Mental health practitioners who work with young people need to be aware of the benefits and harms associated with online activities. There is a spectrum of benefits (e.g., adaptive responses to stress; Modecki et al., 2022) and harms (e.g., increased mental health symptoms; Sohn et al., 2019; and suicide/self-harm; Robinson et al., 2015) associated with online activities for young people (Throuvala et al., 2019). This means there are a broad range of challenges to consider when addressing potential problematic online [s]elf-control and activities. Given the complexities involved with online activities and the limited resources and skills of many parents and teachers (O’Reilly et al., 2018), mental health practitioners are ideally positioned to ask young people safely yet curiously about their online activities.

There is little guidance for practitioners to approach conversations with young people about their online activities (Biddle et al., 2022). One approach guides the assessment of online activities (Carson et al., 2017), but was published five years ago and is therefore dated in an ever-changing online environment. This guide is based on the clinical and research experiences of three authors and focuses on what to ask adolescents about their online activities. As such, they did not include adolescents in the development of the guide and therefore critical aspects of the assessment process may have been overlooked. Moreover, when, and how to ask these questions are absent. New guidelines for mental health practitioners that are developed in consultation with young people about discussing online activities and expand upon what questions to ask to include when and how to ask them are required. A recent study led by Lucy Biddle in Bristol aimed to identify preliminary good practice indicators covering who, what, when, and how practitioners can have useful conversations with young people regarding their online activities (Biddle et al, 2022).

Methods

A mixed-methods Delphi study was used. The Delphi methodology draws upon consensus of expert opinions to answer a research question (Barrett & Heale, 2020). This study involved iterative rounds of quantitative and qualitative data collection from two panels of experts: mental health practitioners (e.g., psychiatrists, psychologists, nurses) from England and Wales (n = 21; 18 Females) and young people aged 13-22 years (n = 22; 17 Females). Three rounds of questionnaires contained statements initially generated through engagement research with mental health practitioners and young people that looked at four core domains of conversing with young people about online activities – who and when, how, what, and outcomes. In each round, participants anonymously rated statements on a 1-5 Likert scale (strongly agree – strongly disagree) with open-ended questions and text boxes provided for additional comments. After each round, analysis clarified, developed, and refined statements and emerging perspectives based on consensus (i.e., 75% [strongly] agree/disagree) among participants. Preliminary good practice indicators were identified for inclusion through statements that reached consensus in both panels.

Results

A total of 27 good practice indicators about how mental health practitioners should engage with young people about online activities were identified from 135 statements. These indicators are categorised and presented below in the table according to ‘who and when’, ‘how’, ‘what’, and ‘outcomes’.

Category	Good practice indicators (paraphrased for brevity)
Who and when	Practitioners should ask all young people about online activities at their first consultation and again at regular intervals. Red flags (e.g., changing patterns/secrecy of device use, sudden change in presentation, disturbance of mood or behaviour) may indicate a particular time that is helpful to ask about online activities.
What	Topics should include activities and content viewed (e.g., gaming, social media use, viewing graphic violence content), online experiences (e.g., cyberbullying, radicalisation, doxing), patterns of use (e.g., frequency, time and time of day spent online, impact on sleep), and specific topics for young people with disordered eating (e.g., pro-ana’ websites) and self-harm/suicidal thoughts (e.g., methods). Also include the names of sites visited, content created, and participation in online groups, and encourage reflection on their behaviour and impact of these behaviours.
How	Conversations should take place within broader conversations with young people without parent(s)/guardian(s) present. Further, clinicians should, explicitly discuss confidentiality, address fears of ‘judgement’, normalise and acknowledge first the benefits and positive aspects of online activities and second the potential harms. Clinicians should be up to date with the online world.
Outcomes	Clinicians should encourage the young person to actively take care of themselves online whilst supporting online usage in a more positive way with online safety included into treatment/safety plans (e.g., strategies to prevent harmful impact on mental health). Several choices of apps can be recommended with recommendations followed up to see if helpful or not. Online activity that is of concern for individuals aged under 12 years old should also be followed up with parents included in the conversation.

Conclusions

This study provides good practice indicators for mental health practitioners to engage with young people to help them become more aware of their online activities in a safe and curious manner. In doing so, it helps to outline the who, when, what and how for clinicians enquiring about internet use in young people.

Strengths and limitations

The good practice indicators are timely given the lack of guidance for mental health practitioners in what is an ever-increasing online world. Importantly, the indicators empower young people in relation to their online activities rather than simply focusing on restriction. This study used a mixed-method Delphi study with consensus from two groups of experts – service end-users and service deliverers – which is critical for developing a robust set of indicators. Questionnaires were completed anonymously thus encouraging the expression of ideas and opinions whilst avoiding dominant personalities and/or hierarchical status(es) (Winkler & Moser, 2016).

