NICE, France — Novel initiatives that collaborate with adolescents to create safe spaces for discussion and prevention can dramatically reduce adverse outcomes due to online threats, such as cyberbullying and websites that promote harmful behaviors, including eating disorders (EDs) and suicide, say leading experts.
A symposium dedicated to these issues was conducted here at the European Psychiatric Association (EPA) 2018 Congress.
In the first presentation, Andrea Fiorillo, MD, PhD, Department of Psychiatry, University of Campania “Luigi Vanvitelli,” Naples, Italy, noted that cyberbullying is an increasing problem that can have a greater impact on youth mental health than abuse from family members.
Initiatives that work on an individual, school, and public health policy level can help reduce online victimization, he said. These range from promoting empathy to providing supportive environments and making legislative changes.
In the second presentation, Danuta Wasserman, MD, PhD, National Center for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden, described how exposure to information about suicide methods and behavior, coupled with pathologic levels of Internet use, can increase suicide risk.
This can be tackled head-on by creating online support groups that help young people form positive online attachments. In addition, a role play–based, in-school program run by Wasserman has cut youth suicide rates in half.
Finally, Max Birchwood, PhD, professor of youth mental health, University of Birmingham, United Kingdom, demonstrated how a school- and app-based online intervention could be used to identify young people at risk of transitioning to EDs.
Scientific Proof
Session cochair Martina Rojnic Kuzman, MD, PhD, associate professor of medicine, Zagreb University Hospital Center, Croatia, told Medscape Medical News that although it has been known for “quite a long time” that the Internet can pose problems for young people in terms of cyberbullying, cybersuicide, and websites that promote anorexia, there is now a scientific evidence base that proves it.
“All the presenters, after identifying these problems, presented some very good interventions that could actually work on all the problems,” said Kuzman. “There are, of course, very many problems that are worrisome, but the Internet can be exploited to provide good solutions to these problems.”
She added that the Internet should not be a replacement for personal relationships.
“The Internet is a service. And I think that people, parents, schools should really help by building social models influencing damaging behavior [on the Internet] rather than maybe just fighting against the Internet,” said Kuzman.
Opening the session, Fiorillo told meeting attendees that cyberbullying is becoming a priority not only for mental health professionals but also for society in general.
He pointed to a number of recent cases worldwide, including that of “Dolly” Amy Jayne Everett, a 14-year-old Australian girl who appeared in advertisements for Akubra Hats. She killed herself after constant online bullying and harassment.
Fiorillo explained that cyberbullying is different from normal bullying because it is a “constant phenomenon” that can be carried out 24 hours a day, 7 days a week. Moreover, it is cloaked by the anonymity of the Internet, and numerous children can be bullied at the same time by a single perpetrator.
Children tend to be reluctant to report that they are being victimized, regardless of whether they are bullied via public comments or private messages and photographs.
A recent study estimated that between 20% and 40% of children have been cyberbullied, although the prevalence is difficult to determine because of a lack of consistent definitions, the heterogeneity of study methods, and differing reports from perpetrators and victims.
Still, it is clear that females are more likely to be victims, that bullies tend to be males, and that cyberbullying often occurs in two waves — the first in persons aged 10 to 11 years, and the second in persons aged 15 to 16 years, said Fiorillo.
Google a “Brain Changer”
Cyberbullying is particularly a problem in adolescents, because the brain and mental health of adolescents are influenced not only by genes but also factors such as social networks, social behaviors, and epigenetic phenomena, he added.
Moreover, during the past 20 years, the Internet, smartphones, and computers have been added to other factors, such as stress and the use of substances, that can influence the maturation of certain brain regions. These regions include the limbic region and the frontal and prefrontal cortices, which tend to develop later than other areas.
“Google is changing our brains,” said Fiorillo, “and the social brain is now much different from the one we used to know in the past, where social interactions were more direct and not mediated by computers.”
This relates to the interplay of genes and environment, in which the use of smartphones and computers by parents, as well as such factors as maternal diet, substance use, and stressful events, are “disrupting family relationships.”
In addition, “many young people are using smartphones, laptops, computers, and so on before going to sleep,” said Fiorillo. He noted that this can influence melatonin levels in early childhood, which can then affect adolescent behavior.
Victims of cyberbullying tend to have low self-esteem, depression, emotional and peer problems, and internalizing problems. Cyberbullies tend to have conduct problems, hyperactivity, low prosocial behavior, and externalizing problems.
A recent UK study showed that children who are bullied but who don’t suffer maltreatment from family members are more likely to have depression and anxiety during adulthood than those who experienced child abuse but weren’t bullied. Another UK study showed that bullying is a major cause of psychosis in adolescents.
“So this is a very important and massive challenge for mental health professionals,” potentially more so than physical or other forms of abuse, he said.
Interventions at All Levels
Fiorillo noted that the prevention and management of cyberbullying require interventions on individual, family, organizational, and public health levels. These include asking children about their online life and working with other health professionals, such as pediatricians, to identify problems.
A number of policy initiatives have been established across Europe, including educational programs and training workshops, the dissemination of materials to schools, and the promotion of a protective environment at schools.
Fiorillo noted that in countries with “legislative components on cyberbullying,” the odds ratios of reports of being cyberbullied are 25% lower than in countries where such policies have not been enacted.
On the individual level, affective and cognitive skills should be addressed to reduce participation in cyberbullying. Plus, empathy training courses may be important, given the lack of nonverbal cues online, Fiorillo said.
“Also, families can play a role,” he said. In addition to monitoring children’s computer use, “it’s important that we limit our time on screen when we are at home, particularly during the weekend.
“Cyberbullying is, I think, a serious challenge for mental health, particularly in children and adolescents who have a delicate brain,” he said. “There is the need to develop and implement ad hoc interventions…for victims but also for bullies.”
