Sizes of the proposed synthetic [17].
\r\n\t
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However, suitable timing of aortic valve replacement has the potential to avoid both early and late fatal events as well as result in improved functional status of the valve. Early diagnosis and treatment will lead to increased preservation of regular ventricular function in addition to the possibility of regaining regular ventricular function from previously irregularly functioning valves. As the basis for the decision to proceed with surgical interventions is how the regular function and structure of the left ventricle, aortic valve and ascending aorta can be affected by appropriately timed and performed valve replacements, it is crucial to understand the implications of these factors.
Aortic stenosis is typically a progressive disease and with increasing stenosis severity there is an increased resistance during left ventricular outflow. In order for the left ventricle to compensate this high resistance while still maintaining normal systemic pressure and cardiac output, a higher left ventricular pressure is generated. This elevated pressure is achieved by concentric ventricular hypertrophy, an increase of mass and thickness in the wall of the left ventricle. Although this might be an effective temporary solution, the left ventricle will eventually exceed the limit of concentric hypertrophy and begin to dilate in order to maintain left ventricular pump function. This dilation leads to a change in the shape of the left ventricle which may induce significant and negative affects to the valves function. Factors such as ejection fraction and fiber shortening suggest that velocity may eventually be reduced, leading to congestive heart failure.
Both phases, that is, cardiac hypertrophy and ventricular wall dilation, could have possible effects on both the hemodynamic and metabolic alternations. As the ventricular wall experiences progressive dilation and increased hypertrophy, the end-diastolic and pulmonary venous pressure increase may lead to an increase in shortness of breath. In addition, as the myocardial wall tension increases due to hypertrophy, more oxygen is required and because the supply of oxygen remains unchanged, myocardial ischemia and the symptom of angina pectoris may occur. Further, the alteration in ventricular shape and dynamics caused from excessive dilation of the left ventricle may create a vicious cycle, inducing chronic congestive heart failure.
Aortic valve replacement will provide a significant reduction of these symptoms and enhanced function for patients with ventricular dysfunction. Even in cases of congestive heart failure and noticeable ineffectiveness of ventricular function, aortic valve replacement may lead to improvement in symptoms and ventricular function, resulting in the reversibility of ventricular dysfunction and improved survival. Hemodynamic assessment of the valve stenosis involves the determination of the valvular gradient and an estimation of both the aortic valve area and the aortic valve area index. If the ejection fraction and cardiac output are normal, severe aortic stenosis is detected by a pressure gradient across the valve with a value equal to or greater than 50 mmHg or by an aortic valve area index that is less than 0.75 cm2/m2 [1]. If the cardiac output is lower than normal, opposed to the pressure gradient the valve area index must be considered as the pressure gradient across the valve can be minimal for decreased cardiac outflow. Aortic valve replacement is recommended even in the presence of a left ventricular ejection fraction that is less than 25% as well as for symptomatic patients with moderate aortic stenosis in which the aortic valve area is in the range of 0.7–1.2 cm2 [1].
An artificial platform which can be used to simulate aortic heart valve replacement or coronary artery bypass surgery does not exist. Current possible options are based on synthetic models that lack adequate realism or animal models which are not available for repetitive practice. It should also be noted that there are multiple limitations in using animal models which do not occur with our proposed synthetic models.
In this study we design and develop synthetic models of ascending aorta which have similar mechanical properties and geometry to those of porcine tissue. The aortic valve, root and other sections, which are made all in one piece, bear physical resemblance to their counterparts of the porcine ascending aorta tissue. In addition to appearing similar to porcine tissue, our proposed models also feel like the tissue so that when sutures are performed it resembles a realistic platform as is experienced in an actual surgical operation. Additionally, we propose synthetic phantoms of coronary artery vascular grafts with objectively analogous geometrical properties. These phantoms also have reliable mechanical properties to that of the native tissue. The proposed platform is an outstanding tool which may be utilized for the simulation of anastomosis as implemented in coronary artery bypass surgery.
In this study, the human ascending aorta made of cryogel-based biomaterials is proposed. To develop the geometry of the root, an innovative surfacing method related to the de Casteljau technique which is used for developing Bezier surfaces is implemented. The 3D geometry of this model is developed using 2D images attained from the axial dissection of a young adult porcine aortic root. The biomaterial implemented for the aortic valve is a blood-compatible cryogel made of polyvinyl alcohol (PVA-c) which is strengthened by bacterial cellulose (BC) natural nanofibers in a mixture of 15% PVA-c and 0.5% BC by weight fraction and the biomaterial implemented for the root is 10% PVA-c. The tensile properties of the fabricated PVA-BC were measured and are similar to those of the porcine aortic valve leaflet tissue in the two radial and circumferential directions. We also attained a near match of the stress-strain curves for the aorta in the circumferential and axial directions by applying 10% PVA-c with 75% initial strain after cycle 3 [2]. A cavity mold was designed and manufactured and the proposed polymeric valve was then fabricated. An extensive finite element analysis was performed in order to optimize the final product (please see the appendix). The proposed model may be further used for animal trials.
Hydrolyzed PVA, 99+% (Sigma-Aldrich) with a molecular weight of 146,000–186,000 is used as the main ingredient for the solution preparation. A suspension of 0.877 wt% BC in distilled water is then added to the PVA solution. The BC solution is produced in shake flasks by a fermentation process using the Acetobacter xylinum bacterium. The BC suspension was prepared and added to the PVA solution. The new solution contains 15% PVA and 0.5% BC by weight fraction while the rest is distilled water as shown in Figure 1 [3].
The proposed platform as to the PVA-BC nanocomposite preparation for the newly designed ascending aorta.
The final solution was dispensed into three metallic molds and placed in a heated/refrigerated circulator (15L Heating Bath Circulator Model SD15H170-A11B). The molds were cycled once between 20 and −20°C at 0.1°C/min for the solution to solidify and gain a deterministic shape (cycle 1). In order to impose anisotropy to the samples, a 75% strain was applied to all three samples while they were placed back into the mold to reach the maximum anisotropy [3, 4]. The direction of stretch was selected to be in the direction with the higher stiffness, however one of the samples was kept non-stretched as a control. The molds were cycled using the freeze-thaw procedure for six cycles where one of the molds was removed at the end of each cycle. The above procedure and PVA-BC were applied for the preparation of the hydrogel implementation in the leaflet structure and a similar procedure was applied for the aortic wall, however as less stiffness is required for the aortic wall, BC fibers were not used and only 10% PVA was implemented.
The results of the experimental tensile tests are reported in the form of load versus extension. These values are converted into stress-strain values by using the dimensions of the samples and the initial gauge length after preconditioning. Given that the samples undergo large deformation, the stress-strain curves obtained for all samples are nonlinear and hyperelastic. To fit the data obtained, an appropriate constitutive model is applied such that [2],
The tensile properties are measured by a servohydraulic testing machine (INSTRON 8872) with a precise load cell that has a maximum capacity of 1 kg. In order to remain consistent with the realistic bio-environment of the samples, all measurements are carried out inside a container filled with distilled water at body temperature. The strain rate for the performed tensile tests is set to 40 mm/s with a maximum of 60% strain. The preconditioning test was achieved for all samples in 10 cycles with an amplitude of 5 cm and a frequency of 2 cycles/s [5, 6]. The mechanical properties obtained for the aortic valve and the ascending aorta are shown in Figure 2a–d. A close match in mechanical properties for the applied PVA-c samples and the porcine aorta was obtained. Figure 2e shows the stress-strain curves of the aorta in both principal directions and the anisotropic PVA-c sample after cycle 3 at 75% initial strain.