The authors acknowledge the lack of diversity, the geographic restrictions to England and Wales, and exclusion of topics such as pornography and online gambling. However, an additional limitation is that surveys may have been influenced by survey fatigue given that Delphi survey items should be minimised to enable completion within 30 minutes (Belton et al., 2019). This may have resulted in statements excluded which otherwise may not have been excluded. That said, the adequate number of people on the panels of experts likely mitigated this limitation.

Implications for practice

The findings of this study offer practitioners clear and practical indicators for conversing with young people about their online activities. Whilst these indicators have been developed with practitioners and young people, they have not been ‘road-tested’. We do not know how useful they may be. We do know, however, that they place the mental health practitioner in the driver’s seat for testing. Only through trying can we further learn what works and what may not be as useful.

Lesbian, gay, bisexual, transgender young people experience increased rates of online peer and sexual victimisation (Ybarra et al., 2015), and are more likely to have online-only friends which can be both beneficial and harmful (Massing-Schaffer et al., 2022). This suggests their online activities are different to young heterosexual people. Further, lesbian, gay, bisexual, transgender young people experience increased discrimination, injustice, and stigma that negatively impacts their mental health compared to their heterosexual counterparts (Chan et al., 2022). Taken together, future research opportunities include developing bespoke indicators for these populations. Indicators can be further clarified, developed, and refined for all young people’s benefit.

Statement of interests

No conflicts of interest.

Links

Primary paper

Biddle, L., Rifkin-Zybutz, R., Derges, J., Turner, N., Bould, H., Sedgewick, F., Gooberman-Hill, R., Moran, P., & Linton, M. J. (2022). Developing good practice indicators to assist mental health practitioners to converse with young people about their online activities and impact on mental health: a two-panel mixed-methods Delphi study. BMC Psychiatry, 22(1), 1-15.

Other references

Barrett, D., & Heale, R. (2020). What are Delphi studies? Evidence-Based Nursing, 23(3), 68-69.

Belton, I., MacDonald, A., Wright, G., & Hamlin, I. (2019). Improving the practical application of the Delphi method in group-based judgment: A six-step prescription for a well-founded and defensible process. Technological Forecasting and Social Change, 147, 72-82.

Carson, N. J., Gansner, M., & Khang, J. (2018). Assessment of digital media use in the adolescent psychiatric evaluation. Child and Adolescent Psychiatric Clinics, 27(2), 133-143.

Chan, A. S. W., Wu, D., Lo, I. P. Y., Ho, J. M. C., & Yan, E. C. W. (2022). Diversity and inclusion: Impacts on psychological well-being among LGBTQ community. Frontiers in Psychology, 13:726343.

Massing-Schaffer, M., Nesi, J., Telzer, E. H., Lindquist, K. A., & Prinstein, M. J. (2022). Adolescent peer experiences and prospective suicidal ideation: The protective role of online-only friendships. Journal of Clinical Child & Adolescent Psychology, 51(1), 49-60.

Modecki, K. L., Duvenage, M., Uink, B., Barber, B. L., & Donovan, C. L. (2022). Adolescents’ online coping: When less is more but none is worse. Clinical Psychological Science, 10(3), 467-481.

O’Reilly, M., Adams, S., Whiteman, N., Hughes, J., Reilly, P., & Dogra, N. (2018). Whose responsibility is adolescent’s mental health in the UK? Perspectives of key stakeholders. School Mental Health, 10(4), 450-461.

Robinson, J., Rodrigues, M., Fisher, S. Bailey, E., & Herrman, H. (2015). Social media and suicide prevention: findings from a stakeholder survey. Shanghai Archives of Psychiatry 27(1), 27-35.

Sohn, S. Y., Rees, P., Wildridge, B., Kalk, N. J., & Carter, B. (2019). Prevalence of problematic smartphone usage and associated mental health outcomes amongst children and young people: a systematic review, meta-analysis and GRADE of the evidence. BMC Psychiatry, 19(1), 1-10.

Throuvala, M. A., Griffiths, M. D., Rennoldson, M., & Kuss, D. J. (2021). Perceived challenges and online harms from social media use on a severity continuum: a qualitative psychological stakeholder perspective. International Journal of Environmental Research and Public Health, 18(6), 3227.

Winkler, J., & Moser, R. (2016). Biases in future-oriented Delphi studies: A cognitive perspective. Technological Forecasting and Social Change, 105, 63-76.

Ybarra, M. L., Mitchell, K. J., Palmer, N. A., & Reisner, S. L. (2015). Online social support as a buffer against online and offline peer and sexual victimization among US LGBT and non-LGBT youth. Child Abuse & Neglect, 39, 123-136.

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