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Internet use and health among children
and adolescents in the United States

by

Michele Ybarra, MPH PhD
Center for Innova...
Today’s talk outline
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General Internet usage data
Internet as a healthcare resource
Online experiences and rel...
Background

The first step in building a successful targeted
intervention online is to understand how
young people use the...
General Internet usage data
Youth Internet use characteristics
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

97% of youth between the ages of 12 and 18
use the Internet (UCLA Center for Comm...
Youth Internet use characteristics
(cont)
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The majority of youth use the Internet for an
hour or less a day (Finkelhor, ...
Internet activities



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95% of youth use the Internet for email
Rainie, & Lewis, 2002).

(Lenhart,

85% of teens use th...
Internet as a healthcare
resource
Internet use for health care
information
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Somatic health
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(Kaiser Family Foundation, 2001)

HIV/AIDS: 31%
Sexua...
Impact of online health
information
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53% have had a conversation with their
caregiver about what they learned (Rideout,
...
Online experiences and
relationships
Friendships online
Communication tool with ‘traditional’ peers
:
 67% talk with peers seen often
 46% talk with peers se...
Sharing information
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Self-disclosure
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(Finkelhor et al., 2000)

7% of youth sent a picture of themselves
to someone...
Cross-section of Internet and
mental health
Internet usage and depression


Most studies have reported that both crosssectionally (Ybarra, Mitchell & Wolak, 2005; Sa...
Odds ratio for reporting Internet harassment

Odds of Internet harassment given report of
depressive symptomatology

4
3.3...
Internet harassment by sex and
depressive symptomatology
Mild/no symptoms
Minor symptoms
Major symptoms

100%

80%

80%

8...
Review of Internet-based
interventions
(Ybarra & Eaton, 2005)
Advantages of Internet-based
interventions
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Cost-effective
Easy to scale up
Overcome some barriers to tradition...
The healthcare provider and
the Internet
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The Internet will never replace traditional
services.

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Because of it’s wide...
Online support groups
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Bring together a group of people with similar
interests / challenges to support each other in
the...
Online support groups


Demand for online support groups is high.



28% of a self-selected sample of online users in
th...
Online support groups
Comprehensive Health Enhancement Support
System (CHESS) is a replicable online support
including dis...
Group therapy for behavioral
change
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Tends to be more structured than online support
groups



Has a trained healthcare...
Group therapy for behavioral
change
Smoking cessation







(Schneider & Tooley, 1986).

Pilot study, N=16, motivated...
Group therapy for behavioral
change
Eating disorder prevention (Winzelberg et al., 2000)





Randomized control trial,...
Self-directed therapy


Similar to ‘bibliotherapy’



Individuals access the Internet site and work
through the modules ...
Self-directed therapy


Depression
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Overcoming Depression on the Internet
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

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(ODIN; Clarke et al., 2002)

8 module...
Self-directed therapy


Anxiety
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FearFighter (Kenwright, Liness, & Marks, 2001)




Aimed at reducing symptoms of an...
Self-directed therapy
Substance abuse prevention/early intervention:
 Coping matters (Matano, Futa, Wanat, Mussman, & Leu...
Self-directed therapy


Others being studied (National Institutes of Mental Health, 2005:
crisp.cit.nig.gov) :
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...
Synopsis of current literature
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The Internet is an influential environment that is
shaping and affecting youth tod...
Opportunities for future
research
Interventions tailored to
resource-poor populations
Given the relative cost-effectiveness of
scaling up Internet-based int...
Youth-based interventions
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Child-based Internet intervention research
online is lagging behind that of adults.



This ...
Conclusions


The Internet is an important new resource
for intervention and prevention efforts.