(a) The utilized anisotropy after cycle 2 at 75% initial strain, (b) the utilized anisotropy after cycle 6 at 75% initial strain, (c) the stress-strain curves in the longitudinal direction in cycle 2, 4 and 6 at 75% initial strain, (d) the tensile properties of the developed hydrogel [C4 is cycle 4, LONG stands for longitudinal, PERP stands for perpendicular, LEAF RAD stands for porcine aortic leaflet in the radial direction, LEAF CIRC stands for porcine aortic leaflet in the circumferential direction and the physiological domain represents the physiological loading condition of the valve] and (e) the closest match of the tensile stress-strain curves of aorta in both directions obtained from the anisotropic PVA at 75% initial strain after cycle 3 [6].
For the design of the geometry of both the ascending aorta and the aortic valve, an advanced and novel surfacing technique based on the de Casteljau method is applied on the Bezier-based surfaces. The 3D geometry was developed by stacking 2D images obtained by the axial dissection of an adult human aortic root and aortic valve. It should be mentioned that the valve used for this purpose was a Mitroflow bioprosthetic valve. The 2D images are digitized and converted into a finite number of control points. This is determined by mapping the 2D geometry of each section using a coordinate measuring machine (CMM) with a laser scanning system such as 3D Digital Corp, 3D scanner cyberware.
The control points are then applied to construct the corresponding Bezier curves to complete the digitization of the 2D images which are used as the bases for the production of the final Bezier surfaces. The main advantage of this technique is that the final surface obtained is easily and quickly tunable. In order to increase the surface quality and apply any desired changes, Bezier curves are accustomed through a trial and error procedure by removing, relocating or interpolating the initial control points. The final surfaces are then brought to a CAD software environment by using a command as known as shell, for example, command Shell of I-Deas. As we are developing 3D and physical models, the thicknesses of the valve leaflets and ascending aortic wall and their respective variation is of particular importance. For this purpose, two surfaces are independently designed to form the top surfaces of both the male and female parts of the mold for each model. Even though the produced shells of the Bezier surfaces possess uniform thicknesses individually, the final products are 3D and have proper variable thicknesses as intended [6, 7, 8].
The thickness of the model is developed by the gap in the final design of the mold which is created due to the distance between these two surfaces. We used Mechanical Desktop V2013i CAD software for the perfection of the models throughout testing. As mentioned earlier, the geometry of the proposed aortic valve is inspired by a design modification on the Mitroflow bioprosthetic valve.
A major advantage of this new design is that the variable thickness of the leaflets is considered (0.7 mm on the free edge and 1.2 mm on the attachment with the stent) which is defined by applying a comprehensive finite element structural analysis and using the related optimized computational methods for further enhancement. The final model of the proposed valve consists of three identical cusps for which the leaflets are symmetrical about their own midlines. The fabricated model and the final prototype for the proposed aortic valve prosthesis composed of PBS thermoplastic material are shown in Figure 3. The valve is then added to the ascending aortic wall model to develop a complete synthetic model (made of PBS thermoplastic material) including the sinuses, two outlets for the right and left coronary arteries and the valve in only one component. The final model of the ascending aorta is shown in Figure 4.
(a) The mitroflow bioprosthetic valve of which the design of the proposed valve is inspired, (b) the final CAD model of the proposed valve, (c) the designed and fabricated mold and its parts for the new design of the PVA-BC polymeric trileaflet valve. A: casing, B: caps ×2, C: main female part, D: main male part, E: the assembled mold, (d) and (e) are the first prototypes of the valve made of PBC thermoplastic material.
(a) The 3D CAD model of the ascending aorta, (b) the fabricated mold and its part of the proposed final CAD model, (c) the prototype of the ascending aorta made of PBC thermoplastic material including the left and right coronary arteries, the sinuses and the aortic valve in a singular component.
The developed material which possesses similar mechanical properties to those of the ascending aortic wall and the porcine heart valve leaflet tissue is implemented in the final models. The designed and fabricated molds were filled with the proposed hydrogels (PVA-BC for the valve leaflet and PVA only for the aortic wall) and the final models were manufactured. These models are similar in geometry and mechanical properties to that of the native tissues and can be an excellent tool for the simulation of aortic heart valve surgery (Figure 5).
(a) The final aortic valve made of PVA-BC and (b) the final aortic root including the valve and sinuses with similar mechanical properties and geometry to that of the native tissue.
The anatomy of the aortic valve is shown in Figures 6 and 7. Figure 6 shows the valve from above, with the orientation as is usually seen throughout a standard transverse aortotomy [9].
The anatomy of the human aortic valve including the right, left and noncoronary cusps (leaflets) as well as the main branches of left and right coronary arteries—top view. The top image is a typical diagram of the ascending aorta and the lower image is the synthetic ascending aorta proposed in this study which is one piece of the aortic root including the valve and coronary outlets.
Demonstration of an opened out view of the aortic valve to illustrate the subvalvular anatomy. As the left ventricle has a common inlet and outlet, the anatomy of the aortic valve and mitral valve is intimately related. The top image is a typical diagram of the opened out ascending aorta including the aortic valve and the lower image is the synthetic ascending aorta proposed in this study which is one piece of the aortic root including the valve and coronary outlets.
A transverse aortotomy is made which is normally placed approximately 15 mm above the level of the right coronary artery. This specific placement is to reduce the possibility of jeopardizing the right coronary artery (caused by low incision placement) which can lead to technical complications in valve seating and aortotomy closure. Avoiding higher incision placement has decreased importance as the aortotomy can easily be angled downward and the anterior lip caused by a high incision can be quickly pulled back. The aortotomy is suggested to be extended to about 10 mm above the commissure between the left and right coronary leaflets and to a similar distance above the commissure between the left and the noncoronary leaflets [9].
After retractors are located, the valve can be seen, and the approach for excision is identified the calcified tissues are completely excised, ensuring to take care to not injure the bundle of His or the aortic wall. In many severely calcified valves, leaflets are free of calcification at the site of attachment prior to the annulus so the incision line can be positioned exactly on the calcium-free ribbon near the annulus. If a calcium-free ribbon near the annulus does not exist, the excision can be made on a hypothetical ribbon relatively close to the annulus. This is to prevent inadvertent excision of a portion of the annulus as such severe calcification may cause damage to the annulus and part of it may be inadvertently removed. A polymer aortic valve prosthesis is designed and fabricated slightly smaller (normally 1–2 mm smaller) in diameter than the diameter of the patient’s annulus. The sinuses are removed in a way that only a rim of aortic wall above the cusps remains. Three sutures are placed through the prosthesis and the patient’s annulus (Figure 8A1, 2 and B1, 2) and the prosthesis is then lowered into the patient’s annulus and inverted into the left ventricle (Figure 8B3). The sutures should then be run toward each commissure and firmly tied ensuring the suture line is kept slightly below the patient’s annulus. In the case of bioprosthesis, special care must be taken to avoid the conduction tissue under the commissure between the right coronary and the noncoronary cusps, however this is not required for the polymeric valve. Following this, the valve is then everted and sutures are initiated at the low points of the sinuses and are brought up to the commissures (Figure 8A3, 4 and B4–B6) [9].
Anastomosis procedure of the prosthetic aortic valve and the ascending aorta built in this study. (1) The sinuses are removed in a way that only a rim of aortic wall above the cusps is left as shown in A1 and B1, (2) the calcific leaflets are removed as described above (B2), (3) three sutures are placed through the prosthesis and the patient annulus for guiding the valve into the right position in annulus, (4) the valve is anchored to the annulus. As shown almost one commissure is attached (A3, A4 and B4, showing the attachment from the aortic side, B5, showing the attachment from the ventricular side) and sutures are carried around to complete the anastomosis (B6).
The left and right cusps are fused together at the commissure which is considered as a relative underdevelopment of the right coronary leaflet (cusp) and the orifice is typically a cut between the left- and noncoronary cusps. The commissure between these two cusps is typically well-developed, however the other commissure may be dissimilar in degree of development and may merely be a primitive raphe. A simple incision is typically made in one (or two) commissure(s) of the right coronary leaflets (cusps). Incision of the other commissure may depend on its degree of development as well as the extension and depth of the right coronary leaflet (cusp).