Cybersuicide
In her talk on cybersuicide, Wasserman reported that although suicide rates are decreasing, almost one death from suicide occurs every 40 seconds, with an estimated rate of 800,000 suicide deaths annually.
Wasserman noted that cybersuicide means suicide or suicidal ideation or attempts that are associated with websites and other sources of information that give vulnerable individuals, especially adolescents and even young children, information about various ways to commit suicide or harm themselves.
The Internet is a “powerful tool” for informing young people about suicide methods, “which means that you can read about everything,” said Wasserman. Such information includes which methods do and do not work and what to use and not use.
Although it is still rare, the Web has been used to make so-called suicide pacts, whereby two people use the Internet to plan to commit suicide together. The Web can also be used to stream a live broadcast of a suicide.
“There are quantitative studies showing that seeing media portrayals on the Internet contribute to the awareness of what to do and what method to use,” said Wasserman.
One study showed that between 2004 and 2017, there was an increase in blogs and discussion forums on suicide-related topics, as well as an increase in the number of specific sites that evaluated suicide methods and in the number of dedicated suicide sites.
During the same period, there was a decrease in the number of formal sites to help prevent suicide. Wasserman said this is worrying, “because it is very important to have help sites that are well designed and appealing to young people.”
This is particularly notable, because a correlation has been shown between pathologic Internet use, suicidal ideation, and nonsuicidal self-injury.
Creating Safe Spaces
It is estimated that more than 4% of adolescents in the European Union use the Internet in a pathologic way, which is defined as using it for more than 5 hours per day for uses other than schoolwork.
Pathologic Internet users were often not living with a biological parent or relatives, their parents or guardians were often unemployed, and/or their parents did not pay attention to them or know what their children did in their free time.
Wasserman said that individuals who are suicidal report spendng much more time online, are more likely to develop online personal relationships, and are more likely to use online forums.
“This is important…because their attachment is very disturbed and they have difficulties in having attachment to the therapist or maybe positive attachments with teachers and other peers,” she said.
“But they have better attachments online, which means that we can use this medium for starting dialogue and constructive individual therapy, and maybe also social therapy, which means that we have opportunities for prevention.”
Wasserman also introduced an evidence-based prevention program that she runs called Youth Aware of Mental Health. This 5-hour school-based program provides adolescents with a safe space within the classroom, with the goal of increasing understanding and empathy.
Three hours of role play are included within two interactive discussion sessions, in which participants are allowed to add their own role playing. “Many children have added cyberbullying and how to increase coping and increase empathy,” Wasserman said.
A study of 11,110 adolescent participants from 168 schools in 10 European countries showed that the program was associated with a significant 55% reduction in incident suicide attempts and a 50% reduction in incident severe suicidal thoughts and plans.
Overall, suicide and cybersuicide can be prevented, “but we need to have more dedicated, young researchers to tailor Internet-based communication and preventive forums, and not only have cognitive-behavioral therapy,” she concluded.
“Social Contagion”
In the session’s final presentation, Birchwood noted an increase in use of social media sites to promote anorexia as a lifestyle.
“Some of my colleagues in the University of Exeter argue that there’s a form of social contagion taking place, promoting thinness and anorexia as a lifestyle,” he said.
Birchwood reported that along with “some rather pernicious ‘pro-ana’ and ‘thin-spiration’ ” websites, Instagram banned five hashtags because of their impact on young people. However, there were already more than 27,000 posts on the site with the thin-spiration hashtag and 130,000 posts with the ‘bonespo’ hashtag.
Birchwood said that although the age at onset for anorexia nervosa is usually 18 years, its origins lie in early adolescence, with dieting behavior a key indicator. Although the early-stage recovery rate can be as high as 80%, recovery after 10 years is low.
To examine whether social media and the Internet can be used in a positive way to assess the prevalence of partial or full EDs in adolescents aged 13 to 14 years and to predict transition to incident cases, he and his colleagues worked with six schools in the United Kingdom.
The investigators used the schools’ existing computer clusters and developed an online app, collectively termed the SchoolSpace, to monitor the emergence of health difficulties among 13- to 14-year-olds recruited over 2 years in four 6-month waves.
The participants were administered a range of questionnaires to assess eating behaviors, anxiety, depression, self-esteem, emotional regulation, dieting habits, body esteem, the use of food rules, and body mass index.
A total of 2060 adolescents were recruited in the four waves; consent levels were almost 100%. The proportion of girls was between 42% and 52%.
The researchers identified 94 participants with moderate or severe ED. Of those, 44 had established ED, and 50 transitioned to ED during the course of the study. They were compared with 532 nontransitioners who did not develop or have an ED.
Results showed that dieting behavior was related to ED and transitioning and that such behavior was increased prior to transitioning. Pretransitioners had high levels of emerging depression and anxiety and low self-esteem.
Disordered eating behavior, as determined on the basis of the Eating Disorder Examination Questionnaire (EDEQ), was significantly associated with transition to ED (hazard ratio [HR], 3.03). Using the Adolescent Dieting Questionnaire, intermediate and extreme dieting were also both associated with transitioning to an ED (HRs, 10.28 and 21.45, respectively).
Receiver operating characteristics curve analysis revealed that a value of 2.962 on the EDEQ was the best predictor of later transition to a form of ED.
The study is “an example of how it is possible to use the Internet and an online presence in a positive, collaborative way with schools and young people to promote mental health and, particularly and crucially, to use it to identify those individuals who are at high risk of developing eating disorders,” said Birchwood.
The researchers have disclosed no relevant financial relationships.
European Psychiatric Association (EPA) 2018 Congress. Presented March 4, 2018.
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