CHAPTER 7

Counseling Families About Internet Use

Alan Tomines, MD

The internet is a worldwide system of interconnected computer networks. At its inception, it was the exclusive domain of the military and academia; currently, the internet is a public gateway to electronic information, communication, and commercial services. The internet has profoundly changed the way we learn, work, play, and interact with others. It has become an integral part of the education and socialization of children, making it an influence of interest for parents, physicians, and researchers. The physician can provide pragmatic counsel to families that focuses on the benefits and risks of the internet, strategies for safer use, and assessment of online behavior in adolescents. The physician should also be prepared to discuss health information that families find on the internet.

A Brief History of the Internet

The internet began in the 1960s as the Advanced Research Projects Agency Network (ARPANET), a US Department of Defense project to share government-funded, university-based computer resources across a reliable communications network. Through the 1970s, ARPANET found acceptance with academics and researchers as a conduit for the exchange of scientific information, in large part because of the newly developed email technology for sending and receiving messages.

Recognizing the potential of the ARPANET, the National Science Foundation (NSF) began a parallel effort to connect the computer science departments at universities that were not affiliated with ARPANET. Initially called the Computer Science Network (CSNET) and later renamed NSF Network (NSFNET), this new network further expanded the exchange of scientific information. In 1990, ARPANET was retired, and many of its networks were absorbed into NSFNET. The resulting network, which was renamed the “Internet,” extended its reach into the business sector and to international researchers but remained relatively inaccessible to the lay public.

During the early 1990s, the European Organization for Nuclear Research (known as CERN) developed protocols to facilitate the sharing of physics research data over the internet. These protocols allowed the sharing of computer files composed of text and images as documents that could be viewed using a special computer program called a “browser.” This system of linked documents was collectively dubbed the World Wide Web or simply “the Web,” with related collections of documents referred to as web pages or websites. In 1993, CERN made its work freely available, resulting in the rapid proliferation of publicly accessible commercial and personal websites—a model that has continued to the present day.

Internet Services and Concepts

Internet access usually is obtained through an internet service provider (ISP), a company that has an internet connection that it shares with consumers on a subscription basis. The most commonly used internet services are email and the Web. A person actively using an internet service is said to be “online.” Use of the Web is sometimes referred to as surfing and is facilitated by search engines, such as Google and Bing, that use keywords or topics to find relevant documents, images, websites, or other services on the internet.

Internet services may be accessed by a wide range of computing devices, from traditional personal and laptop computers to mobile platforms, such as tablets and smartphones (cell phones that provide access to internet services). Smartphones and tablets access scaled-down versions of web-based content via specialized applications commonly referred to as “apps.”

Because of their popularity in the pediatric age group, a few internet services are worthy of physicians’ notice. Web logs (or blogs) are web-based journals. Like a traditional paper-based journal, a blog supports the written presentation of activities, thoughts, or feelings. A blog that is delivered using video usually is referred to as a video blog (or vlog). Blogs and vlogs may be public (available for anyone to read) or private (having restricted access).

Social networking websites, such as Facebook, Twitter, and Instagram, are similar in content to blogs and vlogs, with the added dimension that users are encouraged to create a network of online friends by establishing links to other users’ social networking accounts. Blogs, vlogs, and social networking websites are examples of asynchronous services in which communication between users does not have to take place in real time and the content of which may be moderated and censored by the owner of the service for appropriateness.

By contrast, chat rooms are internet venues that permit the synchronous (ie, real-time) exchange of text messages between multiple simultaneous participants. Chat rooms as independent entities have largely been supplanted by other similar synchronous technologies, including direct messaging communication offered through social networking websites as well as instant messaging, a popular premium service often offered with smartphones. Although sometimes referred to as “text messaging,” instant messaging (IM) is a more inclusive term that reflects the immediacy of interaction as well as the expansion of content exchanged to include multimedia, such as images or audio and video files.

The aggregate of synchronous and asynchronous social networking internet services is collectively referred to as social media. The ready accessibility of internet access, the portability of internet-ready devices, and the convenience of social media apps makes it possible to have a continuous online presence.