In the first step, a transverse aortotomy is prepared and the valve is uncovered with small cusp retractors. Forceps are used to hold the leaflets and an incision is made on the well-developed commissure all the way to the annulus (Figure 9A1 and A2). The assessment is carefully made on the depth of support and the degree of development of the right coronary leaflet. Due to the fact that the right coronary leaflet develops a coaptation area with the other leaflets (and not prolapse), the other commissure is carefully incised. In the last step, the subvalvular area is carefully checked to ensure there is no subvalvular stenosis underneath. The procedure on the proposed synthetic model is shown in Figure 9B1–B4.
The exposure of the valve and incision of the well-developed commissure all the way back to the annulus (A1, A2)—top view. In the synthetic model, initially all three cusps are fused together. The practice is to make the main incision as discussed in the manuscript. (1) The valve is exposed (B1), (2) the incision line is determined (B2), (3) the incision is made all the way back to the annulus (B3) and (4) the incision is completed (B4).
The wall thicknesses of the coronary arteries possess a range from 0.42 to 1.35 mm [10]. The thickness of the saphenous vein wall is approximately 0.79 ± 20 μm [11] and the outer diameter of the lower bound coronary artery is 1.2 mm [12], whereas the diameter of the upper bound harvested saphenous vein is 7 mm with a normal minimum diameter of 3.6 mm and a normal maximum diameter of 4.84 mm within one vessel length [12].
Polyvinyl alcohol cryogel (PVA-c), 99+% (Sigma-Aldrich) hydrolyzed with a molecular weight of 146,000–186,000 was implemented for the solution preparation which is outlined in more detail in our previous studies [10, 11]. The proposed cryogel material requires a thermal cycling procedure in order to physically crosslink the long molecules. Therefore, the design is limited to molds that can be implemented with the anti-freeze cooling bath which takes place within ethylene glycol solution with a temperature change of −20 to +20°C [12].
Ten sizes of arteries, ranging from 1.5 to 7 mm are targeted in order to provide for all of the possible sizes implemented in CABG, which also includes internal mammary artery (IMA), saphenous vein (SVG) and radial artery (RA) grafting. The normal internal diameter for the human saphenous vein is 1.75 mm (without distention) and 2.18 mm (with distension) [5]. The diameter of artery and vein cores chosen for the design are from 1 to 2.5 mm. The length the vessels is simplified to a 10 cm long graft of continuous diameter and a wall thickness with no alterations.
In order to attain the precise dimensions, a flat plate design was implemented. This design consists of two flat symmetrical plates with the dimensions of each artery size fixed into a semicircular channel. When these compartments mate, a cylindrical graft is made (Figure 10a and b).
(a) CAD design, (b) the prototype of the mold for the construction of synthetic grafts. Twelve grafts with variations of sizes are developed in the same batch and (c) tensioning mechanism, the conic fixture holds the cord constantly at the center and the spring behind it is for providing a minimal tension on the cord so it is continuously under stretch [17].
Another main issue addressed by this design is the capability for the cores to always remain concentric with the mold cavity. Our exclusive solution is to implement tension in the cores through a conical centering system. This feature ensures the cores remain centered regardless of orientation or disturbance imparted on the mold during the fabrication process. The conical mechanism is designed with a 45° taper on each end of the cylinder (Figure 10c).
The 3D rendering of the mold was fabricated on SolidWorks R2016 software. Renderings were printed using a Mojo (Proto 3000, Mississauga, Canada) 3D printer with a resolution between layers of 100 μm.
The proposed material has similar mechanical properties to those of the coronary artery tissue. The molds were packed with 10% PVA-c and the final models were fabricated. These models are close in geometry and have similar mechanical properties to that of native tissues and are suitable to model vasculature for the simulation of bypass surgery (Figure 11). The circumferential strength of the proposed models reported here is 0.50 ± 0.12 MPa which is comparable to the native tissue (0.39 ± 0.07 MPa) [13, 14] with less than 5% discrepancy.
The models of synthetic manufactured grafts made of 10% PVA-c [17].
Using this procedure, vessels with a mean outer diameter of 1.30 mm and a mean luminal diameter of 600 μm can be produced where the dimension of the vessel thickness is 350 μm. These vessels have a normal vessel length of 60 mm and thus, vessels have efficaciously been fabricated in small scales. We have the capability of reliably creating vessels with a diameter ranging from 1.5 to 7 mm, Figure 11 and Table 1.
OD (outer diameter) (mm) | Thickness |
---|---|
1.5 | 350 μm |
2.1 | 500 μm |
2.9 | 670 μm |
3.4 | 820 μm |
4.2 | 940 μm |
4.8 | 1.2 mm |
5.5 | 1.4 mm |
6.1 | 1.8 mm |
7 | 2.0 mm |
Sizes of the proposed synthetic [17].
We utilized a range of prolene (polypropylene) sutures (size: 2.0–6.0). The dull-witted marginal is incised with scissors (Figure 12a). A suture is passed (1) through the arterial wall, (2) through the vein and (3) through the arterial wall and (4) tagged. The other end is (1) brought through the vein and (2) the vein is again lowered into place. (3) The suture line is brought up to the right side. (4) The other suture is brought through the heel of the vein, (5) through the artery, (6) up the left side and around the toe, thus, completing the suture line, Figure 12b. In the end (7) a cannulation is utilized to ensure an excellent connection of the graft to the artery (Figure 12c–e).
Anastomosis of a graft to coronary artery on a pig heart. (a) Groundwork on the coronary artery and the approximation of the location of anastomosis, (b) the suturing graft to the location of anastomosis, (c), (d) and (e) represent the cannulation test. Blue water is perfused through graft by applying a suitable pressure and the location of anastomosis is tested and observed for leaks [17].
We utilized a range of prolene (polypropylene) suture of the same size. The grafts are organized, Figure 13a. Both grafts A and B are notched longitudinally, Figure 13b. The incision must be accurate as an unsuitable incision may cause narrowing on the graft at the location of anastomosis. The suturing procedure follows the same routine (Figure 13c–f). (1) A suture is guided inside-outside the artery on graft A and (2) labeled. (3) The suture line is brought up inside-outside the vein on graft B and (4) outside-inside the artery on graft A (Figure 13g and h). (5) The suture is brought up outside-inside the vein on graft B and (6) inside-outside the artery on graft A and (7) around the end of arteriotomy to complete the anastomosis (Figure 13i) [15, 16].
Presentation of side–to-side anastomosis. (a) Three synthetic grafts implemented in this study. (b) Presentation of applying a longitudinal incision, (c) presentation of a side-to-side anastomosis ideally, (d)–(f) are the recommended stages for the side-to-side anastomosis [12], (g) corresponding to stage (d) on the graft, (h) corresponding to stage (e) on the graft and (i) achievement of the anastomosis on the graft [17].
There are other methods which can be implemented for the side-to-side or the end-to-end anastomosis as shown in Figure 14a and b are not explained in detail.
(a) Other methods implemented for the side-to-end anastomosis and (b) end-to-end anastomosis, both on the synthetic platforms [17].
In the final step, side-to-side anastomosis of a small-scale graft to the ascending aorta was simulated, Figure 15. The ascending aorta implemented in this study is made of the cryogel biomaterials, however possessed mechanical properties close to those of the leaflet tissue and the valve conduit. This model contains the sinuses and the aortic valve placed in a singular piece. Then, side-to-side anastomosis of a small graft to the valve conduit was attained using the proposed platform.
(a) Simulation of the side-to-side anastomosis of a small-scale graft to the valve conduit and (b) top view of the valve conduit and the small graft.
