HEADSS up: Adolescents and the Internet

Abstract

INTRODUCTION

The Internet contains a tremendous amount of unregulated information. Internet use gives adolescents access to a wide variety of information and communication devices, and may be associated with certain risks.

OBJECTIVE

To provide health care professionals with information on adolescent Internet use and its associated risks.

DISCUSSION

Ninety-four per cent of Canadian youth surveyed nationwide in 2005 reported having Internet access in their homes. Parents and health care providers need to educate themselves on issues of Internet safety. The divergent means by which adolescents are using the Internet and the inherent risks associated with unsupervised and uneducated use are addressed. Parents and teenagers are provided with tips for safe Internet use, and health care providers are offered sample questions pertaining to adolescent Internet use.

SUMMARY

A large proportion of adolescents use the Internet daily. Studies examining the risks of online exposure in this age group are evolving. Awareness of the range of applications and information available online will facilitate counselling on appropriate Internet use.

The World Wide Web has evolved into an information highway that allows unlimited, and in many cases unrestricted, access to information. A nationwide survey conducted in 2005 revealed that 94% of Canadian youth have Internet access in their home, up from 79% in 2001 (1). The Internet’s impact and influence on adolescent life is far-reaching and its application has grown enormously within the past decade.

It can be difficult to appreciate all of the issues adolescent patients face. The HEADSS (Home, Education, Activities, Drugs, Sex and sexuality, and Suicide and mood) interviewing strategy enables health care providers to explore psychosocial parameters and identify specific risk and protective factors in adolescents (2). It allows for a graduated nonjudgmental progression in history taking.

The present article will use the familiar HEADSS interviewing strategy to organize many of the multifaceted issues that pertain to adolescent Internet activity. It is hoped that the information presented will serve to both educate providers about the diversity of information available online and help engage adolescent patients in these challenging areas. The HEADSS acronym will be divided into individual sections, with individual discussions on Internet use as it applies to adolescent life. A second ‘E’ will be added to address issues of eating and nutrition. Sample questions that may help health care providers with this task have been provided in Table 1. A companion parent’s information sheet has also been provided (Table 2).

TABLE 1.

Sample questions pertaining to adolescent Internet use

Home

Does your family have a computer in your house? If so, how many and what type? Where are they situated? Which computer do you use most frequently? Does your family have access to the Internet? Who in the family uses the Internet? Where do you go online? Are there rules for Internet use in your house? If yes, what are they and how are they monitored? How much do you think your parents know about the Internet?

Education

Have you used the Internet for school projects before? In what way? Have you ever used the Internet to answer a question you had? What kinds of questions? Did you find the answer? Have you ever been confused by something you read about online? In what way? Can you think of an example?

Eating and Nutrition

Have you ever used the Internet to find answers to questions you may have had about nutrition or food? Have you ever seen or read information online about diets or nutrition? What kind of information?

Activities

People use the Internet for many different reasons. What types of activities do you use the Internet for? How much time do you spend on the Internet? Do you use instant messaging? If yes, how many contacts are in your buddy list? What percentage of those people have you met or talked with in person? Do you have your own blog or Web site? Does it have a name? Are there pictures of yourself or friends on your Web site or blog? How about personal information? Have you visited chat rooms while online? What kind of experience has this provided? Have you ever experienced unwanted or hurtful messages while using e-mail or instant messaging? How so? Do you use your computer or the Internet to play games? What types of games? Have you ever gambled or made bets using online games?

Drugs

Have you ever used the Internet to answer questions that you might have had about drugs or other substances? Did you find your answer? Were there any questions that you couldn’t answer?

Sexuality

Sometimes adolescents have questions about sex or sexuality. Have you ever used the Internet to try and find answers to any of these types of questions? Have you ever experienced any unwanted sexual material onthe Internet? Do you have any questions about any sexual material that you might have seen or heard others talk about that can be found on the Internet? Did you know that there are certain things on the Internet that are illegal to look at? Can you give me an example of something you might be able to think of?

Mood, suicide and safety

Have you ever come across information on the Internet that has dealt with death or dying? If you’re feeling down or unsafe, how do you let other people know how you are feeling?

TABLE 2.

Tips for parents that encourage Internet safety

Educate yourself about the Internet. Establish rules and expectations for Internet use. Review these regularly. Talk to your teenagers about how to be safe while online. Encourage open discussions about instant messaging, blog postings and Web site development. Encourage your teenagers to ask questions about information they find online that they are unsure about. Adolescents should be aware that online information may not always be true, and at times can be quite dangerous (health tips, for example). Keep computers/laptops and webcameras in high traffic areas within the home. Talk to your adolescent about why it is dangerous to post personal information online. Limit online activity to times that facilitate indirect supervision. Talk to your teenagers about cyber bullying. Encourage them to come to you if they encounter a problem while online. If there are concerns about your adolescent’s online viewing practices, install password-protected security filters.