The web’s wide scope...
Conclusions


Early results suggest that behavioral
interventions can affect positive behavioral
change and self-efficacy...
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Internet use and health among children and adolescents in the United States

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  • 92% of 12-17 year olds use the Internet for emailing (Lenhart, Rainie, & Lewis, 2002). Further, it is frequently cited as the activity for which a young person uses the Internet (Finkelhor, Mitchell & Wolak).
    Health info includes HIV/AIDS (31%), drug or alcohol abuse (25%), sexually transmitted disease (24%), smoking (23%), pregnancy or birth control (21%) and depression or mental illness (18%).
  • Communication is the most popular
    ¾ of youth between 12 and 17 Instant Message (Lenhart, Rainie, & Lewis, 2002).
  • Communication is the most popular
    ¾ of youth between 12 and 17 Instant Message (Lenhart, Rainie, & Lewis, 2002).
  • Females are significantly more likely than males to search for health information online (Gould, Munfakh, Lubell et al., 2002)
  • These behaviors are associated with greater likelihood of Internet victimization (Finkelhor et al., 2000)
  • There is a suggestion that intensity of Internet use may be associated with depressive symptomatology; this requires further research
  • Females: OR: 1.32 p=.45
    Males: OR: 8.18, p<.001
    Self-reported depressive symptomatology is significantly related to the report of Internet harassment, especially for males:
    All youth: OR = 3.38, CI: 1.78, 3.45
    Among males: OR = 8.18, CI: 3.47, 19.25
    Among females: OR = 1.32, CI: 0.45, 3.87
    After adjusting for additionally significant characteristics, the association remains among otherwise similar males:
    Males: AOR = 3.64, CI: 1.16, 11.39
    Females: AOR = 0.90, CI: 0.27, 3.04
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • This may be because they can anonymously explore and share their feelings on a more intimate level than they might be able to in more traditional settings (Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Similarly, social factors such as race and physical attractiveness are neutralized (McKenna & Bargh, 2000). Online groups bridge many access issues (Farrell et al., 2003; Gutierrez G., 2001; NCI et al., 2001; Christensen et al., 2002a) such as transportation, health insurance, child care, and mobility challenge (e.g., chronic fatigue syndrome; multiple sclerosis) (Davison, Pennebaker, & Dickerson, 2000). Research indicates that people self-disclose a greater degree of sensitive information online compared to in-person (Newman et al., 1997). An early study of youth with serious emotional disturbance found that computer-based exchanges contained more expressions of feelings, more frequent discussion of inter-personal issues, and were generally less negative in expressive style (Zimmerman, 1987). Instead of being a cold and impersonal method of connecting with others, online support groups may represent a safe tool for emotional support.
  • ODIN: A randomized control trial of Overcoming Depression on the Internet (ODIN) (Clarke et al., 2002), an online, self-directed cognitive behavioral therapy for depression, has been conducted using an adult sample of members of a popular Health Maintenance Organization (www.FeelBetter.org). The site consists of eight modules: What is depression; What causes depression; Your thoughts and depression; Identifying irrational thoughts; Positive counter thoughts; Creating positive counter thoughts; The ABC method; Practicing tips and making it work. Additionally, a homework guide is available, as is a ‘Thought Helper’ that can be used to assist participants in identifying their negative thoughts and turning them into positive cognitions. Interactive cartoons are integrated into the text to engage the user.
    MOODGYM:Christensen and colleagues (Christensen, Griffiths, & Korten, 2002b) have designed a web-based cognitive behavioral therapy program for depressive disorder for adults. The MoodGym (moodgym.anu.edu.au) contains five modules: Why you feel the way you do, Changing the way we think, Changing warped thoughts, Knowing what makes you upset, and Assertiveness and interpersonal training. In the context of a cast of web-based fictional characters, the user works through the modules and a personal workbook that contains 29 exercises and assessments. Also included are an interactive game and a feedback form.
