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Caring for the Digital Generation: Understanding Electronic Aggression

      Abstract

      We live in a technology-saturated world, evidenced by widespread, global use of the Internet and other forms of technology. Technology offers nearly limitless connectivity, information-sharing, and communication. Unfortunately, with these opportunities come risks, especially for children, and pediatric healthcare providers have a responsibility to be aware and informed of these risks and how to respond. This article provides a breakdown of the broad phenomenon of electronic aggression and offers practice implications for healthcare providers.

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      OBJECTIVES

      • 1.
        Differentiate between cyberbullying and other forms of electronic aggression.
      • 2.
        List three potential health outcomes associated with electronic aggression.
      • 3.
        Describe at least two criteria needed for effective intervention programs.
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      INTRODUCTION

      The digital world is here and expanding, literally, around the world. At the end of 2019, nearly 54% of the global population, or more than 4 billion people, were using the Internet (
      International Telecommunications Union
      Measuring digital development: Facts and figures 2019.
      ). In the United States, 90% of adults are online (

      Clement, J. (2019). Internet usage in the United States: Statistics & facts. Retrieved from https://www.statista.com/topics/2237/internet-usage-in-the-united-states/

      ), and 94% of children ages 3–18 years have home Internet or mobile access (
      National Center for Education Statistics
      The condition of education 2020.
      ). U.S. teenagers are heavy users of the Internet, primarily with mobile devices. Of those teens, 95% report having access to a smartphone, and 88% report having access to a desktop or laptop computer (

      Anderson, M., & Jiang, J. (2018). Teens, social media & technology. Retrieved from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

      ). Having access to the Internet is commonplace in America's technologically driven society, but even with work, school, extracurriculars, home life, and other daily commitments, nearly 30% of adult users (

      Perrin, A., & Kumar, M. (2019). About three-in-ten U.S. adults say they are ‘almost constantly’ online. Retrieved from https://www.pewresearch.org/fact-tank/2019/07/25/americans-going-online-almost-constantly/

      ) and 45% of teen users (

      Anderson, M., & Jiang, J. (2018). Teens, social media & technology. Retrieved from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

      ) describe being online nearly constantly.
      From the personal computer and the World Wide Web (the Web) to the smartwatch, the current generation is growing up in a technology-saturated world (
      • Crone E.A.
      • Konijn E.A.
      Media use and brain development during adolescence.
      ). People of all ages, and especially young people, have embraced the Internet and the cyberworld for all they have to offer. Entertainment is becoming increasingly Web-based, including live streaming of sporting events and concerts that no longer require a ticket or a drive to a loud, crowded venue. Teaching and learning are occurring online with virtual schools, synchronous classes, and entire e-learning programs. Gaming continues to be popular among youth, with online and live gaming increasing in popularity. Overall, 84% of teens have access to a gaming console, and 90% report playing video games either on a computer, a gaming console or via a mobile device (

      Anderson, M., & Jiang, J. (2018). Teens, social media & technology. Retrieved from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

      ). Communication has been significantly affected by technology with the creation of e-mail, instant messaging, short message service text messaging, and of course, social media. Teens credit social media and the Internet for connecting them to such an expansive, diverse world, but this new world is not without risks (

      Anderson, M., & Jiang, J. (2018). Teens, social media & technology. Retrieved from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

      ).
      The Internet offers users information on every topic imaginable and nearly limitless opportunities for interpersonal connection. Unfortunately, despite the expansive amount of valuable information, entertainment, and opportunities offered through the Web, the impact is not always positive (

      Anderson, M., & Jiang, J. (2018). Teens, social media & technology. Retrieved from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

      ). More than 40% of teens indicate that they often use their smartphones to avoid interacting with others in person (

      Schaeffer, K. (2019, Aug. 23). Most U.S. teens who use cellphones do it to pass time, connect with others, learn new things. Retrieved from https://www.pewresearch.org/fact-tank/2019/08/23/most-us-teens-who-use-cellphones-do-it-to-pass-time-connect-with-others-learn-new-things/

      ), supporting concerns of a loss or poor development of social skills (

      Anderson, M. (2018). A majority of teens have experienced some form of cyberbullying. Retrieved from https://www.pewresearch.org/internet/2018/09/27/a-majority-of-teens-have-experienced-some-form-of-cyberbullying/

      ). Even more concerning about the excessive use of the Internet, are the specific dangers associated with the online world. Children are especially at risk for exposure to racist, sexist, violent, or false information; pornography or obscene material; and child predators who use the Internet as hunting grounds (). In addition, teens and parents alike voice concerns about the Internet and the potential for cyberbullying, exchanging explicit messages or photographs (i.e., sexing), oversharing, persistent distraction, jealousy, anxiety and depression, and all types of drama (

