Criteria for Definitive Examination Eligibility.
\r\n\tThe applications are those related to intelligent monitoring activities such as the quality assessment of the environmental matrices through the use of innovative approaches, case studies, best practices with bottom-up approaches, machine learning techniques, systems development (for example algorithms, sensors, etc.) to predict alterations of environmental matrices. The goal is also to be able to protect natural resources by making their use increasingly sustainable.
\r\n\r\n\tContributions related to the development of prototypes and software with an open-source component are very welcome.
\r\n\r\n\tThis book is intended to provide the reader with a comprehensive overview of the current state of the art in the field of Ambient Intelligence. A format rich in figures, tables, diagrams, and graphical abstracts is strongly encouraged.
",isbn:"978-1-83969-069-3",printIsbn:"978-1-83969-068-6",pdfIsbn:"978-1-83969-070-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"3fbf8f0bcc5cdff72aaf0949d7cbc12e",bookSignature:"Dr. Carmine Massarelli",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10391.jpg",keywords:"Embedded Systems, Technologies, Sensors, Remote Sensing, Smart Homes, Smart Cities, Integrated Monitoring Techniques, Agroecosystem, Smart Public Spaces, Computer Vision, Image Processing, Open-Source",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 12th 2020",dateEndSecondStepPublish:"November 9th 2020",dateEndThirdStepPublish:"January 8th 2021",dateEndFourthStepPublish:"March 29th 2021",dateEndFifthStepPublish:"May 28th 2021",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Environmental technologist expert in the development of Smart Technologies for water management and environmental monitoring, characterization, and monitoring of contaminated and degraded sites, integration of spatial data such as standard methodologies, interoperability, spectral data infrastructures.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"315689",title:"Dr.",name:"Carmine",middleName:null,surname:"Massarelli",slug:"carmine-massarelli",fullName:"Carmine Massarelli",profilePictureURL:"https://mts.intechopen.com/storage/users/315689/images/system/315689.jpg",biography:"Main activities:\n-development of Smart Technologies for water management and environmental monitoring;\n-characterization and monitoring of contaminated and degraded sites;\n-implementation of early warning systems and impact assessment systems also from multitemporal monitoring;\n-integration of spatial data: methodologies, standards, interoperability, spatial data infrastructures;\n-use of open source IT systems for the processing, analysis, and integration of remote sensing data with airborne and satellite sensors for thematic purposes such as characterization, control, and analysis of the territory in support of environmental policies relating to contaminated sites;\n-evaluation of the contamination of environmental matrices with specific tests and chemical analyses;\n-installation of airborne sensors and definition of flight parameters for Earth observation, CASI-1500 hyperspectral and TABI-320 thermal sensors;\n-acquisition of spectral signatures of objects through Fieldspec portable spectroradiometer and creation of databases in SQL language;\n-use of tools such as Ground Penetrating Radar for the advanced investigation of the subsoil with law enforcement agencies.",institutionString:"National Research Council",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Research Council",institutionURL:null,country:{name:"Italy"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"9",title:"Computer and Information Science",slug:"computer-and-information-science"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"297737",firstName:"Mateo",lastName:"Pulko",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/297737/images/8492_n.png",email:"mateo.p@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3621",title:"Silver Nanoparticles",subtitle:null,isOpenForSubmission:!1,hash:null,slug:"silver-nanoparticles",bookSignature:"David Pozo Perez",coverURL:"https://cdn.intechopen.com/books/images_new/3621.jpg",editedByType:"Edited by",editors:[{id:"6667",title:"Dr.",name:"David",surname:"Pozo",slug:"david-pozo",fullName:"David Pozo"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"44178",title:"Screening for Narrow Angles in the Japanese Population Using Scanning Peripheral Anterior Chamber Depth Analyzer",doi:"10.5772/54556",slug:"screening-for-narrow-angles-in-the-japanese-population-using-scanning-peripheral-anterior-chamber-de",body:'Primary chronic angle-closure glaucoma (PACG) is a leading cause of blindness, and has particularly high prevalence rate in East Asia [1–3]. The Handan Eye Study [4] reported that the standardized prevalence of PACG is 0.5%, and two thirds of those with PACG were blind in at least one eye. Many cases of PACG are asymptomatic and often present with severe visual field loss at the first visit. The severe visual impairment from PACG is related to the insidious development of the disease. [5]
Primary angle closure suspect (PACS) is characterized by narrow or occludable angles without raised intraocular pressure (IOP) or glaucomatous optic neuropathy. Primary angle closure (PAC) is the eyes with narrow angles and the appositional closure, peripheral anterior synechiae (PAS) and/or raised IOP but without glaucomatous optic neuropathy. PACG is defined as the case of PAC with glaucomatous optic neuropathy. It has been estimated that 22% of the eyes with PACS progress to PAC and 28.5% progress from PAC to PACG over 5–10 years [6]. Prophylactic laser iridotomy (LI) is the first-line treatment for narrow angles, and may stop the progression of the angle closure process and prevent development of PACG. However, LI is less effective in controlling IOP if optic nerve damage with PAS has already occurred [7].
Assessment of angle width is essential for the diagnosis and managing angle closure [8–10]. Currently, the golden standard for angle assessment has been indirect visualization by gonioscopy. However, it is limited by its dependency on subjective interpretation and difficulties in manipulation techniques. Ultrasound biomicroscopy (UBM) generates high-resolution images of the angle, which can be used in quantitative analysis, and it adds useful information regarding causal mechanisms of angle closure. However, this method also requires trained and experienced technicians and is time consuming. Both gonioscopy and UBM require contact with the globe, and as a result, they can be unpleasant for the patient and can induce artifacts.
New devices for evaluating the anterior ocular segment in a more objective and quantitative manner have been introduced. Anterior-segment optical coherence tomography (AS-OCT) is a noninvasive technique allowing the measurement of the anterior ocular structures. A new generation of OCT, swept-source OCT (SS-OCT), has been recently introduced for the measurement of the anterior ocular segment. The SS-OCT is over tenfold faster than the time-domain OCT and gives a three-dimensional (3D) observation of the anterior ocular segment. The SS-OCT employs 1,310 nmin the nearinfrared light source and its scan rate is 30,000 A scan/s.
The scanning peripheral anterior chamber depth analyzer (SPAC) is a non-invasive device that objectively and quantitatively assesses the anterior ocular segment by employing the Scheimpflug camera principle. The SPAC measures the peripheral ACD and converts the measurements into numerical and categorical grades by comparison with a normative database. The SPAC has been proposed as a clinician-independent screening tool for angle closure.
In the study reported here, we review the advantages and limitations of newer anterior chamber imaging technologies, namely ultrasound biomicroscopy (UBM), anterior segment optical coherence tomography (AS-OCT), and scanning peripheral anterior chamber depth analyzer (SPAC). Additionally, the present study assessed the effectiveness and possibility of the SPAC in the glaucoma screening.
UBM, which originally was used in ophthalmology to image the posterior segment (B-scan ultrasonography), is an objective alternative for anterior chamber angle assessment. Although ultrasound and UBM are based on the same principle, the frequencies are different. Objective and reproducible measurements of the anterior chamber structures can be obtained with cross-sectional imaging by UBM. Electric signals are converted by a radiofrequency signal generator coupled to a piezoelectric transducer into 50 MHz frequency ultrasonic sound waves, which are transmitted to the eye via saline solution that is held in a cup reservoir [11]. The examination may be performed through a viscous material such as sodium hyaloronate. UBM generates high-resolution images of the angle, which can be used in quantitative analysis, and it adds useful information regarding mechanisms of angle closure [11]. Although angle dimensions measured by UBM correlated significantly with gonioscopy in general [12], gonioscopic assessment sometimes resulted in an overestimation of the angle width in eyes with occludable angles [13]. Gonioscopy is the gold standard examination, because it allows direct viewing of the angle. Nevertheless, it may induce changes in the apposition of the iris depending on the technique and the lens.