This chapter summarizes a novel emerging technology by which a complex surgery can be accurately simulated. We proposed a novel model of the ascending aorta made of synthetic material which maintains similar mechanical properties and geometry to that of native tissue by which a complicated heart valve replacement surgery can be simulated step-by-step.
It is known that available surgical simulators lack fidelity or are not adequately lifelike, though in this chapter a high fidelity platform was designed and fabricated. This platform may be used by young surgical residents or cardiac surgeons to develop expertise on the matter. More platforms will be developed so that other valve and ascending aorta related surgeries such as Yacob, David or Bentall procedures can be precisely simulated in a similar fashion.
Additionally to the best of the authors’ knowledge, for the first time a platform for fabricating artificial cryogel micro-vessels is demonstrated in order to address a lack of availability to coronary artery bypass practice materials. Previously, small cryogel vessels did not exist simply because of their complicated geometries. The vessels presented feature a biomaterial with mechanical properties and geometries which are not statistically different from human vessels and the models have been productively implemented to model a coronary artery bypass surgical procedure. The penetration ability and resistance to rupture the sutures with the diverse range of sizes from 2.0 to 6.0 was verified and deemed acceptable using prolene (polypropylene) suture. The proposed material appears to be well-matched with polyglactin (vicryl) sutures as well [17].
For forthcoming work, the suture penetrating ability and resistance to rupture by associating diverse sutures polyglactin (vicryl) versus prolene 5-0/6-0/7-0) by means of a semi-quantitative scoring method will be modeled. Suture retention by utilizing pull test data compared to the real tissues can be also considered. A short case study showing the appropriateness of the cryogel vessels in a virtual model to educate operators and its outcomes (which is essentially semi-quantitative scoring methods) will be implemented. The accessibility of practice tools for surgeons will contribute to improve their adroitness and self-reliance in cardiothoracic surgery.
The authors acknowledge the University of British Columbia and NSERC (Discovery Grant) for financial support.
Children’s experiences with digital technologies actually involve an increasing quote of young users (also defined as “digital natives”) who are born and are developing in environments in which new digital technologies are widely available [1]. This currently occurs from early infancy, due to the rapid diffusion of touchscreen devices among younger children (or “touch generation”; [2, 3]). Children aged 2–4 years actually are able to use touchscreen devices, such as tablets or smartphones, to play or watch movies, and often parents themselves introduce kids to use them in boring social situations (i.e., in the pediatrician’s waiting rooms or in the restaurant; [4]). On the basis of the most recent report on worldwide diffusion of the Internet among young people [1], one in three users is estimated to be a child or teenager (under 18). Generally children use digital technologies in their home, particularly younger children, with intense and prolonged activities especially on weekends. Children often use their digital technologies at school at least a day a week (almost 30% among 9–11 years), although it is prohibited in many countries by school regulations. The access to digital technologies is expanding among young generations, even if many inequalities of resources remain between developed or developing countries [1]: for example, it has been estimated that in Africa (Ghana) children mainly use 0.9 mobile devices to connect to the Internet, against 2.9 in South America (Chile) or 2.6 in Europe (Italy). Similarly, only 12% of children in Africa (Ghana), 21% in the Philippines, and 26% in Albania can connect to the Internet at school, against 63–54% of children in other South America or European countries, such as Argentina, Uruguay, or Bulgaria. This reality raises several questions on how to guarantee the young generations the opportunities offered by new technologies (for studying, enhancing skills, socializing, etc.), protecting them from potential dangers of digitalized world (i.e., contacts with unknown people, exposure to violent/pornographic contents, etc.). In fact, although children grow in a reality permeated by new media, they are not automatically “digitally literate,” that is, able to juggle the digital world and to reflect on it. Studies show that not only young users, but also teenager users “have difficulties in finding, managing and evaluating information, managing their privacy online and ensuring their online personal safety […]and may thus vary in their digital skills” ([5], p. 186).
Together with their children, parents themselves are largely exposed to media experiences in many fields of their life. Digital technologies have quickly changed the way in which family members communicate, enjoy themselves, acquire information, and solve daily problems. Parents are also the first mediators of children’s experiences with digital tools: they have the task of integrating their use into ordinary routines (play, entertainment, learning, mealtime, etc.), promoting constructive and safety uses. Digital parenting describes parental efforts and practices for comprehending, supporting, and regulating children’s activities in digital environments. A growing research on digital parenting identified the main approaches that can allow parents to “mediate” children’s activities with digital technologies [6, 7, 8]. According to Vygotsky’s theory of child development and his concept of proximal development zone [9], parental mediation can be considered a key aspect in facilitating the interactions between children and new media. The proximal development zone is an intermediate area between what the child is able to do alone and what he/she can learn thanks to the guidance of others. In the course of a shared activity, the support and the help are adapted so that the child can improve his/her skills and gradually assume responsibility for acting alone. However, the activities that take place in the virtual environments of the web, unlike the experiences in the real environments, can reverse the relationship between the competent person (the adult) and the learner (the child). Today’s children have an early, almost “intuitive” approach to digital technologies, so in some cases they can become active agents towards their parents. When children’s knowledge and digital competence (e.g., functions/benefits of a new app) overcome that of parents, many shared experiences can be child-initiated, and children can also perform some forms of support and digital teaching to parents. This reverse socialization [10] seems to be a peculiar feature of digital experiences, and it poses new challenges to parental role. Reverse socialization describes all situations where children possess a better understanding or more advanced skills than adults. This gap between generations is more marked in low-income families or low-educated parents who possess limited resources and access to digital technologies [11]. However, over the past years, many parents have developed adequate knowledge and technical skills to share digital experiences with their children [3, 12]; they appreciate benefits of the web and strive to comprehend its complexity.
A common difficulty that parents actually encounter derives from the diffusion of “portable” devices (smartphone and tablet) that children start to use in early infancy (under the age of 2; [13]). Later, due to unlimited Wi-Fi access and enhanced connectivity, children insert activities with mobile devices into many daily routines, for example, during mealtime, school homework, conversations with parents, or before sleeping [14]. Particularly, parents worry about the “pervasiveness” (or ubiquitous) of mobile technologies in daily activities [15], and they fear that an effective guidance and control over them may decrease. Studies with large samples of young digital users (9–16 years old) in many European countries have compared parents’ opinions before (2010 Eu Kids Online Survey; [12]) and after (Net Children Go Mobile; [3]) the diffusion of mobile devices. After 4 years, many parents declare that they know less about their children’s online activities and have more difficulties to closely monitor children’s usage (e.g., time spent connected). Interestingly, parents now are more aware of the risks of using the web [16], and they prefer to talk to children about Internet security (e.g., do not leave personal data online or block unknown people) rather than limiting or prohibiting Internet use [17]. Parents can encourage or limit the use of digital technologies to children according to the opportunities or danger they attribute to them. Since parents themselves are regular, sometimes enthusiastic, users of digital media, their digital skills and confidence and daily frequency of usage (or overuse; [18]), together with beliefs about digital world [3], are all crucial factors that researchers have begun to explore systematically.
Each parent has beliefs, that is, convictions and personal opinions, regarding the usage of media by children, such as their usefulness or damage, or the age at which children should use them. Beliefs are the cognitive dimension of attitudes, guiding individual’s behavior and choices. When parents raise their children, they act and make choices for them following their own perceptions of what is desirable or what they positively value for their child’s development [19]. Although parents are not always aware of their beliefs, these influence parent-child interaction and the child’s opportunity to learn, do experiences [20], and develop digital skills [5]. Parental beliefs are important aspects of parenting and family microsystem, together with factors such as parent’s history and education, socioeconomic status, and culture.
Parents possess personal ideas about modern technologies: they can be considered a source of entertainment/relaxation or a learning tool [21, 22]; conversely, for other people, PC, tablet, and smartphone can be harmful to children’s health (such as sleep problems, obesity, etc.; [23]), for social risks (such as contacts with unfamiliar or social isolation; [24]), or because they interfere with parent-child activities and time spent together [25].
