Cosgrove L. National Phone Survey On Distracted Driving Attitudes and Behaviors. Report No. DOT HS 811 555. 2011. Washington, DC: National Highway Traffic Safety Administration; 2011 28. Centers for Disease Control and Prevention. Distracted Driving. 2014. Available at: www.cdc.gov/ motorvehiclesafety/distracted_driving. Accessed January 15, 2014 29. Kann L KS, Shanklin SL, et al. Youth risk behavior surveillance: United States, 2013. MMWR Surveill Summ. 2014;63(Suppl 4):1-168 30. Hosking SG, Young KL, Regan MA. The effects of text messaging on young drivers. Hum Factors. 2009;51(4):582-592 31. Foss RD, Goodwin AH, McCartt AT, Hellinga LA. Short-term effects of a teenage driver cell phone restriction. Accid Anal Prev. 2009;41(3):419-424 32. Atchley P Atwood S, Boulton A. The choice to text and drive in younger drivers: behavior may shape attitude. Accid Anal Prev. 2011;43:134-142 33. Rice E, Lee A, Taitt S. Cell phone use among homeless youth: potential for new health interventions and research. J Urban Health. 2011;88(6):1175-1182 34. Dixon J, Dehlinger J, Dixon SD. Designing, implementing and testing a mobile application to assist with pediatric-to-adult health care transition. Hum Comput Interact. 2013;8005:66-75 35. Dawe M. Understanding mobile phone requirements for young adults with cognitive disabilities. Paper presented at Proceedings of the Conference on Computers and Accessibility; 2007 36. Ferrer-Roca O, Cardenas A, Diaz-Cardama A, Pulido P. Mobile phone text messaging in the management of diabetes. J Telemed Telecare. 2004;10(5):282-285 37. Franklin VL, Waller A, Pagliari C, Greene SA. A randomized controlled trial of Sweet Talk, a textmessaging system to support young people with diabetes. Diabet Med. 2006;23(12):1332-1338 38. Hanauer DA, Wentzell K, Laffel N, Laffe LM. Computerized automated reminder diabetes system (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes management. Diabetes Technol Ther. 2009;11(2):99-106

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39. Ostojic V, Cvoriscec B, Ostojic SB, et al. Improving asthma control through telemedicine: a study of short-message service. Telemed J E Health. 2005;11(1):28-35 40. Neville R, Greene A, McLeod J, Tracy A, Surie J. Mobile phone text messaging can help young people manage asthma. BMJ. 2002;325:600 41. Puccio JA, Belzer M, Olson J, et al. The use of cell phone reminder calls for assisting HIV-infected adolescents and young adults to adhere to highly active antiretroviral therapy: a pilot study. AIDS Patient Care STDS. 2006;20(6):438-444 42. Bull S. Technology-Based Health Promotion. Los Angeles, CA: Sage; 2011 43. Whitney LB, Romer D, DiClemente RJ, Salzar LF. African American adolescents and new media: associations with HIV/STI risk behavior and psychosocial variables. Ethn Dis. 2011;21:216-222 44. Bull S, Devine S, Ortiz C, Chandler A. Messaging to enhance an effective teen pregnancy prevention project: interim findings from the TOP@4ME project2013. Poster presentation at the Youth1Tech Conference, San Francisco, California. April 8, 2013 45. UNICEF. Supply annual report: innovate for children. 2010. Available at: www.unicef.org/supply/ files/supply_annual_report_2009.pdf. Accessed November 15, 2013 46. Millennium Development Goals. 2013. Available at: www.un.org/millenniumgoals/pdf/ report-2013/mdg-report-2013-english.pdf. Accessed December 2, 2013 47. Dempsey A. HPV text messaging pilot study [personal communication]. November 15, 2013 48. Gold J, Lim M, Hocking JS, et al. Determining the impact of text messaging for sexual health promotion to young people. Sex Transm Dis. 2011;38:247-252 49. Lester RT, Millse EJ, Kariri A. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomized trial. Lancet. 2010;27:1838-1845 50. Lana A, Valle O, Lopez S, Faya-Ornia G, Lopez LM. Study protocol of a randomized controlled trial to improve cancer prevention behaviors in adolescents and adults using web-based intervention supplementation with SMS. BMC. 2013;12:357-365 51. Azjen I. From actions to intentions: a theory of planned behavior. In: Kuhl J, Beckmann, J. eds. Action-Control: From Cognition to Behavior. Heidelberg, Germany: Springer; 1985:11-39 52. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986 53. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the health belief model. Health Educ Q. 1988;15:175-183 54. Rogers E. Diffusion of Innovations. New York: The Free Press; 1971 55. Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res. 2010;12(1):e4 56. Bandura A. Self-Efficacy: The Exercise of Control. New York: WH Freeman; 1997 57. Rosentstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974;2:328335 58. Petty R, Barden J, Wheeler S. Emerging Theories in Health Promotion Practice and Research. San Francisco, CA: Jossey-Bass; 2002 59. Rothman AJ, Bartles RD, Wlaschin J, Salovey P. The strategic use of gain- and loss-framed messages to promote healthy behavior: how theory can inform practice. J Commun. 2006;56:S202-S220 60. Boulos KNM, Wheeler S, Travares C. How smartphones are changing the face of mobile and participatory healthcare: an overview, with example from eCAALYX. Biomed Engin Online. 2011;10:24 61. IMS Institute for Healthcare Informatics. Patient apps for improved healthcare: from novelty to mainstream. 2013. Available at: developer.imshealth.com/Content/pdf/IIHI_Patient_Apps_ Report.pdf. Accessed November 20, 2013 62. Muessig KE, Pike EC, LeGrand S, et.al. Putting prevention in their pockets: developing mobile phone-based HIV interventions for black men who have sex with men. AIDS Patient Care STDS. 2013;27:211-222 63. Ybarra M. Guy to Guy: an mHealth application for young gay men [personal communication]. December 10, 2013

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64. Moreno MA. Sex, Drugs ‘n Facebook: A Parents’ Toolkit for Promoting Healthy Internet Use. Ala­ meda, CA: Hunter House; 2013 65. American Academy of Pediatrics Council on Communications and Media. Media education. Pediatrics. 2010;126(5):1012-1017 66. American Academy of Pediatrics Council on Communications and Media. Children, adolescents, and the media. Pediatrics. 2013;132(5):958-961 67. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention; Committee on Adolescence. The teen driver. Pediatrics. 2006;118(6):2570-2581 68. D’Angelo L Halpern-Flesher B, Abraham A. Adolescents and driving: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2010;47(2):212-214

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Media Matter: But “Old” Media May Matter More Than “New” Media Victor C. Strasburger, MDa* a

Distinguished Professor of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico

“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.” Alvin Toffler Future Shock (1970) “The way adolescents of today learn, play, and interact has changed more in the past 15 years than in the previous 570 since Gutenberg’s popularization of the printing press. Jay N. Giedd, MD (2012) “We put our kids through fifteen years of quick-cut advertising, passive television watching, and sadistic video games, and we expect to see emerge a new generation of calm, compassionate, and engaged human beings?” Sidney Poitier The Measure of a Man (2007) INTRODUCTION

It has now been 50 years since the US Senate held hearings about whether media violence contributes to real-life violence. Thousands of research studies later— including remarkable longitudinal studies from New Zealand,1 Japan,2 and Scotland3—it is clear that traditional media (eg, TV, movies, videos) can potentially have a powerful influence over the attitudes and behavior of children and

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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adolescents.4-6 By time criteria alone, television will always win out.7 What is changing is that children, and especially teens, are watching TV on newer platforms (Figure 1).8,9 What is not clear is the behavioral effect of new media (eg, the Internet, social networking sites, cell phones) on child and adolescent development and behavior. Although new media are being touted as being significant influences and posing significant problems, such as Internet and Facebook depression, cyberbullying, and sexting, there is room for argument and debate over whether new media will ultimately prove to be as powerful as old media in influencing key areas of child and adolescent health (Figure 2). At least 3 recent studies suggest that TV—an “old” medium—has more of an effect than new media on sexual behavior10 and on obesity.11,12 A fourth study finds that despite concerns that excessive use of new media is harmful to adolescent development, in fact, television detracts from academic performance more than heavy use of the Internet or video gaming.13 A fifth study compares TV screen time with computer time and finds that only the former is more often associated with poorer cardiometabolic biomarkers such as blood pressure and lipid profiles.14 Despite the occasional naysayer,15 most child health experts agree that old media—hereafter referred to as traditional media—can have significant attitudinal and behavioral effects on a whole host of health-related concerns, at least according to numerous epidemiologic studies (Table 1).16

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Fig 1. US video viewing audience. Overall usage, number of users 21 (in 000’s) Q1 2012 vs Q4 2011. Copyright © Nielsen. Reprinted with permission.

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Fig 2. Evolution of communication. Copyright © Mike Keefe, Denver Post.

Table 1 Health Effects Of Media Media Violence • More than 2000 studies show a link with aggressive attitudes and behavior • Strong desensitization effect • Exposure of normal children to media violence has been associated with antisocial and even criminal behavior in adults • No studies exist on the effect of media violence on children or adolescents who are mentally ill Sex • Twenty studies have used longitudinal data to show a 23 increased risk of early sexual intercourse with exposure to sexual content at a young age • Dozens of studies show an effect on sexual attitudes and beliefs Drugs • Alcohol and tobacco advertising 5 1 cause of adolescent drinking and smoking • Exposure to movie scenes of smoking and drinking may be the leading cause of teen drinking and smoking Obesity • Strong evidence for screen time causing an increased risk of obesity • Etiologic factors include (1) displacement of active play, (2) exposure to food advertising, (3) changes in eating habits while viewing, and (4) effect of screen time on sleep Other Findings • Several studies link TV viewing with attention deficit disorder (ADD) and attention-deficit/ hyperactivity disorder (ADHD) • At least 14 studies now find language delays in babies ,2 years exposed to screens • Association of TV viewing with depression and an increased risk of imitative suicide • Effect of TV, movies, and magazines on body self-image and on development of eating disorders • Numerous studies document prosocial effects (eg, increased school readiness, possible effect on altruism, empathy, and acceptance of diversity)

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Traditional Media Aggressive Behavior

The communications, psychology, and pediatric literature contains more than 2000 studies on the association between media violence and aggression in children and adolescents according to Harvard’s Center on Media and Child Health (www.cmch.org). A broad consensus of medical and public health organizations is that the evidence is now clear and convincing that media violence is 1 of the causal factors in real-life violence and aggression (although they also agree that it is not the leading cause).17,18 Of all media-related areas, media violence has been the most thoroughly investigated. The US government has issued several reports as well. A US Surgeon General’s report in 1972,19 a National Institute of Mental Health report 10 years later,20 an FBI report on school shootings in 2000,21 and, most recently, a Federal Communications Commission report in 200722 all have concluded that there is “strong evidence” that exposure to media violence can increase aggressive behavior in children and adolescents. Most researchers agree.23,24 While much of the research and many of the government reports have come from the United States, concern about media violence is worldwide.4,25 How much violence is there on TV and in movies? A considerable amount, according to several recent studies. Bullying is surprisingly common in young children’s shows and is seen in 92% of the 50 most popular programs watched by 2- to 11-year-olds.26 In addition, a content analysis of the 2012 to 2013 TV season found that guns or bladed weapons are featured every 3 minutes, and that the TV ratings for violence were inaccurate.27 Similarly, in a study of the top 30 films since 1950, researchers found that PG-13 films now contain as much or more violence as R-rated films. In addition, violence has more than doubled since 1950, and gun violence in PG-13 films has tripled since 1985.28 Violence in James Bond films has doubled, and lethal violence has tripled since the first films.29 A content analysis of the top-grossing movies from 1985 to 2010 found that 90% contained a main character involved in violence, and 77% had the same character involved in a risky behavior, usually either sex or substance use.30 But how strong is the connection between media violence and real-life violence? Researchers sometimes disagree. Comstock and Strasburger31 assert that the connection may be as high as 30%. Others put the figure at closer to 10%.32 But interestingly, the connection is nearly as strong as the connection between cigarette smoking and lung cancer, and is stronger than many widely accepted public health risks such as lead poisoning and IQ or socioeconomic status and school achievement (Figure 3).32 The mere presence of a weapon can increase aggression.33 Why, then, do parents and the general public not believe that there is a connection? The answer is complicated.34 But a significant part of the problem may be

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that most critics of the research point to the current low rate of homicide as contradicting any possible relationship between media violence and real life violence. Homicide actually is quite rare, however, and it makes far more sense to use a more common (and perhaps worrisome) measure of interpersonal violence, such as assault rates, which have climbed significantly as media violence has intensified (Figure 4).

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Sex

For obvious reasons, there are not nearly as many studies on sexual behavior as there are on aggression. However, to date, there are now 20 studies using longitudinal data that potentially allow cause-and-effect conclusions to be drawn (Table 2),10,35-53 and virtually all of them show a significant effect of sexual content in the media on adolescents’ sexual behavior.54-56 In addition, dozens of older studies document how the media can shape children’s and adolescents’ beliefs and attitudes about sex and sexuality.54-56 Nearly all of the studies deal with traditional media, sometimes in combination with newer media. In particular, the risk of early sexual intercourse seems to double with exposure to a lot of sexual content at a young age.55,56 Drugs

Within the past decade, many new longitudinal correlational studies, both in the United States and Europe, have established that exposure to scenes of cigarette

Table 2 Recent Longitudinal Studies of the Effect Of Sexual Content on Sexual Behavior Study

N

Wingood (2003)

480 Rap videos 1 y Exposure to sexual rap videos 14-18 y females predicted multiple partners 1792 TV 1 y Sexual media exposure 12-17 y strongly predicted intercourse a year later 1292 TV 1 y Exposure to popular teen 12-17 y shows with sexual content increased risk of intercourse 1 year later 4808 TV 1 y .2 h TV per day increased 7th-12th grade risk of intercourse 1.353 1107 Sexual media, 2 y 23 increased risk of sexual 12-14y media diet intercourse for white teens (TV, movies, with high sexual media diet magazines, music) 1242 Music 3 y Degrading sexual content 12-17 y predicted earlier intercourse 887 TV 1 y Parental co-viewing of TV 12-16 y protective against early intercourse and oral sex 501 14-16 y TV, movies, 1 y Positive and reciprocal magazines, relationship between media music, video exposure and intercourse games

Collins (2004) Martino (2005)

Ashby (2006) Brown (2006)

Martino (2006) Bersamin (2008) Bleakley (2008)

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Media Type

Duration

Findings

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V. C. Strasburger / Adolesc Med 025 (2014) 643–669 Chandra (2008) L’Engle (2008)

Peter (2008) Brown (2009)

Delgado (2009)

Hennessy (2009)

Primack (2009) Bersamin (2010) Gottfried (2011)

Ybarra (2011)

O’Hara (2012)

Ybarra (2014)

649

744 TV 3 y Sexual media exposure 5 12-20 y strong predictor of teen pregnancy 854 Sexual 2 y Peer and media exposure 12-14 y media diet, increased risk of early sex; including stronger connection to Internet parents and schools were protective 962 Internet 1 y Exposure to sexual content 13-20 y on the Internet increased sexual preoccupation 967 X-rated movies 2 y Early exposure to X-rated 7th-8th graders magazines, media predicts earlier onset Internet of sexual intercourse and oral pornography sex 754 TV, movies 5 y Watching adult-targeted TV 7-18 y increases the risk of intercourse by 33% for every hour per day viewed at a young age 506 TV, movies 2 y Increased risk of intercourse 14-18 y magazines, for white teens and sexual music, video media games 711 Music 1 y Exposure to degrading sexual 9th graders lyrics doubled the risk of intercourse 824 TV 1 y Premium cable TV viewing 14-18 y associated with casual sex 474 TV of 14-16 y varying genres 1 y No effect of sexual content overall on sexual intercourse, but exposure to TV sitcoms did predict earlier intercourse 1159 X-rated media 3 y Intentional exposure to 10-15 y (movies, violent X-rated material magazines, predicted a nearly 63 risk of Internet sexually aggressive behavior pornography) 1228 Movies with 6y Exposure to sexual content in 12-14 y sexual content movies, decreased age at first intercourse and likelihood of using condoms, and increased number of sex partners 1058 TV, movies, 2y Exposure to sexual content in 14-21 y music, Internet, TV, movies, and music video games doubles the risk of intercourse; sexual content on TV and in movies has greater effect than does Internet content

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smoking in movies may be the leading cause of teenagers beginning to smoke.57-61 Several studies have found the same connection between scenes of movie drinking and alcohol use in US and German teens,60,62,63 but the literature on the connection between alcohol advertising and onset of adolescent alcohol use is clear and convincing.64-66 Similarly, a meta-analysis of 51 separate studies found that exposure to tobacco marketing and advertising more than doubles the risk of a teenager beginning to smoke (Table 3).67 In Germany, teenagers were found to be 40% more likely to start smoking for every 10 exposures to tobacco ads in a 2½-year study of 1300 schoolchildren aged 10 to 15 years.68 Obesity

Some of the most exciting research currently being done is now linking screen time to the risk of obesity in young people. Again, some of the most impressive studies are long-term international studies. For example,

• • •

Researchers in Dunedin, New Zealand, followed 1000 subjects from birth to 26 years of age and found that average weeknight TV viewing between the ages of 5 and 15 years was strongly predictive of adult body mass index (BMI), even when all other known factors for obesity were controlled for.1 A 30-year study in the United Kingdom found that a higher mean of daily hours of TV viewed on weekends predicted a higher BMI at age 30 years, and for each additional hour of weekend TV watched at age 5 years, the risk of adult obesity increased 7%.69 A study of 8000 Scottish children found that viewing more than 8 hours of TV per week at age 3 years was associated with an increased risk of obesity at age 7 years.3 Similarly, a study of 8000 Japanese children found that TV viewing at age 3 years resulted in a higher risk of overweight at age 6 years.2

What is not as clear is why. Is it exposure to ads for junk food and fast food on TV?70-73 Is it the displacement effect of 7 hours or more of media use per day?74,75 Is it the effect of screen time on changing eating behaviors?76,77 Or is it the effect Table 3 How Good Is the Research Linking Tobacco Marketing to Onset of Adolescent Smoking? Research Question

No. of Studies

No. of Subjects Studied

Are nonsmoking children exposed to and more aware of tobacco promotion? YES. Does exposure to promotions increase the risk of initiation? YES. Does a dose-response relationship exist? YES.