      Anderson, M. (2018). A majority of teens have experienced some form of cyberbullying. Retrieved from https://www.pewresearch.org/internet/2018/09/27/a-majority-of-teens-have-experienced-some-form-of-cyberbullying/

      ;

      Anderson, M., & Jiang, J. (2018). Teens, social media & technology. Retrieved from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

      ). The risk for negative online experiences varies by time online, and unsurprisingly, those who assert to being online almost constantly report more cyberbullying and online harassment (

      Anderson, M. (2018). A majority of teens have experienced some form of cyberbullying. Retrieved from https://www.pewresearch.org/internet/2018/09/27/a-majority-of-teens-have-experienced-some-form-of-cyberbullying/

      ).
      Research has indicated that young people face these online risks regularly, receiving unwanted sexual solicitations, unintentional exposure to pornography, being harassed or cyberbullied, and experiencing privacy breaches (

      Haelle, T. (2017). Online risks are everyday events for teens–but they rarely tell their parents. Retrieved from https://www.forbes.com/sites/tarahaelle/2017/02/28/online-risks-are-everyday-events-for-teens-but-they-rarely-tell-their-parents/#75ec19393861

      ). Children are unlikely to share these experiences with adults, perceiving them as unknowledgeable and unable to help (
      • Brandau M.
      • Davis M.
      “I need someone: Adolescent victims’ reflections on cyberbullying.
      ;
      • Brandau M.
      • Evanson T.A.
      Adolescent victims emerging from cyberbullying.
      ;

      Finklehor, D., Mitchell, K. J., & Wolak, J. (2000). Online victimization: A report on the nation's youth. Retrieved from http://www.unh.edu/ccrc/pdf/Victimization_Online_Survey.pdf

      ;
      • Juvonen J.
      • Gross E.F.
      Extending the school grounds?–Bullying experiences in cyberspace.
      ). Others may expect adults to overreact, restrict their use of technology, or scold them for caring what others think (
      • Brandau M.
      • Davis M.
      “I need someone: Adolescent victims’ reflections on cyberbullying.
      ;
      • Brandau M.
      • Evanson T.A.
      Adolescent victims emerging from cyberbullying.
      ;
      • Hinduja S.
      • Patchin J.
      Bullying beyond the schoolyard: Preventing and responding to cyberbullying.
      ). These predictable reactions are likely to ensure that youth continue to perceive adults as not capable of understanding and avoid reporting these issues to adults in the future (
      • Hinduja S.
      • Patchin J.
      Bullying beyond the schoolyard: Preventing and responding to cyberbullying.
      ).
      Parents, guardians, school personnel, and healthcare professionals play a major role in reducing and responding to online risks, but to do so, they must acknowledge them as real risks and convey that clearly to children.
      • Byrne E.
      • Vessey J.A.
      • Pfeifer L.
      Cyberbullying and social media: Information and interventions for school nurses working with victims, students, and families.
      explain that to provide education and intervention for online risks, adults working with youth must be familiar with the dynamics of the cyberworld. This familiarity includes having a working knowledge of the technology, awareness of the risks, and an understanding of evidence (behaviors, symptoms, etc.) that may indicate exposure to these risks or victimization (
      • Byrne E.
      • Vessey J.A.
      • Pfeifer L.
      Cyberbullying and social media: Information and interventions for school nurses working with victims, students, and families.
      ). Recent research indicates that even with the heavy use of technology, many U.S. adults lack knowledge of the digital world (
      • Vogels E.A.
      • Anderson M.
      Americans and digital knowledge.
      ). If adults are unaware and uninformed, how can they know how to help? Consequently, we offer this explanation of common types of online risks that are often labeled “cyberbullying” or “electronic bullying” but are, in fact, separate phenomena that fall under the broader category of electronic aggression.
      We present a generalized definition of each phenomenon and, on the basis of
      • Walker L.O.
      • Avant K.C.
      Strategies for theory construction in nursing.
      approach to concept analysis, provide a model case that exhibits the critical attributes of the concept. It is hard to imagine a world without the Internet, but the Web has only been available for 30 years (). Consequently, as times have changed, and the Internet is increasingly used among Americans, it has become necessary to redefine the concept of electronic aggression by clearly distinguishing it among the distinct phenomena it entails. We hope that the model cases help the reader visualize the phenomenon “in action.”
      The purpose of this article was to increase awareness and understanding of many of the risks for electronic aggression, to improve communication between adults and children, and reduce the negative impact of such experiences.