The UBM measurement requires trained and experienced technicians and is time consuming. In addition, UBM require contact with the globe, and as a result, UBM can induce artifacts by inadvertent compression of the globe. Consequently, UBM is not suitable for glaucoma screening examination.
(a) UBM image of the normal anterior segment. This scan demonstrates all anterior segment structures, including anterior lens surface, iris, and ciliary body. In UBM, frequencies of 35-50 MHz and above provide over a threefold improvement in resolution compared with conventional ophthalmic ultrasound systems (b). b. Conventional B-mode ultrasound image of the posterior segment. c and d. UBM image of the normal (c) and the PAC anterior segment (d). Note the shallow anterior chamber depth of the PAC compared with the normal. e and f. UBM image of the anterior segment of the PACG patient before (e) and after laser iridotomy (f). Note the increase of anterior chamber depth after laser iridotomy (LI). Arrow indicates the portion of the LI. g and h. UBM image of the anterior segment of the PACG patient before (g) and after cataract surgery (phacoemulsification and intraocular lens implantation) (h). Note the increase of anterior chamber depth after cataract surgery.
AS-OCT is a non-contact imaging device allowing the visualization and measurement of the anterior ocular structures [11]. The Visante AS-OCT (Carl Zeiss Meditec Inc., Dublin, CA, USA) and the slit-lamp OCT (SL-OCT) (Heildelberg Engineering, Heildelberg, Germany) are the commercially available AS-OCT devices [11]. Compared with the OCT, the SL-OCT has a lower axial and transverse resolution of <25 µm and 20–100 µm, respectively. A major difference between the two devices is their scan speed, which is 2000 A-scans per s for Visante OCT, and 200 A-scans per s for SL-OCT. With a line scan of 256 and 215 A-scans, each image frame takes 0.13 and 1.08s for Visante OCT and SL-OCT, respectively [11]. Furthermore, the SL-OCT requires manual rotation of the scanning beam.
The advantages of the AS-OCT devices are non-contact, easy operation and a rapid image acquisition. The incorporation of automated analysis software allows for rapid estimation of the various anterior segment parameters, including corneal thickness, anterior chamber depth, etc.
Precise location of the scleral spur is a pre-requisite for reliable measurement of the angle. Limited by a relatively low-image resolution, the scleral spur may not always be visible even with the anterior segment OCT. Currently available software analysis programs require the manual localization of the scleral spur, which can at times be difficult, especially in closed angles or where there is a smooth transition from cornea to sclera [14]. Sakata et al. found that the sclera spur could not be detected in approximately 30% of the quadrants, this problem being worse in the superior and inferior quadrants [14].
It has been reported that AS-OCT is highly sensitive in detecting angle closure when compared with gonioscopy. Using gonioscopy as a reference standard results in AS-OCT having a sensitivity of 98.0% [15]. Several explanations have been suggested for the disparate findings between gonioscopy and AS-OCT [11]. The structures of the angle cannot be directly viewed by other techniques than gonioscopy (and may be SS-OCT in future), and therefore, cannot be identified. However, inadvertent pressure on the globe during gonioscopy may alter the configuration of the angle, leading to artificial widening of the angle. Another reason could be a difference in the definition angle closure. On gonioscopy, angle closure was defined as the apposition between the iris and the posterior trabecular meshwork, whereas on the AS-OCT, it was defined as any contact between the iris and the angle structures anterior to the sclera spur in 2-dimensional cross sections obtained by AS-OCT.
When this device is applied to the prospective observational case series, sensitivity and specificity are calculated as 98% (92.2%–99.6%) and 55.4% (45.2%–65.2%) [15]. The low specificity found with AS-OCT may limit the usefulness of these devices in screening for narrow angle.
A new generation of OCT [CASIA, Tomey, Nagoya, Japan], based on swept-source technology (SS-OCT) methods, has been recently developed for the assessment of the anterior ocular segment [16]. The SS-OCT is a variation of the Fourier-domain OCT, over tenfold faster than the time-domain OCT, and gives a three-dimensional (3D) image of the anterior ocular segment. Instead of using a spectrometer as in spectral-domain OCT, swept-source OCT uses a monochromatic tunable fast scanning laser source and a photodetector to detect wavelength-resolved interference signal [17]. The iris profiles and the angle configurations can be visualized three dimensionally and evaluated for 360° [16]. There might be apposition of the peripheral iris to the cornea that would be identified as a closed angle. SS-OCT imaging of the anterior segment could be useful to improve detection of angle closure, while the high cost of these devices may be a limiting factor for their use in screening examination.
a and b. Transectional images of normal anterior segment (a) and plateau iris configuration (b) obtained using Visante AS-OCT (Carl Zeiss Meditec Inc., Dublin, CA, USA). Note the shallowperipheral anterior chamber depth of the plateau iris configuration compared with the normal. c. Transectional image of the conjunctival bleb after trabeculectomy using Visante AS-OCT.
The scanning peripheral anterior chamber depth analyzer (SPAC) is a non-invasive device that objectively and quantitatively assesses the anterior ocular segment by employing the Scheimpflug camera principle [18]. The light from the slit lamp is in the visible spectrum and is projected from the temporal side at an angle of 60° from the optical axis. A camera records cross sectional slit images from the anterior cornea to the anterior iris, and does not rotate as Pentacam-Scheimpflug. The SPAC measures the peripheral ACD and converts the measurements into numerical and categorical grades by comparison with a normative database. SPAC quantitatively measures ACD in a noncontact fashion from the optical axis to the limbus in approximately 0.66 second and takes 21 consecutive slit-lamp images at 0.4 mm intervals. SPAC measurements ranged from 1 to 12, with 1 representing the shallowest anterior chamber. SPAC is equipped with an autofocusing system and a program for the detection of eyes with narrow angle, and usually completes measurement within 15 seconds for a pair of eyes by pressing the start button. The SPAC also reports 3 categorical grades for risk of angle closure: S (for “suspect angle closure”, if there were ≥4 measured points exceeding the 95% confidence interval [CI]), P (for “potential angle closure”, if there were ≥4 points exceeding the 72% CI), and no suffix (for “normal”) [18].
It has been previously reported that the results of peripheral anterior chamber measurement by SPAC were well correlated with those by the van Herick technique as well as Shaffer’s grading system and the ultrasound biomicroscope [19].
Pentacam-Scheimpflug (rotating scheimpflug imaging) uses the Scheimpflug principle in order to obtain images of the anterior segment [10]. It has a rotating Scheimpflug camera that takes up to 50 slit images of the anterior segment in less than 2 seconds [20]. Software is then used to construct a three‐dimensional image. It calculates data for corneal topography (anterior and posterior corneal surface) and thickness, anterior chamber depth (ACD), lens opacification and lens thickness. It also provides data on corneal wavefront of the anterior and posterior corneal surface using Zernike polynomials. Compared with SPAC, Pentacam is highly expensive.
The SPAC automatically calculates central anterior chamber depths (ACD, red line) along the visual axis. SD5.6 (yellow line) means peripheral anterior chamber depth at 5.6 mm apart from the anterior pole of the lens. b. Printout of the results of SPAC measurement. The radius of curvature, the corneal thickness, and the anterior chamber depth are displayed. The SPAC anterior chamber depth value (corneal epithelium to anterior lens) was calculated by summing the corneal thickness and true anterior chamber depth measurements.