    CopingMatters (http://esap.stanford.edu/esp-scripts/firsttimeuser.html) is an online substance abuse prevention and early intervention program offered through employers (Matano, Futa, Wanat, Mussman, & Leung, 2000). Meant as a supplement to services provided by the organization’s managed care program, CopingMatters is aimed at moderate drinkers; persons identified as high-risk for alcohol abuse are referred to traditional services and therapy. The Internet program offers a self-assessment of one’s drinking behavior as well as stress levels. Participants receive educational information and access to ‘mini workshops’ that provide cognitive behavioral training, as well as strategies to cope with stress. An online journal and message board are also available for the user to explore his or her feelings and share thoughts with others. A randomized control study using employees of a large organization (N=8,567) in northern California is ongoing (Matano et al., 2000).
    FearFighter is an Internet-based intervention aimed at reducing the symptoms of anxiety disorder. There are four sections: Fear, panic and phobia (and educational piece about the disorder); Beating your fears, Managing your anxiety/panic, and real stories. Information on the website indicates that a randomized controlled trial is underway. A study was performed using a clinical sample of people with anxiety disorder who completed the intervention on a computer in a therapist’s office (Kenwright, Liness, & Marks, 2001). A high drop out rate was observed (41%), with the greatest number leaving the study following the exposure homework goals. Based upon intent-to-treat analyses however, anxiety scores significantly decreased for participants at the study’s end; alleviation of symptoms was similar to that of the patient population utilizing traditional therapy methods at the same clinic during the same period. How these results extend to the Internet intervention is unclear.
  • ODIN: A randomized control trial of Overcoming Depression on the Internet (ODIN) (Clarke et al., 2002), an online, self-directed cognitive behavioral therapy for depression, has been conducted using an adult sample of members of a popular Health Maintenance Organization (www.FeelBetter.org). The site consists of eight modules: What is depression; What causes depression; Your thoughts and depression; Identifying irrational thoughts; Positive counter thoughts; Creating positive counter thoughts; The ABC method; Practicing tips and making it work. Additionally, a homework guide is available, as is a ‘Thought Helper’ that can be used to assist participants in identifying their negative thoughts and turning them into positive cognitions. Interactive cartoons are integrated into the text to engage the user.
    MOODGYM:Christensen and colleagues (Christensen, Griffiths, & Korten, 2002b) have designed a web-based cognitive behavioral therapy program for depressive disorder for adults. The MoodGym (moodgym.anu.edu.au) contains five modules: Why you feel the way you do, Changing the way we think, Changing warped thoughts, Knowing what makes you upset, and Assertiveness and interpersonal training. In the context of a cast of web-based fictional characters, the user works through the modules and a personal workbook that contains 29 exercises and assessments. Also included are an interactive game and a feedback form.
    CopingMatters (http://esap.stanford.edu/esp-scripts/firsttimeuser.html) is an online substance abuse prevention and early intervention program offered through employers (Matano, Futa, Wanat, Mussman, & Leung, 2000). Meant as a supplement to services provided by the organization’s managed care program, CopingMatters is aimed at moderate drinkers; persons identified as high-risk for alcohol abuse are referred to traditional services and therapy. The Internet program offers a self-assessment of one’s drinking behavior as well as stress levels. Participants receive educational information and access to ‘mini workshops’ that provide cognitive behavioral training, as well as strategies to cope with stress. An online journal and message board are also available for the user to explore his or her feelings and share thoughts with others. A randomized control study using employees of a large organization (N=8,567) in northern California is ongoing (Matano et al., 2000).