4 prospective 12 cross-sectional

}37,649

12 prospective 14 cross-sectional 2 time-series 2 prospective 7 cross-sectional

}349,306

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}25,180

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651

of screen time on sleep?78 All have been implicated, although the displacement effect is the least convincing mechanism according to the research.79,80 Other Health Influences

Several studies have found a possible causal link between exposure to unhealthy body imagery in mainstream media and eating disorders.81-84 Certainly, the effect of traditional media on young girls’ body self-image can no longer be disputed,84 although black girls seem to be more resistant.85 Music choice has also been found to be a strong marker of later problem behavior in a 4-year longitudinal study testing the Music Marker Theory.86 Traditional media have also been linked to the development of attentional problems,87,88 depression, and suicide,89,90 but none of these studies are as strong as the studies on media violence or obesity. In addition, traditional media lead the way in terms of time spent with media: TV remains the most commonly used medium for children and adolescents. Television viewing is now at an all-time high in the United States (for which the best data have been accumulated).91 Black and Hispanic children spend 5 to 6 hours per day watching TV, compared with 3.5 hours for white youth.92,93 What has changed is that TV is not necessarily viewed on the television set in the living room or den anymore. Increasingly, teens are downloading shows to their computers, iPhones, iPads, and cell phones. About 60% of young people’s TV viewing consists of live TV on a TV set, but the other 40% is now either timeshifted or watched online, on mobile devices, or from DVDs.92 New Directions

As voluminous as the research on traditional media is, there remain significant gaps and a need for continuous monitoring of important content. The National Television Study was completed in the late 1990s, but no comprehensive content analysis of violence in American TV shows has been done since then. Likewise, Dale Kunkel’s content analyses of sex on American TV are now at least 7 years old.94 However, researchers have done a better job of keeping up with drug advertising trends and content analyses of Hollywood movies.28,30 Although the United States is the leading exporter of media in the world, there is no reason why content analyses could not be done on a country-to-country or even a regional basis. The debate over media violence has primarily narrowed into a discussion surrounding violent video games (video games seem to fall on the border between old and new media, with “Pong” and “Pacman” being old, and “Call of Duty” and “Halo” being new). In 2011, the US Supreme Court overturned a California law that attempted to limit the sale of violent video games to children younger than 18 years (Brown v. Entertainment Merchants Association et al, No. 08-1448). The law was poorly written and could not pass constitutional muster, but the

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Supreme Court’s reasoning showed how little even some extremely intelligent justices understand media effects.34 Communications research will never be able to resolve the issue of whether first-person shooter video games contribute to mass murders, but the research is increasingly clear that such games do increase aggressive beliefs, attitudes, and even short-term behaviors.95 Still, more research would be useful in this area, particularly regarding any link between mental illness and violent video games. The last comprehensive government report on children and media was in 1982, before the advent of the Internet, cell phones, and iPads.20 A new report would be extremely useful in summarizing the current state-of-the-art knowledge and new directions for researchers. For example, most correlational and longitudinal studies are epidemiologic in nature; what are now needed are cogent reasons why certain racial and ethnic groups react differently to the same content (eg, black girls are relatively resistant to body self-image problems compared with white girls).85 Finally, the dilemma over which aspect of traditional media contributes most to the current obesity epidemic needs to be resolved. And it would be useful to understand whether antiobesity campaigns will tip certain vulnerable teens over into eating disordered behaviors.96 Given the power of the media and the sheer amount of time that young people spend with it, one might think that media literacy would now be a high priority. That is the case in many western countries but unfortunately not in the United States. A hundred years ago, to be literate meant a person could read and write. Now, literacy means being able to read, write, download, text, and tweet. Several studies now attest to the power of media literacy to mitigate against harmful effects of media.97-101 New Media

Despite all that is known about traditional media and their effects, new media have certainly arrived! In the United States American 18-year-olds now average nearly 40 hours per week online from their home computers, including 5.5 hours of streaming video. In a 2012 survey, 78% of 12- to 17-year-olds owned a cell phone, 23% had a tablet computer, and 95% used the Internet.102 More than three-quarters of all teens visit social networking sites, and 94% of teens have a Facebook profile or account (with an average of 300 friends).103,104 At the same time, 19% of teens say that they have posted updates, comments, photos, or videos that they later regretted posting.104 Although teens actually talk less on their cell phones than any other age group except for seniors, one-third of teenagers send an average of more than 3000 texts per month,91,103 and the average teen sends 60 texts per day.105 Possibly because new media are so new or because they have been adopted far quicker than traditional media were, a seemingly disproportionate amount of attention has been focused on them compared with traditional media. Coverage

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about media violence, sex in the media, and alcohol and tobacco advertising seems to pale in comparison with stories on Internet use (and depression), sexting, cyberbullying, and Facebook and Twitter. Only the issues of obesity and food advertising have gained any traction recently, for obvious reasons. Because new media are recent, the amount of research that attests to their behavioral effect is scant at best: a handful of studies on any of the health-related concerns mentioned compared with hundreds or even thousands of studies on traditional media. In addition, because new media are often being used to access traditional media, any behavioral effects found may be the result of the latter, not the former. Most studies on new media are either content analyses or studies of usage. Nevertheless, there are studies with results that are very concerning, and both cyberbullying and sexting may represent new and unique media threats to child and adolescent health. Media Violence

A study of 1500 10- to 15-year-olds found that 38% had been exposed to violent scenes on the Internet.106 Video games may represent a kind of transition between “old” and “new” media, and there is more research on the effect of video games than of other, newer media. Half of all video games contain violence, including more than 90% of games rated appropriate for children 10 years and older.107 Violent video games are extremely popular with male adolescents and can mimic sexual assault (“RapeLay”), the Columbine massacre (“School Shooter”), or torture (“Soldier of Fortune”), or involve gruesome scenes like playing “fetch” with dogs chasing the heads of slaughtered victims (“Postal 2”). Despite the recent US Supreme Court ruling, there is ample evidence from both correlational and longitudinal studies that violent video games can affect both attitudes and behavior.95,108 Recent research suggests that playing violent video games that feature violence against women is positively associated with rape myth acceptance and negative attitudes toward women.95 The most concerning aspect of new media violence, however, is cyberbullying. The magnitude of the problem is difficult to pinpoint. Reports indicate that 9% to 35% of young people say they have experienced electronic aggression.109-111 Most recently, an analysis of the 2011 Youth Risk Behavior Survey found that 16% of high school students reported being cyberbullied in the past year.112 Recent research has found that cyberbullying may be a strong predictor of serious aggressive behavior in perpetrators.110,113 More importantly, the effect of cyberbullying may be far harsher than traditional bullying because (1) cyber­ bullying occurs in the home so that children and teens no longer feel safe there, (2) the bullying is anonymous, unlike in-person bullying at school114 and (3) the content can remain in cyberspace indefinitely. In fact, in a recent meta-analysis, cyberbullying was more strongly related to suicidal ideation than traditional bullying.115

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Sex

The Internet has given millions of teenagers potential access to a plethora of pornography that formerly existed as mostly girlie magazines. Recent studies have found that more than half of teens have been exposed to “unwanted” sexual material online.54 Of concern is the fact that many popular pornographic videos depict violence against women.116,117 A few of the studies listed in Table 1, particularly the work of Valkenburg and colleagues in Amsterdam,50 have implicated Internet pornography in earlier onset of sexual intercourse among teens. However, pornography has been available for decades, and the existing research on adults seems to indicate that nonviolent pornography may not have the same behavioral effects as violent pornography.54 Only 5 studies have specifically examined children or teenagers 1. A longitudinal study of more than 1500 10- to 15-year-olds found a nearly 6-fold increase in the odds of self-reported sexually aggressive behavior with exposure to violent X-rated material over time, whereas exposure to nonviolent X-rated material was not significantly related.53 2. Another longitudinal study found that exposure to X-rated material in a variety of media platforms (magazines, movies, and Internet) increased the risk of early sexual intercourse and oral sex.43 3. A third study found an increase in “sexual preoccupation” with exposure to Internet pornography.40 4. A cross-sectional study of 433 adolescents in New York City found that visiting sexually explicit Web sites was linked to a greater likelihood of having multiple lifetime sexual partners and greater sexual permissiveness.118 5. In the Growing Up With Media longitudinal study of 1058 young people aged 14 to 21 years, 9% reported some type of sexual violence perpetration, and perpetrators had greater exposure to violent X-rated content.119 What is brand new is sexting—the transmitting of sexual images via cell phone. Its prevalence varies widely, depending on the timeframe studied, the exact definition used, and the population studied (Table 4).120-136 The best estimate with the most careful research design seems to come from the recently published Youth Internet Safety Survey 3, which puts the figure at 1.3%.126 But even if only 1% to 2% of teenagers are engaging in sexting, that would represent tens of millions of teens worldwide. To date, the exact behavioral effect of sexting has not been well studied, other than the possible legal repercussions.137 Only 3 studies have linked sexting with an actual increase in sexual behavior.129-131 Research on social networking and sexual content is still in the early stages as well. A study of 270 profiles of 18-year-olds on MySpace found that 24% referenced sexual behaviors,138 but of course MySpace has now been eclipsed by Facebook. Many teenagers now feel that Facebook will soon be eclipsed by Instagram,

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Snapchat, or other social networking sites.104,139-141 Snapchat may change the entire incidence and nature of sexting because photos automatically disappear 10 seconds after being opened (Figure 5). Adolescents who display explicit sexual references on Facebook have online friends who do likewise,142 perhaps the “super-peer” aspect of media influence.6 Among college freshman, displaying sexual references is positively correlated with intention to begin having sexual intercourse.143 Similarly, adolescents who meet their sexual partners online are more likely to report a higher number of sex partners and a lower age at first intercourse, but not having more sexually transmitted infections (STIs).144 As might be expected, young people who view sexually suggestive Facebook photos estimate that more of their peers are having unprotected sex and sex with strangers.145 Drugs

Of all of the health aspects of old and new media, substance use may be the least likely to be influenced by new media compared with traditional media. Research consists mostly of content analyses. For example, 40% of more than 1000 teens surveyed nationwide reported seeing pictures of kids getting drunk, passing out, or using drugs on social networking sites in a recent study.146 In another analysis of 400 randomly selected social profiles, 56% contained references to alcohol.147 Until recently, teenagers could actually purchase cigarettes online in the United States, and they still can buy alcohol online.148 Only 3 studies to date have examined the behavioral effect of new media on substance use. A correlational study from Columbia University found that compared with teens who spend no time

Fig 5. Snapchat.

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Study

Sample

Prevalence

Definition

Sex Tech Survey (2008)

20%

Sent or posted online nude or seminude picture or videos

Harris/Teen Online (2009)

653 teens 13-19y 627 20-26 y 655 teens 13-18y

AP-MTV Survey (2009) South West Grid Survey (2009) Pew Internet Project (2009)

1247 14-24y 535 teens 13-18y 800 teens 12-17y

Texas High Schools

948 14-19 y

Youth Internet Safety Survey 3 (YISS) (2012) Los Angeles (2012) High School (HS) Survey Young Adults (2013)

1560 10-17-year-olds

19% 9% 45% 40% 4% 9% 28% 31% 57% 7.1%

Southwestern HS Survey (2013)

602 HS students in 1 private high school

Received sexually suggestive text messages or e-mails with nude or nearly nude photos Sent messages or e-mails Sending or receiving nude photos of themselves or sexual partners via cell phone Students who knew friends who had shared “intimate” pictures or videos Sent a sexually suggestive nude or seminude picture or video via cell phone Received picture or video Sent a sexually explicit picture (2012) (increased risk of early sex 1 risky sexual behaviors) Asked someone to send a sext Was asked to send a sext Creating, appearing in, or receiving pictures showing breasts, genitals, or bottoms during the past year: 1.3% appeared or created image; 5.9% received an image Sent a sext Knew someone who had sexted (sexters were 73 more likely to be sexually active) Nonsexters Sent and received sexts Received a sext Sent a sext Sent a sexually explicit picture Received a sexually explicit picture

1839 HS students 3447 18-24 y

15% 54% 57% 28% 13% 2% 17%-18% 31%-50%

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Table 4 How Prevalent Is “Sexting”?

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1034 10th graders

Young Adults (2013)

763 18-25 y

21% 24% 31% 31% 18% 44%

YMSM (2013) (Young Men Who Have Sex With Men) Project TRAC (2014) (Talking about Risk and Adolescent Choices) Los Angeles Middle School Students (2014)

1502 18-24 y

87%

Sent a nude or seminude picture Sent a sexually suggestive message Received a nude or semi-nude picture Received a sexually suggestive message Had a nude or seminude picture or video originally meant to be private shared with them Sent or received a sexually explicit or suggestive photo 32% of sexters reported having sex with a new partner for the first time after sexting with them Reported sexting

410 7th graders

22%

Reported sexting in past 6 months 17% messages, 5% pictures

1173 10-15 y

20% 5%

Flemish Teens (2014)

1943 11-20 y

Ybarra & Mitchell (2014)

3715 13-18 y

California (2014) NE University undergraduates (2014)

1008 14-19y 175 18-22y

Received a sext Sent a sext Students texting 1003/day were more likely to send or receive a sext; students who sent or received a sext were more likely to be sexually active 6% Sent a sext 9% Used mobile pornography 7% Sent or showed sexual pictures of themselves either via text or in person during the past year 33% Females reporting partner asked for nude or seminude pictures 54% Reported sexting in high school (28% photographic)

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Urban Texas HS (2013)

657

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658

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on social networking sites, those who do were 5 times likelier to use tobacco, 3 times likelier to use alcohol, and twice as likely to use marijuana.146 A 6-month longitudinal study of 1563 10th-grade students in 5 Southern California high schools found that exposure to friends’ online pictures of partying or drinking was significantly associated with both smoking and alcohol use.149 An even larger study of 1787 California students in the 6th to 8th grades studied over 2 years examined all media use (Internet videos, social networking sites, movies, television, magazine ads, songs, and video games) and found that greater alcohol-related media exposure in 7th grade was significantly associated with a higher probability of alcohol use in the 8th grade.150 Obesity

Since obesity has clearly been associated with sedentary behavior, new media— especially Internet use and video game playing—may be contributing significantly. The effect may also be filtering down to young children with the advent of advergames. A study of the top 5 brands of food and beverages found that all had Internet Web sites, 63% had associated advergames, 50% used cartoon characters, and 58% had a designated children’s area.151 Fewer than 3% actually educated children about healthy nutrition.152 Meanwhile, food companies are investing more money on online, mobile, and viral marketing to children and teens. In 2009, food companies spent $1.79 billion on marketing to youth aged 2 to 17 years. Spending on marketing in new media increased 50% from 2006 to 2009.72 Despite the fact that the Children’s Food and Beverage Advertising Initiative pledged to advertise only healthy dietary choices to children, between July 2009 and June 2010 there were 3.4 billion food advertisements displayed on kids’ Web sites, and two-thirds were for breakfast cereals or fast food.153 Currently nearly 150 Web sites use advergames to market foods with low nutritional value to young children.154 On the positive side, popular video games like Dance Revolution are increasingly being used to encourage exercise at home and to treat or prevent obesity.155-158 Other Health Influences

Pro-anorexia nervosa Web sites have proliferated and apparently are popular with eating disordered teens; more than 100 such site now exist.159 Use of these Web sites may be predictive of having an eating disorder according to 2 recent studies,160,161 but there are no cause-and-effect data to date. One study does suggest a synergism between portrayals of thin women on TV, more time spent on social networking sites, and the development of eating disorders.162 Another study found that cyberbullying of females is often directed at their appearance and results in poorer body self-image.163 Similarly, there are no cause-and-effect studies on the influence of new media on attentional disorders. In a large and unique study of 12,395 adolescents in 11 European countries, researchers recently found a correlation between media use (Internet, TV, and

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video games) and a variety of psychological problems, including suicidal thoughts, anxiety, and depression.164 Cyberbullying has resulted in a few very well-publicized and tragic suicides in the media.165,166 While the possibility of Internet and Facebook depression and addiction has often been raised and has been studied several times,167-174 it remains controversial compared with the far more robust literature on the effect of traditional media on depression and suicide. Heavy use of the Internet or social networking sites may be more of a symptom of mental health problems than a cause.13 On the other hand, college freshmen who display depression references on their Facebook page do want friends to offer support, preferably in person.175 One preliminary longitudinal study in Korea of 195 adolescents and their smartphones found a connection between “addiction” and problematic behavior.167 Far more research is needed, with attention to using exact definitions of addiction, depression (eg, Beck’s Depression Inventory), and more longitudinal timeframes. Conclusions

The most significant problem to date seems to be that new media allow unbridled and unsupervised access to old media, for which the behavioral consequences are now well known. Could new media be more efficacious in influencing attitudes and beliefs than traditional media? That seems unlikely. Traditional media tell stories, and societies have always placed a very high value on storytelling. However, there are certain aspects of new media that are unique and may represent significant threats to child and adolescent health, especially cyberbullying, access to very graphic pornography, and sexting. There also is no question that media, both traditional176,177 and new,95,178-181 can have very positive effects. By the end of 2013, at least 98 studies of the effects of social media on health communication and new media interventions have been performed, and many have shown positive effects.181-184 They include the following:

•

•

Dozens of new studies are documenting the potential effect of high-impact video games on physical fitness and body weight.158,185-188 New video games have also been used to augment cancer chemotherapy in children189 and to try to dissuade teens from driving drunk.190 A video-based method is now being used to improve social skills in teens with autism.191 There is increasing interest in building video games that stimulate prosocial behavior and improve attention and cognitive control.192 In addition, music videos have been used to improve resilience outcomes in adolescents undergoing stem cell transplants.193 Texting is being used to remind teens of clinic appointments and to send them educational messages about taking care of their asthma,194 preventing

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• •

•

STIs,195,196 and using condoms.197 In New York City, texting NOTNOW to 877877 connects to a teenage pregnancy “adventure game.”198 Teens in New Mexico can text their sex questions to BrdsNBz and get an answer within 24 hours from a health expert.199 Text messages could be used in an emergency department for violence prevention and depression screening.200 Social networking sites have been used successfully to increase condom use.201 A college e-mail program to alert students about the risk of disclosing sex/substance behaviors on their public profiles has been successful.138 Web-based programs have been shown to be effective in treating adolescent depression,202 increasing the rate of influenza vaccination,203 treating chronic fatigue syndrome,204 increasing tobacco cessation efforts,205 improving adherence and social coping skills in preteens with type 1 diabetes,206 treating obesity and overweight,207 improving eating behaviors in teenagers,208 increasing condom use,209,210 decreasing STIs,209 and even treating common mental disorders.211 Two Web-based interventions have been successful in delaying initiation of sexual intercourse212 and oral or anal sex.213 Teens in 7 California counties can have a pack of 10 condoms delivered confidentially by requesting them online, thanks to the Condom Access Project.214 As part of its “Staying Alive” campaign, Music Television (MTV) has developed an iPhone app that searches via GPS for the nearest place that sells condoms.215 The University of Oregon’s sex ed app is available for free through the Apple iTunes store.216

New media may have a substantially greater effect in schools than traditional media, and the main behavioral effect of new media may lie in changing the nature of learning and communication rather than affecting health-related issues.217 Clearly, more research is urgently needed on new media before substantial and accurate conclusions can be drawn.218-220 Private foundations and governments must now recognize the urgency of funding such research. With the availability of media 24/7 to most children and teenagers, the need to teach young people media literacy is greater than ever. References 1. Hancox RJ, Milne BJ, Poulton R. Association between child and adolescent television viewing and adult health: a longitudinal birth cohort study. Lancet. 2004;364:257-262 2. Sugimori H, Yoshida K, Izuno T, et al. Analysis of factors that influence body mass index from ages 3 to 6 years: a study based on the Toyama cohort study. Pediatr Int. 2004;46:302-310 3. Reilly JJ, Armstrong J, Dorosty AR, et. al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005;330:1357 4. Sigman A. Time for a view on screen time. Arch Dis Child. 2012 97:935-942 5. Strasburger VC, Jordan AB, Donnerstein E. Children, adolescents, and the media: health effects. Pediatr Clin North Am. 2012;59:533-587 6. Strasburger VC, Wilson BJ, Jordan AB. Children, Adolescents, and the Media. 3rd ed. Los Angeles, CA: Sage, 2014

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7. Powers J, Comstock G. The rumors of television’s demise have been greatly exaggerated: what the data say about the future of television content in a child’s digital world. J Mass Communic J. 2012;2:111 8. Nielsen. State of the media: consumer usage report 2012. 2013. Available at: www.nielsen.com/ content/dam/corporate/us/en/reports-downloads/2013%20Reports/Nielsen-US-ConsumerUsage-Report-2012-FINAL.pdf. Accessed December 26, 2013 9. Stelter B. Youths are watching, but less often on TV. New York Times. February 8, 2012. Available at: www.nytimes.com/2012/02/09/business/media/young-people-are-watching-but-less-often-ontv.html?pagewanted5all&_r50. Accessed December 26, 2013 10. Ybarra ML, Strasburger VC, Mitchell KJ. Relations between sexual media exposure and sexual behavior and violence victimization in a national survey of adolescents. Clin Pediatr. 2014 published online June 13, 2014. DOI: 10.1177/0009922814538700 11. Bickham DS, Blood EA, Walls CE, Shrier LA, Rich M. Characteristics of screen media use associated with higher BMI in young adults. Pediatrics. 2013;131:1-7 12. Falbe J, Rosner B, Willett WC, et al. Adiposity and different types of screen time. Pediatrics. 2013;132:e1497-e1505 13. Romer D, Bagdasarov Z, More E. Older versus newer media and the well-being of United States youth: results from a National Longitudinal Panel. J Adolesc Health. 2013;52:613-619 14. Nang EE, Salim A, Wu Y, et al. Television screen time, but not computer use and reading time, is associated with cardio-metabolic biomarkers in a multiethnic Asian population: a cross-sectional study. Int J Behav Nutr Phys Act. 2013;10:70 15. Freedman JL. Media Violence and Its Effect on Aggression: Assessing the Scientific Evidence. Toronto: University of Toronto Press; 2002 16. American Academy of Pediatrics Council on Communications and Media. Children, adolescents, and the media. Pediatrics. 2013;132:958-961 17. American Academy of Pediatrics Council on Communications and Media. Media violence. Pediatrics. 2009;124:1495-1503 18. American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, American Psychological Association, American Medical Association, American Academy of Family Physicians, American Psychiatric Association. Joint Statement on the Impact of Entertainment Violence on Children. Congressional Public Health Summit. July 26, 2000. Available at: www.aap. org/advocacy/releases/jstmtevc.htm. Accessed February 5, 2013 19. US Surgeon General’s Scientific Advisory Committee on Television and Social Behavior. Television and Growing Up: The Impact of Televised Violence: Report to the Surgeon General. Publication No. HSM 72-9090. Rockville, MD: National Institute of Mental Health, US Public Health Service; 1972 20. Pearl D, Bouthilet L, Lazar J. Television and Behavior. Ten Years of Scientific Progress and Implications for the Eighties. Rockville, MD: National Institute of Mental Health, 1982 21. O’Toole ME. The School Shooter: A Threat Assessment Perspective. Quantico, VA: Federal Bureau of Investigation, US Department of Justice; 2000 22. Federal Communications Commission. In the matter of violent television programming and its impact on children. Statement of Commissioner Deborah Taylor Tate. MB docket No. 04-261, 2007 23. Media Violence Commission, International Society for Research on Aggression. Report of the Media Violence Commission. Aggress Behav. 2012;38:335-341 24. Strasburger VC. 20 Questions about media violence and its impact on adolescents. Adolesc Med State Art Rev. 2014;25:473-488 25. Robertson LA, McAnally HM, Hancox RJ. Childhood and adolescent television viewing and antisocial behavior in early adulthood. Pediatrics. 2013;131:439-446 26. Martins N, Wilson BJ. Mean on the screen: social aggression in programs popular with children. J Communic. 2012;62:991-1009 27. Parents Television Council. Media Violence: An Examination of Violence, Graphic Violence, and Gun Violence in the Media, 2012-2013. Washington, DC: Parents Television Council, 2013 28. Bushman BJ, Jamieson PE, Weitz I, Romer D. Gun violence trends in movies. Pediatrics. 2013; 132:1-5