A qualitative study [26] shows that parents have more pessimistic (70.55%) than optimistic opinions (29.45%) on the Internet use by primary school children: for example, parents worry about the excessive time spent online, the interference in face-to-face conversation, or that children lack of skills and maturity in dealing with some contents suitable for older children (such as violence, sex, or drug-related contents). Other worries concern negative consequences on learning and academic performance (i.e., reduced attention span), physical development (i.e., prolonged sedentary activities), social skills and peer interactions (i.e., fewer opportunities to “learn to play together”), and child’s well-being (i.e., using smartphone to overcome boredom). Interestingly, many parents fear losing control over their children’s online behaviors. Conversely, the positive beliefs concern positive effects of digital technologies on child’s entertainment, communication and learning, access to information, and enhancing of child’s skills (such as brain functioning, self-regulation, autonomy, critical attitude, etc.).
Other researchers [27] explored parent’s perceptions about positive (i.e., they are shared by generations) or negative impact (i.e., they expose family privacy to risks) of social media—such as Facebook or WhatsApp—on family open communication. Teenagers are intensely involved in social media use, but adults also are regular users. On the one hand, parents use social networks to communicate; on the other hand, they fear that they negatively impact family relationships, for example, through the phubbing phenomenon (i.e., ignoring someone or interrupting a conversation or mealtime to check the smartphone). Authors found that parents’ perceptions are a meditational variable between the collective family efficacy (i.e., the perceived efficacy to manage family relationships, to support each other, etc.) and the openness of communication: “it is not only the actual impact of social media on family systems that matters but also parents’ perceptions about it and how much they feel able to manage their children’s social media use without damaging their family relationships” (p. 1).
Parental beliefs may influence the degree to which parents give opportunities or restrict their children’s media use, but beliefs should not be considered the “cause” of behavior towards children. Researches show that parents’ positive beliefs (e.g., “the tablet improves reading skills”) are associated with favorable attitudes, co-using approach, communication, or suggestions to enhance their child’s appropriate use of the Internet [28]. For example, when parents think that smartphones are useful tools (i.e., they promote child’s intelligence and knowledge), they more often allow their preschool children to use them (i.e., at the restaurant), and children become regular users, spending more time (at least 2 h a day) with smartphone activities [29]. Conversely, parents who attribute negative effects to digital media tend to limit activities to children (i.e., put time limits or react for smartphone overuse); in turn, these restrictive behaviors can influence how much the children use these devices [28]. Therefore, the influences of parental beliefs on child’s behaviors are not directed, but they are mediated by parental practices and other factors such as parental education or involvement with mobile device (“attachment”; see, e.g., [30]) that can intervene.
Parental beliefs include also self-efficacy [31, 32], that is, parent’s sense of competence in their own digital skills and in managing their children’s technology usage. An example of parental self-referent estimation of competence is “I won’t bother setting parental controls or passwords because my kids will “hack” around them” (cfr. [33]). In many studies, parental self-efficacy is positively associated with active parental practices: when parents feel confident about their Internet skills, they more often are involved in or monitor their children’s media activities [6]. Recently Shin [34] distinguishes general self-efficacy (the confidence to be a good parent; [35]) from two self-efficacy domains assessing parental beliefs more strictly related to digital tasks: parental “media competency” in using media technology (such as sending/receiving email with a smartphone) and “perceived control over mediation strategies” (the degree to which the parent feels to be able to guide or modify their children’s behaviors on smartphone). All these domains of parenting self-efficacy are associated with each other [34], suggesting that perceived competence on their own digital skills can positively influence parents’ involvement with children (e.g., discussing about smartphone use).
Sanders et al. [33] found that when parents are confident to have adequate digital skills, they more often intervene (i.e., with rules and reinforcement strategies) with their children. Parental self-efficacy also influences parental opinions about technologies and how they talk about them with children [33]. Moreover, parental perception of influence in managing technologies decreased with preadolescents that generally are seen as more self-regulated and reluctant to the parental control than younger children. These findings suggest the importance to recognize the influence of child characteristics (such as age, technology usage, perceived competence, etc.) on digital parenting.
Initially studies on parental engagement in children’s activities with media assumed as theoretical basis the traditional parenting styles [36, 37]. According to Darling and Steinberg [38], parenting styles are defined as the context (or emotive climate) in which parents raise and socialize their children, and they are distinct from practices, that is, the distinct actions contingent to the child’s behavior (e.g., scolding when the child uses the smartphone during mealtime). As it is well known, two main dimensions of the parent’s behaviors, and their natural variations along a continuum, describe the styles: responsiveness/warmth (involvement, acceptance, and affect that the parent expresses towards the child’s needs) and demandingness/control (rules, control, and maturity expectations for the child’s socialization). Parenting styles derive from the combination of these variable dimensions: authoritative parenting (high warmth and high control, e.g., parents listen to the child’s wishes, but they put clear limits to the child’s behaviors); laissez-faire parenting (low warmth and low control; the parents are detached from the needs expressed by the child; they did not give rules or limits to child’s behavior); authoritarian parenting (low warmth and high control; parents expect the child to obey; they neither discuss nor listen to the child’s opinions and can react with harsh discipline); and permissive parenting (high warmth and low control; parents are very affectionate, but they lack in guidance through rules and give few limits to the child’s behavior).
Studies that applied these “classic” parenting styles to children’s behaviors with new communication media did not provide convincing results [39]. As an alternative to the “broad” parenting styles, a description of specific media-related practices is more useful in empirical studies for exploring the link between parental behaviors and child outcomes (e.g., time spent online). Therefore, researchers strove to identify the key dimensions of parental warmth/control more strictly referred to children’s behaviors on the Internet or new media (Table 1). These Internet parenting styles are more strictly linked to children’s actual use of digital technologies, for example, low parental control predicted more time of Internet usage by school-aged children [8].
Style dimensions | Item (examples) |
---|---|
Parental control | Supervision: “I’m around when my child surfs on the Internet” |
Stopping internet usage: “I stop my child when he/she visits a less suitable website” | |
Internet usage rules: “I limit the time my child is allowed in the Internet (e.g., only 1 h a day)” | |
Parental warmth | Communication: “I talk with my child about the dangers related to the Internet (costs, addiction to games, computer viruses, privacy violation, etc.)” |
Support: “I show my child “child friendly” websites (library, songs, crafts, school website, etc.)” |
Dimensions of the internet parenting style (adapted from [8], p. 89).
Parenting style dimensions seem influenced by parents’ individual characteristics such as gender, instruction, beliefs, or prior experiences with digital technologies. For example, in Valcke et al. [8] study, mothers are more controlling but also warmer than fathers, both dimensions associated with an authoritative style. In other studies, younger fathers and those who use the Internet more frequently with their teenagers are higher in control [40]. Parental instruction and experiences with digital technologies are other important variables: higher educated parents are more involved and high in control, probably because higher instructional levels also correspond to greater parents’ competence with the Internet [8].
The first studies explored parenting styles related to Internet usage at home, but more recently other authors explored the influence of digital parenting styles on children’s usage of mobile devices (tablet and smartphone). Konok et al. [30] found that children (3–7 years old) who use the devices for more time every day have parents who are more permissive (e.g., they talk with children about applications on devices, but have low levels of demandingness), more authoritative (e.g., they give time limits, but they do not block the use because they expect the child to regulate himself), and less authoritarian (i.e., the parent restricts and prohibits mobile use). Interestingly, these parenting styles are also associated with parental beliefs about positive/negative consequences of early media usage: parents who have higher permissive or authoritative digital style declared more beneficial (i.e., skill improvement, entertainment, and early learning of digital skills) than negative effects (i.e., reduced time for other activities, developmental problems, and danger/addiction) for children’s mobile usage.