The ideal community-based screening test should be clinician-independent, quick, and noninvasive, and have high sensitivity and specificity. SPAC has an advanatage of detecting eyes at risk of ACG by non-physicians in public health screening [20]. When using gonioscopy as the gold standard [8,10], the performance of SPAC combined grade (P or S and/or ≤ grade 5) gave a sensitivity and specificity of 93.0% and 70.8%, respectively [19]. With sequential testing using both SPAC and van Herick, the specificity and sensitivity improves to 94.4% and 87.0%, respectively [21, 22]. Therefore, the SPAC examination in conjunction with the van Herick method is considered as a choice of the first-line screening tests for angle closure following precise examination by OCT, UBM, or gonioscopy (Fig. 4). Kashiwagi et al. [23] proposed the protocol of detecting angle closure glaucoma using SPAC in public health examination. Their protocol consisted of 2 phases: primary screening using SPAC measurements of ACD by nonphysicians and definitive examination by glaucoma specialists (Fig. 4), and was revealed useful for detecting eyes at risk of angle closure glaucoma [22].
Flow chart for the detection and diagnosis of the narrow anterior chamber.
To investigate the frequency of eyes with a shallow anterior chamber at risk, the SPAC was used in subjects visiting a health screening center. In addition, the influences of age and sex on the distribution of central and peripheral ACD were also examined. Indeed, a productive approach would be to target high-risk groups, such as the elderly, far- sighted, and in particular, women.
Cross-sectional, observational, community-based study.
This was a cross-sectional study in an institutional setting [24]. Subjects older than 30 years were recruited at an annual community health checkup project held in the city of Akita (with a population of 325,537), the capital of Akita Prefecture, Japan. A total of 1,173 subjects participated in the comprehensive examinations from September 10, 2007 to October 26, 2007. Of these, 710 individuals underwent glaucoma screening. All of the participants were ethnically Japanese.
This study was performed after the approval by the Ethical Committee of Akita Prefecture Health Care Foundation. All study procedures adhered to the principles outlined in the Declaration of Helsinki for research involving human subjects, and all participants gave written informed consent for this research prior to their participation.
Exclusion criteria were (1) eyes with previous ocular surgery, trauma, or significant ocular disease; (2) eyes with any inborn aberrations, which might affect the morphology of the optic disc (eg, superior segmental optic disc hypoplasia).
The initial non-contact ocular examination was conducted by trained non-ophthalmologists and included measurement of refraction and keratometry (Topcon KR-8100PA, Tokyo, Japan), IOP by noncontact pneumotonometry (Topcon CT-90A, Tokyo, Japan), angle width (Scanning Peripheral Anterior Chamber Analyzer, Takagi Seiko, Nagano, Japan), non-mydriatic optic disc photography by stereoscopic fundus camera (30o angle, 3-DX/NM, Nidek, Gamagori, Japan), and confocal laser scanning tomography (Heidelberg Retina Tomograph II, software version 3.0, Heidelberg Instruments, Heidelberg, Germany). IOP was measured three times, and the mean value was adopted.
When at least 1 finding suggested the presence of glaucoma, the subjects were recruited for definitive examination (Table 1). A definitive examination was performed when a subject was suspected to have glaucoma based upon the findings of the initial non-contact ocular examination. The definitive examination consisted of the following procedures: slit-lamp biomicroscopy, Goldmann applanation tonometry, gonioscopy, and optic nerve head evaluation using a Goldmann three-mirror lens (Haag-Streit International, Koeniz, Switzerland) and a visual field test with the Humphrey Field Analyzer II 24-2 SITA Standard Program (Carl Zeiss Meditec Inc, Dublin, CA, USA). Diagnosis of glaucoma was made based on optic disc appearance, including cup-to-disc ratio, rim width, nerve fiber layer defect, the visual field test, and the clinical records that were obtained through screening and definitive examinations. When present or suspected, glaucoma was categorized based upon the criteria of previous population studies (Table 2). In the definitive diagnosis, anomalous discs, including tilted discs, were carefully excluded. The final diagnosis of glaucoma was determined by 4 glaucoma specialists.
1) Intraocular pressure of 21mm Hg or higher in either eye | \n\t\t|
2) Presence of abnormalities in the stereoscopic fundus photographs, including one or more of the following glaucomatous changes: | \n\t\t|
\n\t\t\t | 1. Vertical cup/disc ratio of the optic nerve head was more than or equal to 0.6 | \n\t\t
\n\t\t\t | 2. Rim width at the superior portion (11-1 h), or inferior portion (5-7 h) was less than or equal to 0.2 of disc diameter ratio was | \n\t\t
\n\t\t\t | 3. Difference in the vertical cup/disc more than or equal to 0.2 between both eyes | \n\t\t
\n\t\t\t | 4. Nerve fiber layer defect or splinter disc hemorrhage was found | \n\t\t
3) Failure to take stereoscopic fundus photographs | \n\t\t
Criteria for Definitive Examination Eligibility.
\n\t\t\t\tCategory 1\n\t\t\t | \n\t\t
The vertical cup-to-disc ratio of the optic nerve head is 0.7 or more, or the rim width at the superior portion (11-1 h) or the inferior portion (5-7 h) is 0.1 or less of the disc diameter, or the difference of the vertical cup-to-disc ratio is 0.2 or more between both eyes, or a nerve fiber layer defect is found, and the hemifield based visual field abnormality is compatible with optic disc appearance or nerve fiber layer defect. | \n\t\t
\n\t\t\t\tCategory 2\n\t\t\t | \n\t\t
When the visual field test is not reliable or available, the cup-to-disc ratio of the optic nerve head is 0.9 or more, or the rim width at the superior portion (11-1 h) or the inferior portion (5-7 h) is 0.05 or less of the disc diameter, or the difference of the vertical cup-to-disc ratio is 0.3 or more between both eyes | \n\t\t
\n\t\t\t\tGlaucoma suspect\n\t\t\t | \n\t\t
When the cup-to-disc ratio of the optic nerve head is 0.7 or more portion (5-7 h) is 0.1 or less but more than 0.05 of the disc diameter but less than 0.9, or the rim width at the superior portion (11-1h) or the inferior, or the difference of the vertical cup-to-disc ratio is 0.2 or more but less than 0.3 between both eyes, or the nerve fiber layer defect is found, and the visual field test is not reliable or available or does not show hemi-field based compatible defect, the eye is diagnosed with suspected glaucoma | \n\t\t
Criteria for Glaucoma Diagnosis.
The vertical cup-to-disc ratio of the optic nerve head is 0.7 or more, or the rim width at the superior portion (11-1 h) or the inferior portion (5-7 h) is 0.1 or less of the disc diameter, or the difference of the vertical cup-to-disc ratio is 0.2 or more between both eyes, or a nerve fiber layer defect is found, and the hemifield based visual field abnormality is compatible with optic disc appearance or nerve fiber layer defect.