Internet Benefits and Access

The physician should be able to identify the benefits of internet use. The internet provides access to a wealth of educational resources and cultural experiences. Access to these resources allows children to exercise their reading, writing, information-seeking, and technology skills. The internet also provides the opportunity to easily communicate with family and friends. Additionally, children with common interests can use internet services to commiserate with and encourage other children. For example, the social networking websites Ben’s Friends (www.bensfriends.org) and Rareshare (https://rareshare.org) connect patients with uncommon medical conditions to help them share their collective experiences.

The physician may also actively participate in reducing disparities in internet access. Internet use and access is correlated with socioeconomic status. Although currently most households have access to a computer with access to the internet, millions of individuals do not have access. The pediatrician may help families gain access to the internet by identifying institutions that provide safe online environments, such as libraries, community centers, and schools. As patient-centered internet-based health interventions are increasingly being studied as a supplement to traditional health care delivery, addressing disparities in internet access may help bridge gaps in care in underserved communities.

The physician should also be aware that children with disabilities may have difficulty using the internet without assistive technology, that is, hardware or software designed to improve the accessibility of computers. Children with visual impairment or blindness may be aided by the use of special software, including screen magnifiers, braille embossers, or screen readers (ie, software that uses a computer-generated voice to read email and web pages), although many websites are not compatible with screen readers. Children with hearing impairment or deafness may be aided by ensuring that their computers are set to provide visual cues rather than audio prompts; typically, such functionality is built into operating systems. Children with mobility or dexterity challenges may have difficulty using a traditional keyboard and mouse; alternative keyboards and pointing devices, computer touch screens, and tablet devices can be suggested as supporting technologies. Pointing devices that use sound or infrared beams, as well as software that responds to the spoken word, may be viable alternatives in cases in which manual control is not possible.

Internet Threats

Although the internet has many benefits, being online entails some risks. The physician should be able to inform parents and guardians about the threats posed by the internet.

To understand internet threats, it is helpful to recognize that the internet has neutral properties that do not cause threats but that allow them to exist. First, the internet is anonymous: People may not be who they represent themselves to be. Second, the internet is interactive: Unlike traditional media (eg, newspapers, radio, television), the internet user may have real-time interactions with another person, or with sophisticated computer programs that respond as if human. Third, the internet has few restrictions: Anyone can put almost anything on the internet, without regard to credibility or appropriateness. Finally, the internet is public and permanent: Although information on a website may be removed, it is possible for anyone who visits a website to make an electronic copy of what is there, and many websites are archived and may be retrievable from websites, such as the Internet Archive (http://archive.org), long after their removal from internet search engines.

Although these properties of the internet are neutral, they enable some of the most common internet threats: exposure to strangers and/or predators; interpersonal victimization; exposure to pornography; and participation in online gaming, gambling, and shopping.

The anonymity and interactivity of the internet enables online predators. More than one-third of adolescents online have “friends” whom they have never met in person. Approximately three-fifths of adolescents active online have received an instant message or email from a stranger, and approximately 1 in 6 has been contacted by someone who made them feel scared or uncomfortable. More than 90% of teenagers have shared personal information about themselves online, including name, birth date, interests, and contact information.

Online interpersonal victimization is the receipt of harassment or unwanted sexual attention over the internet. One-fifth of children have reported being victimized; 1 factor that places individuals at high risk for victimization is talking about sex with someone online. Cyberbullying is a specific type of online interpersonal victimization consisting of receipt of electronic communications that are harmful or threatening. Cyberbullying may be as prevalent online as “traditional” bullying, with nearly one-fifth of middle school–age children reporting that they had been cyberbullied at least once in the previous 12 months. Approximately 88% of teenagers have witnessed other people being mean or cruel online, with 21% saying that they have joined in.

Although children may be individually targeted by strangers or cyberbullies, they may also passively encounter undesired internet content. More than 40% of children reported having been exposed to pornography online, and nearly two-thirds of those children described this exposure as unwanted. In adolescents between the ages of 15 and 17 years, more than 70% reported accidentally being exposed to online pornography, with a risk factor for exposure being the downloading of images.

Sexting is the exchange of sexually explicit text, images, or multimedia, generally via IM. Sexting sits at the convergence of pornography and cyberbullying, with the added danger that some adolescents may not perceive sexting as harmful or threatening. In some jurisdictions, minors who have participated in sexting have been charged with possessing child pornography.