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178. Boyar R, Levine D, Zensius N. TECHsex: Youth Sexuality and Reproductive Health in the Digital Age. Oakland, CA: ISIS, Inc; 2011 179. Prot S, McDonald KA, Anderson CA, Gentile DA. Video games: good, bad, or other? Pediatr Clin North Am. 2012;59:647-658 180. Rideout V. Social Media, Social Life: How Teens View Their Digital Lives. San Francisco, CA: Common Sense Media; 2012 181. Guse K, Levine D, Martins S, et. al. Interventions using new digital media to improve adolescent sexual health: a systematic review. J Adolesc Health. 2012;51:535-543 182. Nguyen P, Gold J, Pedrana A, et. al. Sexual health promotion on social networking sites: a process evaluation of the FaceSpace project. J Adolesc Health. 2013;53:98-104 183. Hieftje K, Edelman J, Camenga DR, Fiellin LE. Electronic media-based health interventions promoting behavior change in youth. JAMA Pediatr. 2013;167:574-580 184. Moorhead SA, Hazlet DE, Harrison L, et al. A new dimension of health care: systematic review of the uses, benefits and limitations of social media for health communication. J Med Internet Res. 2013;15:e85 185. Mills A, Rosenberg M, Stratton G, et al. The effect of exergaming on vascular function in children. J Pediatr. 2013;163:806-810 186. Pempek TA, Calvert SL. Tipping the balance: use of advergames to promote consumption of nutritious foods and beverages by low-income African American children. Arch Pediatr Adolesc Med. 2009;163:633-637 187. Baranowski, T, Abdelsamad, D, Baranowski, J, et al. Impact of an active video game on healthy children’s physical activity. Pediatrics. 2012;129:e636-e642 188. LeBlanc AG, Chaput JP, McFarlane A, et al. Active video games and health indicators in children and youth: a systematic review. PLoS One. 2013;8:e65351 189. Beale IL, Kato PM, Marin-BowlingVM, Guthrie N, Cole SW. Improvement in cancer-related knowledge following use of a psychoeducational video game for adolescents and young adults with cancer. J Adolesc Health. 2007;41:263-270 190. News Staff. Florida county uses video game simulation to teach teens about drunk driving. December 6, 2012. Available at: www.tampastar.com/index.php/sid/211210139/scat/3951354e01311858. Accessed December 27, 2013 191. Plavnick JB, Sam AM, Hume K, Samuel L. Effects of video-based group instruction for adolescents with Autism Spectrum Disorder. Exceptional Children. September 22, 2013. Available at: www. highbeam.com/doc/1G1-342874178.html. Accessed December 22, 2013 192. Bavelier D, Davidson RJ. Games to do you good. Nature. 2013;494:425-426 193. Robb SL, Burns DS, Stegenga KA. Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant: a report from the Children’s Oncology Group. Cancer. 2014;120:909-917 194. Yun T-J, Arriaga RI. A text message a day keeps the pulmonologist away. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. 2013;1769-1778 195. Carroll JA, Kirkpatrick RL. Impact of Social Media on Adolescent Behavioral Health in California. Oakland, CA: Adolescent Health Collaborative; 2011 196. Perry RCW, Kayekjian KC, Braun RA, et al. Adolescents’ perspectives on the use of a text messaging service for preventive sexual health promotion. J Adolesc Health. 2012;51:220-225 197. Suffoletto B, Akers A, McGinnis KA, et al. A sex risk reduction text-message program for young adult females discharged from the emergency department. J Adolesc Health. 2013;53:387-393 198. Vander Veen C. NYC targets teen pregnancy with mobile phone game. Available at: www.govtech. com/health/NYC-Targets-Teen-Pregnancy-with-Mobile-Phone-Game.html. Accessed December 14, 2013 199. Karimi F. BrdsNBz: New Mexico teens can text sex questions to hotline. September 20, 2013. Available at: www.cnn.com/2013/09/20/us/new-mexico-sex-talk-text-service/. Accessed December 26, 2013

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200. Ranney ML, Choo EK, Cunningham RM, et al. Acceptability, language, and structure of text message-based behavioral interventions for high-risk adolescent females: a qualitative study. J Adolesc Health. 2014;55:33-40 201. Bull SS, Levine DK, Black SR, Schmiege SJ, Santelli J. Social media-delivered sexual health intervention: a cluster randomized controlled trial. Am J Prev Med. 2012;43:467-474 202. Merry SN, Stasiak K, Shepherd M, et al. The effectiveness of SPARX, a computerized self help intervention for adolescents seeking help for depression: randomized controlled non-inferiority trial. BMJ. 2012;344:e2598 203. Stockwell MS, Kharbanda EO, Martinez RA, et al. Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial. JAMA. 2012;307:1702-1708 204. Nijhof SL, Bleijenberg G, Uiterwaal CSPM, Kimpen JLL, van de Putte EM. Effectiveness of Internet-based cognitive behavioural treatment for adolescents with chronic fatigue syndrome (FITNET): a randomized controlled trial. Lancet. 2012;379:1412-1418 205. Gordon JS, Mahabee-Gittens M, Andrews JA, Christiansen SM, Byron DJ. A randomized clinical trial of a Web-based tobacco cessation education program. Pediatrics. 2013;131:e455-e462 206. Grey M, Whittemore, Jeon S, et al. Internet psycho-education programs improve outcomes in youth with type 1 diabetes. Diabetes Care. 2013;36:2475-2482 207. Ajie WN, Chapman-Novakofski KM. Impact of computer-mediated, obesity-related nutrition education interventions for adolescents: a systematic review. J Adolesc Health. 2014;54:631-645 208. Whittemore R, Jeon S, Grey M. An internet obesity prevention program for adolescents. J Adolesc Health. 2013;52:439-447 209. Chong A, Gonzalez-Navarro M, Karlan D, Valdivia M. Effectiveness and spillovers of online sex education: evidence from a randomized evaluation in Colombian public schools. Working paper, 2013. Available at: www.nber.org/papers/w18776. Accessed December 22, 2013 210. Markham CM, Shegog R, Leonard AD. 1CLICK: harnessing web-based training to reduce secondary transmission among HIV-positive youth. AIDS Care. 2009;21:622-631 211. Andersson G, Titov N. Advantages and limitations of Internet-based interventions for common mental disorders. World Psychiatry. 2014;13:4-11 212. Roberto AJ, Zimmerman RS, Carlyle KE, Abner EL. A computer-based approach to preventing pregnancy, STD, and HIV in rural adolescents. J Health Commun. 2007;12:53-76 213. Tortolero SR, Markham CM, Peskin MF, et al. It’s your game: keep it real: delaying sexual behavior with an effective middle school program. J Adolesc Health. 2010;46:169-179 214. Yan H. Free condoms for your 12 year-old? California health council can help. May 1, 2013. Available at: www.cnn.com/2013/05/01/health/california-free-condoms/. Accessed December 27, 2013 215. Sniderman Z. MTV app locates places to get condoms. August 9, 2011. Available at: mashable. com/2011/08/09/mtv-condom-app. Accessed February 5, 2013 216. Thompson D. Sex ed? UO’s “SexPositive” is the app for that. Portland Business Journal. October 4, 2013. Available at: www.bizjournals.com/portland/blog/health-care-inc/2013/10/sex-ed-ous-sexpositive-is-the-ap.html?page5all. Accessed December 22, 2013 217. Strasburger VC. School daze: why are teachers and schools missing the boat on media? Pediatr Clin North Am. 2012;59:705-716 218. Giedd JN. The digital revolution and adolescent brain evolution. J Adolesc Health. 2012;51:101105 219. Moreno MA, Whitehill JM. New media, old risks. Arch Pediatr Adolesc Med. 2012;166:868-869 220. Giedd JN. The digital revolution and adolescent brain evolution. J Adolesc Health. 2012;51:101105

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Social Media and Mental Health in Adolescent and Young Adult Populations Blake Wagner III, BAa; Sarah Ketchen Lipson, MEda,b; Charlotte Sandy, MAc; Daniel Eisenberg, PhDa* Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan; bCenter for the Study of Postsecondary and Higher Education, University of Michigan, Ann Arbor, Michigan; c School of Social Work, University of Michigan, Ann Arbor, Michigan

a

Introduction

Social media has forever changed how we interact with the world, and this has implications for mental health. In many ways, Facebook, Twitter, Instagram, and other social media sites have become an integral part of our individual identities. This is particularly true in adolescent and young adult populations. The penetration and reach of social media are remarkable in youth populations; a full 97% of US college students report having a social media profile.1 Consequently, it is essential for researchers, physicians, and other practitioners to understand the relationships between social media use and the mental health of young people. Mental health is one of the most important health concerns in younger populations. Nearly 1 in 3 young people has an apparent mental disorder,2 and the severity of reported symptoms seems to be steadily increasing.3 Fewer than half of affected individuals have sought treatment.4 The traditional face-to-face modalities of mental health service delivery can provide evidence-based treatment, but this method reaches only a small percentage of those in need because of factors including stigma, transportation, parental consent, and availability of providers.5 Given the high prevalence of untreated mental health problems and the expansive use of social media among adolescents and young adults, there are exciting possibilities of using social media as part of intervention strategies, particularly for the most underserved groups.

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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The purpose of this article is to provide an overview of the powerful and evolving relationship between social media and youth mental health. We review what the early literature suggests about the multifaceted role social media plays in identity development and self-esteem regulation, and how these connections provide a conceptual basis for a connection between mental health and social media. We provide a summary of the empirical research on the association between social media use on youth mental health. We include a discussion of the potential uses of social media-based interventions to address mental health. Finally, we conclude with a brief discussion of priorities for future research. Connections between Social Media Use and Mental Health: Conceptual Discussion Role of Social Media in Identity Development

There is a consensus across nearly every theoretical orientation in psychology that there is a strong and direct relationship between self-identity and propensity for developing psychopathology. Adolescence is a period marked by exploration and development of one’s identity. Identity construction occurs through the interplay between perception of self and social experiences.6,7 Until recently, perception of self was largely internalized, and social experiences were primarily limited to physical, in-person interactions. Since the advent of social networking sites (SNSs), however, the landscape for adolescent identity construction has drastically changed. Social networking sites bring a number of new possibilities for the formation of identity. First, with the aid of SNS profiles, adolescents can project their once internalized perception of self into a digital format, which can be easily accessed, evaluated, and monitored by members of their social networks. Second, SNSs enable adolescents to explore or redesign various aspects of their identity and even experiment with new identities, all through ongoing modification of their online presence, otherwise known as self-presentation.8 Together, social interaction, social comparison, and feedback (eg, a Facebook “like” or comment) from fellow SNS users help shape this process, as young people strive for social acceptance. Finally, there is a positive correlation between Facebook use and social capital, which is directly tied to well-being and can play a significant role in identity affirmation.9 Self-Presentation on SNSs

Self-presentation on SNSs can be thought of as the digital manifestation of one’s identity. Therefore, depending on how one’s self-presentation is received by the social network, it can affect mental health. Sites such as Facebook consist of various features and tools that adolescents can use to craft their self-presentation (eg, photos, status updates, lists of favorite music). Interestingly, adolescents prefer a “show-

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ing” to a “telling” approach in presenting themselves. In other words, adolescents tend to convey their self-image implicitly through photos, friend lists, and Facebook wall posts rather than explicitly through written self-summaries.8(p1824-1826) To increase the likelihood of gaining social acceptance and to satisfy fundamental ego needs, young people tailor their profiles (known as “impression management”) to influence others’ perceptions of them.10,11 For example, young people may repeatedly take “selfies” (self-taken pictures of oneself) with their smartphones until they capture an ideal portrait to upload. Before SNSs, “impression management” was largely restricted to one’s in-person corporeal image, and it was more difficult to conceal undesirable features of one’s self-image. This new ability to promote one’s ideal self-image via SNSs has important implications related to self-esteem and self-worth. Presenting a false or distorted identity might lead to higher social approval in the short run, but it is not a sustainable strategy and ultimately could exacerbate the risk of mental health problems. The art of crafting and managing one’s self-presentation can be considered a matter of trial and error. Uploaded photos, posts, and status updates, or any other shared content that attracts a subjectively satisfying amount of interest (eg, “likes” or affirming comments) among members of one’s social network can be interpreted as accepted or approved behavior, which reinforces that particular behavior. Conversely, behavior that is rejected or generates an unsatisfying amount of perceived affirmation or attention likely will cause one to revert back to a previously accepted identity state or may engender experimentation of a new identity.12 Zhao et al8(p1830-1832) found that college students who use Facebook have a tendency to present different versions of themselves, which have been categorized as “now selves” and “hoped-for possible selves.” A “now self ” represents a current version of oneself that coincides with how the individual is perceived by others in a face-to-face social context, whereas a “hoped-for possible self ” represent a self-presentation that is generally unfamiliar to others. This phenomenon of presenting multiple identities may be explained by a conscious or subconscious desire to test latent or unexplored aspects of oneself. Self-Disclosure on SNSs

According to recent studies, disclosing information (eg, status updates) to friends on SNSs can lead to increases in perceived connectedness and sense of belonging as well as decreases in perceived loneliness.13 Of course, this apparent benefit varies by audience and by individuals. Content that adolescents feel is suitable for sharing with their close-knit peer groups may be ill received by family members, teachers, and current or potential employers, which could yield unfavorable shortand long-term consequences. Thus, not surprisingly, young people have expressed concerns about privacy issues on SNSs such as Facebook.14

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Self-disclosure varies considerably across personality types. In general, extroverts tend to engage with social media more frequently and disclose more information than do introverts. Extroverts report using SNSs as a means of social extension,15,16 whereas introverts use Facebook to keep up with the lives of their friends.17 Young adults with higher degrees of neuroticism are especially likely to craft a self-presentation that exaggerates positive qualities and minimizes negative ones.18 Such individuals are preoccupied by social comparison and by the attention and approval of their peer network. Social networking sites can be unique social outlets for shy and socially anxious individuals. Ebeling-Witte et al19 found that those with high levels of social anxiety feel more comfortable expressing themselves, including sharing aspects of their lives they may have otherwise kept hidden, on SNSs compared to inperson contexts. Social Networking Sites As a Means of Regulating Self-Esteem

For the current generation of adolescents and young adults, being “liked” on Facebook, being “retweeted” on Twitter, or receiving a “heart” on Instagram is a potential indicator of social acceptance and could influence self-esteem. The mass popularity of Facebook and similar social media sites can be readily explained and understood by psychological and sociologic theory. Strong connections to social networks are predictive of a sense of purpose, belongingness, and security. All of these outcomes are associated with positive psychological states. The central tenet of the Self-Affirmation Theory is that we all share a fundamental need to perceive ourselves as valuable, worthy, successful, and good.20 Social networking sites provide a reliable mechanism by which individuals can cultivate these attributes, essentially on an “on-demand” basis. In fact, studies have shown that young adults use Facebook postings to regulate their mood states. For example, Gonzales and Hancock21 found that exploring and editing Facebook results in subjective increases in self-esteem for most young adults. Moreover, when experiencing psychological distress, Facebook users have a tendency to unconsciously turn to their Facebook profile to boost or restore their sense of self-worth.22 Rise of Narcissism and Individualism

The disturbing rise in narcissism and the decline in empathy among American youth over the past several decades are well documented.23 This trend of rising narcissism predates social media, and personality features are believed to be entrenched by age 7 years. Hypothesized causal factors include the “self-esteem movement” of the 1980s, which encouraged parents and teachers to lavish unmerited praise; the decline in playtime undirected by adults; and the increased societal pressure to perform and achieve.24

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However, there is a clear consensus that use of social media reinforces and strengthens narcissistic tendencies.25 Self-promotional behavior has been linked to narcissism; for example, a study by Winter et al11(p198-199) found a positive correlation between self-promotional behavior and narcissism among college students. For many people, an important function of Facebook and other SNSs is to seek constant attention, admiration, and affirmation of themselves and their social networks. Posting Instagram “selfies,” having one’s own YouTube channel, sharing mundane musings via Twitter, and endlessly self-promoting through Facebook no doubt reinforce an exaggerated sense of self-importance. The use of Facebook, Twitter, and Instagram is arguably centered on the promotion of beauty, talents, abilities, and extrinsic accomplishments. As a result, most Facebook profiles are not an accurate depiction of the highs and lows of life; rather, they represent a distorted and unrealistic highlight reel. As narcissistic behavior proliferates in SNSs, this behavior is increasing in social acceptability.26 Through the lens of social learning theory, this phenomenon could significantly influence the behavior of new and existing users. A study conducted by Burke et al27 examined the behavior of 140,000 new Facebook users and found that these individuals monitored and adapted their behavior based on that of friends. Several important social learning effects were observed. For example, individuals were more inclined to post idealized images of themselves to Facebook upon viewing content posted by their peers. Neira et al28 posit that as users become more engaged in SNSs, their ability to distinguish the beautified and embellished content of peers from the actual reality of this content will inevitably decrease. Connections between Social Media Use and Mental Health: Empirical Findings

The previous section described a number of pathways—including self-identify, self-promotion, self-disclosure, self-esteem, and social capital—through which social media use might influence mental health. These pathways imply both supportive and harmful effects. This section reviews empirical evidence on the association between social media use and mental health and, as expected, finds evidence of both positive and negative effects. Evidence of Positive Effects

The very foundation on which social media was developed—to enhance communication and strengthen human connection—undoubtedly has enriched human relationships. Indeed, there is growing evidence that social media may have a beneficial influence on psychological well-being.29 Valkenburg et al30 posit that Facebook users report increases in subjective ratings of self-worth. This has been attributed to the ability to exhibit oneself as “attractive, successful, and embedded in a network of meaningful relationships.”22(p325) Moreover, Malikhao and Servaes23(p72) found a positive association between the number of

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Facebook friends and user-reported levels of personal connectedness. This phenomenon is attributed to stronger perceptions of social support, which often lead to reductions in stress as well as increases in perceived well-being.31,32 Many adolescents and young adults are able to connect and find communities in which they can communicate with like-minded individuals.33 In these communities, they can often acquire resources and seek help for concerns, including mental health issues. Educators and parents have also identified how SNSs have the potential to enhance learning and creativity, which have been linked to positive health outcomes and well-being.34 In these ways, social media is beginning to exhibit its potential for improving mental health. Evidence of Negative Effects

While multiple positive effects of social media on mental health have been demonstrated, there is also plenty of evidence of negative effects. Several recent studies have found social media use to be associated with decreased subjective well-being and self-esteem, and increased psychological distress. For example, research by Kross and colleagues35 collected repeated measures of Facebook use and well-being, and found that Facebook use predicted decreased subjective satisfaction and well-being. Interestingly, interacting with other people did not predict these negative outcomes, nor were there moderating effects on factors such as gender, motivation, perceived supportiveness, or depression. Similarly, O’Dea and Campbell36 found that users of online SNSs reported significantly lower selfesteem and increases in psychological distress. There are also some studies that link suicidal ideation or depression and social media use. Research conducted by Masuda et al37 on suicidal ideation of individuals in online social networks revealed that the number of communities the individuals belonged to and the fraction of suicidal neighbors were the largest correlates of suicidal ideation. More generally, Moreno38 discussed how social media might influence norms and promote contagion of health-related behaviors such as substance use. Of course, this modeling of behavior and norms has the potential to be either harmful or helpful, depending on the behaviors and norms and how they are presented. Internet Addiction

Several studies have addressed how Internet addiction pertains to social media. Kuss and Griffiths39 hypothesize terms such as “Facebook Addiction Disorder” or “SNS Addiction Disorder,” but little research to date supports the creation of such labels. Some measures, such as the Bergen Facebook Addiction Scale and the Internet Addiction test,40,41 have been developed for the purpose of research. Rideout and colleagues42 distinguished “light,” “moderate,” and “heavy” media users: “light” users consume fewer than 3 hours of media in a day, while “moder-

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ate” users consume between 3 and 16 hours per day, and “heavy” users consume 16 or more hours of media per day. They found a relationship between media usage and discontentedness. However, Israelashvili et al43 caution against pathologizing a means of adolescent identity exploration as addiction. They emphasize that not just the quantity but also the nature of social media use matters. Cyberbullying