When the visual field test is not reliable or available, the cup-to-disc ratio of the optic nerve head is 0.9 or more, or the rim width at the superior portion (11-1 h) or the inferior portion (5-7 h) is 0.05 or less of the disc diameter, or the difference of the vertical cup-to-disc ratio is 0.3 or more between both eyes
When the cup-to-disc ratio of the optic nerve head is 0.7 or more portion (5-7 h) is 0.1 or less but more than 0.05 of the disc diameter but less than 0.9, or the rim width at the superior portion (11-1h) or the inferior, or the difference of the vertical cup-to-disc ratio is 0.2 or more but less than 0.3 between both eyes, or the nerve fiber layer defect is found, and the visual field test is not reliable or available or does not show hemi-field based compatible defect, the eye is diagnosed with suspected glaucoma
All subjects underwent examination with SPAC. Paramedical staff correctively measured the ACD of 658 subjects (703 eyes of 354 men, 607 eyes of 304 women). SPAC examines the region from the optical axis to the temporal limbus in approximately 0.66 s, taking 21 consecutive slitlamp images at 0.4-mm intervals. The camera-captured cross-sectional slit-lamp images are immediately subjected to analysis, and the radius of curvature, the corneal thickness, and ACD values are displayed. The SPAC yields numeric and categorical grades that are calculated by comparison with the ACD values derived from a sample of Japanese subjects [18]. In our study, the range of ACD values of the patients was divided into 12 groups, each representing an equal increment in the ACD. Group 12 consisted of eyes with the deepest mean ACD values, whereas eyes with the shallowest mean ACD values were allocated to group 1.
Based on the data provided by SPAC, the following parameters were determined: distribution of ACD from the central and the peripheral region, distribution of the grades of ACD, and frequency of suspected (S) or possible (P) angle-closure eyes. The high risk of angle closure group includes eyes judged as S or P, or grade ≤5 by SPAC. These eyes were eligible for the definitive examination, The SPAC automatically calculates central ACD along the visual axis. Peripheral ACD means anterior chamber depth at 5.6 mm apart from the anterior pole of the lens (Fig. 3).
Of 1420 eyes of the 710 participants of the glaucoma screening study, reliable SPAC results were analyzed in 1310 eyes of 658 participants (Table 3). 104 eyes of fifty two participants were omitted from the study. The main reason for exclusion were that SPAC measurements could not be completed at the screening sites for various reasons, such as subjects\' ocular or physical problems. 100 eyes were unable to fixate the fixation lamp due to poor visual acuity, and 2 subjects (4 eyes) were unable to keep their faces on the chin rest during measurement. Between the included and excluded subjects, the male/female ratio was not statistically different (P = 0.44, χ2 test).
\n\t\t\t | \n\t\t\t\t30’s\n\t\t\t | \n\t\t\t\n\t\t\t\t40’s\n\t\t\t | \n\t\t\t\n\t\t\t\t50’s\n\t\t\t | \n\t\t\t\n\t\t\t\t60’s\n\t\t\t | \n\t\t\t\n\t\t\t\t70’s\n\t\t\t | \n\t\t\t\n\t\t\t\tTotal\n\t\t\t | \n\t\t
\n\t\t\t\tMale\n\t\t\t | \n\t\t\t21 (42, 3.2%) | \n\t\t\t105 (209, 16.0%) | \n\t\t\t126 (252, 19.2%) | \n\t\t\t73 (143, 10.9%) | \n\t\t\t29 (57, 2.2%) | \n\t\t\t354 (703, 53.7%) | \n\t\t
\n\t\t\t\tFemale\n\t\t\t | \n\t\t\t20 (40, 3.1%) | \n\t\t\t98 (196, 15.0%) | \n\t\t\t114 (228, 17.4%) | \n\t\t\t57 (114, 8.7%) | \n\t\t\t15 (29, 2.2%) | \n\t\t\t304 (607, 46.3%) | \n\t\t
\n\t\t\t\tTotal\n\t\t\t | \n\t\t\t41 (82, 6.3%) | \n\t\t\t203 (495, 37.8%) | \n\t\t\t240 (480, 36.6%) | \n\t\t\t130 (257, 19.6%) | \n\t\t\t44 (86, 6.6%) | \n\t\t\t658 (1310, 100%) | \n\t\t
Number of patients and eyes and the percentage of eyes (in parenthesis) examined by SPAC in each age group.
Descriptive statistical analysis for the determination of mean±standard deviation (SD) for continuous values was performed with SPBS software (Nankodo Publisher, Statistical Package for the Biosciences version 9.51, Tokyo, Japan). Data from both eyes of each individual were used, as it was more efficient and informative than data for single eyes. Comparisons of the different SPAC parameters between males and females or among each age group were analyzed with paired and unpaired t tests. Pearson correlation coefficients were calculated to assess the strength of the correlations between SPAC parameters and potential confounders. For all analyses, P<0.05 was considered statistically significant.
A glaucoma specialist judged that 26 eyes of 19 subjects required the definitive examination, and all 19 subjects were enrolled in the definitive examination. The definitive examination revealed that 1 subject had PACG (0.08%), 1 subject had PAC (0.08%), and 1 had ciliary cyst (0.08%). None of all these eyes showed IOP elevation of more than 21mm Hg. Laser iridotomy was performed on PACG and PAC subjects. None of these subjects presented with subjective symptoms that are thought to demonstrate a strong association with angle closure.
Association of gender and age with SPAC parameters are summarized in Table 4.
In male subjects of 30 to 60 years of ages, the central and the peripheral anterior chamber depths were gradually decreased with ages. There were significant differences in these depths among 30, 40, and 50 age groups (p<0.0001). However, there was no significant difference in depths between 60 years and 70 years age group (Fig. 5). In female subjects, the ACD tended to be shallower in women than in men in each generation. The central and the peripheral anterior chamber depths were gradually decreased with ages. There were significant differences among each age group (p<0.0001) (Fig. 5). Correlation of anterior chamber depth and aging was statistically analyzed using linear regression equation (y = ax + b). Both central and peripheral ACD were significantly correlated with aging (p<0.0001) (Fig. 6). Regression equations were shown in Fig. 6.
\n\t\t\t | \n\t\t\t | \n\t\t\t\t30’s\n\t\t\t | \n\t\t\t\n\t\t\t\t40’s\n\t\t\t | \n\t\t\t\n\t\t\t\t50’s\n\t\t\t | \n\t\t\t\n\t\t\t\t60’s\n\t\t\t | \n\t\t\t\n\t\t\t\t70’s\n\t\t\t | \n\t\t
\n\t\t\t\tMale\n\t\t\t | \n\t\t\t\n\t\t\t\tGrade\n\t\t\t | \n\t\t\t11.2 (1.7) | \n\t\t\t10.3 (1.0) | \n\t\t\t9.6 (0.9) | \n\t\t\t9.0 (0.9) | \n\t\t\t9.3 (0.9) | \n\t\t
\n\t\t\t\tCentral ACD\n\t\t\t | \n\t\t\t3.6 (0.3) | \n\t\t\t3.4 (0.2) | \n\t\t\t3.3 (0.3) | \n\t\t\t3.2 (0.3) | \n\t\t\t3.3 (0.3) | \n\t\t|
\n\t\t\t\tPeripheral ACD\n\t\t\t | \n\t\t\t1.6 (0.2) | \n\t\t\t1.3 (0.2) | \n\t\t\t1.1 (0.1) | \n\t\t\t1.0 (0.1) | \n\t\t\t1.2 (0.1) | \n\t\t|
\n\t\t\t\tFemale\n\t\t\t | \n\t\t\t\n\t\t\t\tGrade\n\t\t\t | \n\t\t\t10.4 (1.2) | \n\t\t\t9.7 (1.0) | \n\t\t\t8.8 (0.9) | \n\t\t\t8.5 (0.9) | \n\t\t\t7.5 (0.8) | \n\t\t
\n\t\t\t\tCentral ACD\n\t\t\t | \n\t\t\t3.5 (0.4) | \n\t\t\t3.3 (0.3) | \n\t\t\t3.2 (0.3) | \n\t\t\t3.1 (0.3) | \n\t\t\t2.9 (0.3) | \n\t\t|
\n\t\t\t\tPeripheral ACD\n\t\t\t | \n\t\t\t1.4 (0.1) | \n\t\t\t1.1 (0.1) | \n\t\t\t1.0 (0.1) | \n\t\t\t0.9 (0.08) | \n\t\t\t0.9 (0.1) | \n\t\t
Average and standard deviation (parenthesis) of central and peripheral anterior chamber depth in male and female in each age group.