      CATFISHING

      Social media plays a major role in how we communicate; it allows us to stay connected to family and friends and to create new acquaintances without geographic boundaries. However, social media and the Internet also provides some anonymity to the user, freeing individuals to recreate themselves or become someone else altogether. This presentation and recreation of self may boost confidence and reduce social inhibitions for one party but is a devious attempt to control the perceptions of others (
      • Fullwood C.
      • Attrill-Smith A.
      Special issue on “constructing the self online”.
      ). Although certainly not the norm or socially acceptable, fake accounts and personas are not uncommon on social media and have unfortunately led to a phenomenon known as catfishing.
      Catfishing is defined as using a fake online profile or persona for a deceptive purpose (
      • Smith L.R.
      • Smith K.D.
      • Blazka M.
      Follow me, what's the harm? Considerations of catfishing and utilizing fake online personas on social media.
      ). This deception is often used in romantic relationships with one partner pretending to be someone other than themselves, primarily in appearance; this is especially common on online dating sites (). Catfishing has also been noted in some cases to gain information for use as blackmail, to set someone up for robbery, or simply to manipulate someone's feelings. Collegiate athletics have used catfishing to monitor the online activities of student-athletes (
      • Smith L.R.
      • Smith K.D.
      • Blazka M.
      Follow me, what's the harm? Considerations of catfishing and utilizing fake online personas on social media.
      ). There have been numerous high-profile cases of catfishing, including the 2013 Manti Te'o (Notre Dame football player and Heisman candidate) story that garnered national attention. The MTV channel created a reality television show (Catfish: The TV Show) and has highlighted many cases of catfishing in romantic online relationships. There are often potential legal implications associated with catfishing, including fraud, misappropriation of likeness, and infliction of emotional distress (
      • Smith L.R.
      • Smith K.D.
      • Blazka M.
      Follow me, what's the harm? Considerations of catfishing and utilizing fake online personas on social media.
      ). However, because of the newness of the concept, there are only a limited number of laws currently in place to prosecute cases of catfishing.

      Model Case

      A 14-year-old girl has a new boyfriend whom she met online in a chat room. The girl has never met the boy in person, but he told her that he was 16 years old and went to a high school in a neighboring county. The boy sends his online girlfriend pictures of him in his baseball uniform, and they have talked on the phone nearly every night for 2 months. One night, after a long, intimate phone conversation, the boy asks the girl to meet in person. The girl is worried that the boy may not like her as much “in-person” but agrees to meet him anyway. The girl rides her bicycle to the park to meet the boy and is shocked to find out he was an 18-year-old high school senior. The boy and a group of his friends (boys and girls) are waiting at the park for the girl. Their online “relationship” was all a joke meant to humiliate the otherwise quiet and reserved girl, and the boy tells her that he has posted the audio of their phone conversations and their messages online. The girl rides her bicycle home in tears, devastated.
      This model case is a classic example of catfishing in a romantic relationship with an intent to deceive another person and manipulate their feelings.

      CYBERBULLYING

      Cyberbullying is a frequently used term relating to electronic aggression and is often used interchangeably with electronic, online, and virtual bullying. Cyberbullying is also frequently termed “electronic aggression,” and although cyberbullying is a type of electronic aggression, it is a unique phenomenon. The term cyberbullying was coined in 1999 but is still used without a universal definition (
      • Englander E.K.
      • Donnerstein E.
      • Kowalski R.
      • Lin C.A.
      • Parti K.
      Defining cyberbullying.
      ). The lack of a standard definition affects the prevalence rates reported across various studies and hinders policy development and legislation nationwide. The U.S. Department of Health and Human Services () and the , define cyberbullying simply as bullying that occurs electronically or digitally. However, much of the research in the literature uses a definition provided by
      • Smith P.K.
      • Mahdavi J.
      • Carvalho M.
      • Fisher S.
      • Russell S.
      • Tippett N.
      Cyberbullying: Its nature and impact in secondary school pupils.
      , defining cyberbullying as an “aggressive, intentional act distributed by an individual or group, using contact in an electronic medium, continuously and relentlessly against someone who cannot stand up for himself or herself easily” (p. 376). This definition, although comprehensive, gives reference to the power imbalance (common with traditional bullying) originally perceived as a required element for electronic bullying. However, years of research have indicated that anyone can be cyberbullied.
      The Cyberbullying Research Center, created by cyberbullying pioneers
      • Hinduja S.
      • Patchin J.
      Bullying beyond the schoolyard: Preventing and responding to cyberbullying.
      offer a more formal definition of the term in their book, writing that “cyberbullying is defined as willful and repeated harm inflicted through the use of computers, cell phones, and other electronic devices” (p. 11). Their definition is concise and includes what they believe are the most important attributes of cyberbullying: (1) willful; (2) repeated; (3) harmful; and (4) computers, cell phones, and other electronic devices (
      • Hinduja S.
      • Patchin J.
      Bullying beyond the schoolyard: Preventing and responding to cyberbullying.
      ).
      • Hutson E.
      Cyberbullying in adolescence: A concept analysis.
      supports these attributes, adding “aggressive” as another important element, and recommending this as a single, universal definition to guide research and practice.