In addition to the aforementioned threats, recent studies point to the internet and digital media use as having a role in addictive behavior and attention-deficit/hyperactivity disorder as well as in detracting from healthy behaviors, such as physical activity and adequate sleep. With the wide variety of benefits of and threats posed by the internet, the physician should be prepared to provide parents and guardians with strategies for appropriate and safe internet use.

Strategies for Appropriate Internet Use

The physician may assist parents and guardians with promoting appropriate internet use by informing them of the benefits and threats, helping them set guidelines for screen time and content, and encouraging them to be active participants with their children online. Parents or guardians who may not be technically savvy or may require basic instruction on internet use may be advised of the availability of classes offered by libraries, schools, and community groups.

The American Academy of Pediatrics (AAP) has provided age-specific guidance for the use of digital media, including the internet. These recommendations include the avoidance of most screen media for children younger than 18 months; limiting screen use to 1 hour per day for children ages 2 through 5 years; and consistent time limits for children age 6 years and older, specifically identifying activities that are not allowed. The AAP offers a Family Media Plan tool (www.healthychildren.org/English/media/Pages/default.aspx) to assist parents and guardians in creating developmentally appropriate plans for managing digital media use.

By sharing time online, parents and guardians can promote and model responsible internet behavior. These adults should talk with their children about what they see together on the internet and encourage children to share what they have experienced when online alone, whether good or bad. Placing the computer or other internet-enabled device shared by the family in a public location in the home will encourage the idea that the internet is a shared experience; however, caregivers should be aware that mobile devices allow children to access the internet independently and covertly.

Parents and guardians should set and enforce house rules for internet behavior. Children should be encouraged to be good citizens, including not doing anything that may be hurtful to others and not plagiarizing information that they find freely on the internet. Children should not communicate with or plan to meet strangers known only to them through the internet, nor should they respond to messages that are unsolicited or that make them feel uncomfortable. Children should not share personal information or pictures with others on the internet, nor should they download files from the internet. For older children, safety pledges can be used as formal agreements of acceptable use.

To facilitate parental or other caregiver oversight of internet use, the physician should advise that computers and mobile devices may be configured to allow internet access only during certain hours of the day and to disable access to the internet after a specified amount of time has elapsed. As possible, children should be provided with a separate account to access devices and the internet. Having a separate account promotes autonomy for older children while allowing parents or guardians to restrict internet content. Monitoring software automates tracking of internet usage by creating a reviewable record of websites and images viewed, messages sent and received, and even individual keystrokes entered. The potential benefits of monitoring software should be weighed against the invasion of the child’s privacy, and parents and guardians should understand that some children are savvy enough to erase their internet browsing history; consequently, the absence of a web browsing history may be a cause for suspicion. Parents and guardians should also regularly monitor IM activity on smartphones.

Strategies for Safer Internet Use

Although encouraging appropriate use and behavior is important to enjoying the benefits of the internet, the physician should also recommend the use of internet safety tools to protect against inappropriate use and external threats.

Software to protect malware is not directly targeted to children, but it is something about which parents and guardians should be aware. Malware generally includes viruses and worms (ie, software programs that can corrupt the information saved on a computer), spyware (ie, software that tracks internet activity and sends this information to another person), and pop-ups (ie, a new browser window that may contain marketing or other undesired content). Viruses and worms are generally downloaded as attachments in email, whereas spyware and pop-ups are introduced by surfing the Web. Attempts should be made to protect against spam (ie, unsolicited email) as well, which may contain undesired content or solicitations.

Filters are special computer programs that allow the presentation of acceptable internet content and that block content deemed to be inappropriate. Filtering may use 1 or more of the following methods: “blacklists” of websites that are specifically blocked; “white lists” of websites that are specifically permitted; the blocking of specific words or terms; and the maturing technology of blocking suspicious image content. Filters are neither perfectly specific nor perfectly sensitive and may require adjustment by the parent or guardian to achieve an acceptable level of filtering. Parents and guardians may contact their ISP to enable server-side filtering (ie, filtering of content before it enters the home). If server-side filtering is too restrictive for some members of the household or not sufficiently restrictive for others, a client-side filtering approach may be considered, in which filtering software is installed directly on computers or mobile devices. Client-side filters work with standard web browsers, although special child-oriented web browsers may be acquired that have client-side filtering built in.