Average of central and peripheral anterior chamber depth at each age group. The central ACD (a) and the peripheral ACD (b) were measured at each age group in male (blue bars) and female (red bars). The y-axis represented anterior chamber depth (ACD) as millimeters. The decrease with age in each ACD was shown quantitatively in both men and women.
Correlation of the aging and the anterior chamber depth (a: central ACD, b: peripheral ACD) in all subjects. Although the distribution was wide, the central and peripheral ACD decreased with aging. There was a significant negative correlation between ACD and aging by lineal regression analysis.
The high risk of angle closure group includes eyes judged as S or P, or grade ≤5 by SPAC. The prevalence of the high risk eyes was 1.7% and 2.3% among men and women, respectively. In particular, the prevalence of the high risk eyes was especially high in women 60 years age (6.1%) and 70 years age (6.9%). These data suggest that women older than 60 years may be vulnerable to possible angle closure. Women older than 60 years were at greater risk than male (p<0.0021) or female of younger age (p<0.0001) (Table 5). However, these eyes at risk did not show abnormalities in IOP or optic disc.
\n\t\t\t | \n\t\t\t\t30’s\n\t\t\t | \n\t\t\t\n\t\t\t\t40’s\n\t\t\t | \n\t\t\t\n\t\t\t\t50’s\n\t\t\t | \n\t\t\t\n\t\t\t\t60’s\n\t\t\t | \n\t\t\t\n\t\t\t\t70’s\n\t\t\t | \n\t\t\t\n\t\t\t\tTotal\n\t\t\t | \n\t\t
\n\t\t\t\tMale\n\t\t\t | \n\t\t\t0/42 (0%) | \n\t\t\t0/209 (0.51%) | \n\t\t\t6/252 (2.4%) | \n\t\t\t5/143 (3.5%) | \n\t\t\t1/57 (1.8%) | \n\t\t\t12/703 (1.7%) | \n\t\t
\n\t\t\t\tFemale\n\t\t\t | \n\t\t\t0/40 (0%) | \n\t\t\t1/196 (0.05%) | \n\t\t\t4/228 (1.7%) | \n\t\t\t7/114 (6.1%) | \n\t\t\t2/29 (6.9%) | \n\t\t\t14/607 (2.3%) | \n\t\t
\n\t\t\t\tTotal\n\t\t\t | \n\t\t\t0/82 (0%) | \n\t\t\t1/405 (0.24%) | \n\t\t\t10/480 (2.1%) | \n\t\t\t12/257 (4.7%) | \n\t\t\t3/86 (3.5%) | \n\t\t\t26/1310 (2.0%) | \n\t\t
Number and frequencies (percentage) of eyes at risk in each age group.
The present study qualitatively demonstrates the decrease with age in the peripheral and the central ACD in both men and women in the Japanese subjects attending the health community checkup. Eyes at risk for angle closure were more frequent in women 60 years of age or older. Compared with other populations in Japan, the similar results were reported using SPAC [25] (Table 6). Kamo et al. [25] also reported that the frequency of eyes at risk for angle closure increased in women 50 years of age or older, and it is corresponding to our present results.
It has been reported that the prognosis of eyes with PACG especially acute angle closure is poor compared with that of eyes with PAC undergoing suitable treatment [6, 7]. Therefore, detecting eyes at risk of PACG or PAC is very important. The van Herick technique was employed for primary screening in previous epidemiologic studies of ACG eyes [21]. It has been reported that the results of peripheral ACD measurement by SPAC were well correlated with those by the van Herick technique as well as Shaffer’s grading system and the ultrasound biomicroscope [22]. As the sequential testing using both SPAC and van Herick demonstrates high specificity and sensitivity [23], we considered that the SPAC examination in conjunction with the van Herick method is considered as a choice of the first-line screening tests for angle closure following precise examination by OCT, UBM, or gonioscopy. Further, almost all of the previous studies were conducted under the guidance of an ophthalmologist, and there are few reports of angle closure screening conducted as part of a public health examination that does not involve an ophthalmologist. Primary screening using SPAC measurements of ACD by nonphysicians seems to have possibility to induce cost-effective angle closure screening.
It seems that screening for PACG at least with SPAC and van Herick method should be performed in all the patients over 50 every 6 months and in those with shallow (peripheral) anterior chamber or high IOP, the angle should be further evaluated. LI should be performed in all PAC and PACG patients and those who do not respond to LI should undergo cataract surgery.
\n\t\t\t | \n\t\t\t\t40’s\n\t\t\t | \n\t\t\t\n\t\t\t\t50’s\n\t\t\t | \n\t\t\t\n\t\t\t\t60’s\n\t\t\t | \n\t\t\t\n\t\t\t\t70’s\n\t\t\t | \n\t\t
\n\t\t\t\tAkita\n\t\t\t | \n\t\t\t0.24 | \n\t\t\t2.1 | \n\t\t\t4.7 | \n\t\t\t3.5 | \n\t\t
\n\t\t\t\tYamanashi30)\n\t\t\t\t\n\t\t\t | \n\t\t\t0 | \n\t\t\t2.7 | \n\t\t\t4.1 | \n\t\t\t2.8 | \n\t\t
Comparison of frequencies of eyes at risk (judged as S or P by SPAC) between Akita (the present result) and Yamanashi in Japan.
In England Anne Longfield, England’s Children’s Commissioner, has written to the biggest social media companies, urging them to commit to tackling issues of disturbing content. Her letter follows the suicide of 14-year-old Molly Russell, who tragically killed herself after viewing distressing self-harm images on Instagram. The letter urges social media companies to back the introduction of a statutory duty of care where they would have to prioritise the safety and wellbeing of children using their platforms. Ms. Longfield’s letter ends with the following message to the digital industry:
\n\n \nWith great power comes great responsibility and it is your responsibility to support measures that give children the information and tools they need growing up in this digital world—or to admit that you cannot control what anyone sees on your platforms.\n
According to literature use of the internet has risen rapidly in the last decade [1]. The way in which young people interact has changed significantly over the last decade. Social media enables them to develop online connections with people within their immediate friendship group but also to form connects with people who are more geographically dispersed. As a result of the digital revolution in recent years, young people are now able to communicate with others more efficiently and gain access to knowledge and advice more rapidly. For those living in rural communities, social media can facilitate social communications which otherwise would not be possible.
\nMy own discussions with young people in schools indicates that social media is an extremely important part of their daily lives. It brings many benefits but is also exposes them to risks. Young people are often very aware of these risks and understand how to keep themselves safe. However, sadly this does not prevent all of them from harm, as is evident through recent cases of teenage suicides as a result of social media, which have been highlighted in the media in the United Kingdom (UK) and more widely.
\nThis chapter highlights some of the detrimental and positive effects of social media use on children and young people’s mental health. The implications for schools, parents, social media and advertising companies and the government are addressed. This chapter highlights that schools cannot solve all of the problems and that other stakeholders also have a responsibility to keep young people safe when they are online.
\nResearch suggests that social media use is far more prevalent among young people than older generations [1]. Young people aged 16–24 are the most active social media users with 91% using the internet for social media [1]. Young people use social media for a variety of purposes, including for entertainment, to share information and network with others and to gain support and health information [1].