      Model Case

      A 13-year-old boy has been teased for the last year by peers who say he is too small for his age. They post pictures of him on Instagram with demeaning captions and encourage their friends to like and respond to the posts with more teasing. The boy has withdrawn from his family and friends and wrote in his journal that no one cares about his feelings or whether he lives or dies. His sister found his journal and showed it to their parents, who involved the perpetrators’ parents. The perpetrators continue to post humiliating photographs of the boy on Instagram under new, anonymous usernames. The boy feels hopeless and is considering self-harm.
      In this case, the actions against the boy present as cyberbullying as the behavior on the part of the perpetrators is willful, intended to cause harm, involves repeated postings via electronic devices, and demonstrates aggression by continuing to post and encouraging others to join in.

      FLAMING

      Hostile communication or misogynistic discourse has had a persistent presence on the Internet (
      • Jane E.A.
      Flaming? What flaming? The pitfalls and potentials of researching online hostility.
      ). The word “flaming” was originally used to describe “incessant talking or pointless chatter” (
      • Joinson A.
      Disinhibition and the Internet.
      , p. 79). Nowadays, flaming is generally viewed as a type of antisocial or inappropriate behavior occurring on the Internet. Flaming is broadly defined as “heated online communications involving invective, insults, negative affect and so on” (
      • Jane E.A.
      Flaming? What flaming? The pitfalls and potentials of researching online hostility.
      , p. 66), and often includes the use of profanity or vulgarity (
      • Joinson A.
      Disinhibition and the Internet.
      ;
      • O'Sullivan P.B.
      • Flanagin A.J.
      Reconceptualizing ‘flaming’ and other problematic Messages.
      ). Political flaming is a specific type of flaming that is centered on communication on politics and is especially common among adults and even news media reporters (
      • Cicchirillo V.
      • Hmielowski J.
      • Hutchens M.
      The mainstreaming of verbally aggressive online political behaviors.
      ).
      Flaming can occur within various corners of the Internet, including forums and game chats, involving individuals of all ages. The term flaming is often used interchangeably with other types of online hostility, such as cyberbullying and trolling, but is a distinct behavior. Contrary to similarly aggressive online behaviors, flaming involves a direct interaction between Internet users, purposeful violation of social norms, and a negative perception by the receiver (
      • Kern R.L.
      • Gil-Egui G.
      Women behaving badly: Negative posts on Facebook memorial pages.
      ;
      • O'Sullivan P.B.
      • Flanagin A.J.
      Reconceptualizing ‘flaming’ and other problematic Messages.
      ). Intent to violate social norms is a key characteristic of flaming.
      • O'Sullivan P.B.
      • Flanagin A.J.
      Reconceptualizing ‘flaming’ and other problematic Messages.
      explain this quite descriptively, writing that flaming is “like a metaphorical flamethrower that the sender uses to roast the receiver verbally” (p. 70).
      Operationally, flaming was identified as a computer-based phenomenon as early as 1984 (
      • Joinson A.
      Disinhibition and the Internet.
      ). Flaming is often attributed to increased anonymity and a lack of immediate consequences to those involved (
      • Kern R.L.
      • Gil-Egui G.
      Women behaving badly: Negative posts on Facebook memorial pages.
      ;
      • O'Sullivan P.B.
      • Flanagin A.J.
      Reconceptualizing ‘flaming’ and other problematic Messages.
      ). However, a prior study found four times as much flaming when users knew one another (). Interestingly, incendiary comments by “known” parties (with profile pictures and names) receive less outrage (
      • Puryear C.
      • Vandello J.A.
      Inflammatory comments elicit less outrage when made in anonymous online contexts.
      ). Furthermore, the reduced social cues associated with online communication may also contribute to disinhibited behavior. To clarify, the lack of social cues and context that is inherent in the online world results in nonadherence to social norms that generally apply in face-to-face settings; consequently, instances of disinhibited behaviors, such as flaming, occur because individuals fail to recognize the need for self-control or the presence of social norms (
      • Voggeser B.J.
      • Singh R.K.
      • Goritz A.S.
      Self-control in online discussions: Disinhibited online behavior as a failure to recognize social cues.
      ). Regardless of why individuals choose to flame, it is important to be aware of this behavior and recognize the risks for those on the receiving end of online abuse (
      • Lee H.
      Behavioral strategies for dealing with flaming in an online forum.
      ;
      • Sambaraju R.
      • McVittie C.
      Examining abuse in online media.
      ).