Cyberbullying is defined as online communication used by individuals or groups to intentionally and repeatedly engage in hostile behaviors to harm others.44 The estimated prevalence of experiencing cyberbullying varies between 6% and 42% across youth samples.44(p57) Results on the relationship between social media use and cyberbullying have been mixed. However, based on statistical analyses conducted using the 2006 Pew Internet American Life Survey, Sengupta and Chaudhuri45 found that having SNS memberships did not strongly predict online abuse or harassment for teenagers. Mental Health Interventions through Social Media Embracing Digital Culture and Related Demands of Youth

An estimated 80% of adolescents and young adults own an SNS profile, and nearly half visit and interact with SNSs daily.46,47 Interestingly, the use of social media is not bound by socioeconomic factors. A study conducted by the Pew Research Center (PRC) found that the “digital divide” (differences by income and class in use of technology) has been rapidly receding.48,49 In fact, lower socioeconomic populations are actually more likely to go online compared to higher income groups, and an estimated 79% of homeless youth access social media accounts weekly.50 Seeking and Sharing Health Information Online

The Internet is a common means of obtaining health information, with nearly 60% of the general population browsing the Web before seeking any form of in-person support.51 According to a study conducted by Horgan and Sweeny,52 68% of young people reported they would turn to the Internet if they needed mental health information. Moreover, young people in particular have shown that SNSs such as Facebook have become an increasingly popular platform for sharing and seeking health information.53 An estimated 45% to 57% of SNS users share health information with their peers.54 Several studies have demonstrated the motivation to share this type of information as “making a good impression,” “inspiring others,” or “connecting with existing friends and family around wellness activities.”47(p43-44) With the fundamental shift from fee-for-service reimbursement to eventual capitation models, there is an opportunity for the development and implementa-

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tion of public health-level social media interventions. Under such risk-based models, economic incentives are placed on wellness and prevention. Social Media Interventions: An Integrated Approach

Some of the more promising interventions have been integrated with existing social media platforms (eg, Facebook, Twitter), which significantly reduces the user burden of having to adopt and become accustomed to a new platform (eg, online support groups). Furthermore, Koff and Moreno55 found that most young people perceive the use of research and data on Facebook positively. The legal system and adolescents both consider publicly available Facebook profiles as public spaces and therefore suitable for research purposes. It is also important to note that young people prefer to communicate via SNSs rather than traditional e-mail.56 Having access to users’ profiles (ie, profiles available to the public) can inform the type of intervention to deliver as well as ways to tailor interventions to increase their relevance to the target audience.57 Despite the apparent advantages of leveraging existing relationships within one’s social network for support rather than having to develop new relationships in an unfamiliar environment, there are important drawbacks to consider with the integrated approach. First, adolescents have a propensity to accept information at face value without questioning or assessing the validity of this information. Therefore, one could make the assumption that information received from close-knit peer groups is not critically assessed and, therefore, is subject to spurious information. Second, the stigma associated with revealing or discussing personal health issues is problematic. Though some close-knit peers may be aware of one’s health issues, SNS typically are visible to a much larger social network. Examples of Integrated Social Media Interventions

Screenings Depression screenings have been conducted using Facebook with a rapid startup and very low cost.58 This ability to identify at-risk individuals has significant implications for intervention research. For example, interventions can be tailored at an individual level based on one’s profile characteristics. Wellness Activities Munson et al59 adapted an evidence-based intervention, 3GT (Three Good Things), for Facebook. 3GT allows users to share positive experiences with their social network. Interventions such as 3GT that leverage preexisting social networks have the potential to reach a limitless audience through peer-to-peer sharing across social networks.

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Facebook Pages Yager and O’Keefe60 used a different strategy of leveraging existing social media platforms by creating a Facebook page (“Teen Sexual Health Information”) to promote sexual health and wellness. This approach proved to be a viable method of disseminating information among adolescent populations. The researchers posit that similar initiatives could augment health care services or strengthen ties between adolescents and their physicians. Physician-Patient Uses In recent years, social media has emerged as a useful tool for fostering closer ties between physicians and patients. Physicians who have integrated social media in their practice have reported general improvements in health outcomes, higher rates of adherence to medication, improved communication, and increases in trust and rapport.61 Social media can also indirectly provide physicians with a better understanding of their patients through the observation of patients’ behavior that otherwise may go unreported. For example, young people who exhibit high-risk behavior or depressive symptoms may not feel comfortable disclosing these aspects of their lives in a face-to-face context. Young people, in particular, have requested instant messaging with physicians, which raises important liability issues. One way to offset this liability is to limit the messaging to 1-way messaging: from patients to physicians. Patients in return may receive an automated reply from physicians providing contact information to crisis hotlines (eg, 911, local team suicide hotlines).49(p12) Social Media Interventions: A Standalone Approach

In contrast to integrated social media interventions, standalone approaches require users to adopt and become familiar with a new social media platform. However, the standalone approach provides a few distinct advantages. First, the site is generally not accessed by the public but rather is used primarily by individuals within the special interest group (eg, youth with eating disorders). Second, the content of the site is tailored and specific to the needs of the special interest group. Thus, standalone approaches are important to consider even if it may be more difficult to attract users. Examples of Social Media Standalone Interventions

Blogging Young people are able to express themselves through SNSs by writing regularly on blogs and sharing their thoughts and feelings with friends online.62 According to a study by Baker and Moore,63 people who spend time blogging tend to have a large network of friends and report high rates of social support for psychological issues.

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Mental Health Forums and Health-Specific SNSs Two notable studies conducted needs assessments asking young people their preferences for a “new” Web-based community for individuals struggling with mental health problems. In the first study, Bradley et al64 found the following preferences of young people regarding a Web site for individuals experiencing psychological distress: usefulness, credibility, privacy, convenience, and accessibility. In the second study, Gowen and colleagues65 surveyed more than 200 young people with mental health conditions and found that they wanted a site that provided information about living independently and how to overcome social isolation. Moreover, most of the sample reported wanting a site that allowed them not only to receive support but also to provide it to others in need. ReachOut is an example of a Web site that satisfies many of the preferences of young people with mental illness. ReachOut provides resources and tools for young people suffering from mental health issues. In addition, the site includes forums for young people with similar conditions to connect and support one another. Nicholas66 found that most ReachOut users reported increased knowledge about mental health issues (83% of users) and learned more about where to access help (77% of users). Physician-Patient Q&A Forums Physician-patient interactive health networks are emerging as an increasingly popular way of obtaining trusted health information. Anyone can pose healthrelated questions and receive answers from qualified health professionals and physicians. “HealthTap” and “Sharecare” are 2 of the most widely used examples. e-Health Groups and Health Communities Another promising use of social media sites is in the development of wellnessrelated communities. There has been a rapid expansion of commercial applications, which develop online social support platforms to promote adherence for those with health conditions such as diabetes, weight-loss, and smoking cessation. The use of social media allows for widespread recruitment and the creation of an online therapeutic milieu. Members can receive support and education to assist them in the process of making health-related behavior changes.67 For example, in diabetes management, members can share recipes, ways to increase exercise, and both their challenges and successes. Similar to the findings suggesting the positive correlation between the number of Facebook friends and perceived personal connectedness, the same was observed in e-health groups. Specifically, the more friends that members had, the higher their engagement within the site.62(p181) The role social influence plays in these communities has demonstrated great promise in prodding behavior change.68

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Internet Support Groups Perhaps the most researched of the SNS interventions are online support groups, but these have often generated unfavorable outcomes. More promising Internet support groups (ISGs) have been those facilitated by a physician or trained mental health professional.69 To date, most ISGs have targeted adult and older adult populations. The “virtually anytime and anywhere group support” could be a useful and valuable model, especially for young people. Virtual Worlds Arguably the most innovative form of social media aims to augment or replace traditional in-person therapy modalities with “virtual worlds” through the use of client and therapist avatars.70 In place of face-to-face therapy, therapists and patients can meet for a session in a virtual world. Such practice has been used to overcome barriers to in-person therapy (eg, geographic barriers) as well as more targeted subgroups that have been shown to benefit from therapeutic communities, such as individuals with borderline personality disorder. Rigorous evaluation of the effectiveness of this approach is limited; however, the data that have been analyzed show similar effects to traditional in-person therapy.71 Conclusions

Research on how social media influences mental health is still in the early stages. There have been mixed results on the effect of SNSs on self-esteem and wellbeing, and further research must analyze the nature of those relationships.72 It will be important to improve our understanding of how these effects vary by gender,73,74 personality factors such as narcissism and aggressive tendencies,75 and other individual factors. There are still many underexplored topics of research. A prime example is the relationship between body image and mental health. While anecdotal evidence suggests a negative relationship between body image and social media, more research is warranted to confirm these findings.76 Social media undoubtedly will continue to have a significant effect on youth mental health, and, as a result, it can be expected that research initiatives will grow exponentially. Some of the most important areas warranting concentrated research include the possibilities of using social media as a platform for prevention. All available evidence suggests that social media will have a growing and pervasive effect on human interaction across cultures. The effects on mental health are mixed thus far; however, the potential for having a broad-scale influence on positive social norms and improved coping efficacy is undeniable. Researchers and practitioners should be encouraged by the potential to reach even the most underserved subpopulations in a cost-effective manner.

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52. Horgan A, Sweeney J. Young students’ use of the Internet for mental health information and support. J Psychiatr Ment Health Nurs. 2010;17(2):117-123 53. Vance K, Howe W, Dellavalle RP. Social Internet sites as a source of public health information. Dermatol Clin. 2009;27(2):133-136 54. Jones S, Fox S. Generations online in 2009. Pew Internet & American Life Project; 2009. Available at: www.pewinternet.org/2009/01/28/generations-online-in-2009. Accessed November 5, 2014 55. Koff RN, Moreno MA. Older adolescents’ perceptions of personal Internet use. Coll Stud J. 2013; 47(2):390-393 56. Lenhart A, Madden M, Smith A, Macgill A. Teens and social media: an overview. [PowerPoint]. Pew Internet & American Life Project. Washington, DC: Pew Research Center; 2009 57. Griffiths F, Lindenmeyer A, Powell J, Lowe P, Thorogood M. Why are health care interventions delivered over the Internet? A systematic review of the published literature. J Med Internet Res. 2006;8(2):e10 58. Youn SJ, Trinh N, Shyu I, et al. Using online social media, Facebook, in screening for major depressive disorder among college students. Int J Clin Health Psychol. 2013;13(1):74-80 59. Munson SA, Lauterbach D, Newman MW, Resnick P. Happier together: integrating a wellness application into a social network site. In: Persuasive Technology. New York, NY: Springer; 2010:2739 60. Yager AM, O’Keefe C. Adolescent use of social networking to gain sexual health information. J Nurse Pract. 2012;8(4):294-298 61. Modahl M, Tompsett L, Moorhead T. Doctors, patients & social media. Waltham, MA: Quantia MD Publication; 2011:1-14 62. Kazdin AE, Rabbitt SM. Novel models for delivering mental health services and reducing the burdens of mental illness. Clin Psychol Sci. 2013;1(2): 170-191 63. Baker JR, Moore SM. Distress, coping, and blogging: comparing new MySpace users by their intention to blog. Cyberpsychol Behav. 2008;11(1):81-85 64. Bradley KL, Robinson LM, Brannen CL. Adolescent help-seeking for psychological distress, depression, and anxiety using an Internet program. Int J Ment Health Promot. 2012;14(1):23-34 65. Gowen K, Deschaine M, Gruttadara D, Markey D. Young adults with mental health conditions and social networking websites: seeking tools to build community. Psychiatr Rehabil J. 2012;35(3):245 66. Nicholas J. The role of Internet technology and social branding in improving the mental health and wellbeing of young people. Perspect Public Health. 2010;130(2):86-90 67. Poirier J, Cobb NK. Social influence as a driver of engagement in a web-based health intervention. J Med Internet Res. 2012;14(1):e36 68. Centola D. Social media and the science of health behavior. Circulation. 2013;127(21):2135-2144 69. Griffiths KM, Calear AL, Banfield M. Systematic review on Internet support groups (ISGs) and depression (1): do ISGs reduce depressive symptoms? J Med Internet Res. 2009;11(3):e40 70. Gorini A, Gaggioli A, Vigna C, Riva G. A second life for eHealth: prospects for the use of 3-D virtual worlds in clinical psychology. J Med Internet Res. 2008;10(3):e21 71. Yuen EK, Herbert JD, Forman EM, Goetter EM, Comer R, Bradley J. Treatment of social anxiety disorder using online virtual environments in second life. Behav Ther. 2013;44(1):51-61 72. Omolayo BO, Balogun SK, Omole OC. Influence of exposure to Facebook on self-esteem. Eur Sci J. 2013;9(11):148-159 73. Pujazon-Zazik M, Park MJ. To tweet, or not to tweet: gender differences and potential positive and negative health outcomes of adolescents’ social Internet use. Am J Mens Health. 2010;4(1):77-85 74. Gross EF. Adolescent Internet use: what we expect, what teens report. J Appl Dev Psychol. 2004;25(6):633-649 75. Ko C, Yen J, Liu S, Huang C, Yen C. The associations between aggressive behaviors and Internet addiction and online activities in adolescents. J Adolesc Health. 2009;44(6):598-605 76. Meier EP, Gray J. Facebook photo activity associated with body image disturbance in adolescent girls. Cyberpsychol Behav Soc Netw. 2014;17(4):199-206

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The Role of Media on Adolescent Substance Use: Implications for Patient Visits Jason R. Kilmer, PhDa,b*; Ryan P. Kilmer, PhDc; Paul M. Grossberg, MDd a Assistant Professor, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington; bAssistant Director of Health & Wellness for Alcohol & Other Drug Education, Health and Wellness, Division of Student Life, University of Washington, Seattle, Washington; cProfessor of Psychology, Department of Psychology, Co-Director of the Community Psychology Research Laboratory, University of North Carolina at Charlotte, Charlotte, North Carolina; dClinical Professor Emeritus, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Chef: “Look, children, this is all I’m going to say about drugs…stay AWAY from them. There’s a time and a place for everything—and it’s called college. Do you understand?” Trey Parker South Park, Season 2, Episode 4 Aired May 27, 1998 More than half of high school seniors (50.4%), more than one-third of high school sophomores (38.8%), and 1 in 5 8th-graders (20.3%) report lifetime use of any illicit drug, and rates of any lifetime alcohol use are high (68.2% of 12thgraders, 52.1% of 10th-graders, and 27.8% of 8th-graders).1 Substance use by adolescents and young adults can be associated with a range of unwanted effects, including impaired academic performance, social consequences (eg, fighting and effect on friendships), automobile accidents, and increased risk for health concerns.2 In addition, youth are exposed to and engage in a tremendous amount of media, both “old” (eg, television, music) and “new” (eg, social media via the Internet).

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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Among 8- to 18-year-olds in the United States, total media use, including television, music, computer, video games, print, and movies, exceeds 7.5 hours per day (although, because of multitasking, total media exposure is 10 hours 45 minutes).3 For some, only the hours spent sleeping exceed the time associated with media exposure. With access to the Internet, and with movies, television shows, and music now readily available via smartphones (20% of media consumption occurs on mobile devices), exposure to media is more mobile than in the past.3 In addition to traditional media, access to social media sites (eg, Facebook) allows people to see messages, photos, and videos. According to 1 study, approximately 40% of boys and girls between 8 and 18 years of age visit a social networking site in a typical day. Among those children who do, the average boy spends 47 minutes per day and the average girl spends 61 minutes per day on these sites.3 Another recent report with a more narrow age range noted that about 81% of teens who use the Internet use social networking sites, and that 73% of 14- to 17-year-olds visit a social networking site at least once per day.4 These various media outlets can be the source of exposure to portrayals of alcohol and other drug use, advertisements for alcohol or tobacco, and images or messages about substance use. A full review of the risk factors faced by youth and adolescents, their alcohol and other drug use, and the role of the media is outside the scope of this article. However, we will highlight findings regarding the potential effect of media exposure on substance use by adolescents and young adults and discuss the implications and recommendations for physicians, nurses, social workers, counselors and other health professionals who treat adolescents (hereinafter referred to as clinicians). Linkages Between Media Exposure and Substance Use

The potential associations between adolescents’ media use and their risk of using alcohol and other drugs have garnered considerable attention in the professional literature for decades.5,6 More recently, Anderson and colleagues2 reviewed 13 longitudinal studies examining the relationship between media exposure related to alcohol (including television, advertisements, and movie content) and actual alcohol use among adolescents. They concluded that 12 of the 13 studies suggested that exposure to media portrayals of alcohol and commercial advertisements was associated with an increased likelihood of initiating alcohol use among abstainers and increased consumption among those already drinking at baseline. In a similar vein, Tucker and colleagues7 described a reciprocal, positive feedback loop, such that greater alcohol and other drug-related (AOD) media exposure may encourage experimentation with alcohol, which, in turn, “may encourage adolescents to seek out more AOD-related media content as a way to reinforce their emerging social identity as a drinker”.7(p. 463) Thus, in a medical setting, assessing what patients are watching, and how much time is spent exposed to media, is a worthwhile undertaking in work with those who have already reported drinking as well as abstainers.

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Gaston: “…Dismissed! Rejected! Publicly humiliated! Why, it’s more than I can bear.” Lefou: “More beer?” Gaston: “What for? Nothing helps…” (From Beauty and the Beast, Disney, released November 22, 1991) Movies certainly are influential and may contribute to impressions of the prevalence, acceptability, and function of alcohol,8 as illustrated in the quote above from a G-rated movie, in which beer is offered as a means of coping with unwanted feelings. Adolescents view an average of 1 hour of film per day, and approximately two-thirds of youth and adolescents value seeing the most current movies.9 Alcohol use was depicted in 56.6% of movies rated G or PG assessed by Dal Cin and colleagues,8 and 19.2% of the G and PG movies assessed contained at least 1 exposure to a specific alcohol brand. In an evaluation of the 90 top-grossing domestic teen films (focused on teens, a teen 12 to 17 years old as a central character, or teens in minor and major roles) from the 1980s, 1990s, and 2000s, there were 712 instances of substance use (7.91 per movie), primarily tobacco (51%) and alcohol (44%).9 Although 68 of the 90 teen-oriented movies reviewed by Callister and colleagues9 featured substance use, only 4 featured scenes in which the choice of using (or declining an offer) was explicit; of the 27 times substances were offered, they were declined 9 times. The authors suggest that not showing offers (or opportunities to decline) more frequently could communicate approval and acceptance. Evidence from the extant literature suggests that this exposure has consequences for youth. For example, a longitudinal examination of movie depictions of alcohol and its subsequent use indicated that, after accounting for multiple covariates, baseline movie alcohol exposure predicted increased adolescent alcohol use and peer alcohol use 8 months later for those classified as “ever drinkers.”10 Furthermore, Stoolmiller and colleagues11 found that movie alcohol exposure was one of several variables that predicted onset of alcohol use and progression to binge drinking, accounting for 28% and 20% of these transitions, respectively, after controlling for covariates. “Teen drinking is very bad… Yo, I got a fake ID, though.” J-Kwon Tipsy, Hood Hop, 2003 (Peak position #2 on Billboard Hot 100) Substance use references in popular music and in music videos are significant, with prevalence varying by music genre. An evaluation, by Primack and colleagues, of the 279 most popular songs of 2005 showed that 93 (one-third) contained explicit substance use references.12 They concluded that with 15- to 18-year-olds exposed to an average of 2.4 hours of music per day, the average ado-

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lescent is exposed to 591 explicit substance use references per week. These references vary by genre, with references to alcohol most common in rap music (53% of songs) and country music (33% of songs), and references to marijuana most common in rap songs (53% referred to marijuana use). In a review of music videos played on television in New Zealand, Sloane and colleagues13 demonstrated that among 93 videos portraying alcohol, only 2 had a negative tone toward alcohol. Alcohol was shown more often in hip hop (30.5% of all such videos) and rhythm and blues (30.4%) videos than in pop (18.1%) or rock (11.0%) videos. These issues apply to youths’ use of “new” media as well. On the Internet, youth can encounter a diverse range of substance use images and content intended for consumers older than 21 years. For example, in a study involving Facebook, 6 of the pages for 12 popular brands of alcohol could be accessed by those younger than 21 years, and some applications accessible by minors provided the chance to send “virtual shots” of alcohol to Facebook friends.14 Approximately 93% to 95% of teens use the Internet, on which youth can view videos portraying substance use, often without restriction to content.4,15 For example, in a study examining videos portraying smokeless tobacco (or “dip”), 13% of videos were posted by underage youth, and none of the videos had age restrictions for viewing.16 Moreover, social media use (ie, online social networking, reading or writing blogs, photo or video sharing, maintaining a personal webpage, or creating other digital media) “is central to many teenagers’ lives.”15(p.v) Furthermore, social media sites can include multiple representations of substance use content. For instance, research indicates that youth readily post information about their health risk behavior on social media, modeling such actions for a wide audience or promoting a nonoptimal social norm.17 As a case in point, analysis of the MySpace profiles for 500 18-year-olds found that 41% of them referenced substance use in their posts.17 Although MySpace has been replaced by Facebook, Instagram, Pinterest, and other sites in recent years, the substantive finding still holds meaning (ie, that many adolescents freely reference the use of alcohol or other drugs on social networking sites). Adolescents report that they interpret such references as reflecting actual use and that, in many instances, the postings may have been motivated by an attempt to “look cool” or be accepted by peers.18(p422) Individual Differences and the Need to Attend to Context