\nEvidence suggests that social media use can result in young people developing conditions including anxiety, stress and depression [1]. There are various reasons for this, and this section will explore the contributing factors. Research has found that four of the five most used social media platforms make young people’s feelings of anxiety worse [1]. Research suggests that young people who use social media heavily, i.e., those who spend more than 2 hours per day on social networking sites are more likely to report poor mental health, including psychological distress [2].
\nCyber-bullying is a significant problem which affects young people. Evidence suggests that seven in 10 young people experience cyberbullying [1]. Cyberbullying exists in a variety of forms. It can include the posting of hurtful comments online, threats and intimidation towards others in the online space and posting photographs or videos that are intended to cause distress. This is not an exhaustive list. Cyberbullying is fundamentally different to bullying which takes place in person. The victim of the bullying may find it difficult to escape from because it exists within the victim’s personal and private spaces such as their homes and bedrooms. Additionally, the number of people witnessing the bullying can be extremely large because of the potential of social media for online posts to be shared across hundreds, thousands and millions of people. For the victim this can be significantly humiliating and result in a loss of confidence and self-worth. Humiliating messages, photographs and videos can be stored permanently online, resulting in the victim repeatedly experiencing the bullying every time they go online. Victims of cyberbullying can experience depression, anxiety, loss of sleep, self-harm and feelings of loneliness [3].
\nSocial media has also been associated with body image concerns. Research indicates that when young girls and women in their teens and early twenties view Facebook for only a short period of time, body image concerns are higher compared to non-users [4]. Young people view images of “ideal” bodies and start to make comparisons with their own bodies. This can result in low body-esteem, particularly if young people feel that their own bodies do not compare favourably to the “perfect” bodies they see online. Young people are heavily influenced by celebrities and may desire to look like them. If they feel that this is unattainable it can result in depression, body-surveillance and low body-confidence. Young people can then start to develop conditions such as eating disorders. The issue of body image is not just a female issue. Young males are also vulnerable and influenced by the muscular, well-toned bodies that they see online. We now live in an age when males are taking increasing interest in their appearance and viewing images of muscular, toned bodies can result in them putting their bodies through extensive fitness regimes and males are also vulnerable to developing eating disorders.
\nThe opportunity for people to use digital editing software to edit their appearance on photographs can also result in young people developing a false sense of beauty. It is worrying that there is a rise in the number of young people seeking to obtain cosmetic surgery [1] and the popularity of “selfies” in recent years has resulted in an increase in images which portray beauty and perfection. These images can have a negative impact on body-esteem and body-confidence.
\nResearch demonstrates that increased social media use has a significant association with poor sleep quality in young people [5]. It seems that young people enjoy being constantly connected to the online world. They develop a “Fear of Missing Out” (FoMO) which is associated with lower mood and lower life satisfaction [6]. This can result in young people constantly checking their devices for messages, even during the night, resulting in broken sleep. Sleep is particularly important during adolescence and broken sleep can result in exhaustion and lack of opportunity for the brain to become refreshed. Lack of sleep quality can have a range of detrimental effects, but it can also impact on school performance and their behaviour. My own conversations with school leaders suggest that many adolescents demonstrate signs of tiredness during the school day. This can result in disengagement in lessons, thus having a detrimental effect on academic attainment.
\nThe link between social media use, self-harm and even suicide is particularly worrying [1]. The fact that young people can access distressing content online that promotes self-harm and suicide is a significant cause for concern. This content attempts to “normalise” self-harm and suicide and can result in young people replicating the actions that they are exposed to.
\nResearch suggests that young people are increasingly using social media to gain emotional support to prevent and address mental health issues [7]. This is particularly pertinent for young people who represent minority groups, including those who identify as lesbian, gay, bisexual or transgender (LGBT), those with disabilities and those representing black and minority ethnic groups. The use of social media to form online digital communities with others who share similar characteristics can be extremely powerful. Young people from minority groups are able to become “global citizens,” thus reducing isolation. Participating in online networks presents them with an opportunity to meet with others who share their identities, to gain mutual support and advice and to gain solidarity. These networks can reduce feelings of loneliness and support the development of a positive, personal identity. They can also support young people to become more resilient to adverse situations which can help them to stay mentally healthy.
\nWhile online communities can be beneficial, they also bring associated risks. For example, members of the LGBT networks can become easy targets for abuse, discrimination, harassment and prejudice. It is therefore critical that young people understand how to keep themselves safe online and develop appropriate digital resilience to enable them to address these challenges.
\nSocial media use can allow young people to express themselves positively, letting young people put forward a positive image of themselves [8]. The problem with this is that people tend to use social media to present the best version of themselves and of their lives. This can result in others making unhealthy comparisons between their own lives and the idealised lives that are depicted on the internet, resulting in low self-esteem.
\nSocial media platforms enable young people to share creative content and express their interests and passions with others [1]. This can help to strengthen the development of a positive identity among young people and provide them with numerous opportunities to experiment with a range of interests. This is particularly important for young people who live in rural communities who may find it more challenging to develop social connections in the offline world.
\nStudents living in boarding schools benefit from using social media platforms because it enables them to maintain contact with family members and friends at home. This is particularly important because students living away from home may experience isolation and homesickness and social media platforms facilitate these connections.
\nSocial media platforms offer young people a useful tool to make, maintain or build social connections with others [1]. Additionally, research suggests that strong adolescent friendships can be enhanced by social media interactions [9]. Thus, young people can use social media to cement the friendships that they have formed in the offline world and to develop new friendships that would not have been possible in the offline word due to geographical restrictions.
\nSchools play a critical role in keeping children safe online. A well-planned digital curriculum should cover themes such as digital resilience and digital citizenship so that young people know how to respond to distressing content and how to behave responsibly online. The curriculum should also provide digital literacy skills so that children and young people have the skills to keep their own accounts safe through privacy settings, blocking perpetrators of abuse, reporting abuse and setting passwords. Schools should also support children and young people to critically engage with content they see online. They should be taught to question and interrogate content for accuracy, exploitation, abuse and discrimination.
\nSchools also play a critical role in developing young people’s mental health literacy. This should cover common mental health conditions, including stress, anxiety, depression, self-harm and cyberbullying. Educating young people about mental health is essential and reduces the stigma that has traditionally been associated with mental health conditions. Young people also need to have strategies for managing their own mental health. If their mental health is adversely affected by their experiences online, they need to be taught strategies to self-regulate their emotions and strategies to aid digital resilience. Some young people who have negative experiences online respond by closing down their social media accounts. This situates the control with the perpetrators of abuse and removes control from the victim because they are disadvantaged. Developing practical approaches to aid digital resilience in the face of adversity must be a key component of the digital curriculum that schools provide. Young people need to know how to respond to abuse, who to report it to and how to block the accounts of perpetrators. In addition, they need to be taught about the importance of maintaining secure social media accounts and how to keep themselves safe by not sharing personal information.
\nSchools need to provide a social need to provide a social media curriculum which is progressive and age appropriate. Given the prevalence of fake content online and content which has been digitally edited, young people need to be taught to critically evaluate content that appears online so that they understand the harmful effects of some content. Themes including exploitation, body-esteem and gender stereotyping can be addressed through critically evaluating online content.
\nChildren and young people often have a good understanding of the issues associated with social media because they are the users of it. Therefore, they experience the issues, sometimes frequently. Working in partnership with young people through empowering them to lead on aspects of social media education is a powerful way of developing student partnership and empowers them to be leaders. Often, young people understand the online applications better than teachers and they are acutely aware of the issues that occur online. Student-led events such as student-led workshops and conferences, which highlight the issues that relate to social media and mental health, are powerful ways of providing ownership to students. Developing digital ambassadors who act as peer mentors to younger students is also a powerful strategy for developing students’ confidence and leadership skills. Young people who need someone to talk to about the issues that they are experiencing online can be paired with a digital ambassador who can provide them with confidential advice. Processes for recruiting digital ambassadors would need to be carefully considered by schools and the scheme would need to be properly led and managed by a member of staff to monitor its effectiveness. Student-led peer mentoring schemes are valuable because some students prefer to talk to peers about the issues that they are experiencing rather than teachers or parents.