HOME

Although adolescents are prone to log on to the Internet whenever connections are available, most frequently they do so from the comfort of their own homes. One-quarter of American youth that go online at home do so in the privacy of their rooms (3). The recent trend toward wireless connections also facilitates private use. Canadian youth that have access to their own computer report almost twice as much online activity than those who share a computer (1).

Educating teenagers and parents is an important step in the effective and safe use of the Internet. In a recent cross-sectional study (4) examining adolescents’ self-report on Internet safety, 25% of respondents reported unsafe experiences online. Almost 75% of all Canadian students surveyed reported the presence of household rules pertaining to Internet use (1). The presence of such rules has been shown to impact adolescent online exposure. As an example, 17% of Canadian youth in grades six and seven with household rules for Internet use reported visiting sites containing pornography, gore or hate material, compared with 43% of age-matched youth that visited such sites in houses that did not have any such rules (1). Computer placement in high traffic areas within the home can help facilitate online monitoring. Homes that contain desktops (as opposed to laptops) are also more likely to be placed in high-traffic areas, which enables indirect supervision.

Asking questions about family Internet use can help introduce a nonthreatening discussion about general Internet use. As with any adolescent interview, it is important to establish a rapport with the patient before delving into personal and specific questions.

EDUCATION

Many high schools and universities have added online courses, assignments and testing to their curriculum. Although the number of adolescents going online is increasing across all ages, there is an obvious surge in grade seven students (80% of grade seven students versus 60% of grade six students online) (3). Seventy-two per cent of Canadian adolescents surveyed in 2005 reported using the Internet for school purposes, and almost all of these individuals go online daily (1). In fact, most interviewed teenagers and parents report that the Internet’s role in the completion of school projects is vital, and that online resources have replaced the need for library visits (5). Given the ease of transfer of information online (ie, copy and paste), teenagers need to be educated about copyright laws and the risks associated with such infringement. A survey completed in 2001 revealed that 18% of high school students surveyed admitted to knowing someone that had used the Internet to cheat on a paper or test (5).

The Internet also plays an important role in how adolescents educate themselves about confidential and specific health matters. Over 50% of Canadian youth surveyed on Internet use reported using the Internet to access information on matters other than school work (1). In a recent study (6) on diabetes self-education in children and adolescents, 42% of respondents had searched for diabetes information on the Internet, and 97% anticipated future use. Similarly, approximately 50% of adolescent respondents (n=2026) of a German telephone survey with Internet access reported using the Internet to look for advice or information about health or health care (7).

Adolescents need to be educated on how to maximize their appraisal and analysis of the legitimacy of online information. Health care providers are a pivotal link in the provision of skills required to critically appraise online information and identify pertinent and useful health information, links and services.

EATING AND NUTRITION

There are an abundance of nutritional Web sites available online. Many are aesthetically appealing and easy to use, but they can often provide inaccurate nutritional information (8). A study (9) involving Ontario youth in 2003 found that information on body image and nutrition ranked second only to disease-specific information in terms of adolescents’ expressed need for further information on health-related topics.

Practitioners involved in the management and treatment of adolescents with eating disorders need to be sensitive to the diverse range of nutritional information available online. Specifically, physicians should be aware of the existence of pro-anorexia (or pro-ana) Web sites. These sites contain information that promote and support anorexia nervosa, and contain themes that deal heavily with issues of control, success and perfection (10).

ACTIVITIES

The spectrum of activities available online continues to grow exponentially. Instant messaging (IM), downloading music, playing games and Web site surfing were identified as the most common activities undertaken by Canadian youth in 2005 (1).

Instant messaging

The Internet has had a significant impact on the manner in which adolescents (and adults) communicate. Technologies such as e-mail and IM have created a new social context for communication that has been embraced by adolescents. For many, e-mail has replaced traditional means of correspondence. IM is a text-based tool that allows users the opportunity to chat online with others that are simultaneously online. Adolescents regularly use IM as a means of direct communication, replacing the need for telephone conversations. The use of IM was the most popular activity noted overall by Canadian youth surveyed in 2005 regarding online activities of choice (1).