    FearFighter is an Internet-based intervention aimed at reducing the symptoms of anxiety disorder. There are four sections: Fear, panic and phobia (and educational piece about the disorder); Beating your fears, Managing your anxiety/panic, and real stories. Information on the website indicates that a randomized controlled trial is underway. A study was performed using a clinical sample of people with anxiety disorder who completed the intervention on a computer in a therapist’s office (Kenwright, Liness, & Marks, 2001). A high drop out rate was observed (41%), with the greatest number leaving the study following the exposure homework goals. Based upon intent-to-treat analyses however, anxiety scores significantly decreased for participants at the study’s end; alleviation of symptoms was similar to that of the patient population utilizing traditional therapy methods at the same clinic during the same period. How these results extend to the Internet intervention is unclear.
  • FearFighter is an Internet-based intervention aimed at reducing the symptoms of anxiety disorder. There are four sections: Fear, panic and phobia (and educational piece about the disorder); Beating your fears, Managing your anxiety/panic, and real stories. Information on the website indicates that a randomized controlled trial is underway. A study was performed using a clinical sample of people with anxiety disorder who completed the intervention on a computer in a therapist’s office (Kenwright, Liness, & Marks, 2001). A high drop out rate was observed (41%), with the greatest number leaving the study following the exposure homework goals. Based upon intent-to-treat analyses however, anxiety scores significantly decreased for participants at the study’s end; alleviation of symptoms was similar to that of the patient population utilizing traditional therapy methods at the same clinic during the same period. How these results extend to the Internet intervention is unclear.
  • CopingMatters (http://esap.stanford.edu/esp-scripts/firsttimeuser.html) is an online substance abuse prevention and early intervention program offered through employers (Matano, Futa, Wanat, Mussman, & Leung, 2000). Meant as a supplement to services provided by the organization’s managed care program, CopingMatters is aimed at moderate drinkers; persons identified as high-risk for alcohol abuse are referred to traditional services and therapy. The Internet program offers a self-assessment of one’s drinking behavior as well as stress levels. Participants receive educational information and access to ‘mini workshops’ that provide cognitive behavioral training, as well as strategies to cope with stress. An online journal and message board are also available for the user to explore his or her feelings and share thoughts with others. A randomized control study using employees of a large organization (N=8,567) in northern California is ongoing (Matano et al., 2000).
  • Several additional studies aimed at testing the effectiveness of Internet-based therapy are currently being conducted. Clarke and colleagues have a grant from the National Institutes of Health to pursue Internet-based cognitive behavioral health interventions for mental disorders among youth, specifically depression and behavior problems (National Institutes of Mental Health, 2003). Severson and colleagues (National Institutes of Mental Health, 2003) are testing a pre-existing video-based parenting intervention for use on the Internet. Parents of children in Head Start who are randomized to the treatment group will receive computer and Internet access in the home, and access to the parenting intervention on the Internet. Support will be provided via home visits and phone calls by ‘parent coaches’. Sullivan is converting a book-based tobacco prevention program (“Family Matters”) for online delivery. Four booklets and a health educator component. Litz and colleagues are testing a cognitive behavioral therapy for survivors with Post Traumatic Stress Disorder following the attack on the Pentagon on September 11th, 2001 (National Institutes of Mental Health, 2003). Participants randomized to the treatment group will receive intensive input from a therapist during a single, in-person therapy session, and then directed to a systematic series of self-directed homework and educational activities online. Rotondi and colleagues (National Institutes of Mental Health, 2003) are also implementing an Internet-based intervention for families and individuals suffering from schizophrenia. Following an in-person workshop focused on symptom management and daily functioning, participants have access to six online modules that integrate individual and family therapy strategies.