      Model Case

      A 13-year-old girl, after watching her favorite college sports team lose a high-stakes basketball game, posted the following on the college's online athletics forum (usernames are fictitious):
      GirlFan08: I hate to break it to you, fans, but I don't think this team has what it takes to be a championship team this year. I'm a fan, win or lose, but I think it's going to be “lose” this year.
      Fanatic2004: GET OVER YOURSELF, @GirlFan08. You have no idea what you're talking about, it's ONE game. Besides, no real fan cares what SOME GIRL has to say about sports! Go play with your Barbies or something.
      BBallFan4Life: Who asked you anyway?! That was 5 seconds reading a worthless opinion from some stupid girl that I can't get back.
      GirlFan08: I watch every game. Why does it matter if I'm a girl? I can like sports too.
      Fantatic2004: We really DON'T CARE what you have to say, GIRL!!! Everyone knows boys know more about sports than girls! Girls + sports = NO. You're just some lame teenybopper who thinks she knows sports because she watches a game every now and then. #getalifeloser #girlssuck
      Flaming is the behavior highlighted in the model case above. Although some might consider this cyberbullying, this is isolated aggressive behavior in response to social media discussions. The perpetrators have direct contact with the target, though they may be strangers, and make a clear attempt to violate social norms by questioning the target's knowledge of sports on the basis of perceived gender norms.

      OUTING AND TRICKERY

      One essential element of the Internet is the ability to share and to share with a potentially limitless reach. The Internet is a wonderful tool when seeking to share information willingly; however, in some cases, information can be unwillingly shared. Outing and trickery are two especially deceptive forms of electronic aggression that occur when information is shared without consent. provides a longstanding definition of outing as “sharing someone's secrets or embarrassing information or images online” (p. 2). To “out” someone, an individual or group may record (often secretively) an individual during an activity, during an intimate moment, or in revealing or compromising situations. Taking pictures or videos of an individual in a public bathroom, locker room, gym, or dorm room, without their consent, may lead to a very public humiliation.
      Trickery is very similar to outing but involves coaxing someone into “revealing their secrets or embarrassing information, then sharing it online” or electronically” (, p. 2). Trickery takes outing to a different level in that the person being outed reveals their secrets or potentially embarrassing information willingly, and that information is then shared electronically without their consent. Trickery commonly occurs with “frenemies” who pretend to befriend an individual, obtain the needed information, and then unjustifiably share it with others. It is also not uncommon for a scorned former romantic partner to share private or intimate photographs meant for that person only, with others, in an attempt to embarrass or humiliate the former partner.

      Model Case

      Outing

      The unfortunate, real-world experience of Rutgers University student, Tyler Clementi, highlights the devastating impact of outing. Tyler was a gay male who was filmed, unknowingly, in an intimate act with another man in his dorm room. The perpetrator, Tyler's roommate, shared the images he obtained from a hidden webcam on the Internet. Tyler was only open to close family and friends about his sexual preferences at that time and was humiliated to learn that he had become a topic of ridicule in his new college environment. Perceiving this to be an event that he could not overcome, Tyler took his own life a few days later (

      Tyler Clementi Foundation. (n.d.). Tyler Clementi's story. Retrieved fromhttps://tylerclementi.org/tylers-story/

      ).

      Trickery

      A 15-year-old girl is in a new romantic relationship with a boy she communicates with online. After a couple of months of texting and talking on the phone, the boy presses the girl to share intimate photographs with him. Nervous, but excited about her new, mature romantic relationship, the girl shares intimate photographs with her new “boyfriend.” A few days later, the girl receives a message from the boy stating he does not want to be her boyfriend anymore. The girl is heartbroken to learn that the boy never wanted to be in a relationship with her but wanted to obtain intimate photographs of multiple girls he met online. The boy posted screenshots of their racy text conversations as well as the intimate pictures of the girl on an Instagram account with similar postings about other girls. The girl is ashamed and wonders if she will be in trouble with her parents if she asks for their help in removing the postings.
      Outing and trickery, although distinct behaviors, can be used as an element of cyberbullying or as stand-alone behavior. If outing and trickery are used repeatedly, with the intent to harm or humiliate another individual, this would be considered cyberbullying by way of outing and trickery. The model case for outing is tragic and resulted in the real-world death of a talented and loved young man who was outed with private information that was shared without his knowledge or consent. In the model case for trickery, the girl was “outed” after she shared her secrets and intimate photographs with someone she trusted to keep them private.

