Physical health

Blue light exposure disturbs melatonin production, disrupting natural circadian rhythm and resulting in poor sleep7 which directly correlates with poor concentration, worsening school performance and delayed development.8 9 Childhood obesity is multifactorial, with screen time replacing physical activity, and increasing advertisement of junk food being directly associated with increased prevalence.10 Prolonged use of in-ear headphones, particularly high-volume use, is linked to a fivefold increase in long-term hearing morbidity.11

Misinformation (poorly sourced or lacking context) and disinformation (deliberate or malicious) relating to health, often result in detrimental impacts on medical compliance, including parents/carers refusing treatments for children.12

Online health forums enable groups with specific medical conditions to connect. While this may be beneficial for education, awareness and peer-to-peer support, misinformation is often shared. Interpreting misinformation without health literacy or personal medical context can lead to unfounded medical anxieties and inappropriate medical requests and expectations, termed ‘cyberchondria’.13 14

Mental health

Mental illness often presents atypically in children, frequently manifesting as behavioural concerns or physical symptoms.

Digital use activates dopamine-mediated reward pathways in the brain fuelling overuse and ‘digital addiction’ resulting in dysfunctional vitamin D and melatonin metabolism correlating with poor sleep, depression, inattention and low energy.15 16 Online platforms and gaming websites use personalised algorithms to exploit digital addiction.17

The ‘online self’ is created with an audience in mind; users feel pressured to meet social standards and expectations. Therefore, young people associate popularity online to personal adequacy affecting their self-esteem. Social media platforms have sophisticated software, allowing users to edit content, creating unrealistic body expectations leading to body dissatisfaction.18 ‘PRO-ANA’ websites further promote this ‘slim ideal’ providing advice about obtaining slim physiques including encouragement of anorexic and bulimic behaviours. This culture is significantly impactive, leading to increased body dissatisfaction and disordered eating.19

Young people can easily access pornography online, creating unrealistic views of sexual intimacy and healthy relationships, resulting in behavioural changes and clinical presentations concerning their ‘abnormal’ genitalia.20 21

Cyberbullying permits perpetrators to use internet anonymity to target victims, including ‘trolling’ where targeted hurtful or provocative comments are posted. These online behaviours are significantly associated with victim anxiety and depression.22

Deliberate self-harm is a leading cause of mortality in young people. Self-harm imagery is increasingly accessible online via hashtags and forums. Exposure, alongside peer-to-peer encouragement online, coincides with the rapid increase in paediatric self-harm.23 Nuanced risks are constantly evolving; including digital self-harm in which individuals target themselves with negative content online to self-inflict psychological distress or communicate psychological distress indirectly.24

Online safety

Internet anonymity poses significant risks for online exploitation of children. Online grooming occurs when perpetrators build trusting relationships, allowing manipulation, exploitation and abuse of victims. This may include sexual exploitation, with the sending or receiving of explicit images. Location tracking and poor privacy settings facilitate stalking behaviours and enable evolution of online connections into physical meetings creating significant safety risks.

Criminals target young people online coercing them into facilitating illegal contraband and drug smuggling—referred to as ‘county-lines’. Clinicians need a low threshold for raising concerns as these children travel between different counties and have limited contact with healthcare services.25 Radicalisation increasingly begins online, with extremist groups targeting vulnerable children, playing to their insecurities to convert them to extremist ideologies.

Digital history

Taking a full digital history in every consultation is impractical, therefore recognition of common digital harm outcomes should prompt further questioning.

In preadolescents, it’s important to start open conversations with parents determining their child’s screen time and online activities, making possible links to the presenting complaint.

In adolescent consultations, it’s important to ask sensitive questions one-to-one as parental presence may limit disclosure. Digital history can be explored using the HEADSSS assessment (box 1), for example, asking about device access and supervision in ‘home’, privacy settings in ‘safety’, screen time in ‘activities’ and potential inappropriate interactions and exposure in the sexual history.26

If concerns are apparent, the Social Media Disorder Scale may be used to further define the problem. There is both a 9-step screening version and a 27-step in-depth version that may be used to understand trends in behaviour and focus on specific problems.27

Different concerns may be discussed which warrant a more urgent response (table 2).

Please consider the case study in box 2.

Interventions

Investigation and management of digital harm requires a proactive multi-agency approach.

Red flags must be raised to local safeguarding leads to support onward referrals to social care. Reporting of adverse digital events is crucial to identify dangerous content. Online abuse and sexual exploitation should be reported via the Child Exploitation and Online Protection Command website.28 Alongside this, Childline’s ‘Report Remove’ tool allows confidential reporting and removal of sexual images.29 In instances where new or worsening mental health diagnoses are suspected, Child and Adolescent Mental Health Services referral is required.

To aid digital harm discussions, up-to-date awareness of what young people are accessing online is important, however, can be difficult due to the constant evolution of digital media. The NSPCC resource ‘Keeping Children Safe Online’ provides information for parents, carers and professionals regarding popular online sites.30 Websites such as ‘Internet Matters’—provide professionals with a helpline for advice regarding digital safety issues. In the UK, health professionals have access to the e-learning for health module: online safety and digital harm, providing in-depth information, case studies and learning points.31

Amber flags should be managed using a holistic multi-agency approach in conjunction with parents and carers. Involving education providers facilitates ongoing emotional support, addressing bullying concerns and providing digital safety teaching. Professionals can help families implement social prescribing measures, including screen-time recommendations of less than 2 hours daily, ‘prescribing’ screen-free activities and advising on safe and constructive internet use. Parents and carers should be signposted towards the following online resources:

• Digital five-a-day—positive internet use for creativity, connectivity and education as well as encouraging screen-free activities.32

• MindED—‘parenting in a digital world’ e-learning module.33

• NSPCC—‘keeping children safe online’—resource providing up-to-date information and advice on what to do if your child sees inappropriate content online and guidance on reporting harmful content.30

Young people should be encouraged to build digital resilience through an understanding of online safety, including the importance of adequate privacy settings, not engaging with strangers online, how to report and block inappropriate content and most importantly when to seek help from a trusted and informed adult.