Digital parenting styles change also according to children’s characteristics, such as age [41], self-esteem [42], emotion regulation [43], or behavioral problems [44] that can intervene, mediating the link between parenting and children’s actual behavior with digital technologies. Particularly, styles vary and accommodate with children’s age: authoritative parents during infancy become more permissive with older children [41]. Overall, these findings reappraise the idea that there is a linear, cause-effect relationship between parenting and child outcomes on digital behaviors, but bidirectional and transactional parent-child influences [45] should be considered.
Alternatively to digital parenting styles, many researchers adopted parental mediation as perspective for exploring parental influences on children’s digital behaviors. Parental mediation refers to “the diverse practices through which parents try to manage and regulate their children’s experiences with the media” ([7], p. 7). Parental mediation strategies were initially introduced in empirical studies as a potential factor influencing children’s use of television [46] and videogames [47]. These studies, exploring how parents can effectively reduce excessive exposure or enhance children’s self-regulated behaviors, inspired the following researches on digital technologies. Actually in literature two broad mediation approaches are distinct: enabling (or instructive) mediation and restrictive mediation [16]. These strategies are only partially similar to those parents who adopt “traditional” media: for example, co-viewing is a mediation strategy generally applied to television use [48], but it is difficult to apply it to portable media (particularly, smartphone and tablet) that children often use alone or outside the home environment. As a consequence, parents can feel worried because they cannot effectively control their children’s media use and involvement in digital life [11, 49].
The (a) enabling mediation is also defined as “active” or “instructive mediation” in that parents engage different activities with the aim to enhance their child’s appropriate use of the digital technologies: for example, they explain to him/her how to use a media device, talk about the contents of new app/websites, or play a videogame together (co-use mediation). Nevertheless, in many empirical studies, (b) co-use (or co-viewing mediation) does not imply parent-child conversations, but the parent is present when the child displays the activity with the media without discussing the content [13]. The (c) restrictive mediation is characterized by a strict attention to rules and control to the child’s digital activities: for example, parents decide when the child can have his/her tablet, pose time restrictions, or react when the child uses the smartphone too long. The (d) technical restriction is a particular kind of restrictive approach adopting software applications or other technical tools to control the child’s activities (e.g., installing filters on PC for children’s safety). Nevertheless, parents rarely use them and declare they prefer child-directed strategies, such as giving explanations or sharing the device [6].
Active mediation is the most frequent approach adopted in European families with 9–16 years old children, whereas restrictive mediation strategies are more common with younger children [16]. Interestingly, when children are interviewed about the mediation approach adopted in the family, they agree with their parents’ responses [12].
All mediation strategies are linked with changes in children’s digital behaviors, for example, less time exposure with online activities [12], or reduction of negative outcomes (i.e., aggressive behaviors, overuse, etc.; see [50]), but their efficacy is relative and it changes as a function of the child’s development (i.e., age and digital skills) and his/her actual activity with media. Active mediation is linked with positive outcomes (such as social and cognitive skills), particularly with younger children (0–3 ages): for example, during video/movie watching, parents stimulate attention, comment, or pose questions to children, giving them occasions for language exposure and cognitive and digital learning [51]. Nevertheless, we cannot link children’s outcomes uniquely to a distinct mediation strategy, since parent-child interactions are complex and many contextual or individual factors can intervene. Parents often use a combination of mediation strategies, and they change the mediation approach according to the activity the child is doing (e.g., using the tablet for school homework or for visiting Facebook; [11]).
Other authors explored the influence of family sociocultural factors. For mediation to be effective to guide children’s experiences in the web, parents need to have themselves knowledge and skills of the new digital media (see Section 4 in this chapter). Particularly in conditions of sociocultural disadvantage, parents may lack basic digital skills [52], or they may not be able to explain to children how digital reality works and rapidly changes [53]. Unlike the traditional media (such as television or video game console), parents can give a difficult task to assure a help or guide children with the ever-changing technologies. Recently, Nikken and Opree [11] found that mostly low-educated, low-income, and single parents are likely to experience low competence and greater insecurity with new devices (such as electronic screen), declaring that it is difficult to apply co-use or active mediation strategies with their young children (1–9 ages). In addition, Warren and Aloia [49] found that when parents perceive high stress levels, the restrictive mediation and the discussions with children about contents and the use of media increase.
Parental mediation strategies may change according to their child’s age and his/her digital skills, but longitudinal studies are scarce in literature. Developmental changes have been observed from childhood to adolescence: active mediation strategies more often are adopted with younger children, whereas restrictive mediation fades with older and adolescents [17]. Parents generally expect greater autonomy and self-regulation skills from adolescents, and the influence of some parental strategies decrease over time: for example, the efficacy of restrictive strategies (i.e., rules for time or negative consequences for overuse) in reducing screen time decreases with older children [33]. From a developmental perspective, particularly the effects of restrictive approach are unclear. Some studies evidence that restrictive strategies (such as limiting access to media) are effective with younger children [6], but not with older kids. Adolescents can perceive parental control/limitations as a violation of their needs (i.e., self-determination, privacy, peer relationships, etc.) and react with increased online activities [54].
After all, parents wish their children can develop self-regulation, critical view, and awareness of opportunities or risks of digital technologies. In many studies, parental active mediation—for example, discussing with children issues such as cyberbullying, sexting, and online frauds—is more effective than restrictive mediation in reducing risks [16, 55]. Conversely, the efficacy of restrictive mediation must be considered relatively, since in literature both positive and negative associations with online risks emerge [56]. Mascheroni et al. [57] comment, “While restrictive mediation can be effective in reducing children’s exposure to online risks, it has numerous side-effects, because it limits children’s opportunities to develop digital literacy and build resilience and discourages children’s agency within the child-parent relationship. Enabling mediation, instead, encompasses a set of mediation practices (including co-use, active mediation of internet safety, monitoring and technical restrictions such as parental controls) that are aimed at empowering children and supporting their active engagement with online media. The question is, then, how to ensure children’s access to online opportunities while protecting them from potential harmful effects.”
Interestingly, parents adopt their approach according to their child’s competence in digital technology use (digital literacy). In line with a bidirectional model of parent-child influences [45], not only parenting influences child’s behaviors, but also the child’s actual behavior or perceived digital competence influences parental behaviors. Generally, restrictive mediation strategies are more often adopted with less digitally skilled children, but this approach could be counterproductive: limiting online activities for protecting the child from risks, in turn, can deprive him/her to opportunities for developing adequate digital skills [5]. Conversely, parents more often use active mediation strategies (e.g., they share experiences or talk about media) with skilled children than with children who have scarce competencies [58].
The predominance of online activities in the life of many children often worries parents, who observe that spending much time online removes children from face-to-face relationships and social activities. Empirical studies confirm the negative effects of Internet unsuitable use on social participation, since high levels of online activities are associated with few friends, reduced offline relationships [59], and increased loneliness [60]. Particularly loneliness, that is, social isolation and lack of intimacy with close friends, was found to be strongly associated with Internet excessive use [61]. However, causal relationship between Internet excessive use and loneliness is still under investigation [62], in an attempt to understand if loneliness can be the antecedent or the consequence of the individual’s excessive involvement with Internet activities. Two alternative hypotheses have been proposed to explain the link between poor social involvement, feeling lonely, and the development of problematic Internet use in children. According to the first hypothesis, loneliness is one of the main antecedents of excessive online activities, together with low self-esteem, poor social skills, social anxiety, and frequent conflict with parents. Some authors (e.g., [63]) hypothesized that adolescents who feel lonely or experience high anxiety in face-to-face social situations may use social networks and online exchanges more frequently than non-lonely adolescents. According to this “compensation hypothesis,” they are increasingly involved in Internet activities that provide alternative experiences for social life. The second hypothesis assumes that time spent online causes loneliness and social withdrawal, isolating and depriving people of real social experiences. Therefore, loneliness can be considered as a possible outcome of Internet overuse [64], like when prolonged activities online reduce time spent with family and friends. Finally, there are studies that did not confirm the link between loneliness and Internet problematic use [65] or that evidence some positive consequences on individual socioemotional well-being. For example, contradicting the assumption that using the web impoverishes social life and increases isolation, in some studies higher levels of Internet activities are positively associated with social connection and perceived support. Unfortunately studies with children and adolescents are still lacking, but the attention among researchers is growing [60, 66].