    From Greg Clarke’s abstract: This application proposes to develop and pilot several variants of Internet WWW mental health "self help" skills training sites for children, adolescents and parents. The two main interventions will address adolescent depression and child behavior problems, as representatives of internalizing and externalizing disorders. The development process will involve piloting these skills-training Web interventions in several representative settings--a large non-profit HMO, a public health clinic, and in public schools--while integrating them with more traditional health care delivery. Users will be permitted to log onto the interventions Web sites from the home or work settings as well. Using both qualitative and quantitative data, we will evaluate the acceptability and satisfaction with these interventions from the perspective of users (patients themselves), providers, and other pertinent stakeholders in each of the settings listed above. We will also conduct effect-size and effect-size variability estimates of the impact of these interventions on both clinical outcomes as well as health care utilization and costs, as a preliminary to conducting full randomized controlled trials. The research team will build on their experiences developing and evaluating several in-person psychotherapy treatments, an Internet depression intervention for adults, and an interactive multimedia software for assessing and intervening with disruptive behavior disorders. This proposed Internet-based intervention development application is significant because (1) Web-based interventions may help address unmet need, and overcome barriers to mental health service; (2) The intervention takes a public health perspective that is unusual in mental health. There will likely be low intensity intervention effects, but because the program will be available to a much larger percentage of the population than typically receives person-to-person services, the overall population effect is likely to be of significant magnitude; (3) The low intensity nature and low incremental cost of delivery of the Web-based interventions suggest that they may be cost-effective; (4) The proposed web interventions address a gap in the existing pool of mental health resources on the Internet at the present time, because they will provide access to Internet-appropriate versions of rigorously tested, research based interventions.
    Severson: There is a need for validated, low-cost parenting interventions that can reach populations of at-risk households. Internet based programs can reach an increasingly large number of parents and provide a unique channel of access. This project will adapt an existing empirically proven video-based parenting program, the Incredible Years Series (Webster-Stratton, 1984), for delivery via the Internet enhanced with home visits. Internet programs can be interactive, personalize information based on participant characteristics and interests, provide a high degree of choice and flexibility, and provide social support from peers and professionals. Using an experimental design we will evaluate the impact of the interactive Internet parent training intervention as compared to usual-care (control) among parents in rural and urban low-income preschool children. After screening four-year-old children from five Head Start programs in Oregon for high risk aggressive conduct disorder behaviors, 180 families will be randomized to either the intervention or control conditions with 90 families from each of two consecutive cohorts. All families will be provided with a computer and Internet connection to provide for computerized data collection and control for the effects of the introduction of new technology in families with low-incomes. Parent coaches will make home visits and phone calls to assist parents with the use of the computer and questions/concerns about the program. Parenting practices will serve as the primary outcome, augmented by measures of child social behavior. Subject characteristics and process measures will be examined as predictors or mediators. Latent growth models will be used to evaluate contextual variables and parenting variables that may be predictive of concurrent and longitudinal measures of child behaviors. Cost-effectiveness analysis of the intervention will be performed to determine the net benefits to participants in relation to the costs of conducting the intervention. A Spanish-language version of the program will be developed for a pilot evaluation with parents whose primary language is Spanish. The proposed design will provide important practical information about the feasibility and effectiveness of an Internet parenting intervention in effecting both parenting behavior and child behavior over a three year period.
  • Transcript of "Internet use and health among children and adolescents in the United States"