Evaluating the potential influence of various forms of media on youth demands attention to individual development, personal characteristics and resources, and the surrounding environmental contexts. Any outcome is multiply determined, and, as such, focusing on the influence of a given factor, condition, or influence can limit understanding of an issue and its development as well as the effect and reach of interventions. In fact, research indicates that factors in youths’ environ-

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ments tend to cluster together to support healthy trajectories or problems in adjustment.19 Thus, while the present article focuses on the role of media, it is important to account for variations across youth and their ecologies. For instance, any given media message will not have the same influence across individuals.20 Developmental considerations are key, in light of differences in cognitive and affective capacities and resources across varying ages, and individual differences in characteristics such as self-control and regulation also influence the effect of mass media (eg, advertising, movie exposure) on substance use among youth.21 Other individual attributes and resources, found more generally to be associated with positive adjustment outcomes (eg, positive mental health functioning, school performance, peer relationships, behavioral competence and control, etc), also may be of relevance, such as good intellectual functioning, positive self-system views (eg, positive self-worth, strong selfefficacy, perceived competence, positive future expectations), realistic control attributions, and the like.22-26 Contextual factors influence, interact with, and are affected by individual characteristics, qualities, and resources. In fact, when considering individual development, adjustment, or adaptation, youths’ broader social contexts are also of critical importance, with influences across family (parents, siblings), peers, neighborhood, community, and cultural factors. Connections to competent, supportive, caring adults are well-established correlates of positive adaptation,24,26 and parents are a core proximal influence on youths’ lives. In turn, multiple qualities of the parent-child relationship (warmth, nurturance, responsiveness, conflict) and caregiving behaviors (eg, specific parenting practices, discipline approach, parental monitoring) contribute to youths’ adjustment trajectories.25,27 The role of parenting on the effect of media exposure on adolescent substance use has been examined in multiple studies. Specifically, parental restrictions on movies have been associated with lower risk of drinking (or problematic alcohol use).28,29 Furthermore, Dalton and colleagues30 showed that parental rules and monitoring of their children’s movie viewing were associated with a lower risk of adolescent drinking. Relative to those who were allowed to watch R-rated movies without a parent, children whose parents prohibited them from watching R-rated movies were significantly less likely to be at risk for smoking or drinking, even after accounting for a range of factors, including friend and parent smoking or drinking, and parental monitoring of non–media-related behavior. Beyond rules and monitoring, the very presence of parents or other family members has the potential to affect youths’ exposure to media representations of substance use and its subsequent influence. Using an ecologic momentary assessment to capture real-time exposure of youth (mean age 12.8 years, standard deviation 1.6) to alcohol- and smoking-related media (including portrayals

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on television or in movies as well as advertisements in print or in stores), Scharf and colleagues31 suggested that alcohol-related media exposures were twice as common as exposures to smoking. For alcohol, almost half (44%) occurred at the point of sale (eg, outside a store or gas station, on a window of a store or gas station, etc), 15% occurred on billboards, and 22% occurred on television. Of note, 69% of alcohol-related media exposures and 56% of smoking-related exposures occurred in the presence of family. The authors concluded that, particularly with younger children, the presence of family could “buffer” the effect of exposure. Parents are powerful influences on teens as well, even though peer influence, support, and connections grow in salience in adolescence. Peers play a role in adolescent drinking or other substance use11 and also seem to mediate the effect of media exposure on alcohol or other substance use.20,32 For example, a longitudinal investigation found that higher levels of movie exposure to alcohol was associated with increased drinking among participants’ peers, which related to participants’ willingness to drink and later increases in alcohol use.32 Implications for Clinicians

There are several implications for adolescent medicine clinicians. For instance, the American Academy of Pediatrics (AAP) policy statements on media education include suggestions for clinical practice, such as recommendation that pediatricians serve as role models for appropriate media by limiting television and video use in waiting rooms and using materials to promote reading.33,34 The AAP recommends that clinicians provide advice to parents about media exposure, including coviewing and discussing content with their children, teaching critical viewing skills, emphasizing alternative activities, limiting total entertainment screen time to less than 1 to 2 hours per day, avoiding use of media “as an electronic babysitter,” and discouraging screen media exposure to children younger than 2 years. These are important and relevant recommendations, although dramatic changes in smartphone and other media access and exposures pose significant new challenges in updating and implementing these recommendations. The point should not be lost, however; it is critical for clinicians to talk with their patients and their caregivers. As is the case with many health issues, how that conversation is conducted matters greatly. Media As “Conversation Catalyst”

Addressing the ever-present media influences on adolescent substance use and sexual behaviors often seems overwhelming to both parents and clinicians, who may be less facile with media platforms and social networking than teens. It is crucial in such discussions to go beyond abstractions and to address specific strategies. As noted in a different context, “academic researchers, agencies and organizations, and even those in the media regularly highlight the need to ‘talk to your children.’”35(p418) However, well-intentioned professional advice for parents to “talk to your children” as well as for clinicians to “talk to your patients” is

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inadequate and unlikely to produce effective conversations about behavior change without attention to skills and practice. Promising research has shown that straightforward parent interventions with their high school seniors (via a parent training handbook or Web-based resources) can result in reduced drinking in the first year of college.36-38 In these efforts, effectiveness improved with increased parental monitoring, and parentteen communications improved with specific attributes (eg, empathy, staying calm, and being clear, understandable, trustworthy, and available). These skills are teachable, broadly applicable, and appreciated by parents and adolescents alike. Fortunately, in the often-dreaded, awkward discussions about “sex, drugs, and rock ‘n’ roll,” conversations with a child about the “rock ‘n’ roll” part (and other forms of media) usually are easier to initiate. In fact, talking about media in a way that promotes media literacy can naturally lead into talking about influences and teen perspectives on alcohol, drugs, and sexuality in a more meaningful way for parents as well as clinicians. Asking adolescent patients what they are listening to (eg, “What kind of music do you like listening to?”) often helps set the stage for assessing patients’ media literacy. Follow-ups inquiring what teens think of the messages in popular songs and videos can facilitate a positive conversation about risks and values and ways to stay safe. It is critical to underscore that tangible guidance is necessary for many parents, and resources are abundant, including materials on the AAP parenting Web site HealthyChildren.org and other online and print resources (Table 1). Clinicians can refer parents to these readily available resources as well as offer additional recommendations on the basis of their knowledge of the youth patient. In the clinic, the clinician can also briefly discuss these professional guidelines with parents and adolescents, which can help facilitate the follow-up conversations that will occur in private between the clinician and patient and, hopefully, at home later between the parent and teenager. Most importantly, these recommendations and resources will be optimally effective when clinicians integrate them into comprehensive health care discussions grounded in their knowledge of the adolescent patient’s history and personal attributes. Examples of prompts using these AAP guidelines include the following: “…more than half the programs on television contain sex scenes or references to sex, yet the major television networks generally refuse to air commercials for condoms and other birth control products…Why do you think that is?” “What do you plan to do to stay healthy and safe?”

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Table 1 Resources for Parents American Academy of Pediatrics. Talking to kids and teens about social media and sexting. Available at: www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/ Talking-to-Kids-and-Teens-About-Social-Media-and-Sexting.aspx. Accessed August 11, 2014 American Academy of Pediatrics. Points to make with your teen about media. Available at: www. healthychildren.org/English/family-life/Media/Pages/Points-to-Make-With-Your-Teen-AboutMedia.aspx. Accessed August 11, 2014 American Academy of Pediatrics. How to make a family media use plan. Available at: www. healthychildren.org/English/family-life/Media/Pages/How-to-Make-a-Family-Media-Use-Plan. aspx. Accessed August 11, 2014 Johannson M. Talking to kids about social media and other online activities. Social Media Today. Available at: www.socialmediatoday.com/content/talking-kids-about-social-media-and-otheronline-activities. Accessed August 11, 2014 National Institute on Alcohol Abuse and Alcoholism. Make a Difference: Talk To Your Children About Alcohol. NIH Publication 13-4314. 2009. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Available at: pubs.niaaa.nih.gov/publications/MakeADiff_HTML/makediff.htm. Accessed August 11, 2014

“Tobacco and alcohol companies insist that they’re not trying to target minors, yet the brands of cigarettes most popular with teens just happen to be the brands that advertise most heavily in magazines read by teens, and teens list ads for alcohol among their favorite commercials…What do you think about that?” Moreover, some research supports parental movie restrictions, and a growing body of work points to the need for clinicians to emphasize parental management of media use and exposure.11 Although the current literature does not include a research-grounded program to guide parents regarding facilitating their children’s media use,20 physicians, nurses, social workers, and others can provide psychoeducation to support caregivers in talking with their children, including specific, concrete examples of what and how to ask. It is apparent that health care professionals also benefit from clear, tangible guidance. Multiple studies have revealed inherent clinician discomfort, lack of skills, and hesitancy in conversing with patients about substance use.39-42 A robust body of medical literature continues to support the effectiveness of motivational interviewing (MI) in helping patients change behavior and can help enhance the effect of these conversations.43-46 While the spirit and methods of MI are straightforward, implementation is not easy. Clinician skills in MI require practice, feedback, and attentiveness to the clinician’s own behavior in talking with patients (ie, a less directive and more guiding approach, with fewer “you need to…” statements and more “what do you think about?” prompts, with the goal of the patient voicing the need and plan to make a change).

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There are multiple avenues for clinicians to learn and refine MI skills, ranging from books and articles,47-52 to local and national workshops, classes, and online training (www.motivationalinterview.org), to virtual reality simulations,53 with the keys being experiential learning and attention to patient feedback. Similar to parents noting their teen’s “eye roll,” we strongly recommend that clinicians closely observe their patients’ nonverbal cues (eg, looking down, being less engaged) and verbal defensiveness or resistance. In discussing motivational interviewing, it is often pointed out that “readiness to change is not a patient trait but a fluctuating product of interpersonal interaction.54(p70) This clinical conversational “dance” takes practice and a willingness to engage patients in behavioral discussions differently from the customary, cliniciandirected approach to diagnosis and treatment. Clinicians are expected to be experts at the latter, but patients are their own behavioral “experts” and in control of what they do. A teenager left feeling that the clinic visit was more like “wrestling” than “dancing” about his or her behaviors is much more likely to continue the status quo and avoid behavior change. Motivational interviewing puts the onus of behavior change on the patient and helps clinicians create more effective and satisfying conversations with patients about managing behaviors. Furthermore, discussing sensitive health topics with youth during primary care visits has been independently associated with youth taking more active roles in their treatment and having more positive perceptions of their clinicians.55 Regardless of one’s specific approach, it is clear that alcohol screening and brief intervention are essential, given that 1 in 3 children starts drinking by the end of 8th grade and that, of these, half report having been drunk.56 Evidence-based recommendations57 from the National Institute on Alcohol Abuse and Alcoholism58 are to ask 2 age-specific screening questions (about friends’ and patient’s drinking). For ages 9 to 14 years, it can be fruitful to start with the less-threatening friends question58(p8) “Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year?” Followed by: “How about you?” For high school ages 14 to 18 years, ask the patient question first: “In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?”

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Followed by: “If your friends drink, how many drinks do they usually drink on an occasion?”58(p8) In addition, the AAP online course, “Media: Wired Kids and Your Practice” (pedialink.aap.org) provides in-depth guidance to better assess and counsel families about media use for infants, children, and adolescents. Clinicians can also collect data from parents to get a sense of child exposure to and involvement in media. In fact, the AAP has updated a caregiver-completed media history form (offered separately from their policy statement on media exposure; see: www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Documents/ MediaHistoryForm.pdf) for more detailed screening in clinical practice. In summary, media is a critical “conversation catalyst” providing parents and clinicians an important platform from which to jump into the “adolescent abyss” of risky behaviors and guide appropriate and healthy development. How clinicians talk with teenagers about behaviors is much more important than the actual content, and the time needed for effective conversations is usually less than a few minutes, mitigating the most often cited barrier to addressing these issues in clinic. The clinician-patient relationship provides a powerful opportunity to influence patient behaviors positively. Prevention and Interventions Utilizing Media

While this article has largely framed the risks associated with media messages about and portrayals of alcohol and other drugs, the ubiquitous nature of smartphones and related mobile devices provides an opportunity: media can also be used to engage in prevention work. Several studies have demonstrated significant reductions in drinking and its consequences among college students after Web-based or computer-delivered personalized feedback interventions,59 and subsequent research could explore possible adaptations for younger targets in addition to assessing the degree to which similar success can be achieved with this younger age group. With the option of using smartphones as a specific delivery mechanism, individual physicians, nurses, or social workers, or clinics more broadly, can attempt text message-based interventions, with the goal of reducing health risk behaviors and increasing the likelihood of healthy choices. Text message–based educational or intervention programs have been the focus of burgeoning attention in recent years, with applications targeting treatment adherence, healthy eating (or reductions in disordered eating), sexual health and risk behavior, and the like.60,61 Such approaches seem to have some potential for reducing problem

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drinking in emerging adults (largely aged 15-20 years62). A benefit of using text messages in this manner is that the specific message(s) sent can be generalized to an age band of youth or tailored to individuals on the basis of screening or other information. That said, additional research is needed to examine the effectiveness and effect of these efforts, and to address challenges to “real-world” applications of such efforts. In addition to using media for pro-social goals, pediatricians, nurses, and social workers can assess for or make recommendations to foster assets and resources that promote healthy adaptation and protect against risks for substance use among adolescents. Although in-depth assessment of these protective qualities and factors falls outside the purview of most adolescent medicine practices (eg, positive affect, self-esteem, internal locus of control; see Fergus and Zimmerman22 for a detailed discussion), clinicians can readily incorporate some basic recommendations into clinic visits. Moreover, because of the nature of their role and their relationships with patients and their caregivers, these recommendations can carry particular weight. Thus, for example, because youth participation in extracurricular or community activities seems to reduce the negative influence of peer substance use, clinicians can encourage involvement with pro-social organizations or activities (eg, school sports, YMCA/YWCA, scouts, faith-based youth group).22,25 Given the salience of parental monitoring, open youth-parent communication, and parental-enforced structure and rules around media use, with studies suggesting that they help reduce the negative effects of media exposure or peer substance use,11,22,30 adolescent clinicians can also support parents and reinforce their communication and monitoring efforts in discussions with youth patients and caregivers. “Video killed the radio star…” The Buggles Video Killed the Radio Star, 1979 This lyric, from the first video aired on MTV on August 1, 1981, suggests the “passing of the baton” from one popular form of media to another. In the last decade, we have seen forms of media and access to media change significantly, and it is challenging to foresee what types of media will most influence youth in the years to come. Over the years, a constant has been the strong and respected roles of parents and clinicians whose influences can continue to affect the health of youth and adolescents in positive ways. The overarching goal of encouraging media literacy and critical thinking in adolescents and young adults will hopefully prevail as the media landscape shifts in ways we cannot predict. Future research can expand on the scientific literature examining parent-delivered interventions to target a range of health behaviors. More research is needed to examine the effect of brief, motivational-enhancement interventions on reducing the use and influence of media on adolescents.

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21. Wills TA, Gibbons FX, Sargent JD, et al. Good self-control moderates the effect of mass media on adolescent tobacco use and alcohol use: test with studies of children and adolescents. Health Psychol. 2010;29(5):539-549 22. Fergus S, Zimmerman MA. Adolescent resilience: a framework for understanding healthy development in the face of risk. Annu Rev Public Health. 2005;26:399-419 23. Luthar SS, ed. Resilience and Vulnerability: Adaptation in the Context of Childhood Adversities. New York: Cambridge University Press; 2003 24. Masten AS. Ordinary magic: resilience processes in development. Am Psychol. 2001;56(3):227-238 25. Masten AS, Coatsworth JD. The development of competence in favorable and unfavorable environments. Am Psychol. 1998;53(2):205-220 26. Wyman P, Sandler IN, Wolchik S, Nelson K. Resilience as cumulative competence promotion and stress protection: theory and intervention. In: Cicchetti D, Rappaport J, Sandler I, Weissberg R, eds. The Promotion of Wellness in Children and Adolescents. Thousand Oaks, CA: Sage; 2000;133189 27. Cleveland MJ, Reavy R, Mallett KA, Turrisi R, White HR. Moderating effects of positive parenting and maternal alcohol use on emerging adults’ alcohol use: does living at home matter? Addict Behav. 2014;39(5):869-878 28. Dalton MA, Ahrens MB, Sargent JD, et al. Relation between parental restrictions on movies and adolescent use of tobacco and alcohol. Eff Clin Pract. 2002;5(1):1-10 29. Hanewinkel R, Morgenstern M, Tanski SE, Sargent JD. Longitudinal study of parental movie restriction on teen smoking and drinking in Germany. Addiction. 2008;103(10):1722-1730 30. Dalton MA, Adachi-Mejia AM, Longacre MR, et al. Parental rules and monitoring of children’s movie viewing associated with children’s risk for smoking and drinking. Pediatrics. 2006;118(5):1932-1942 31. Scharf DM, Martino SC, Setodji CM, Staplefoot BL, Shadel WG. Middle and high school students’ exposure to alcohol- and smoking-related media: a pilot study using ecological momentary assessment. Psychol Addict Behav. 2013;27(4):1201-1206 32. Dal Cin S, Worth KA, Gerrard M, et al. Watching and drinking: expectancies, prototypes, and peer affiliations mediate the effect of exposure to alcohol use in movies on adolescent drinking. Health Psychol. 2009;28(4):473-483 33. American Academy of Pediatrics Council on Communications and Media. Media education. Pediatrics. 2010;126(5):1012-1017 34. American Academy of Pediatrics Council on Communications and Media. Children, adolescents and the media. Pediatrics. 2013;132(5):958-961 35. Gil-Rivas V, Kilmer RP. Children’s adjustment following Hurricane Katrina: the role of primary caregivers. Am J Orthopsychiatry. 2013;83(2):413-421 36. Donovan E, Wood M, Frayjo K, Black RA, Surette DA. A randomized, controlled trial to test the efficacy of an online parent-based intervention for reducing the risks associated with collegestudent alcohol use. Addict Behav. 2012;37(1):25-35 37. Doumas DM, Turrisi R, Ray AE, Esp SM, Curtis-Schaeffer AK. A randomized trial evaluating a parent based intervention to reduce college drinking. J Subst Abuse Treat. 2013;45(1):31-37 38. Turrisi R, Ray AE. Sustained parenting and college drinking in first year students. Dev Psychobiol. 2010;52(3):286-294 39. Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ. 2002;325(7369):870 40. Bradley KA, Epler AJ, Bush KR, et al. Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking. J Gen Intern Med. 2002;17(5):315-326 41. D’Amico EJ, Paddock SM, Burnam A, Kung FY. Identification of and guidance for problem drinking by general medical providers: results from a national survey. Med Care. 2005;43(3):229-236 42. McCormick KA, Cochran NE, Back AL, et al. How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med. 2006;21(9):966-972

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43. Jensen CD, Cushing CC, Aylward BS, et al. Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. J Consult Clin Psychol. 2011;79(4):433-440 44. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press; 2013 45. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-312 46. Wachtel T, Standiford M. The effectiveness of brief interventions in the setting in reducing alcohol misuse and binge drinking in adolescents: a critical review of the literature. J Clin Nurs. 2010; 19(5-6):605-620 47. Barnes AJ, Gold MA. Promoting healthy behaviors in pediatrics: motivational interviewing. Pediatr Rev. 2012;33(9):e57-68 48. Grossberg P, Halperin A, MacKenzie S, et al. Inside the physician’s black bag: critical ingredients of brief alcohol interventions. Subst Abus. 2010;31(4):240-250 49. Naar-King S, Suarez M. Motivational Interviewing with Adolescents and Young Adults. New York: Guilford Press; 2011 50. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press; 2008 51. Tellerman K. Catalyst for change: motivational interviewing can help parents to help their kids: part 1. Contemp Pediatr. 2010;27(12):26-38 52. Tellerman K. Catalyst for change: motivational interviewing can help parents to help their kids: part 2. Contemp Pediatr. 2011;28(1):47-54 53. Fleming M, Olsen D, Stathes H, et al. Virtual reality skills training for health care professionals in alcohol screening and brief Intervention. J Am Board Fam Med. 2009;22(4):387-398 54. Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. Am J Prev Med. 2001;20(1):68-74. 55. Brown JD, Wissow LS. Discussion of sensitive health topics with youth during primary care visits: relationship to youth perceptions of care. J Adolesc Health. 2009;44(1):48-54 56. Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future National Results on Drug Use: Overview of Key Findings, 2010. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2011 57. Brown SA, Donovan JE, McGue MK, et al. Youth alcohol screening workgroup II: determining optimal secondary screening questions. Alcohol Clin Exp Res. 2010;34(Suppl s2):267A 58. National Institute on Alcohol Abuse and Alcoholism. Alcohol screening and brief intervention for youth: a practitioner’s guide. 2011. Available at: www.niaaa.nih.gov/YouthGuide. Accessed June 13, 2014 59. Cronce JM, Bittinger, JN, Liu J, Kilmer JR. Electronic feedback in college student drinking prevention and intervention. Alcohol Res. In press 60. Preston KE, Walhart TA, O’Sullivan AL. Prompting healthy behavior via text messaging in adolescents and young adults. Am J Lifestyle Med. 2011;5(3):247-252 61. Selkie EM, Benson M, Moreno M. Adolescents’ views regarding uses of social networking websites and text messaging for adolescent sexual health education. Am J Health Educ. 2011;42(4):205-212 62. Haug S, Schaub MP, Venzin V, et al. A pre-post study on the appropriateness and effectiveness of a web-and text messaging-based intervention to reduce problem drinking in emerging adults. J Med Internet Res. 2013;15(9):e196