\nSchools also play a critical role in educating parents about the relationship between social media and mental health. It is important that parents understand the online applications that their children are using, and schools can play a critical role in developing their understanding. Schools can also provide guidance to parents on the signs and symptoms of mental ill health so that they are better able to identify mental health problems in their child. Schools can provide guidance to parents on how to support their child’s mental health at home and guidelines about responsible use of social media in the home. It is critical that parents understand the association between poor sleep quality, mental health and academic attainment and schools can play an important role in this. Schools also play a crucial role in developing parents’ knowledge about how to be a good social media role model for their child.
\nSchools cannot solve the problems associated with social media in isolation. This section outlines the responsibilities of parents, social media companies and advertising companies. The responsibilities of the government are also outlined.
\nParents are in a unique position to influence their child’s social media use. They should establish clear expectations about the amount of time their child spends online. However, imposing rules on children can lead to conflict and the breakdown of relationships between parents and children. It is far more effective for parents and children to negotiate the rules jointly so that young people have ownership of determining the boundaries of acceptable and unacceptable behaviour. If rules are imposed rather than negotiated it is likely that young people will find ways to break the rules and therefore adopting a top-down approach may not be the most effective way of encouraging young people to develop healthy social media use.
\nSome parents may try to restrict their child’s use of social media by installing filters or by disconnecting the internet supply at specific times of the day or week. However, young people will find ways to subvert this and policing their use of the internet in this way is unlikely to foster digital responsibility. It might be more effective for parents to talk to their child about what it means to be a digitally responsible citizen and to explain why it is important to restrict screen time, particularly during the night. Families might want to consider allocating specific time each day or week when no-one accesses technology.
\nIn addition, parents also need to be role models. They cannot expect their child to demonstrate the skills of digital citizenship and digital responsibility if they are not prepared to demonstrate these skills. It is therefore important for parents to model healthy online behaviours so that their children can then replicate these. It is also important for parents to develop their own digital literacy, so they are aware of the platforms and software that their child is interacting with. Parents also need to develop knowledge of the risks that their children are exposed to, given that these are constantly changing. If parents do not keep abreast of developments, they will not be able to support their child effectively.
\nParents should negotiate rules with their children about what constitutes appropriate use of the internet. Imposing rules on children is unlikely to be effective because young people will find ways to resist or subvert these. It is also important that parents provide their children with a degree of autonomy about their internet use. It is unlikely to be helpful if parents continually monitor what their children are doing online. However, it is reasonable for parents to set some rules for appropriate use to protect their child from harm. Examples include:
not using technology during the night;
restricting technology use during mealtimes or other social occasions;
limiting the amount of screen time which children are exposed to.
It will be more effective if young people are involved in discussions with their parents about what might constitute appropriate use of the internet.
\nSocial media companies have a responsibility to protect young people from harm. They can do this in a variety of ways by:
establishing strict and robust policies on the age at which users can access platforms;
blocking accounts of perpetrators of abuse;
reporting abuse to the police;
removing inappropriate content immediately;
filtering specific content before it goes live;
producing information to service users about responsible and safe use of social media;
generating warning messages when users have exceeded reasonable levels of screen time;
responding rapidly to reports of abuse.
This is not an exhaustive list. However, it illustrates the sorts of actions that can be adopted by social media companies to protect children and young people from harm. Companies have not responded quickly enough to reports of abuse or inappropriate content as cases of suicide in the UK suggest that social media companies have failed to protect young people from harm. The government also has a clear responsibility to hold companies to account which fail to protect children and young people from harm. Simply fining companies is not enough and will not necessarily address the problem. The government needs to take firmer action against social media companies which breach their safeguarding responsibilities.
\nIn addition, advertising companies have a responsibility to ensure that young people do not develop low body confidence. They can achieve this in a variety of ways. These include:
providing warning messages that images may have been digitally edited;
ensuring that images of bodies on products represent a range of body types, including a range of body sizes, disabled bodies and people of colour;
avoiding gender-stereotypes when advertising products;
producing warning messages about the dangers associated with product-use so that young people are aware of the risks;
portraying natural bodies without make-up on some products.
Our own research in Cambridge [10] with students in secondary schools demonstrates that they had a good understanding of the benefits and risks associated with social media. Focus groups demonstrated that the students had developed an excellent understanding of the benefits of social media and the relationship between social media use and mental ill health, including sleep deprivation, cyberbullying and low body-esteem. They had also developed a better understanding of how to keep themselves safe online. The quotes and Figure 1 below are taken from our research report [10].
\nStudents’ perspectives on social media.
\nSocial media helps you to communicate with your friends if they are far away. It makes you feel good when you get a like on your posts. (Student Y8)
\n\nYou can talk to your friends and family on social media. The disadvantages are that you can get stalked. People can create fake accounts. You can get cyber-bullied. People can hack into other people’s accounts and you might not know who is communicating with you. People can become jealous of other people’s lives and this can make you sad and depressed. (Student Y9)
\n\nSome of the pictures can be fake so people can make out that they are leading an exciting life but really, they are not, and this can make others feel worthless. (Student Y8)
\n\nSocial media results in an expectation to show the good part of your life. It can impact on others because they think you are having a good time and they might not be having such a good time. (Student Y9)
\n\nPeople make mean comments and it makes you feel bad. The bullying can be anonymous, and it reaches a larger audience. You can ignore the insults and carry on with your life. You can report the person or block them. (Student Y9)
\n\nMen are expected to be muscular. You get upset because you think “why don’t I look like that?” (Student Y8)
\n\nI realize that social media has an impact on my sleep. I find it addictive and I am always checking what friends are doing through social media and texting. (Student Y9)
\n\nI think online bullying is different to bullying in school. It is easier to say horrible things to someone through social media because you are not saying it to their face. (Student Y8)
\n\nWe can become stressed through social media because celebrities show images of being slim. This mainly affects women but now men are becoming bothered about how they look. This is stress that becomes a mental health problem. (Student Y9)
\n\nYou feel you must look as good as celebrity people because people feel you need to be as good looking otherwise you don’t get a good reputation. (Student Y8)
\n\nCyber bullying is when you post hateful messages online to directly hurt a person. (Student Y8)
\n\nSeeing slim models online (body image) can make your self-esteem feel low. (Student Y8).
\nThe students summarised the advantages and disadvantages of social media below:
\nCyberbullying is bullying which takes place in the online world, including bullying which takes place on social media. It takes multiple forms. These include:
posting hurtful comments;
posting videos which are targeted directly at a person to cause distress;
posting photographs which are designed to cause distress;
inciting others to make hurtful comments aimed at a person;
sending hurtful text messages using a mobile phone;
sending hurtful private messages to a person [11].
According to Glazzard and Mitchell [11]:
\n\nCyberbullying is fundamentally different to face-to-face bullying in several ways. Firstly, victims cannot escape from it when they are at home because it takes place on mobile phones, tablets and computers. Secondly the abuse is witnessed by a larger audience; messages are in the public domain and can be repeatedly forwarded. This can result in victims experiencing the abuse on multiple occasions, which results in further psychological distress. Thirdly, the evidence of the abuse is usually permanently stored online which means that the abuse is not erased. These messages serve as a permanent reminder of the abuse and this can result in abuse being continually experienced by the victim.