    1. 1. Internet use and health among children and adolescents in the United States by Michele Ybarra, MPH PhD Center for Innovative Public Health Research Mbarara University, Department of Pediatrics, Grand Rounds, 2005, Mbarara, Uganda * Thank you for your interest in this presentation.  Please note that analyses included herein are preliminary. More recent, finalized analyses may be available by contacting CiPHR for further information.
    2. 2. Today’s talk outline       General Internet usage data Internet as a healthcare resource Online experiences and relationships Review of Internet-based interventions Opportunities for future research Questions
    3. 3. Background The first step in building a successful targeted intervention online is to understand how young people use the Internet.
    4. 4. General Internet usage data
    5. 5. Youth Internet use characteristics   97% of youth between the ages of 12 and 18 use the Internet (UCLA Center for Communication Policy , 2003) Home Internet access (US Department of Commerce, 2002)   Half of youth 10-13 years old 61% of youth 14-17 years old
    6. 6. Youth Internet use characteristics (cont)  The majority of youth use the Internet for an hour or less a day (Finkelhor, Mitchell & Wolak, 2000; Woodard, 2002);   14% spend three hours or more per day online (Ybarra, Mitchell & Wolak, 2005). Boys and girls are equally likely to have used the Internet (Rideout, Foehr, Roberts & Brodie, 1999)
    7. 7. Internet activities   95% of youth use the Internet for email Rainie, & Lewis, 2002). (Lenhart, 85% of teens use the Internet for school work (US Department of Commerce, 2002)  76% of older teens (15-17 y.o.) have searched for health information (Kaiser Family Foundation, 2001)
    8. 8. Internet as a healthcare resource
    9. 9. Internet use for health care information  Somatic health     (Kaiser Family Foundation, 2001) HIV/AIDS: 31% Sexually transmitted diseases: 24% Pregnancy or birth control: 21% Mental health   Drug and alcohol abuse: 25% Depression or mental illness: 18-23% (Kaiser Family Foundation, 2001) Foundation, 2001; Rideout, 2001)   Violence: 23% Suicide: 12% (Rideout, 2001) (Gould, Munfakh, Lubell et al., 2002) (Kaiser Family
    10. 10. Impact of online health information  53% have had a conversation with their caregiver about what they learned (Rideout, 2001)  41% have changed their behavior (Kaiser Family Foundation, 2001)  14% have sought healthcare services (Rideout, 2001)
    11. 11. Online experiences and relationships
    12. 12. Friendships online Communication tool with ‘traditional’ peers :  67% talk with peers seen often  46% talk with peers seen infrequently (Ybarra, Mitchell & Alexander, 2005) Communication with online peers :  56% have talked with a ‘stranger’ online  16% have formed a close friendship with someone met online (Ybarra, Mitchell & Alexander, 2005; Finkelhor et al., 2000)  3% have a close online friendship with an adult
    13. 13. Sharing information  Self-disclosure   (Finkelhor et al., 2000) 7% of youth sent a picture of themselves to someone else online 11% of youth posted personal information (e.g., home address) online
    14. 14. Cross-section of Internet and mental health
    15. 15. Internet usage and depression  Most studies have reported that both crosssectionally (Ybarra, Mitchell & Wolak, 2005; Sanders, Field, Diego et al., 2000; Gross, Juvonen, Gable, 2002) and longitudinally (Kraut, Kiesler, Boneva, 2002), general Internet usage* does not significantly differ by the report of depressive symptomatology. *the average number of days / week a youth is online
    16. 16. Odds ratio for reporting Internet harassment Odds of Internet harassment given report of depressive symptomatology 4 3.38*** 3 2 1.37 1 Mild or no symptoms (Reference) Minor depressive-like symptoms Major depressive-like symptoms
    17. 17. Internet harassment by sex and depressive symptomatology Mild/no symptoms Minor symptoms Major symptoms 100% 80% 80% 83% 80% 60% 60% 40% 20% 21% 19% *** 14% 12% 6% 14% 8% 3% 0% Not harassed Females Harassed Not harassed Males Harassed
    18. 18. Review of Internet-based interventions (Ybarra & Eaton, 2005)
    19. 19. Advantages of Internet-based interventions      Cost-effective Easy to scale up Overcome some barriers to traditional services: stigma, anonymity, transportation, cost Ensures fidelity of intervention Self-paced and allows the user to tailor the intervention to them
    20. 20. The healthcare provider and the Internet  The Internet will never replace traditional services.  Because of it’s wide reach however, the Internet can enhance the care received from providers.  Also, the Internet may provide services or information for people who would not otherwise access care for various reasons: stigma, transportation/distance to clinic, money, etc.
    21. 21. Online support groups  Bring together a group of people with similar interests / challenges to support each other in their behavior change efforts.  Similar to traditional support groups  Anonymously explore feelings  Social factors neutralized