      CYBERSTALKING

      Technology, present in the lives of people of all ages, has become an important tool in both developing and maintaining relationships; this is true even with romantic relationships, with some partnerships and marriages beginning with a simple text message or e-mail. Unfortunately, technology use also allows for unwanted monitoring and tracking behaviors known as stalking. Cyberstalking (virtual or online stalking) is defined as the “repeated pursuit of an individual using Internet-capable devices” (
      • Reyns B.W.
      • Henson B.
      • Fisher B.S.
      Stalking in the Twilight Zone: Extent of cyberstalking victimization and offending among college students.
      , p. 1).
      • van Baak C.
      • Hayes B.E.
      Correlates of cyberstalking victimization and perpetration among college students.
      describe three key components of cyberstalking, indicating the behavior must: (1) involve repeated threats and/or harassment occurring at least twice; (2) occur via electronic or computer-based communication; (3) lead to fear or concern for one's safety.
      Online stalkers are persistent and regularly send unwanted electronic communications that may be intimidating, threatening, or very often, sexual in nature or spy on their targets using location trackers, social media postings, or applications, such as Find My Friends or Find My iPhone (
      • Buhi E.R.
      • Clayton H.
      • Surrency H.H.
      Stalking victimization among college women and subsequent help-seeking behaviors.
      ;
      • Reyns B.W.
      • Henson B.
      • Fisher B.S.
      Stalking in the Twilight Zone: Extent of cyberstalking victimization and offending among college students.
      ;
      • Reyns B.W.
      A situational crime prevention approach to cyberstalking victimization: Preventive tactics for Internet users and online place managers.
      ). Cyberstalking may also include spreading false information; outing and trickery; and obtaining addresses, phone numbers, bank information, and other types of personal information (
      • Mullen P.
      • Pathé M.
      • Purcell R.
      Stalkers and their victims.
      ). The harassing nature of these behaviors are inherent in any type of stalking, but cyberspace allows for the behavior to occur without the interference of time or space (
      • Reyns B.W.
      • Henson B.
      • Fisher B.S.
      Stalking in the Twilight Zone: Extent of cyberstalking victimization and offending among college students.
      ). For some victims, stalking may occur in-person and online. Others may be monitored by current romantic partners without their permission and with or without the victim's knowledge, keeping the partners connected via an “electronic leash” (
      • Marcum C.D.
      • Higgins G.E.
      • Nicholson J.
      I'm watching you: Cyberstalking behaviors of university students in romantic relationships.
      ). In some fields of study, cyberstalking by romantic partners may be labeled as “cyberdating abuse,” but the behaviors are the same (
      • Burke S.C.
      • Wallen M.
      • Vail-Smith K.
      • Knox D.
      Using technology to control intimate partners: An exploratory study of college undergraduates.
      ).

      Model Case

      An 18-year-old girl is in a new relationship. The girl's ex-boyfriend, after learning of her new relationship, becomes angry and seeks revenge. The boy had access to the girl's social media account passwords when they were together, and she has not changed her passwords. Accessing her Twitter account, the boy monitors all the photographs and videos she posts, including those with her new boyfriend. Using location tracking, he also monitors her location, and “finds” her at various locations around town. The girl notices she is running into her ex-boyfriend frequently and feeling as though her privacy is being violated, confronts him about how he always seems to know where she is. The boy denies monitoring her and claims their interactions are coincidental. One evening, the boy tracks the girl to the movie theater and confronts her new boyfriend. The confrontation leads to a physical altercation in which the police are called to intervene.
      Repeated harassment, monitoring, and location tracking of an individual is evident in the above case and are textbook characteristics of traditional stalking. The use of technology for such behaviors has evolved into cyberstalking and, as demonstrated in the model case, may often lead to or co-occur with traditional, in-person stalking behaviors.

      TROLLING

      Historically, and as described in various folktales, a troll is a mythical, brute creature with an ugly appearance. In the cyberworld, this “ugly appearance” manifests as an undesirable presence online. A troll, in today's society, most often refers to a “person who posts provocative messages and off-topic messages on the Internet . . . with the intention of provoking other users into displaying emotional responses or disturbing the discussion process” (
      • Gemiharto I.
      • Sukaesih M.
      The phenomenon of Internet trolling and the spreading of hate speech on social media.
      , para. 1). Some studies claim that there is no universal definition to support trolling as always involving harmful intention (
      • Komaç G.
      • Çağıltay K.
      An overview of trolling behavior in online spaces and gaming context.
      ).