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Adolescent Health and the Electronic Health Record: Can It Be a Social Media Tool for Quality Adolescent Care? Lindsay A. Thompson, MD, MSa,b*; Maureen Novak, MDa; Anzeela M. Schentrup, PharmD, PhDc a Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida; Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida; c Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida

b

The Electronic Health Record: A Key to Adolescent Health

The past decade marks a rapid paradigm shift in the way people communicate; consequently, the online world is here to stay. This shift affects every type of human interaction, including those between patients and their healthcare providers. As described in other articles in this issue, all of us, from adolescents to physicians, are continuously bombarded with new apps and online platforms and tools. While there are conflicting and sometimes contentious reports on the effects of social media on children, it nonetheless seems logical, even imperative, to capitalize on the power of social media and to maximize its possible benefits to adolescents (akin to Sesame Street for preschooler television viewing).1 Shouldn’t the widespread use, fascination with, and interactive qualities of social media be harnessed for positive use in adolescent health care? This article predicts how current and future use of the electronic health record (EHR) may offer, if implemented well, the chance to harness the benefits of social media-like communication for the health care of children, specifically adolescents. We will draw on the current landscape of medical care and health

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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care reform and include discussions of EHRs, new policies such as the Health Information Portability and Accountability Act (HIPAA) and the “Meaningful Use” incentives, and specifically relate them to issues in adolescent health and health care. Since it is unknown how these new policies and technologies affect adolescents, we will address the question of whether they augment or antagonize the quality of adolescent health care. Can we draw on some known adolescent behaviors (such as heavy usage of online resources and social networking) to our advantage? This article will summarize the intersection of the EHR with adolescent health by highlighting that EHRs, specifically newly available patient portals, can and likely will be a social media (of sorts) for personal medical records. We will discuss 3 specific themes: the key issues for quality adolescent health care, with specific attention to issues of confidentiality and age; the opportunities and challenges that EHRs offer, with an explanation of the legal and functional boundaries of the current EHR systems; and examples of how health care systems are implementing adolescent EHR services, including after-visit sheets and adolescent health portals. Adolescent Health and Goals

Because of extensive physical and psychosocial changes and challenges, adolescents face significant health consequences that are vastly different than those of younger children and older adults. As the goals of Healthy People 2020 articulate, we aim to improve the healthy development, physical health, safety, and well-being of adolescents and young adults.2 Table 1 highlights the Healthy People 2020 objectives that are centered on critical outcomes for the health of individual adolescents and affect nationally adolescents and young adults.2 Given that most of the leading causes of morbidity and mortality in this age group are preventable, access to quality care that includes prevention, screening, and counseling holds a key role in assisting adolescents as they transition to adulthood. Effective use of an EHR could augment delivery of care to this population. As Table 1 suggests, many of these indicators of Healthy People 2020 could be substantially improved with effective use of EHRs. Given the lack of significant improvements in recent history of any of these vital objectives, it is imperative that creative use of the EHR be addressed as a source of untapped potential. Consider how today’s national health concerns such as obesity, substance use, and the morbidity associated with these modifiable behaviors affect the adolescent population. Adolescents have developmentally appropriate behaviors that can affect their health. Specifically, normative experimentation and increasing autonomy can have negative health consequences if associated with maladaptive responses, or lack of community, family, or economic support. Health care needs are affected by foster care, homelessness, substance use, incarceration, and issues surrounding sexuality. These needs are prone to challenges that are complicated by an individual adolescent’s developmental stage, evolving autonomy, and community resources including access to appropriate health care. Messages contained within an EHR can both

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Table 1 Healthy People 2020 Adolescent Objectives: Outcomes of Electronic Health Record Implementation Objective

Outcome

Increase the proportion of adolescents who have Tracking of well visits would allow physicians to undergone a wellness checkup in the past target adolescents who are in need of care 12 months Increase the proportion of adolescents who Identifying adolescents with poor community connectiveness allows for systematic participate in extracurricular or out-of-school interventions activities Identify at-risk adolescents needing enhanced Increase the proportion of adolescents who are adult involvement through either community connected to a parent or other positive adult agencies or counseling caregiver Identify those adolescents in foster care because Increase the proportion of adolescents and many have specific health care needs young adults who transition to self-sufficiency from foster care Increase educational achievement of adolescents Tracking of educational achievement highlights and young adults strengths and needs, allowing for specific health care–related interventions (eg, testing for learning disabilities, attention-deficit/hyperactivity disorder) Identify at-risk adolescents for further screening Reduce the proportion of adolescents who have assessment and treatment been offered, sold, or given an illegal drug on school property Identification of sexual orientation or gender Increase the proportion of middle and high identity allows for specific targeted health care schools that prohibit harassment based on a interventions student’s sexual orientation or gender identity Derived from Healthy People 2020. Available at: www.healthypeople.gov/2020/topics-objectives/ topic/Adolescent-Health/objectives. Accessed November 6, 2014.

inform and serve as a link or a virtual medical home for these difficult-to-reach populations during times that may be difficult for adolescents. Despite this potential, adolescence is not just an awkward time of life; adolescents have specific health care needs that are not easily met by the current health care system. These models typically are centered on the needs of younger children, with parental consent for services and interventions with a familycentered approach, or they are adult-centric, with the individual being solely responsible for his or her own health care decisions. Adolescent health does not easily fit into either model as adolescents navigate toward adulthood. Although adolescent specialists who specifically work within the context of the developing adult exist, most adolescents do not benefit from that expertise because of their small numbers. All health care providers of adolescents and young adults, including pediatricians, family practitioners, nurse practitioners and physician assistants, should provide comprehensive, high-quality care that acknowledges the adolescent’s growing autonomy and meets the specific needs of each adolescent while bridging the family’s needs. Important domains that affect the deliv-

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ery of health care to adolescents include accessibility to care; economics of health care, including health insurance; developmentally appropriate services for the increasingly ethnically diverse adolescent population; coordinated delivery of care; and application of appropriate communication skills to work with this age group, including confidentiality and identification of those individuals at higher risk who require more in-depth support. The EHR can potentially, if designed with adolescents in mind, facilitate all of these challenges. Key Issues for Providing Adolescent Care: Age and Confidentiality in the Era of the EHR

Age and confidentiality are issues that must be addressed within any system that provides care to adolescents and young adults, including the newest and current demands of the EHR. Treating adolescents younger than 18 years proves difficult when balancing the demands of confidentiality with the need to provide comprehensive care because they are still considered minors. For those younger than 18 years, there are national, state, and institutional norms for when adolescents at certain ages are presumed to be able to make health care decisions.3 Currently, the younger age limit for adolescence is considered to be 10 years, with the upper limit being 25 years for survey and research purposes. In this article, we will use the span from 12 to 18 years since 18 is the legal age for consent, although we do recognize that adolescence and young adulthood functionally blend for many individuals into their mid-twenties. In addition, choosing 12 as the lower limit is complex and potentially arbitrary because the variation in independence and dependence is large and is particularly important when thinking about legality and functionality for adolescent care. Since age is only a proxy for developmental maturity, there are no absolute guidelines or tests that can be used, although other countries have tried to approximate this.4 As Bourgeois et al3 detail in their 2008 article, many use age 13 as the age at which children can also have access to their online information, except when sensitive parent or child data require additional confidentiality concerns (see next paragraph). However, an online search of adolescent access to EHRs reveals that children’s hospitals and other institutions that care for adolescents use varied approaches. For example, some institutions use age 14 or 15, others carve out special circumstances for ages 12 to 15, and others avoid the controversial situation completely. We believe that starting the process around age 12 and providing gradual experiences interfacing with the EHR will allow adolescents a familiarity with online access to health and health care professionals during, or ideally before, the time they need confidential access. In addition to complexities surrounding age, confidentially issues in adolescence are numerous and emotionally charged, requiring attention when implementing an EHR. Specific concerns are reproductive health (contraception, sexually transmitted infections [STIs], and sexuality), substance use, and mental health.3,5 Yet, at the same time that institutions are asked to protect this information, families are encouraged to assist their adolescents in developing autonomy and pro-

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vide guidance in decision-making, precisely in these sensitive and important areas. Key features of confidentiality for adolescents vary from state to state, such as the age of consent (see previous paragraph), emancipation, and what is defined as confidential and what is not. Respecting the confidentiality of the adolescent is a developmental step, and without clear policies, lack of confidentiality can be a barrier to care. The HIPAA and related legislation have not, to date, addressed the specific needs of the adolescent population. Yet these confidentiality issues must be articulated for successful integration of the EHR in adolescent health. The Intersection between Adolescents, Online Health, and Online Health Care Adolescent Health-Seeking Behaviors Online

Returning to the online world, it is well documented that the Internet and social media are pervasive and powerful sources of information for adolescent and young adults. It is not surprising that they use the Internet to obtain health information. Topics that adolescents are interested in are easily explored on the Internet, especially those that they find hard to openly discuss with parents and guardians. Adolescents can easily access the Internet, and it is perceived as a confidential, private, and less threatening means to obtain information. Interactive sites allow adolescents to provide specific data and then receive personalized results. The Internet can be an important adjunct to in-person professional health guidance. As of 2010, Internet access was nearly universal for adolescents and young adults, and up to 80% of young adults use the Internet wirelessly.6 Studies from more than a decade ago found that adolescents most often accessed sites with information about STIs, nutrition, exercise, and sexuality.7 This access has only increased over time, with adolescents competently and comfortably using the Internet and social media for information about a variety of health topics. They see the Internet as a safe, confidential place to access information about sensitive health topics such as substance use, sexuality, and mental health. Girls are more likely to access sensitive topics than boys (23% vs 11%).6 As a group, adolescents appreciate the ease of access, the privacy, and the value of the information. However, the quality and quantity of the online information are a concern. Despite comfort with the Internet, adolescents do not utilize formal search strategies, tending to use haphazard methods. For example, when searching for confidential human immunodeficiency virus (HIV) testing, adolescents typed “HIV,” which is too broad for the desired information.8 Adolescents and young adults, like older Internet users, tend to scan Web pages. This causes them to often miss the requested information that may be deeper in a Web site and therefore gravitate to sites where the information is obviously placed. Misspelled searches are more common with younger users. Yet, unlike adults, adolescents are more likely to review searches beyond the first several results. Importantly,

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adolescents and young adults seem to respect sites that parents, teachers, and health care providers support and suggest for further information.9 The Internet can be a bridge to access health care by linking the searched information to health care providers and making it easier for adolescents to contact their providers to explain the information they found on the Internet. Support from health care providers can help filter appropriate information for young adults.10 As a result, online health information sources are a useful supplement to traditional information provided to adolescents by health care providers and schools. As we learn more about the information technology that adolescents use, the EHR capability should be adapted appropriately. Content that is directed by the personal physician has the potential to be more accurate and better tailored to each adolescent’s needs. Perhaps the use of social networking sites, such as Facebook, Instagram, and whatever is the next new site, will allow import of physician-approved content for enhancement of adolescent health. Truthfully, it remains unknown how effectively adolescents are using social media for health information and how effective it can be for hard-to-reach populations. While it is known that adolescents use social media as a friendship extension and as a supportive environment, studies on how adolescents interpret health messages in social media remains a cautiously positive emerging field of social science.11-13 This is a unique opportunity for research into adolescent health service delivery and social media. Review of EHR and Patient Health Portals

Given the affinity of adolescents for online resources, adolescents stand to substantially gain from the new push for EHR use.14 Electronic health records are now a national expectation for hospitals, with the EHR incentive Meaningful Use program coming into effect. Within a functional and accurate EHR, a personal health record can and should exist. These personal portals, geared toward patient communication, engagement, and satisfaction, hopefully have the characteristics defined by Britto and Wimberg15 as being “lifelong, integrating information, controlled by the patient or family, private, secure, and can facilitate communication between family and providers.” In 2007, only 1% of the population had access to an Internet-based personal health record,16 yet by 2011, another report cited that up to 20% of physician offices have patient portals available.17 This massive growth has been driven not only by demand but also by legislation. While there are many significant legislative advances, a few key ones stand out. Historically, the increased adoption of EHRs, as well as personal health records, came from significant policy recommendations. The HIPAA was enacted in 1996, and while it first emerged as an assurance when changing jobs (hence the word Portability), the second part is what has emerged as its legacy. Among other articulations, it says that every person has “a right of access to inspect and obtain a copy of protected health information…in the format requested.”18 Likewise, in 2003, the Institute of Medicine commented on EHRs. Listed among their recommendations

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for common industry standards for EHR functionality is the expectation that a key capability of an EHR system is to provide electronic patient-provider communication and provide patient support to access medical records.19 In addition, as a product of the 2009 Health Information Technology for Economic and Clinical Health Act, which promoted use of health information technology, the era of Meaningful Use emerged by 2010. Stating that the goal of EHR is not “adoption alone but meaningful use of EHRs,” the government implemented a financial incentive program for hospitals, clinics, and physicians, and this program will become financially punitive if not initiated.20 As a staged program for health care systems and institutions, there are 14 core objectives in stage 1 to address and systematically implement. Similarly, individual healthcare providers have 15 core objectives to meet as part of the program for eligible professionals. Importantly, these were intended to affect all aspects of the US health care system and had different provisions for Medicaid (which is particularly important for adolescents) versus Medicare physicians.20 Yet many of the required provisions significantly affect adolescent care, without explicit provisions on how to adapt to this particular population. For example, physicians should engage patients and families in their health care with the objective to provide patients with an electronic copy of their health information (including diagnostic test results, problem lists, medication lists, medication allergies, discharge summary, procedures) upon request.20 There is no mention of the specific confidentiality needs of the adolescent population. Table 2 lists the possible positive and negative effects each Meaningful Use Indicator may have on adolescent care. Confidential Services and the EHR: Case Examples of After-Visit Summaries and Patient Portals

Every personal health record, and EHR in general, must support the highest levels of privacy and security for all users. However, these needs are complicated by the changing needs of adolescents as they develop. Adolescents will mature to a point at which they can and should transition to interacting with the health care system themselves.21 Likewise, the role of the parent or guardian for each adolescent will need to transition to a supportive/advisory role as opposed to the decision-making/primary one. Implementation of the personal health record needs to be able to adapt with the adolescent and to follow the state-based regulations for confidentiality in adolescence. With the transition to autonomy, which often is overlooked in adolescent health care provision, this measure will potentially allow adolescents to appropriately self-manage.3 Controversy persists on when to allow this self-management, especially for the younger adolescent. Many advocate for age 13 years as the start of transitioning to online access, but many institutions transition any time from age 12 to 15 years.3 As stated earlier, 1 (of many) Meaningful Use objectives is to “provide patients with an electronic copy of their health information.”20 This objective would specifically be met by an electronic patient portal. In their efforts to satisfy these Meaningful

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Use incentives, most institutions have individually decided how their adolescent patients will interact with patient portals based on age, state laws, and whether the institution wants parents and adolescents to have independent portal access. However, despite the potential for active patient and provider interaction using patient health portals, effective implementation in the adolescent population has yet to become standard of care.22 While likely the most complex to implement, we believe that the adolescent population is the most likely to engage providers in this format and benefit from this manner of communication with their health care providers. Another concern is the provision of an after-visit summary (AVS), an EHR-generated patient-centered summary of each visit, whether in the emergency department or the primary care office. Table 3 provides a clinical example, divided into common and best practices of the AVS. Simple adolescent-oriented steps can be taken by an institution when designing the AVS that will be used with adolescents if the institution is willing to think of the EHR as an effective means of communication. Table 2 provides a complete summary of potential positive and negative effects on adolescent care. Implementing patient health portals may be more complex than the AVS. Institutions must prospectively articulate how to integrate adolescent-oriented policies into the EHR. Three ad hoc models have emerged that characterize how an institution might choose to implement an adolescent health portal. The models maximize confidentiality, family engagement, or parental roles. In the first model of maximizing confidentiality, adolescents, usually defined as those between the ages of 12 and 17 years, with their parents, agree to a confidential relationship between the adolescent and their health care provider for secure, electronic communication. Conceptually aligned with guidelines for quality adolescent care, adolescents can access physician-controlled portions of their EHR to request appointments, ask questions, view medications, and receive laboratory results.5 Physicians consequently have a significant role in teaching adolescents how to effectively care for themselves as they transition to adulthood. Parents or legal guardians are given limited or no access. While this approach maximizes confidentiality, many parents may be uncomfortable with this arrangement because it caters to the need for privacy for the highestrisk patients and situations and minimizes parental supervision that may be quite appropriate in less sensitive situations. We have implemented and researched this model that maximizes confidentiality at the University of Florida. Adolescents are consistently enrolling and using the portal without significant gender differences and at a greater rate than that among parents of younger patients. While we anticipated that parents may feel threatened or not perceive benefit by a challenge to their parental role, to date we have actually had no negative feedback.23 This likely is because of carefully constructed conversations between providers and parents about the importance of adolescents’ independent access to health care. However, parents of younger

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Meaningful Use Indicators 1. Computerized   providers order entry (CPOE) 2.

3. 4. 5. 6. 7.

Possible Positive Effect on Adolescent Care Increased efficiency

Possible Negative Effects on Adolescent Care

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Affect thinking through who should receive information. Billing insurance(s) could increase confidentiality breaches.  Drug-drug and drug-allergy Provision for higher quality of Unlikely breach if maintained internally. If interaction checks care in avoiding interactions medications listed on any patient record, information may disclose medication exposures to unknowing parents or guardians. Record demographics Provision for higher quality of Need clear categories for guardianship and care in providing accessible emancipated minors. demographic information  Implement 1 clinical Increased efficiency Important, but hospitals/governing bodies often do decision support rule not prioritize adolescent issues because they are difficult; more likely to implement adult decisions.  Maintain up-to-date Increased efficiency Important, yet can conflict if adolescent is not problem list of current knowledgeable about all diagnoses or if parent or and active diagnoses guardian views confidential problems on a list.  Maintain active medication Provision for higher quality of Many medications are given because of sensitive list care in having up-to-date adolescent issues. information  Maintain active medication Provision for higher quality of Many medications are given because of sensitive allergy list care in avoiding interactions adolescent issues.

Clinical Example Oral contraceptive is electronically ordered; parent or guardian is notified or insurance is billed. Patient has allergic reaction to ceftriaxone used to treat a sexually transmitted infection (STI). Information is inadvertently given to a parent of an emancipated minor. Institutions opt to prioritize influenza administration to adults and not the pediatric population. Problem list includes high-risk behavior. Oral contraception is listed. Allergy to antibiotic is discovered that was prescribed for an STI.

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Table 2 Meaningful Use Indicators and Possible Negative Effect on Adolescent Health Care Delivery

9. Record   smoking status for patients 13 years

Provision for higher quality of care in identifying imminent danger Provision for higher quality of care in increasing discussion about smoking cessation Provision for higher quality of care in public health

Many institutions record smoking as a vital sign. See above; important but can breach confidentiality if viewed by parent.

Parent finds out about smoking behaviors that were disclosed confidentially. Parent finds out about smoking behaviors that were disclosed confidentially. Audit provider quality measures with respect to adolescent health care.

10. Report   hospital clinical Doubtful chance for breach in confidentiality. quality measures to Centers for Medicare and Medicaid Services (CMS) or states 11.  Provide patients with an Could be a key tool for Doubtful chance for breach in confidentiality. See text for more explanation; electronic copy of their adolescent engagement institutional decisions about who can health information, view an online portal will dictate its on request chance for confidentiality breach and effectiveness. 12.  Provide patients with an Could be a key tool for Access to online tool can be difficult and deciding who Emergency department discharge for electronic copy of their adolescent engagement can access extremely is important. pelvic or abdominal pain; adolescent is discharge instructions diagnosed with pelvic inflammatory disease (PID). 13.  Capability to electronically Provision for higher quality of Difficult to decipher issues related to confidentiality Other providers may release exchange key clinical care in providing care and to determine who gives authorization. laboratory test results from an STI information between coordination screening that are now viewable by providers of care and parents or guardians. patient-authorized entities 14.  Protect electronic health Vital to all patient interactions, How to retain confidentiality in all situations? Parents or guardians can still request information especially adolescent care records through hospital/institutional channels.