Given the paucity of research with adolescents, we conducted an unpublished study1 to explore the relationships among excessive Internet use, preferred online activities, and adolescent’s perceived loneliness. In addition, we hypothesized that among adolescents better parent-child communication and higher parental emotional availability were positively related with less time spent online and less frequent online activities. In fact, studies indicate that parent-child communication and parental involvement play a protective role to excessive online activities [67]. A community sample of 177 high school students (66% females), aged 16–22 years old (M = 18, DS = 1.01), completed a questionnaire measuring the sense of loneliness (UCLA Loneliness Scale; [68]) and the Compulsive Internet Use2 Scale (CIUS, [69]) for assessing problematic involvement in Internet activities. Daily frequency of favorite online activities (chatting, e-mailing, visiting social networking sites, listening to music, watching videos, playing online games, etc.) was also measured. Regarding parenting factors, adolescents filled out (a) the Lum Emotional Availability of Parents questionnaire (LEAP; [71]) assessing adolescent’s perception of parental responsiveness, sensitivity, and emotional involvement and (b) two scales (derived from [70]) measuring the frequency of communication (how often the adolescent communicates with parents about his/her online activities) and the quality of parent-child communication (the adolescent feels understood, or comforted, or taking seriously from parents when he/she talks about Internet activities). In our study loneliness was not associated with Internet compulsive use (CIUS scores), but with specific online activities. Adolescents with higher loneliness levels reported higher frequency of music listening, but they declared less access to social networks (such as Facebook). This result contradicts the hypothesis of social compensation assuming that the teenagers use online exchanges to replace the sense of loneliness in real life [61]. An alternative explanation, proposed by others [72] is that a process downward with a “spiral pattern” is activated: loneliness leads to a decrease in social involvement which in turn increases the sense of isolation. Interestingly, those who spent more time online and were problematic users (higher CIUS scores) were more frequently involved in solitary activities, such as watching videos, listening to music, playing games offline, and visiting social networking sites. Perceived emotional availability from the father (but not from the mother) was negatively related with time that adolescents spent online. Teenagers who perceived greater emotional availability from both parents used the Internet more often for working on school projects and homework or doing search. A better quality of communication with parents is associated with less use of the Internet for gambling and online games. Overall these results confirm a virtuous relationship between quality of family communication, emotional availability of parents, and productive use of the web.
An interesting evidence emerging from empirical literature is the protective role of parent-child communication for preventing Internet unsuitable use in children [73]. Conversely, Internet excessive use is associated with low quality of communication in the family [74]. Particularly with teenagers, the open and effective parent-child communication is a key dimension of family relationships and climate. Assuming a bidirectional perspective of adolescent-child influences, some authors focus on the role of youths’ self-disclosure and spontaneous communication on parenting. Stattin and Kerr [75] claim that parental efforts to monitor adolescent’s activities or to discuss about them are ineffective if teenagers do not trust their parents and if they are not willing to open up spontaneously. Parental monitoring on children’s activities can be less effective when it is parent-driven (e.g., the parent tries to follow the child’s activities on Facebook) than when it is child-driven, that is, activated by children’s self-disclosure and open communication. Conversely, when parents try to control teenagers’ online communication (e.g., the friends on Facebook, the photos posted on Instagram, etc.), parent-child conflicts increase, and adolescents can perceive parental behaviors as an obstacle to their autonomy or an intrusion to privacy [76].
Van den Eijnden et al. [70] identify two key dimensions of parent-child communication about children’s digital behaviors. The first parenting practice refers to the frequency of communication about Internet usage (e.g., “How often do you and your parents talk about who you have Internet contact with?”), whereas the quality of communication about Internet use measures adolescent’s perception of mutual respect and acceptance during conversation (“When my parents and I talk about my Internet use, I feel taken seriously”). Authors explore how these parental behaviors, together with other Internet-specific parental practices (rules about time online, rules about contents, reactions to excessive use), link to compulsive Internet use (CIU) in adolescents. Findings from their longitudinal study are particularly interesting, showing a protective effect of the quality of communication, but not of frequency of communication, on the risk of developing CIU. In other words, a good quality of parent-child communication about the use of Internet decreased the risk of CIU (6 months later), whereas this relationship was not observed for the frequency of parent-child exchanges about adolescent’s online activities. Authors discuss these findings by highlighting the bidirectional nature of parent-child influences. When adolescents show compulsive Internet behaviors, the frequency of parent-child communication decreases. Probably gradually parents get discouraged and give up the idea of achieving a positive change in their child’s problematic behaviors through frequent conversations.
Regarding the parental rules about online activities, studies evidence some mixed results. When parents give their children rules about the content of the Internet, the compulsive use of web decreases; conversely, strict rules about time allowed for online activities seem to be counterproductive, linking to compulsive Internet behaviors in children [70]. Moreover, considering the child’s influences on parent’s behaviors, it is possible that when the child remains connected online without time limits, her/his behavior in turn stimulates stricter rules by parents. Other studies evidence that parental rules about Internet use are less influential on their children’s behaviors than their parents’ behaviors. Liu et al. [77] found that when parental behaviors are consistent with parental rules regarding digital technologies and the Internet (e.g., the smartphone must not be used during mealtime, personal data cannot be given online, etc.), the rules negatively predict Internet problematic use in adolescents. This result reminds us the importance of educational consistency (i.e., rule-behavior agreement) from parents. Conversely, when parental rules and parental behaviors do not agree, only the parents’ behaviors are positively predictive of children’s excessive Internet use. According to social learning theory [78], a parental modeling process intervenes, that is, an observational learning in which the parent’s behavior acts as antecedent for similar behavior in the child. Therefore, parents act as a role model for their children’s digital behaviors, and young children learn how and under what circumstances to use a mobile, for example, the smartphone, observing parents’ activities with that device. Interestingly, studies show that the time parents spend with computers positively relates with time spent by their children [79]. Similarly, parental involvement in favorite Internet activities (visiting social networking sites, video streaming, etc.) is positively associated with the same activities engaged by children. In addition, as some researchers remind us “it is not only overt parental behavior (i.e., digital device use) but also attitudes and emotions that can be modelled for children to imitate” ([30], p. 4). Taken together, these findings suggest that parents’ agreement and modeling of adequate behaviors are crucial factors for promoting self-regulation and safety use of digital technologies in young children.
Today’s reality is widely digitized, and it offers people of all ages opportunities for socialization, amusement, learning, job, and knowledge that were unthinkable until a few decades ago. Precisely in the weeks in which the authors were engaged in the revision of this chapter, COVID-19 pandemic was involving more than 130 countries in the world. The lockdown and restrictions at home quickly changed daily activities of children and parents, transferring to the screen of the devices many activities previously carried outdoor (school lessons, play with peers, etc.). It is still too early to know what impact the epidemic will have on children’s physical and mental health, but the attention of professionals and researchers is not lacking [80]. Surely during COVID-19 screen time has increased exponentially in the families: in some ways for the parents it was a relief, because through the Internet children continued their school courses and contact with peers. In addition, children avoided boredom through videogames or website dedicated to music, creativity, etc. On the other hand, the intensive online activities have renewed parents’ concerns about the well-known risks [23, 81], such as increased sedentary and physical inactivity, prolonged use at night, sleep disorders, isolation, and escape in digital world by teenagers.