    22. 22. Online support groups  Demand for online support groups is high.  28% of a self-selected sample of online users in the United States indicates that their online searches are mostly for online support groups (Boyer et al., 2002).
    23. 23. Online support groups Comprehensive Health Enhancement Support System (CHESS) is a replicable online support including discussion groups, resource area, etc. Reported outcomes for HIV (Boberg, Gustafson, & Hawkins, 1995) and breast cancer (Gustafson et al., 2001; Gustafson et al., 1998) modules include significant improvements in:       Emotional health, Cognitive functioning, Quality of life measures, Relationship with their provider, Confidence in making decisions, and Information competence
    24. 24. Group therapy for behavioral change  Tends to be more structured than online support groups  Has a trained healthcare provider ‘leading’ group
    25. 25. Group therapy for behavioral change Smoking cessation     (Schneider & Tooley, 1986). Pilot study, N=16, motivated to quit Online support group moderated by a mental health professional. Enhanced with 4-week self-directed behavior management program (e.g., self-report diary of smoking, supportive messages) 5 participants were abstinent 90 days post-quit, a rate similar to many traditional programs
    26. 26. Group therapy for behavioral change Eating disorder prevention (Winzelberg et al., 2000)    Randomized control trial, N=60, college woman at risk 8-week structured intervention with a moderated-led psycho-educational component. Discussion group, self-monitoring journals, and behavior monitoring exercises. Intervention group had significantly lower drive to be thin and improved body image 3 months postintervention.
    27. 27. Self-directed therapy  Similar to ‘bibliotherapy’  Individuals access the Internet site and work through the modules on their own.
    28. 28. Self-directed therapy  Depression  Overcoming Depression on the Internet    (ODIN; Clarke et al., 2002) 8 modules, homework guide, “thought helper” Depressive symptomatology similar between intervention and control groups at RCT study end. MoodGYM (Christensen, Griffiths, & Korten, 2002:    5 modules, homework, interactive game Significant decreases in depressive and anxiety symptomatology observed pre-post test among selfselected sample. Ybarra and colleagues are preparing to modify MoodGYM for adolescents :
    29. 29. Self-directed therapy  Anxiety  FearFighter (Kenwright, Liness, & Marks, 2001)    Aimed at reducing symptoms of anxiety disorder. 4 sections: Fear, panic, phobia, and education Clinical sample using the program while in an officesetting:  Significant symptom alleviation pre-post test;  Results similar to traditional therapy.  High drop-out rate.
    30. 30. Self-directed therapy Substance abuse prevention/early intervention:  Coping matters (Matano, Futa, Wanat, Mussman, & Leung, 2000)     Offered through employers Supplement traditional services from managed care organization Aimed at moderate drinkers RCT (N=8,567) ongoing
    31. 31. Self-directed therapy  Others being studied (National Institutes of Mental Health, 2005: crisp.cit.nig.gov) :      Parenting skills intervention (Severson et al.); Youth problem behavior (Clarke et al); Child / family tobacco use prevention (Sullivan et al.); PTSD (Litz et al.); and Families and individuals affected by schizophrenia (Rotondi et al)
    32. 32. Synopsis of current literature    The Internet is an influential environment that is shaping and affecting youth today The Internet is a powerful tool that can modify the behavior of some youth Adult Internet-based behavioral interventions have reported positive results
    33. 33. Opportunities for future research
    34. 34. Interventions tailored to resource-poor populations Given the relative cost-effectiveness of scaling up Internet-based interventions, this is a yet-untapped resource that could be integrated into a comprehensive prevention and intervention programs in resource-poor settings.
    35. 35. Youth-based interventions  Child-based Internet intervention research online is lagging behind that of adults.  This is ironic given the large numbers of youth online and the general integration of Internet technology into the daily lives of our youth (UCLA Center for Communication Policy, 2003).
    36. 36. Conclusions  The Internet is an important new resource for intervention and prevention efforts.  The web’s wide scope represents an opportunity to reach people that may not otherwise seek treatment either because of stigma, access to providers, or need for privacy.
    37. 37. Conclusions  Early results suggest that behavioral interventions can affect positive behavioral change and self-efficacy.  As the Internet continues to grow in popularity, innovative and rigorous research is needed to utilize its technology as an aid in public health approaches to youth-based health treatment and prevention.
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