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8. Record/chart   changes in vital signs

STI, sexually transmitted infection

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Table 3 Common and Best Practices of the After Visit Sheet Common AVS Practice: At the end of an Emergency Department visit for a 15-year old girl with abdominal pain, a resident hands the parent an after visit sheet with a summary of her diagnosis of pelvic inflammatory disease. Best AVS Practice: At the end of an Emergency Department visit for a 15-year old girl with abdominal pain, a resident hands the parent an after visit sheet with a summary of her abdominal pain while giving providing the adolescent a different unique one that explains pelvic inflammatory disease and how to obtain further treatment, and follow up as well as information on safe sex practices.

children view more aspects of the patient portal. This identifies the need for future educational opportunities to better orient adolescents to the utility of the portal for obtaining health information. Providers also may feel concerned about this model because not all adolescents at all times need high levels of confidentiality. Providers may be concerned that removing parents from having the same level of access to them through the patient portal will create unintended barriers to communication on important health issues. However, our providers have nonetheless voiced approval to having these secure means of communication. Alternatively, other institutions have adopted portals that maximize family engagement. In this model, both parent and adolescent have access to the adolescent portal. In contrast to maximizing confidentiality, adolescents and parents see the same information that the physician has made viewable. In many ways, this model reflects current media policies and recommendations.24 For example, pediatricians commonly encourage parents to both monitor and discuss their adolescents’ use of the Internet to address cyberbullying and inappropriate friendships. Similarly this model introduces adolescents to responsible interactions with the health care system with parental supervision and invites a cooperative approach between parents and adolescents to managing health. However, this mode of communication cannot be used when high-risk adolescent issues arise because it does not provide a solution to the ongoing problems of adolescent confidentiality. Importantly, providers must remember to not place any confidential materials into the portal. Finally, some institutions have opted for a parent-oriented model. Here, only parents have access to their adolescent’s portal; adolescents do not. By policy, no sensitive information is ever made available. This popular choice is likely a result of deep institutional concerns about lapses in confidentiality, avoiding it completely. Unfortunately, there is also no expectation or capability for adolescents to manage their health care. Institutions have created portals to satisfy a meaningful use requirement yet have only nominal information therein, such as immunization records. This policy avoids financial penalties and legal concerns, but it does not allow for EHR use that is truly meaningful.

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Working through efforts to earn Meaningful Use incentives has clearly brought to light many of the ongoing difficulties in ensuring adolescent confidentiality, causing institutions to make explicit, organization-wide choices about confidentiality and parental involvement. While a model that ensures a high level of confidentiality may not be needed for every child, all the time, it ensures confidentiality and educates toward the transition to adult care. We are concerned that many institutions may opt to forego the explicit decision-making process involved in making patient portal use “meaningful” for adolescents. It is important for those who care for adolescents and young adults to have a voice in this discussion at their institutions. If we could encourage widespread use of patient portals through which adolescents could meaningfully access their health record like they do their Facebook profile, we could potentially embed all of these meaningful use recommendations therein. What these will look like is still uncharted territory. We know from Web sites, written materials, and even our verbal interactions with adolescents that the style needs to be both mature compared to school-aged children and yet not as formal as would be expected with adults. To date, there are no publicized adolescent-specific electronic health portals designed to attract users the way Facebook, Instagram, and other sites popular with this age group do. We also know that adolescents are sensitive to the styles of other users.25 Adolescent participation in this portal design process likely will ensure that their peers find it acceptable and usable. Conclusions

The future has myriad possibilities for adolescent health care. One strategy that is well documented to improve adolescent health is engaging adolescents in their health management. In the era of EHRs, we as pediatricians and adolescent specialists have a unique opportunity to implement this strategy. This would entail promoting adolescents’ active understanding of their health and health care as documented in their EHR, appropriate AVS for adolescents themselves, and active use of patient portals. One could theorize that using a patient portal in ways as adolescentfriendly as Instagram and Snapchat will yield improved transition services to adulthood because adolescents will be more accustomed to interacting with the health care system. Perhaps, although still unknown, adolescents will use a social medialike EHR to seek and improve their health information, receipt of health care, and even share their health views to friends. Could incentives be used to engage early adolescents throughout their adolescent years? Could we improve health literacy through this interaction? If we are proactive, we can parlay adolescents’ use of the Internet and their proclivity for social media into a powerful user-friendly EHR. References 1. Strasburger V, Donnerstein E, Bushman B. Why is it so hard to believe that media influence children and adolescents? Pediatrics. 2013;133(4):1-3

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2. US Department of Health and Human Services. Healthy People 2020: adolescent health. 2013. Available at: www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid52. Accessed June 24, 2014 3. Bourgeois FC, Taylor PL, Emans SJ, Nigrin DJ, Mandl KD. Whose personal control? Creating private, personally controlled health records for pediatric and adolescent patients. J Am Med Inform Assoc. 2008;15(6):737-743 4. Wheeler R. Gillick or Fraser? A plea for consistency over competence in children: Gillick and Fraser are not interchangeable. BMJ. 2006;332:807 5. Hagan J, Shaw J, Duncan P. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Elk Grove Village, IL: American Academy of Pediatrics; 2008 6. Lenhart A, Purcell K, Smith A, Zickuhr K. Social media and young adults. Pew Research Internet Project. February 3, 2010. Available at: www.pewinternet.org/2010/2002/2003/social-media-andyoung-adults/. Accessed June 24, 2014 7. Borzekowski D, Rickert V. Adolescent cybersurfing for health information: a new resource that crosses barriers. Arch Pediatr Adolesc Med. 2001;155(7):813-817 8. Hansen DL, Derry HA, Resnick PJ, Richardson CR. Adolescents searching for health information on the Internet: an observational study. J Med Internet Res. 2003;5(4):e25 9. Jones RK, Biddlecom AE. Is the Internet filling the sexual health information gap for teens? An exploratory study. J Health Commun. 2011;16:2:112-123 10. Skinner H, Biscope S, Poland B, Goldberg E. How adolescents use technology for health information: implications for health professionals from focus group studies. J Med Internet Res. 2003;5(4):e32 11. Byron P, Albury K, Evers C. “It would be weird to have that on Facebook”: young people’s use of social media and the risk of sharing sexual health information. Reprod Health Matters. 2013;21(41):35-44 12. Giorgio MM, Kantor LM, Levine DS, Arons W. Using chat and text technologies to answer sexual and reproductive health questions: Planned Parenthood pilot study. J Med Internet Res. 2013;15(9):e203 13. Stockwell MS, Fiks AG. Utilizing health information technology to improve vaccine communication and coverage. Hum Vaccin Immunother. 2013;9(8):1802-1811 14. Anoshiravani A, Gaskin G, Groshek M, Kuelbs C, Longhurst C. Special requirements for electronic medical records in adolescent medicine. J Adolesc Health. 2012;51:409-414 15. Britto MT, Wimberg J. Pediatric personal health records: current trends and key challenges. Pediatrics. 2009;123(Suppl 2):S97-S99 16. Bright B. Benefits of electronic health records seen as outweighing privacy risks. Wall Street Journal. November 29, 2007. Available at: online.wsj.com/articles/SB119565244262500549. Accessed November 6, 2014 17. Wynia MK, Torres GW, Lemieux J. Many physicians are willing to use patients’ electronic personal health records, but doctors differ by location, gender, and practice. Health Aff (Millwood). 2011; 30(2):266-273 18. US Department of Health and Human Services. Summary of the HIPAA privacy rule. Available at: www.hhs.gov/ocr/privacy/hipaa/understanding/summary/. Accessed June 24, 2014 19. The Institute of Medicine. Key Capabilities of an Electronic Health Record System: Letter Report. Washington, DC: The National Academies Press, Committee on Data Standards for Patient Safety; 2003 20. National Learning Consortium. EHR incentives & certification. Available at: www.healthit.gov/ providers-professionals/meaningful-use-definition-objectives. Accessed June 24, 2014 21. Health Resources and Services Administration Health Information Technology. What are some of the privacy and security considerations for PHRs for children? Developing EHRs. Available at: www.hrsa.gov/healthit/toolbox/Childrenstoolbox/DevelopingPediatricPHRs/index.html. Accessed June 24, 2014 22. Sarkar U, Bates DW. Care partners and online patient portals. JAMA. 2014;311(4):357-358 23. Thompson LA, Black EW, Saliba H, Schentrup AM. Parents’ knowledge of and opinions about healthcare laws and technology in primary care. Inform Prim Care. 2013;20(1):69-74 24. American Academy of Pediatrics Council on Communications and Media. Media education. Pediatrics, 2010;126(2):341 25. Karp R. I’m 13 and none of my friends use Facebook. August 11, 2013. Available at: mashable. com/2013/08/11/teens-facebook/. Accessed June 24, 2014

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Physician Blogging for Parent Health Education Yolanda N. Evans, MD, MPHa*; Paula J. Cody, MD, MPHb a Associate Professor of Pediatrics, Division of Adolescent Medicine, Seattle Children’s Hospital and University of Washington, Seattle, Washington; bAssistant Professor of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

What Is a Blog?

Social media have become a necessary tool in medicine. Adolescents and their families are regular users of online social media1,2 Multiple reasons include sharing their experiences and searching for resources and information, or seeking out services that can aid in diagnosis and treatment. Physicians have begun to use social media to promote accurate information on topics ranging from vaccines to cancer therapy. While social media can take many forms, blogging is designed to provide information from the author’s point of view. A blog is short for the term web log and is defined as “a web site that contains an online personal journal with reflections, comments, and often hyperlinks provided by the writer.” (Merriam Webster Dictionary) As such, a blog has the potential to be a useful tool for physicians who would like to teach on a variety of topics and reach a wide audience. How Blogs May Intersect with Adolescent Health

Medical organizations, hospitals, and individual physicians are using blogs to reach their patients. Blog authors come from a variety of disciplines and offer a wide range of content. This content may include information on a specific medical condition, such as autism; it may be an expression of an individual health care professional’s experiences in medicine; or it may be written for an audience of parents offering health information for raising their children. Table 1 lists examples of medical blogs on the Internet.

*Corresponding author E-mail address: [email protected] Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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Table 1 Examples of Medical Blogs Author type Individual Physician Kevin Pho, MD (www.kevinmd.com/blog) Howard Luks, MD (www.howardluksmd.com) Wendy Sue Swanson, MD (seattlemamadoc. seattlechildrens.org) Hospital Sponsored Mayo Clinic News Blog (newsnetwork.mayoclinic.org) Thriving: Boston Children’s Hospital (childrenshospitalblog.org)

Content area

Audience

Wide range of topics from personal encounters and patient stories to legislation Specific evidence based content on orthopedic injuries and treatment Wide range of topics on issues related to pediatric health using her experience as a pediatrician and mother

Anyone with a desire to hear a physician’s perspective

Medical research and news

Patients and families

Pediatric health topics on common issues (such as obesity) and patient stories

Patients and families

Athletes, health care professionals with an interest in sports-related orthopedic injuries Written for parents of infants and children

Blogs authored by health care professionals can serve as portals for dissemination of medical research in terms that are understandable by the nonscientist and up-to-date health information on various health conditions. Blogs can engage the reader by allowing for comments to which the blog author can respond. They also can provide patients and families with experiences from others that they can relate to. Previous work has reported benefits to parents of newborns or of children with specific health conditions by blogging to share experiences.3-5 Parents and adolescents who read blogs written by medical professionals may share similar benefits. Studies also support the possible benefit to teens of blogging to foster information sharing and social connection.5 Case Study: Teenology101 blog

Although there are numerous blogs for expectant mothers and for parents of infants and young children, few are dedicated to topics applicable to adolescent health. In 2011, Seattle Children’s Hospital Marketing and Communications partnered with the Division of Adolescent Medicine to create a blog exclusively devoted to adolescent health. The authors include a pediatric nurse and an Adolescent Medicine Subspecialty board-certified physician. Content for the blog is generated by reader requests, trending media topics, emergent health concerns, and clinical encounters. Examples of common topics include dating and intimate relationships, contraception, discipline, substance use, eating and wellness, Internet safety, and driving. Figure 1 shows an example of a blog post. New entries are posted an average of twice weekly. From January 2012 to December 2013, there were 185 blog posts with a variety of post methods, including traditional text, YouTube videos, and podcasts.

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This week of September 8-14th is National Suicide Prevention week so we wanted to take a moment to bring up this important topic again (teenology101.seattlechildrens.org/teen-suicide/). Suicide is one of the leading causes of death for young people ages 15-24 and it is very preventable! During this week, let’s remember those whose lives ended too soon and watch for warning signs of depression and suicidal thinking amongst friends and loved ones. Why are teens at risk for suicide? Well, there are many reasons but here are some that stand out: •

•

•

Teens are going through many emotional changes. As they grow and develop, teens are starting to have their own personal identity. At the same time, there is intense pressure to conform with peers. Sometimes these two conflict and the situation can feel hopeless. It can feel like there is no way out. Teens are impulsive. Their brains are not fully finished developing. The pre-frontal cortex is the portion of the brain that controls impulse and helps us think through consequences. In teens it isn’t mature yet. For this reason, teens often act on the impulse of what will fix the problem right now instead of thinking about future consequences. Warning signs may be missed. Talking about death, giving away cherished possessions, and expressing thoughts of feeling hopeless may be mentioned in passing or during times when loved ones aren’t giving their full attention. We may miss hearing these warning signs.

So what can a parent do to help prevent suicide? •

•

• •

Listen. If you hear your teen mention in passing ‘I wish I were dead.’ Don’t ignore it, or think they were just saying that to get a reaction. Consider any statement about suicide as a warning sign. Our response as adults can be as simple as asking more about why they made the statement. Seek help from a medical provider or behavioral health professional if your teen tells you they are thinking of ending their life. Don’t let ‘I’m fine’ be the end of the discussion. Most teens will say they’re fine because they don’t want to be a burden on the people they love. Ask a bit more about how they are feeling. Ask if they have things in their life that are stressful right now and what do they do when they feel sad or stressed to help feel better. If they don’t have any helpful strategies, that is concerning. Make sure your teen has supportive adults. Even if it’s not a parent, make sure your teen has at least one supportive adult who they trust in their life. This can be a teacher, therapist, minister, or auntie. It should be someone they can contact whenever they need to. Keep lethal things out of the home. Teens who attempt suicide with a firearm are more likely to complete suicide than those who take a bottle of pills. If your teen talks of suicide, consider if they should be allowed to drive or have access to prescription medications.

One of the greatest risk factors for suicide is a previous suicide attempt. If your teen has tried to end their life before or if they tell you they have a plan to commit suicide seek professional help immediately. This includes going to the local emergency department or calling 911. Each hospital has behavioral health specialists on staff that can assess your teen’s safety and help with treatment options. Resources: National Suicide Prevention Lifeline (www.suicidepreventionlifeline.org) Youth Suicide Prevention (www.yspp.org) TEENLINK (866teenlink.org) 

Fig 1. Blog example from teenology101.

There were 103,230 page views during this time period. Certain blog posts lead to increased media attention, including requests for the blog authors to discuss topics on local television, radio, and in print interviews. The hospital marketing and communications team also used selected blog posts for the hospital Twitter feed and Facebook content. Selection was based on the individual marketing representatives but in general was relevant to trending media content.

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Opportunities Presented by Blogs

As depicted in the case study, blogging has many advantages for both the author and the reader. It is accessible to anyone with Internet access and allows for dissemination of health information without the need to travel to a physician’s office. The blog’s content has the potential to reach well beyond current blog subscribers if it leads to media attention, comments on social media networking sites, or is picked up by other bloggers. This exposure broadens the reach of the original blog author. Blog content can be distributed in ways that allow for those with limited health literacy to access information by explaining evidence-based research in general terms, utilizing video blogs and pictures. Challenges Presented by Blogs

Despite the opportunities blogs provide, challenges remain. Most blogs are not peer reviewed, and most medical bloggers are not compensated for their time and contributions, so their continuation of the blog may be limited. Most healthrelated blogs by medical professionals in the United States are written only in the English language, which restricts their reach to primarily English-speaking populations. Some of the most pressing challenges are those of professionalism and medical liability. While hospital sponsored blogs are monitored by an institution and authors are held to the standards of that institution, unsponsored blogs are not monitored. There is no set standard for writing that ensures blogs are written at a level that most readers can understand, nor are there standardized guidelines pertaining to the medical accuracy of information posted or standards that posted information be grounded on evidence-based practices. The physician blogger must be cautious to not provide direct patient care via blog posts. Medical bloggers are bound by the same legal and clinical standards that apply to any patient interaction, and there is no exemption of medical professionalism. Blog authors must be mindful of respect for patients and adhere to confidentiality laws when posting about clinical interactions. The American Medical Association’s code of medical ethics addresses medical professionalism using online media. A physician “must maintain appropriate boundaries of the patientphysician relationship in accordance with professional ethical guidelines, just as they would in any other context.”6 The American College of Physicians reminds physicians that they must remember their role when using online media. Information posted on the Web is not easily erased, and negative comments can affect patient trust and physician reputation.7 Future Directions and Recommendations for Physicians

As physicians and patients continue to use new outlets to engage in education and communication, more information will be needed on which methods are

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feasible and practical. Parents and adolescents do utilize medical blog resources, but more research is needed to understand exactly what they find useful and what health-related topics are best discussed using blogs. Adolescents show interest in social media and blogging, and there is great potential for targeted accurate information for health prevention and education, but there is no available peer-reviewed study describing adolescents’ comfort with accessing medical blogs for health-related topics. For physicians interested in utilizing a blog as a health education tool, the American Academy of Pediatrics has a set of guidelines available for its members on how to use social media and blogging: www.aap.org/en-us/my-aap/Documents/ SocialMedia_guidelines.pdf. However, these guidelines are brief. Physician bloggers must abide by standards of medical professionalism and biomedical ethics when posting content online. Collaboration with a public relations or media communication team can be of great help when designing, promoting, and developing new topics for the blog. This team can also aid the physician author in obtaining information on blog readership, popular posts, and traffic sent to the blog site in order to increase readership and expand the blog’s reach. We recommend expanding the available literature on patient and parent interest in how health information is presented to them, including incorporating modalities that utilize social media, blogs, and the Internet. For medical professionals, more guidelines are needed for those who would like to initiate a blog, including appropriate information on writing style, blog promotion, and partnering with people outside of the medical field to maximize the reach of Internet resources. References 1. Chou WS, Hunt YM, Beckjord EB, et al. Social media use in the United States: implications for health communication. J Med Internet Res. 2009;11(4):e48 2. Fox S, Jones S. The social life of health information. Pew Internet and American Life Project. 2009. Available at: www.pewinternet.org/files/old-media//Files/Reports/2009/PIP_Health_2009.pdf. Accessed August 15, 2014 3. Clarke JN, Lang L. Mothers whose children have ADD/ADHD discuss their children’s medication use: an investigation of blogs. Soc Work Health Care. 2012;(51)5:402-416 4. McDaniel BT, Coyne SM, Holmes EK. New mothers and media use: association between blogging, social networking, and maternal well-being. Matern Child Health J. 2012;16(7):1509-1517 5. Andersson M, Gustafsson E, Hansson K, Karlsson M. External mirroring of inner chaos: blogging as experienced by the relatives of people with cancer. Int J Palliat Nurs. 2013;19(1):16-23 6. Shore H, Halsey J, Shah K, Crigger BJ, Douglas SP; AMA Council on Ethical and Judicial Affairs. Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media. J Clin Ethics. 2011;22(2):165-172 7. Farnan JM, Snyder Sulmasy L, Worster BK, et al. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-627