      Cheng, J., Bernstein, M., Danescu-Niculescu-Mizil, C., & Leskovec, J. (2017). Anyone can become a troll: Causes of trolling behavior in online discussions. In C.P. Lee & S. Poltrock (Eds.), Proceedings from the CSCW’17: Conference on Computer-Supported Cooperative Work and Social Computing. doi:10.1145/2998181.2998213

      argue that anyone can behave like an online troll, with mood and previous exposure to trolling behavior impacting an individual's decision to troll. However, a recent qualitative analysis (
      • March E.
      • Marrington J.
      A qualitative analysis of Internet trolling.
      ) describes trolling as “abusive, aggressive behavior” (p. 1) with terms such as provoke, deliberate, reaction, and upset used by participants to define the Internet trolling. Generally-speaking, trolling is evidenced by toxic and hostile online behaviors perpetrated for one's amusement, and is positively associated with narcissism, psychopathy, and Machiavellianism, commonly known as the Dark Triad (
      • Buckels E.E.
      • Trapnell P.D.
      • Paulhus D.L.
      Trolls just want to have fun.
      ;
      • Howard K.
      • Zolnierek K.H.
      • Critz K.
      • Dailey S.
      • Ceballos N.
      An examination of psychosocial factors associated with malicious online trolling behaviors.
      ;
      • Komaç G.
      • Çağıltay K.
      An overview of trolling behavior in online spaces and gaming context.
      ;
      • Paulhus D.L.
      • Williams K.M.
      The Dark Triad of personality: Narcissism, Machiavellianism, and psychopathy.
      ). Simply put, “cyber-trolling appears to be an Internet manifestation of everyday sadism” (
      • Buckels E.E.
      • Trapnell P.D.
      • Paulhus D.L.
      Trolls just want to have fun.
      , p. 97).
      Unlike cyberstalkers or cyberbullies, trolls do not often know the individual or group they are victimizing, at least not personally (
      • Howard K.
      • Zolnierek K.H.
      • Critz K.
      • Dailey S.
      • Ceballos N.
      An examination of psychosocial factors associated with malicious online trolling behaviors.
      ). On Twitter, trolling has become somewhat of an art form among businesses, especially the hamburger chain Wendy's, that regularly trolls the competition with humorous Tweets meant to draw attention to their business and stir up a laugh among customers and Twitter users. Celebrities have been known to “clapback” at online “haters” with sarcastic comments and humor in the form of trolling. However, trolling is sometimes viewed as less “fun” and viewed as a more acute, less harmful, impersonal attack compared with a more chronic or enduring nature of cyberbullying (
      • March E.
      • Marrington J.
      A qualitative analysis of Internet trolling.
      ). Actress Selena Gomez (

      Rochlin, M. (2017, Mar. 22). Selena Gomez (and others) on adapting ‘Thirteen Reasons Why’ for Netflix. Retrieved from https://www.nytimes.com/2017/03/22/arts/television/selena-gomez-thirteen-reasons-why-netflix.html

      ) commented on the impact of trolling on self-esteem, stating:
      • They're not like, “You're ugly.” It's like they want to cut to your soul. Imagine all the insecurities that you already feel about yourself and having someone write a paragraph pointing out every little thing-even if it's just physical.
      Attempting to defend yourself is counterproductive and is known as “feeding the trolls.” Trolls,

      Ahmed, I., & Papadopoulos, L. (2019). Don't feed the trolls: How to deal with hate on social media. Retrieved from https://docs.wixstatic.com/ugd/f4d9b9_ce178075e9654b719ec2b4815290f00f.pdf

      contest, are not looking for a mature debate with a clear winner or loser, but seek to be heard by as many people as possible in hopes of changing opinions or perceptions. In many cases, though, and at the very least, trolling has the potential to be disruptive, provoking, and emotionally distressing to those on the receiving end, making it an online form of abuse.

      Model Case

      Below is an example of real-life trolling among Twitter business accounts that were meant to be humorous.
      @Hooters: Whatcha got?
      @Wendys: @Hooters Uniforms our employees can wear in the winter.
      Here is an example of Twitter trolling and a sarcastic celebrity “clapback”:
      @AnonymousUser: @jk_rowling Caught this article on yahoo. I will now burn your books and movies too.
      @jk_rowling: Well, the fumes from the DVDs might be toxic and I've still got your money, so by all means borrow my lighter.
      The model case for trolling displays the “fun” side of trolling, often used as a public relations maneuver to garner an audience, and the quick-witted style of trolling that is often used by celebrities and professional athletes to retaliate against online trolls and draw attention to their negativity. Popular profiles with a large following have the potential to be the most disturbing and emotionally provocative, which is the ultimate goal of the troll.