When a child encounters inappropriate internet content or messages that are hurtful or distressing, parents and guardians should alert their ISP as well as the owner of the website on which the content was or messages were discovered. As appropriate, the parent or guardian should also contact the appropriate legal authorities and the National Center for Missing & Exploited Children (www.missingkids.com). Commercial websites that collect personal information from children younger than 13 years are required to follow the Children’s Online Privacy Protection Act of 1998, which is enforced by the Federal Trade Commission. According to this law, internet website operators must post their policy indicating what personal information is collected, how that information will be used, and if that information will be shared with a third party. Parents or guardians must consent to the collection and use of personal information and may revoke this consent at any time.

Additional internet safety information is available to families through reputable web-based resources, such as the Federal Trade Commission resource OnGuardOnline (www.onguardonline.gov), the National Center for Missing & Exploited Children’s NetSmartz Workshop (www.netsmartz.org), iKeepSafe (www.ikeepsafe.org), and INOBTR (“I Know Better”) (www.inobtr.org). Parents and guardians should also be aware of other venues in which their children may access the internet, such as schools, libraries, and friends’ homes, and they should find out what internet safety policies and technologies have been instituted in these environments.

Adolescents on the Internet

Most adolescents have access to the internet from home, and many more may gain access to the internet at school or at a friend’s house. Additionally, 95% of adolescents report that they have access to a smartphone, and 45% report that they have a nearly continuous online presence. Parents and guardians should be aware that adolescents who have excessively restrictive internet rules at home are more likely to attempt internet access outside the home, where it may be more difficult to monitor their activity.

Adolescents have mixed views on the effect of the internet, specifically social media, on their lives. Approximately 45% of adolescents believe that social media has neither a positive nor a negative effect, approximately 30% describe its effect as mostly positive, and nearly 25% describe its effect as mostly negative. Open parent-/guardian- child communication about internet use should be encouraged so that adolescents feel that they can discuss what they see on the internet with their parent or guardian without jeopardizing their internet access privileges.

Adolescents may engage in risky online behaviors, including communicating with and planning to meet strangers in person. Based on review of past cases, the Federal Bureau of Investigation has identified specific behaviors that may indicate a child is engaging in risky online behaviors, including spending several hours online, especially at night; having pornographic images on the computer; turning the monitor off or quickly changing the screen when a parent or other caregiver enters the room; and using unrecognized user names or accounts. Other offline behaviors that should arouse suspicion include telephone calls from unknown adults, outgoing calls to unrecognized telephone numbers, gifts or packages received, and unexplained credit card activity.

The physician should consider addressing online activities in the adolescent psychosocial review of systems. Asking adolescents about online activities may unveil risky online behaviors or provide an opportunity to discuss concerns about their health and well-being. Nearly one-third of adolescents have searched the internet for health information, often related to sex and sexually transmitted infections, nutrition, and exercise and fitness. Adolescent girls in particular have a tendency to search for information on physical abuse, sexual abuse, and dating violence as well. Online activities worthy of inquiry include health topics searched for on the internet, which social networking accounts the adolescent has, sharing personal information on the internet, communicating with strangers, meeting people known only via the internet, and engaging in (or being a victim of) cyberbullying or sexting. Adolescents should also be reminded that the internet is not private and that colleges and employers may discover information about the adolescent on what appear to be “private” social networking pages.

Health Information on the Internet

Patients regard physicians as the preferred and most trusted source for health information; however, patients increasingly seek out health information on the internet before, or sometimes in lieu of, consulting with their physician. It is important to remind families that health information on the internet may be outdated, incomplete, incorrect, intentionally misleading, or easily misinterpreted. When a patient has questions about information found on the internet, the physician should take care not to disregard the information outright. These inquiries provide opportunities to educate the patient and address issues of concern, and the patient may value the physician’s opinion of the information.

The physician may support patients by suggesting evidence-based health information resources on the internet, such as the AAP’s official website for parents (www.HealthyChildren.org); the US National Library of Medicine website MedlinePlus (www.medlineplus.gov); the Centers for Disease Control and Prevention (www.cdc.gov); and the US Department of Health and Human Services (https://healthfinder.gov). The specialist should be prepared to identify online information sources and support groups, particularly for rare, chronic, or debilitating conditions. The physician should caution families caring for children with special medical conditions about the characteristics of less reliable online resources or support groups, which may include novel or alternative treatment regimens, advice to stop treatment, or charging of fees for participation or treatment.

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