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Note: Page numbers of articles are in boldface type. Page references followed by “f ” and “t ” denote figures and tables, respectively. A Academy for Eating Disorders, 556 Adolescent mHealth, 635–638 Adolescents age of, to access health records, 701, 704 developmentally appropriate behaviors, 699 disordered eating behaviors, 553 extroverts/introverts, 673 health-related blogs, 678, 712 identity development, 671–672 Internet access, 702 media use, 685 novelty, 536 searching the Web, 702–703 self-disclosure, 672–673 self-presentation, 671–672 social media, 622–623 specific health care challenges, 700–701 Adolescents and Driving, 638 After-visit summary (AVS), 705, 708t Aggravated assault, rate, 647f Aggressive and gender-stereotypic scripts, 578 Aggressive behavior, 646–647. See also Media violence AIDS. See HIV/AIDS Alcohol screening, 692 Alternative sexual scripts, 579 AM, 578 3 American Academy of Pediatrics’ Media Matters campaign, 629–630 Avatars, 680 AVS. See After-visit summary (AVS) B Balance between online/offline activities, 625–626 “Bareback” sex, 545 Bijp, 534 Blocked social media platforms, 534 Blog, 711 Blogging, 678, 711–715 AAP guidelines, 715 benefits/advantages, 712, 714 blog, defined, 711 case study (Teenology 101 blog), 712–713, 713f confidentiality, 714 ethics, 714

examples of medical blogs, 712t hospital sponsored blogs, 712t, 714 professionalism, 714 Body image, 559, 680. See also Pro-eating disorder (pro-ED) sites Boundaries, 626, 627t, 628 BrdsNBz, 660 Brown v. Entertainment Merchants Association et al., 651 Bullying, 564, 565f, 646. See also Cyberbullying Bupropion, 615 C Cell phones. See Mobile phone use Censorship, 535, 536 Child pornography statutes, 596–599 Children’s Food and Beverage Advertising Initiative, 658 China blocked platforms, 534 censorship, 535, 536 microblogging site (Weibo), 538 mobile Internet traffic, 535 popular social media sites, 534 sensitive political issues, 535–536 Cigarette smoking, 648–650, 650t Civil liability, 600–602 Client and therapist avatars, 680 Clinicians blogging, 711–715 cyberbullying, 570–571 family media plan, 625 healthy Internet use. See Healthy Internet Use Model keeping up-to-date, 629 media exposure, 689 motivational interviewing, 691–692 physician-patient interaction, 678 physician-patient Q&A forums, 679 pro-ED sites, 560–561 psychoeducation, 691 sex and social media, 548–550 support for parents, 690, 694 COCM. See Council on Communications and Media (COCM) Cognitive behavioral therapy, 615 Communication, 627t, 628–629 Condom use, 660

Copyright © 2014 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287

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Index / Adolesc Med 025 (2014) 716–723 Condomless sex, 579 Confidentiality, 701–702, 714 Confidentiality-oriented health portal, 705 ConRed program, 569 Council on Communications and Media (COCM), 629 Cronbach alpha, 612 Cross-cultural and cross-platform differences, 533–541 censorship, 535, 536 China. See China different platforms/different social needs, 536, 537 indigenous platforms, 534 individualist vs. collectivist cultures, 537–538 intrapersonal variation, 538 Korean students, 537–538 microblogging, 538 political issues, 535–536 sweeping generalizations, 537 Cyberbullying, 564–573, 653, 676 anonymity, 565, 595 anti-bullying campaigns, 569 anti-bullying laws, 591–595 characteristics of cyberbullies, 567 civil liability, 600–601 clinician’s role, 570–571 defined, 564 early and middle adolescents, 566 legal implications, 569 older adolescents and college students, 566–567 parental involvement, 570 power imbalance, 565 prevalence, 566 psychological effects, 568 risk factors, 567 schools, role, 568–569 suicide, 567–568, 659 traditional bullying, compared, 565f Cyberbullying laws, 591–595 CyWorld, 534, 537, 538 D Dance Revolution, 658 Depression screenings, 676 Diffusion of innovation theory, 636 Digital divide, 676 Disease management apps, 636, 638 Disordered eating behaviors. See Pro-eating disorder (pro-ED) sites Distracted driving, 633–634, 638 Douban, 534, 536 Down, 544 E E-health groups, 679 Eating disorder (ED), 553. See also Pro-eating disorder (pro-ED) sites

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Education and media literacy American Academy of Pediatrics Media Matters campaign, 629–630 AAP online course, 693 cyberbullying, 568–569 importance, 660 positive effects, 652 pro-ED sites, 559 resources for parents, 691t sex online, 587 eHarmony, 544 EHR. See Electronic health record (EHR) Elaboration likelihood model, 637t Electronic aggression, 564. See also Cyberbullying Electronic harassment cyberbullying. See Cyberbullying privacy rights, 601–602 state laws, 591f unauthorized forwarding of sexts, 600–601 Electronic health record (EHR), 698–710 after-visit summary (AVS), 705, 708t age of adolescent/interfacing with EHR, 701, 704 confidentiality, 701–702 confidentiality-oriented health portal, 705 family engagement-oriented health portal, 708 Healthy People 2020 adolescent objectives, 700t HIPAA, 703 Institute of Medicine recommendations, 703–704 Meaningful Use incentives, 704 Meaningful Use indicators, 706–707t parent-oriented health portal, 708 patient health portals, 705–709 Empirical studies. See Research studies Epidemiologically risky sexual scripts, 579 Escitalopram, 615 Extracurricular or community activities, 694 Extrarelational sex, 579 Extroverts, 673 F Facebook alcohol references, 687 China, 534 dating partners, 543 depression references, 659 depression screenings, 676 3GT, 676 health promotion activities, 546 increasing number of available services, 535 “Just/Us” intervention, 547 mood states, 673 now self/hoped-for possible self, 672

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Facebook (continued) personal connectedness, 675 popularity in U.S., 536 pro-ED content, 554, 559 RenRen, compared, 538 retreat from, in search of more novel networks, 536 self-presentation, 671–672 self-promotion, 674 self-worth, 673 sexual propositions, 544 sexual references, 655 social capital, 671 Facebook addiction disorder, 675. See also Problematic Internet use (PIU) Facebook Addiction Scale, 675 Facebook-delivered “Just/Us” intervention, 547 Family engagement-oriented health portal, 708 Family media plan, 625, 691t First Amendment, 593–594, 598 First-person shooter video games, 652 Flickr, 535 Fourth Amendment, 601 G Gain and loss framing, 637t Gay/bisexual dating/hookup apps, 543–544 Gays and lesbians geosocial networking apps, 543–544 HIV prevention and social media, 547–548 Muessig’s intervention, 636 Generalized Pathological Internet Use Scale (GPIUS), 611f Geosocial networking apps, 543–544 Get Yourself Tested (GYT) campaign, 548 GPIUS. See Generalized Pathological Internet Use Scale (GPIUS) Grindr, 543 Group sex, 545 Guy2Guy (G2G), 636 GYTNOW.org, 548 H Health behavior change theory, 636, 637t Health belief model, 636, 637t Health communities, 679 Health Information Portability and Accountability Act (HIPAA), 699, 702–703 Health Information Technology for Economic and Clinical Health Act, 704 Health promotion activities, 693–694 apps, 636, 638, 660 blogging, 711–715. See also Blogging e-health groups, 679 Facebook pages, 677–678 health communities, 679 health-specific SNSs, 678–679

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Internet support groups (ISGs), 679–680 list of various health promotion initiatives, 659–660 mental health, 676–680 mental health forums, 678–679 mobile phone use, 634–638 physician-patient Q&A forums, 679 screenings, 677 sexual health promotion, 546 sharing health information online, 676 virtual therapy sessions, 680 wellness activities, 677 Health promotion apps, 636, 638, 660 Health-related blogs, 711–715. See also Blogging Health-specific SNSs, 678–679 HealthTap, 679 Healthy Internet Use Model, 624–630 balance, 625–626, 627t boundaries, 626, 627t, 628 communication, 627t, 628–629 media screening questions, 627t Healthy People 2020 adolescent objectives, 700t HealthyChildren.org, 690, 691t HIPAA. See Health Information Portability and Accountability Act (HIPAA) HIV/AIDS risk/prevention and social media, 545, 547–548 serostatus disclosure, 545 Homeless youth, 634 Homicide, 647, 647f Hoped-for possible self, 672 Hospital sponsored blogs, 712t, 714 Hotspots, 634 Hyves, 534 I I-POE. See Index of Problematic Online Experiences (I-POE) IAT. See Internet Addiction Test (IAT) Identity development, 671–672 Imprisonment rate, 647f Index of Problematic Online Experiences (I-POE), 611f Indigenous social media platforms, 534 Individualist vs. collectivist cultures, 537–538 Instagram, 535–536, 559 Intentional infliction of emotional distress, 600–601 Interactive sites, 702 Internet Addiction Scale, 611f Internet Addiction Test (IAT), 609–610, 611f, 675 Internet Dependence Scale, 611f Internet support groups (ISGs), 679–680 Internet use addiction disorder, 605. See also Problematic Internet use (PIU)

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Index / Adolesc Med 025 (2014) 716–723 Introverts, 673 ISGs. See Internet support groups (ISGs) J “Just/Us” intervention (Facebook), 547 K KiVa program, 569 Korean students, 537–538 L Legal issues, 590–604 child pornography statutes, 596–599 civil liability, 600–602 cyberbullying laws, 591–595 First Amendment, 593, 594, 598 Fourth Amendment, 601 intentional infliction of emotional distress, 600–601 online privacy law, 601–602 public disclosure of private facts, 600 “Romeo and Juliet” statutes, 597 sexting laws, 595–600 unauthorized forwarding of sexts, 600–601 Lesbians. See Gays and lesbians LinkedIn, 535 Literacy, 652. See also Media literacy Longitudinal studies. See Research studies M Make a Difference: Talk to Your Children About Alcohol, 691t Match.com, 544 Mayo Clinic News Blog, 712t Meaningful Use incentives, 704 Meaningful Use indicators, 706–707t “Media: Wired Kids and Your Practice” (AAP online course), 693 Media history form, 693 Media literacy. See Education and media literacy Media violence new media, 653 traditional media, 645f, 646–647, 651–652 Medical blogs, 711–715. See also Blogging Men who have sex with men (MSM). See Gays and lesbians Mental health, 670–683 health promotion, 676–680. See also Health promotion activities identity development, 671–672 narcissism, 673–674 negative effects of social media, 675–676 positive effects of social media, 674–675

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self-disclosure, 672–673 self-esteem, 673 Mental health forums, 678–679 Mental health interventions, 676–680. See also Health promotion activities Methylphenidate, 615 mHealth, 635–638 mHealth apps, 636, 638, 660 MI. See Motivational interviewing (MI) Microblogging, 538 MISTER, 544 Mixi, 534 Mobile health (mHealth), 635–638 Mobile phone use, 631–642. See also New media American Academy of Pediatrics policy statements, 638 China, 535 clinical recommendations, 638–639 developmental considerations, 632–634 distracted driving, 633–634, 638 epidemiology, 631–632 health behavior change theory, 636, 637t health promotion activities, 634–638 mHealth, 635–638 risks, 633 SMS technology obsolescence, 636 social learning theory, 632 street youth, 634 youth living with disabilities/chronic disease, 634 Mobile phone use prevention advocacy efforts, 639 Moreno, Megan, 547, 550 Motivational interviewing (MI), 615, 691–692 Movies. See Traditional media MSM. See Gays and lesbians Murder rate, 647f Music marker theory, 651 MySpace, 535, 546, 554, 654 N Narcissism, 673–674 National Eating Disorders Association (NEDA), 559, 560 National Television Study, 651 New media, 652–659 cyberbullying, 653, 659 drugs, 655, 658 eating disorders, 658. See also Pro-eating disorder (pro-ED) sites health promotion/positive effects, 659–660 media violence, 653 negative effects, 644 obesity, 658 sex, 653–654 video viewing audiences, 644f Niche markets, 535

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Index / Adolesc Med 025 (2014) 716–723

NOTNOW, 660 Novelty, 536 Now self, 672 O Obesity, 645f, 650–651, 658 OCS. See Online Cognition Scale (OCS) OkCupid, 544 One-way messaging, 677 Online boundaries, 626, 627t, 628 Online Cognition Scale (OCS), 611f Online dating sites, 544 Online gambling, 606. See also Problematic Internet use (PIU) Online harassment. See Electronic harassment Online health information sources, 703 Online pornography, 576–584 aggressive and gender-stereotypic scripts, 578 alternative sexual scripts, 579 child pornography statutes, 596–599 condomless sex, 579 content analyses, 580–581t epidemiologically risky sexual scripts, 579 exposure to pornography, 576–578 extrarelational sex, 579 multiple sexual partners, 579 negative effects of pornography exposure, 579, 582–583t, 584, 654 pornography, defined, 576 research studies (content analyses), 580–581t research studies (effects of pornography exposure), 582–583t research studies (exposure to pornography), 577t sexual script theory, 578 “teen” pornography, 579 Wright’s acquisition, activation, application model (3AM), 578 Online privacy law, 601–602 Online pro-eating disorder activity. See Proeating disorder (pro-ED) sites Online solicitation, 586, 587 Online therapeutic milieu, 679 Orkut, 534 P Parent-oriented health portal, 708 Parents cyberbullying, 570 daily Internet use, 623 familiarity with social media, 623 family media plan, 625 media-related communication with children, 628 movie restrictions, 691

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problematic Internet use (PIU), 614 resources, 550, 691t sex and social media, 549–550 substance use, 688–691, 694 Patient health portals, 705–709 Pediatric Research in Office Settings (PROS) research-based network, 624, 629 Physician-patient Q&A forums, 679 PIU. See Problematic Internet use (PIU) POF.com, 544 Political issues, 535–536 Pornography, 576. See also Online pornography PRIUSS. See Problematic and Risky Internet Use Screening Scale (PRIUSS) Privacy rights, 601–602 Pro-eating disorder (pro-ED) sites, 553–563, 658 accessibility, 554–555 age and gender demographics, 559 clinical recommendations, 560–561 competition among users, 557–558 diagnosed and undiagnosed individuals, 555–556 exchange of weight loss and concealment information, 558 high turnover rate, 559 ideologies (pro-ED to pro-recovery), 556 interactive elements, 554, 555 Internet resources, 561t media literacy, 559 negative ED-related outcomes, 558–559 personalized diet-related tools, 555 physician’s role, 560–561 pro-Ana/pro-Mia, 554, 557 reinforcement of ED identity, 558 social support and anonymity, 557 thinspiration, 554 wannabe anorexics (wannarexics), 555 Pro-social organizations/activities, 694 Problematic and Risky Internet Use Screening Scale (PRIUSS), 612, 613f Problematic Internet use (PIU), 605–620, 675–676 assessment tools, 609–613 concept mapping, 608–609 core constructs, 609 demographic groups, 606, 608 drug therapy, 615 gender differences, 608 health/behavioral problems, 608 Healthy Internet Use Model, 624–629 Internet use addiction disorder, 605 online gambling, 606 overview (model), 609, 610f parents, 614 prevalence, 606, 607t prevention and treatment, 614–615 psychological therapies, 615

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research studies (prevalence), 607t risk factors, 606–608 scales, 611f screening, 612–614 self-screening, 614 social networking site use, 606 Problematic Internet Use Scales, 611f PROS. See Pediatric Research in Office Settings (PROS) research-based network Pseudonyms, 535 Public disclosure of private facts, 600 Public health surveillance, 548 Pure, 544 R “RapeLay,” 653 Rating systems, 587 ReachOut, 679 Reasonable expectation of privacy, 601, 602 RenRen, 534–536, 538 Research studies effect of sexual content on sexual behavior, 648–649t mental health, 678–679 pornography, 577t, 580–581t, 582–583t prevalence of sexting, 656–657t problematic Internet use, 607t Resources for parents, 691t Romano v. Steelcase Inc., 601 “Romeo and Juliet” statutes, 597 S “School Shooter,” 653 Schools. See Education and media literacy Screentime policies, 624 Scruff, 544 Section on Adolescent Health (SOAH), 629 Self-affirmation theory, 673 Self-disclosure, 672–673 Self-esteem, 673 Self-esteem movement, 673 Self-promotion, 674 Selfies, 672 Serostatus disclosure, 545 Sex, Drugs ‘n Facebook: A Parents Toolkit for Promoting Healthy Internet Use (Moreno), 550, 638, 642 Sex and social media, 542–552. See also Sex online clinician’s role, 548–550 Facebook-delivered “Just/Us” intervention, 547 gay/bisexual dating/hookup apps, 543–544 geographical proximity, 543 geosocial networking apps, 543–544 health benefits, 545–548 health promotion activities, 546

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health risks, 543–545 heightened sexual expectations, 545 HIV risk/prevention, 545, 547–548 online dating sites, 544 parental resource, 550 popularity of social media, 543 public health surveillance, 548 quality of health communication, 548 serostatus disclosure, 545 sexting. See Sexting sexual exploitation, 586 sexual negotiation, 545 sexual propositions, 544 social media-based interventions, 546–548, 550, 550t, 635–638 STI testing, 548 stigmatized sexual behaviors, 545 use, 544t Sex and traditional media, 648–649t Sex online, 574–589, 653–654. See also Sex and social media education and media literacy, 587 governmental regulation, 587 pornography. See Online pornography potential solutions, 587 rating systems, 587 risks, 574–575 sexting, 584–586. See also Sexting sexual exploitation, 586 Sexting, 654 child pornography statutes, 596–599 defined, 595 negative effects, 596 new sexting statutes, 599–600 prevalence, 596, 654, 656–657t reasons for, 585 risk taking, 585 unauthorized forwarding of sexts, 600–601 Sexting laws, 595–600 Sexual exploitation, 586 Sexual negotiation, 545 Sexual propositions, 544 Sexual references, 543, 655 Sexual script theory, 578 Sexually explicit conduct, 596 Sharecare, 679 Sharing health information online, 676 Shy and socially anxious individuals, 673 Sino Weibo, 534. See also Weibo Smartphones. See Mobile phone use Smokeless tobacco, 687 SMS technology obsolescence, 636 Snapchat, 535, 544, 655 SNS addiction disorder, 675. See also Problematic Internet use (PIU) SOAH. See Section on Adolescent Health (SOAH) Social cognitive theory, 636, 637t Social learning theory, 632, 674

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Social media. See also New media adolescent usage, 622–623 China. See China conversation catalyst, 689–693 cross-cultural/cross-platform differences, 533–541 cyberbullying. See Cyberbullying defined, 621 Facebook. See Facebook family dynamic and, 623 friendship extension, 703 health promotion. See Health promotion activities mental health. See Mental health negative effects, 623 next steps and future directions, 629 niche markets, 535 popularity, 542–543, 685 pseudonyms, 535 quality of health communication, 548 sex. See Sex and social media sexual references, 543 substance use references, 687 supportive environment, 703 users’ move from PC-based to mobile-based platforms, 535 Social media interventions. See Health promotion activities “Soldier of Fortune,” 653 “Staying Alive” campaign, 660 STI testing, 548 Stigmatized sexual behaviors, 545 Storytelling, 659 Street youth, 634, 638 Substance use/abuse, 684–697 alcohol screening, 692 contextual factors, 688 effects of media exposure, 685–687 individual differences, 688 parents, 688–691, 694 social media, 655, 658, 685–687 tobacco marketing, 650, 650t traditional media, 648, 650 Suicidal ideation, 675 Suicide, 567–568, 659 Sweeping generalizations, 537 T Technology obsolescence, 636 Teen Outreach Program with Media Enhancement (TOP4ME), 635 “Teen” pornography, 579 Teen Sexual Health Information (Facebook page), 676 Teenology 101 blog, 712–713, 713f Television. See Traditional media Theory of planned behavior, 636, 637t Thinspiration, 554

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3GT, 676 Thriving: Boston Children’s Hospital (blog), 712t Tinder, 544 Tinker v. Des Moines Independent School District, 593 Tobacco marketing, 650, 650t Todd, Amanda, 567–568 TOP4ME. See Teen Outreach Program with Media Enhancement (TOP4ME) Tort claims, 600–601 Traditional media, 645–652 aggressive behavior, 646–647 drugs, 648, 650 eating disorders, 651 health effects, 645t media violence, 646–647, 651–652 music marker theory, 651 need for new research, 651, 652 obesity, 650–651 sex, 648–649t storytelling, 659 video viewing audiences, 644f Tumblr, 535–536 TV watching, 651. See also Traditional media Twitter, 535–536, 538, 546 U Unauthorized forwarding of sexts, 600–601 University of Oregon’s sex ed app, 660 V Video games negative effects, 651–652, 653 positive effects, 658 Violent video games, 651–653 Virtual therapy sessions, 680 VKontakte, 534 W Wannabe anorexics (wannarexics), 555 WeChat, 534–536 Weibo, 534–536, 538 Weixin, 534. See also WeChat Wellness-related communities, 679 WhatsApp, 535 Wright’s acquisition, activation, application model (3AM), 578 Y Yahoo, 559 Youth Internet Safety Survey 3, 654 Youth Risk Behavior Surveillance Study, 634, 653 YouTube, 535

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Adolescent Medicine: State of the Art Reviews December 2014 Volume 25, Number 3 American Academy of Pediatrics Section on Adolescent Health Edited by: Victor C. Strasburger, MD; Megan A. Moreno, MD, MSED, MPH Adolescent Medicine: State of the Art Reviews helps you stay up-to-date in key areas of current clinical practice. This widely respected resource continues to deliver high-quality, evidence-based information needed for day-to-day diagnostic and management problem-solving.

Topics in this issue include Cyberbullying

ADOLESCENT MEDICINE: STATE OF THE ART REVIEWS

Social Networking & New Technologies

Sexting

Blogging

Electronic Health Records Facebook

Social Networking & New Technologies

Problematic Internet Usage

Online Safety

For other adolescent medicine and pediatric resources, visit the American Academy of Pediatrics online Bookstore at shop.aap.org/books.

DEC 2014 25:3

AAP

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