Following social distancing and the temporary closure of schools for limiting COVID-19 infection, the Ministries of Education in many developed countries quickly activated online courses and other websites for distance learning. These online solutions have the aim to guarantee children’s right of instruction but also to mitigate the negative effects of home confinement [82]. However, online courses shift the teaching from school to home and make the parents a resource for support and effective learning. The question is: what can be the role of parental mediation and digital competence? As the authors know, there are no empirical studies on this topic, but previous studies with primary school children showed negative associations between parental control, interference in homework, and children’s learning [83]. Currently, in many cases teachers expect parents to ensure that their children connect on time and follow the video lessons, so parental support could be useful, but tensions and parent-child conflicts can also occur. There is also the risk that parents may help children, interfering with digital learning or impeding them from carrying out the assigned activities independently. Close attention and research effort are needed for comprehending how this aspect of digital parenting works, supporting parents in their efforts and ensuring a good home learning to children.
In line with the available studies before COVID-19 [4], we believe that during lockdown the digital activities satisfy children’s basic psychological needs, such as socialization and emotional support by the family (grandparents and cousins) and other significant people (teachers and peers). Social media facilitate the expression of emotions (such as fear and sadness), self-disclosure, and the keeping of romantic relationships by adolescents particularly [84]. Video calling and regular contacts through smartphone have been recommended as an important source of reassurance in the cases of isolation of the caregiver or family due to prevention of COVID-19 infection or recovery [85].
What probably becomes necessary in the time of COVID-19 is a renegotiation of family routines, that is, a balance between screen time and other moments of family life. In this regard, the WHO [85] recommends that parents maintain regular routines for children (school/learning, free time/relaxing, bedtime, etc.) and also to create new opportunities for joint activities (such as co-use for creative, amusing, or physical activity in front of the screen). With young children, many shared activities offer also a context to express and communicate their feelings (both fears and wishes) in a supportive parental relationship. Even in actual COVID-19 circumstances, we believe that parental behaviors (such as self-limiting screen time for smart working, chatting, or gaming) are more influential than restrictive mediation or limitations imposed to children.
Having the digital knowledge and the skills to move in the digital world, without suffering the dangers, is not a matter of age, but of education and learning, that is, digital literacy. It is a serious responsibility towards the new generations and a complex challenge for which the adults (parents, teachers, psychologists, or educators) do not feel prepared. As Martin ([86], p. 135) reminds us: “Digital literacy is the awareness, attitude and ability of individuals to appropriately use digital tools and facilities to identify, access, manage, integrate, evaluate, analyze and synthesize digital resources, construct new knowledge, create media expressions, and communicate with others, in the context of specific life situations, in order to enable constructive social action; and to reflect upon this process.” Currently, parents’ difficulties stem from the fact that they—as digital users—have different levels of involvement, technical skills, and beliefs that influence mediation practices towards their children. If parents feel less skilled or worry about unknown dangers of the web, they could activate more restrictive practices, but rarely they will be able to critically discuss with their children in a constructive manner. In addition, parents believe not to be up to their children in juggling in the digital world, in pursuing technological innovations, or in protecting children from danger or media abuse. Sometimes parents consult the websites for suggestions on how to effectively manage kids in their digital activities, but information disseminated through the websites is not always scientifically founded (fake news). The researcher Danah Boyd [87], in describing the complexity (“It’s complicated”) of teenagers’ life on the web, claims that the media magnify the virtues (the “superpowers”) of digital natives, but at the same time they trigger parental fears talking about serious dangers such as Internet addiction, sexual enticement, or incitement to suicide. Conversely, rarely parents turn to professionals for advice. A study [28] conducted with families of very young children (under 7 years) shows that parents choose the type of help (professionals such as pediatricians, or friends and family) based on the child’s problems and his/her digital activities. The professionals are consulted if the child is an only son or he/she uses the media too long. Parental sense of competence in managing the child’s activities increases if parents are confident of the usefulness of the media (e.g., educational games for learning) and if there are more kids in the family. Parents turn to friends and family for advice when they have a negative view of the effects of the media. This result makes us reflect, but unfortunately there are not many similar studies.
A correct parental mediation of children’s digital activity must build on the information and recommendations that come from the scientific community. The American Academy of Pediatrics [2] has taken a clear stance for prudent and moderate use of the web in infancy (0–5 years) and has prohibited touchscreen device use under the age of 2. The careful use of these devices at such an early age is crucial for the infants’ brain and social development. However, in contrast to these professional recommendations, often parents themselves introduce babies to media use during infancy (e.g., to “take calm” the kid, or to stop whims and cry; [30]). Young children spent daily an amount of time with screen media (iPod, smartphone, video game player, etc.) that grows during infancy (42 min under 2 years and 2 h/39 min at 2–4 years, respectively; [88]). The risks for excessive screen exposure are extensively confirmed in literature and particularly the negative consequences for early users who may present physical problems (such as obesity), developmental difficulties (i.e., language or learning), and unhealthy routines (low sleep quality) (Figure 1).
Developmental risks associated with excessive media exposure (from [88]).
The recommendations for effective parental mediation on children’s digital activities are unequivocal [2]: (a) avoid the use of digital devices before 18–24 months with the exception of video chatting in the presence of the parent; (b) do not allow the child (18–24 months older) to use the devices alone and for more than 1 h a day; (c) do not press for an early use, the child will spontaneously approach the media when ready; (d) help the child apply what he/she learns from using the device to the real world; (e) know that in infancy, direct experiences, manipulation, and unstructured play are crucial for the child’s brain and for social, cognitive, and linguistic development; (f) void the vision of fast programs, with too many distracting elements, or violent contents that the child is unable to understand; (g) avoid using devices to calm the baby, an hour before bedtime; and (h) constantly monitor the media contents to which the child is exposed. Finally, the experts (pediatricians and psychologists) turn also to the industry that produces media devices, so that it adopts a scientifically founded and more ethical approach, for example, installing apps (such as connection stop or automatic shutdown during night hours) that can protect very young children from the risks of overuse.
Therefore, parent education interventions are necessary both to disseminate scientific knowledge on the influence of new technologies on children’s health and development and to help parents to cope with the challenges of digital reality. Parent education cannot be reduced to merely correcting ineffective parenting practices or to a list of instructions on what the parent should do. In fact, all studies indicate that the effectiveness of mediation strategies (restrictive or active approach) is relative, because parental practices interact with the characteristics of both adults (digital skills, beliefs, and activities on the media) and children (age, development, digital literacy skills, etc.). Instead, professionals should help parents to improve and adjust their guidance according to children’s age and developing skills. This is possible to be realized if parents also increase their knowledge and digital skills (media literacy programs), given the importance of these factors in parenting. Less skilled parents, or those who fear the unknown pitfalls of the web, are more likely to intervene only on restricting or prohibiting children’s activities. Conversely, “it is likely that more skilled children and parents are more free to explore and benefit from online opportunities, while also building up resilience against harm by meeting a degree of online risk” ([16], p. 19).
Digital parenting is a very complex and “complicated” task not only because the digital technologies rapidly change, but also because they offer children multiple experiences (learning, communication, socialization, entertainment, etc.) that influence their development, but which are not entirely overlapping to the experiences that take place in the real environment [89]. Particularly, digital natives have the opportunity to know the reality and themselves, developing their own identity [76], with a multiplicity of means and without the supervision of the traditional agents of socialization, primarily the parents (or the teachers). With the awareness of how difficult it is to give definitive answers about the advantages or dangers of digital technologies, more effort is needed from researchers. More evidence-based studies are needed, to understand how technological progress is changing the psychological (neurocognitive, emotional, and social) development of young digital users. However, despite the growing diffusion of digital tools in infancy, studies with very young children are still lacking. Particularly, future research could benefit from longitudinal studies to which to explore the relationships between parenting and children’s experiences in digital environments, their opportunities, or risks.
Authors are listed below with their open access chapters linked via author name:
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