Instant messaging is often used to “hold difficult conversations” because it affords protection from emotional reactions. One problem with IM is that a user’s true identity remains protected. There are obvious risks associated with this fact. Of note, 52% of Canadian youth have pretended to be a different age while online, and 25% pretend to have different personality traits, abilities and appearances (1). Safety tips specific to IM or chat room use have been provided in Table 3 (11). One vital safety tip regarding adolescent Internet activity is that first-time meetings with unknown ‘internet buddies’ should not occur unsupervised. Some adolescents may choose to proceed with such meetings despite the risks. In such cases, a harm reduction approach would encourage meetings to occur in high traffic settings during daylight hours with other friends present. Guardians should absolutely be informed of such visits. Open communication between parents and their teenagers around such issues may help prevent conflict and decrease potential risk.

TABLE 3.

Internet safety tips for adolescents

Talk with your parent/caregiver about Internet expectations. Keep your true identity private. Never post personal information in public cyber places. Avoid posting pictures of yourself or friends on Web sites or in chat rooms. Assume that any information you post online will be available for anyone to see or read. Avoid unsupervised first-time meetings with cyber buddies. Let others know if you experience unwanted or hurtful material while online. Remember that people online may not be who they say they are. Remember that information on the Internet is unregulated and there are many Web sites that contain information that is both dangerous and illegal.

Chat rooms

Chat rooms allow for the ‘real-time’ exchange of text messages between groups of Internet users. Most chat rooms are completely unsupervised and unmonitored. The safety tips outlined above for IM also apply to chat room use.

Cyber bullying

Cyber bullying has recently received increased media focus and is an evolving concern. A British survey in 2002 (12) found that one in five youth aged 11 to 19 years had experienced some form of bullying via their computers or cell phones, including death threats. Seventy-five per cent of those bullied stated that they knew the bully, and more concerning, over 25% reported that they told no one of the incident(s). Almost 10% of Canadian youth surveyed on Internet use stated they had been bullied over the Internet within the past school year (1). Because bullying tends to occur in the absence of adult supervision, the Internet has become the perfect tool for reaching others anonymously.

Adolescents should be aware that certain online activities are considered criminal acts. Specifically, it is considered a crime to communicate with someone for the purpose of causing them to fear for their own safety or the safety of others. Posting information designed to insult or damage a person’s reputation could also be subject to criminal charges. As well, spreading hateful or discriminatory information based on race, national or ethnic origin, colour, religion, age, sex, sexual orientation, marital status, family status or disability is considered a violation of the Canadian Human Rights Act (13).

Web sites, blogs and live journals

Many adolescents create and develop individual Web sites, a large number of which are hosted by free Internet Web sites providers. Recently, blogs and live journals have increased in popularity. Blogs and live journals are easy-to-use Web sites that allow users to post thoughts and/or pictures (similar to online diaries). Interactions are also possible with outside users. Postings are available for anyone to see.

Discussions and education regarding the potential impact and risk of posting personal information and/or pictures online should be undertaken routinely with adolescent patients.

Webcameras

One in five Canadian youth surveyed in 2005 owned a personal webcamera (or ‘webcam’) (1). Adolescents should be counselled about the dangers of transmitting live visual feeds into unknown areas and posting other identifying data that could be used to trace their whereabouts. As with most harm reduction strategies, education about how these activities increase the risk of unwanted solicitation and adverse outcomes is key.

Online gambling

It has become clear over the past two to three years that the field of gambling has embraced the technical revolution occurring online. Increased access to this technology fosters the risk of ‘technological addictions’ (14). One of the major issues yet to be addressed with respect to Internet gambling is that of underage gambling. At least two studies (15,16) have suggested that young regular Internet users are more likely to gamble while online. Twelve per cent of Canadian youth surveyed on Internet activities reported visiting gambling sites within the past year (1). Paediatricians, in their quest to educate themselves about their patients’ online behaviours, need to include specific questions directed toward these activities.

Online gaming

The video game industry is a multibillion dollar business that has been driven by regular advancements in computer technology. Real-time three-dimensional graphics are now commonplace, and multiplayer, online, role-playing video games are more popular than ever. A cross-sectional study (17) of seventh and tenth graders in California who reported end-of-day Internet use revealed that a small subgroup of adolescent males were involved in heavy online gaming. Concerns with heavy online gaming include increased exposure to violence (through video games), increased sedentary activity, decreased time devoted to other activities, and cyber addiction. A cohort study (13) in 2004 looking at attributions of a specific gaming population found that almost 20% of adolescents sacrificed other hobbies, sleep and their education/work to play video games.

Internet usage

Adolescents regularly use (or ‘surf’) the Internet to gather information on news, sports, weather, consumer products and other areas of personal interest. Many health care providers are naive with respect to the diversity of information available online, both good and bad. Recent media attention focusing on Web sites that promote, for example, terrorism or recipes for explosives run the risk of attracting curious adolescents interested in seeking more information on such topics. The associated risk of visiting such Web sites can be addressed with broader conversations on Internet surfing and safety.