\nForms of cyberbullying are outlined below and taken from Glazzard and Mitchell [11]:
\nHarassment: Harassment is the act of sending offensive, rude, and insulting messages and being abusive. It includes nasty or degrading comments on posts, photos and in chat rooms and making offensive comments on gaming sites. Posting false and malicious things about people on the internet can be classed as harassment [11].
\nDenigration: This is when someone may send information about another person that is fake, damaging and untrue. It includes sharing photographs of someone for the purpose to ridicule and spreading fake rumours and gossip. This can be on any site online or on apps. It includes purposely altering photographs of others to ridicule and cause distress [11].
\nFlaming: Flaming is when someone purposely uses extreme and offensive language and deliberately gets into online arguments and fights. They do this to deliberately cause distress in others [11].
\nImpersonation: Impersonation is when someone hacks into someone’s email or social networking account and uses the person’s online identity to send or post vicious or embarrassing material to or about others. It also includes making up fake profiles of others [11].
\nOuting and trickery: This is when someone shares personal information about someone else or tricks someone into revealing secrets and subsequently forwards it to others. They may also do this with private images and videos too [11].
\nCyberstalking: Cyberstalking is the act of repeatedly sending messages that include threats of harm, harassment, intimidating messages, or engaging in other online activities that make a person afraid for their safety. The actions may be illegal depending on what they are doing. Cyberstalking can take place on the internet or via mobile ‘phones. Examples include:
silent calls;
insulting and threatening texts;
abusive verbal messages;
cases of stolen identities [11]
Exclusion: This is when others intentionally leave someone out of a group such as group messages, online apps, gaming sites and other online engagement. This is also a form of social bullying and is very common [11].
\nBullying by spreading rumours and gossip: Online abuse, rumours and gossip can go viral very quickly and be shared by many people within several minutes. It is not uncommon for former close friends or partners to share personal secrets about victims [11].
\nThreatening behaviour: Threatening behaviour which is directed at a victim to cause alarm and distress is a criminal offence. Taking screenshots of the evidence and reporting it is one way of challenging this [11].
\nHappy slapping: This is an incident where a person is assaulted while other people take photographs or videos on their mobile phones. The pictures or videos are then circulated by mobile phone or uploaded on the internet [11].
\nGrooming: Grooming is when someone builds an emotional connection with a child to gain their trust for the purposes of abuse and exploitation. It is conducted by strangers (or new “friends”) and may include:
pressurising someone to do something they do not wish to do;
making someone take their clothes off;
pressurising someone to engage in sexual conversations;
pressurising someone to take naked photographs of themselves;
making someone engage in sexual activity via the internet [11].
Groomers may spend a long time establishing a “relationship” with the victim by using the following strategies:
pretending to be someone they are not, for example, saying they are the same age online;
offering advice or understanding;
buying gifts;
giving the child attention;
using their professional position or reputation;
giving compliments;
taking them on trips, outings or holidays [11].
Inappropriate images: It is very easy to save any pictures of anyone on any site and upload them to the internet. Uploading pictures of someone to cause distress is a form of cyberbullying. This also includes digitally altering pictures to embarrass someone [11].
\nBystander effect: Witnessing cyberbullying and doing nothing about it is not acceptable. Some people are worried about getting involved but victims of bullying need brave witnesses to make a stand. Perpetrators of bullying thrive when they have an audience. Making a stand against what they are doing is an important way to reduce their power. Most sites now operate a reporting facility so that online abuse can be reported and addressed. Bystanders are not innocent. They have a responsibility to report abuse that they witness [11].
\nThe following text is taken from our blog [12].
\n\nResearch from Queensland University of Technology has identified that half of young people aged 18–24 are less productive and more tired because of their mobile phones. Scientists have adopted the term “technoference” to describe the way that mobile phones intrude on and interrupt everyday conversations and the way they interrupt other aspects of people’s daily lives.
\n\nIt is worrying that family life is being interrupted by technology. While technology has significant benefits, continual use of technology can impact detrimentally on the quality of people’s interactions and conversations. We live in a society where people are constantly attached to their technology. People interact with technology on public transport, in meetings and during leisure time rather than engaging in productive, meaningful conversations. It seems that people would rather interact with a phone rather than having a conversation and while this is not necessarily a problem in some contexts, it can have a negative impact in other contexts. For example, young children require social interaction with adults. This allows them to develop secure attachments with significant others, it enables them to learn about the world and through conversation children are exposed to language. Exposure to language underpins reading and writing development. Children who have rich exposure to language become better readers, better writers and understand far better what they are reading. Lack of exposure to language can impact detrimentally on the structure of the brain. This can create reading difficulties and even lead to difficulties which are consistent with dyslexia, even though the difficulties may not have a genetic origin. The brain is malleable. It is responsive to environmental influences and lack of exposure to language can impact on phonological and phonemic awareness. Both of these skills play a critical role in reading development. Interacting with technology can restrict opportunities for communication between babies, children and their parents and can interrupt the flow of normal conversation.\n
\n\nIt would appear that adolescents seem to be attached to their phones during the night. They are desperate to network and keep up-to-date with their online peers. This results in broken sleep and tiredness during the school day. Adolescents need approximately 8–10 hours sleep but our research demonstrates that some get as little as 2 hours sleep. These students attend school in a state of exhaustion. They are too tired to concentrate and it affects their learning and their behaviour. Disengagement in lessons results in them falling behind in their schoolwork and they then develop other problems such as low confidence and low self-worth.
\n\nReal-time social connections are vital for positive wellbeing. Schools play a key role in teaching young people about how to stay healthy and in particular, the need for sleep. However, parents also play a critical role in supporting young people to develop positive habits through setting boundaries. Examples of boundaries might include restricting access to technology in bedrooms and at mealtimes. Also, parents need to be good role models by ensuring that they do not allow technology to interrupt conversations and other daily experiences.\n
\nStatistics demonstrate the risks of internet use on young people’s lives. Key statistics are summarised below [13]:
year on year increases in the numbers and rates of police-recorded online child sexual offences in England and Wales and Northern Ireland
increases in police-recorded offences of obscene publications or indecent photos in all four UK nations over the last 5 years
increases in the number of URLs confirmed by the Internet Watch Foundation (IWF) as containing child sexual abuse imagery since 2015
less than half of children aged 12–15 say they know how to change their settings to control who can view their social media
the majority of parents, carers and members of the public agree that social networks should have a legal responsibility to keep children safe on their platforms.
Additionally:
a total of 5161 crimes of sexual communication with a child have been recorded in 18 months [14];
in 2019 there has been almost a 50% increase in offence in offences recorded in latest 6 months compared to same period in previous year [14];
in 2010 there has been a 200% rise in recorded instances in the use of Instagram to target and abuse children over the same time period [14];
there have been over 5000 online grooming offences recorded in 18 months [14].
Social media use can have a detrimental impact on children and young people’s mental health. It can result in anxiety, depression, body image concerns, self-harm, substance abuse and even death. However, for young people social media is a tool for networking, keeping in touch with friends, exchanging information, a source of support and advice and a rich source of knowledge. Preventing children and young people from using social media is not an appropriate solution, given all the benefits that come with it. Schools, parents and the digital industry need to do all they can to keep children safe from harm through adopting a proactive approach rather than a reactive approach when crises occur.
\nWe wish to thank Leeds Beckett University and the Carnegie Centre of Excellence for Mental Health in Schools for facilitating this research.
\nThe authors declare no conflict of interest.
Supporting women in scientific research and encouraging more women to pursue careers in STEM fields has been an issue on the global agenda for many years. But there is still much to be done. And IntechOpen wants to help.
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