      DISCUSSION

      Electronic aggression is a broad, public health issue encompassing several distinct behaviors. As technology has evolved, the modalities and venues for electronic aggression have expanded, and various phenomena have emerged. It can be likened to a rainstorm in which electronic aggression is the suddenly appearing storm cloud, raining the various types of electronic aggression down on the technology user. Whether it be catfishing, cyberbullying, cyberstalking, flaming, trolling, or outing and trickery, the consequences may be severe. Internalizing and externalizing behaviors may appear but not be associated with an underlying issue with electronic victimization (
      • Zahn-Waxler C.
      • Klimes-Dougan B.
      • Slattery M.J.
      Internalizing problems of childhood and adolescence: Prospects, pitfalls, and progress in understanding the development of anxiety and depression.
      ). Victims of electronic aggression or harassment, as compared with those who have not been victimized electronically, are considerably more likely to consume alcohol and other drugs; get in trouble at school or skip school; have poor academic performance; and experience anxiety, depression, chronic fear, self-harm and suicidality (
      • Guinta M.R.
      • John R.M.
      Social media and adolescent health.
      ;
      • Hertz M.F.
      • Jones S.E.
      • Barrios L.
      • David-Ferdon C.
      • Holt M.
      Association between bullying victimization and health risk behaviors among high school students in the United States.
      ;
      • Landoll R.R.
      • La Greca A.M.
      • Lai B.S.
      • Chan S.F.
      • Herge W.M.
      Cyber victimization by peers: Prospective associations with adolescent social anxiety and depressive symptoms.
      ). These issues have the potential to impact psychosocial development and hinder successful transition into adulthood.
      Healthcare providers (HCPs)—especially school, pediatric, and mental health nurses—are in a key position to recognize the presence of internalizing and externalizing behaviors as they may be the HCPs most likely to see children regularly (
      • Liu J.
      • Chen X.
      • Lewis G.
      Childhood internalizing behavior: Analysis and implications.
      ); school nurses are likely to interact with children daily. Building trust and rapport is the first step to connecting with youth, but to be viewed as allies, healthcare professionals must demonstrate an awareness and understanding of the pressing issues (
      • Vessey J.A.
      • DiFazio R.L.
      • Strout T.D.
      “I didn't even know you cared about that stuff”: Youths’ perceptions of health care provider roles in addressing bullying.
      ). Identifying electronic aggression as a real risk is paramount. To understand these risks, HCPs must have a foundational comprehension of the dynamics of these behaviors. This understanding includes having a working knowledge of the terminology and modalities in which this behavior occurs. This knowledge will allow for prevention and intervention efforts tailored to meet the specific needs of those impacted by cyberbullying victimization and those most at-risk.
      Once aware of the dynamics and risks of electronic aggression, HCPs can collaborate with community leaders and adolescent stakeholders to develop prevention and intervention programs that connect youth, family, schools, and the community (
      • Nation M.
      • Crusto C.
      • Wandersman A.
      • Kumpfer K.L.
      • Seybolt D
      • Morrissey-Kane E.
      • Davino K.
      What works in prevention. Principles of effective prevention programs.
      ). To be effective,
      • Nation M.
      • Crusto C.
      • Wandersman A.
      • Kumpfer K.L.
      • Seybolt D
      • Morrissey-Kane E.
      • Davino K.
      What works in prevention. Principles of effective prevention programs.
      explain that programs must be comprehensive, culturally relevant, include a diversity of teaching methods from well-trained staff, promote positive relationships, and evaluate the effectiveness of such programs, among other criteria. To be comprehensive and relevant, it is necessary for developers of these programs to be well-informed and prepared to address the evolving needs of our youth. In addition, these programs must be inclusive of all “players” (e.g., youth, families, school personnel, HCPs, law enforcement) involved in reducing the risks and consequences associated with electronic aggression (
      • Vandebosch H.
      Schools and cyberbullying: Problem perception, current actions and future needs.
      ), including the youth themselves.
      HCPs can offer a variety of educational approaches to inform youth of the benefits and risks of technology use, including discussions at office visits, classroom or community presentations, or by providing online or print resources for managing and coping with electronic victimization. In today's technology-driven society, youth may prefer to seek support in an informal or even virtual environment. Virtual environments may provide the opportunity for youth, especially those who are more introverted, to seek help without feeling judged, shamed, or stigmatized (
      • Weinstein E.C.
      • Selman R.L.
      • Thomas S.
      • Kim J.
      • White A.E.
      • Dinakar K.
      How to cope with digital stress: The recommendations adolescents offer their peers online.
      ). HCPs can collaborate with other adolescent stakeholders to develop and manage those virtual communities to ensure youth are receiving the information and support they need.
      Regardless of the venue or the approach used, healthcare professionals have a duty to respond to the needs of youth by listening, informing, and supporting. The primary commitment of nurses is to all recipients of healthcare, individuals or groups, and nursing care must be adapted to meet the unique and holistic needs of the patient (
      American Nurses Association
      Code of ethics for nurses with interpretive statements.
      ). We, as nurses, owe it to fellow humankind to be informed and prepared.

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      Biography

      Melvina Brandau, Assistant Professor, School of Nursing, Ohio University, Athens, OH.
      Snehaa Ray, Graduate Student, School of Applied Health Sciences and Wellness, Ohio University, Athens, OH.