DRUGS

The Internet contains an enormous amount of information on the recreational use of psychoactive and illicit substances. It also allows the means of arranging for both the purchase and delivery of substances, including alcohol and marijuana. Use of IM is one of the easiest ways to conduct such activities. Materials required for drug use (eg, pipes and bongs) are readily available for purchase online with no identification requirements. Online recipes are not limited to food and beverages; drug recipes (eg, how to make cannabis brownies) are easily found using basic search techniques. A small cross-sectional survey recently published in Pediatrics (18) examined the effect of the Internet on drug-use knowledge, attitudes and behaviours in a small cohort of adolescents being managed for substance abuse. All of the participants reported that Internet-based information had affected the way in which they had used psychoactive substances. Another study in 2000 revealed that 24% of college students surveyed stated they had used the Internet to obtain information on illicit substances, and 27% felt that such information increased the likelihood that they would use drugs (19).

SEX AND SEXUALITY

There is a tremendous range of information available online with respect to sexuality. This ranges from information on sexual health resources to online pornography. Forty-four per cent of online youth have reported Internet use specifically for sexual health information (20). A survey of 412 socioeconomically and ethnically diverse tenth graders from New York found that information on sexual health and sexually transmitted infections comprised two of the top three most frequently researched health topics (21).

Searching for answers to sexual health questions online allows the user an avenue to avoid the embarrassment and intimidation that can often be present during a visit to a health care provider (22).

The issue of pornography and its impact on youth and adolescence continues to evolve. In a Kaiser Family Foundation survey regarding Internet health information searches (a random telephone survey of 1209 youth aged 15 to 24 years), 70% of those aged 15 to 17 years reported having been exposed to pornographic material unintentionally (20). Two-thirds of teenagers and parents report that they do things online that they would not want their parents to know about (23). Data from the Youth Internet Safety Survey (24) revealed that adolescents that seek pornography online and offline were much more likely to be male, with only 5% of self-identified seekers being female. Most of the youth identified (87%) were 14 years of age or older. Evidence-based studies in the area of pornographic impact on adolescents are lacking. Physicians should be aware that the extent of material available for ‘free viewing’ is extremely diverse, and often does not represent society’s perception of ‘normal’ sexual activity. Adolescents should be counselled about this if the matter is broached. As well, issues of the legality in the viewing of certain materials should be reinforced (eg, child pornography). Specifically, adolescent Internet users should be aware that ‘IP activity’ (eg, the activity from an individual’s Internet home address) can be tracked by service providers as well as authorities. Parents or care providers that have concerns about online pornographic viewing can be encouraged to install password-protected filters onto their home computers that serve to limit such exposure.

Recently, media attention has focused on the very serious and real threat of online luring and online sexual exploitation of minors. Adolescents should be educated about the direct risks of allowing themselves to be photographed or taped in a sexual manner. Educating adolescents about the protection of their identity and privacy while online is key if the victimization of vulnerable youth is to be prevented.

SUICIDE AND MOOD

Unfortunately, when it comes to online information about suicide and self-harm, there are many Web sites that provide disturbing and potentially harmful information. Under these circumstances, the Internet provides an avenue for isolated or depressed youth to seek out others with similar feelings and/or experiences. Self-harm in adolescents is becoming increasingly common (25). A recent study examining the diversity of such information online identified more than 400 self-injury message boards, most of which were populated by adolescent females (26). These investigators concluded that such message boards run the risk of normalizing and encouraging self-injurious behavior as well as adding potentially lethal behaviours to the repertoire of established adolescent self-injurers. There is debate as to whether young adolescents should be questioned directly about their participation on such message boards, given the risk of introducing a potentially harmful activity. Exploring this area with questions on how and why such behaviours began may serve as a better approach, and may allow for an avenue to discuss further concerns.

SUMMARY

The Internet is here to stay. Internet access will only continue to improve as technology advances. Physicians need to educate themselves on the great diversity of applications that are currently available and be aware of the potential impact Internet use and exposure can have on adolescents. Studies examining the risks of online exposure in adolescents are evolving. Adolescents need to be aware that much of the information contained on the World Wide Web is unregulated and, in some cases, potentially harmful. The anonymity associated with the Internet allows an avenue for exploration of identity and sexuality issues, but education on such matters is key. Issues of privacy protection and the critical appraisal of information obtained online should be addressed with all adolescents. Health care providers should attempt to embrace some of the innovative communication tools that are currently available as a means of promoting and improving health awareness in their adolescent patients.