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My grandfather, 82 years but not old, is the wisest man I know. He is a lawyer and I remember going to court to see his advocacy, which would be so classy that I still get goose-bumps. He would come back home, study for a couple of hours daily, recite religious books and do yoga. He was the perfection that anybody could imagine. As he retired 10 years back from active practice, I gifted him a smartphone to kill the possible boredom. Was that a mistake? Did I make him a scroller from the scholar?

Nowadays, he is on his phone most of the time. He is not interested in study, religious books or yoga. When we insist, he would say, he did enough on his days, and continue with scrolling. On the other hand, I have a nephew, who is eight years old. We could not prevent exposing him to mobile from his early years. He wouldn’t feed or poop without rhymes. At two years old, he was already unlocking my phone, using a pattern, and would sing different English rhymes. “This guy is a genius”, I thought but I was just encouraging him to be a scroller. Nowadays, he spends almost 6 hours a day in front of the screen, which would double on weekends. He fights for mobile, skips his homeworks, throws tantrums on trivial issues, keeps busy to himself, and seldom talks with the relatives. It looks as if we even have to make an appointment to see him. 

Sometimes I wonder if it is only my grandfather and my nephew, but as I observe, it’s similar in me, my wife, my friends, relatives, and most of the people around me. Different games, social media, YouTube and especially short videos are stealing our time. Every time, we promise to scroll for a few minutes and realize after an hour or two. You may argue the academic need of scrolling but believe me, it’s beyond. We are gradually and unknowingly moving to be scrollers from scholars.

Would you be surprised, if I tell you, “This is an addiction, similar to that of addiction to alcohol or cigarette”? Do you believe that this is an illness? 

Yes! You should.

There is something called “Internet addiction” or “Gaming disorder” in standard textbooks and it is gaining a huge amount of attention nowadays. Internet addiction is increasing exponentially and approximately, with one in every 10 people already affected. The World Health Organization formally included Internet gaming disorder as a mental disorder from 2018. The brain mechanism behind the addiction to the internet and alcohol is similar. There is a huge surge of dopamine, which gives reward for the act and compels us to repeat the act.

Internet gaming disorder is often together with or may be caused by childhood neurodevelopmental disorders such as Attention Deficit Hyperactivity Disorder (ADHD), depression or anxiety. Other risk factors are stress, dysfunctional families, loneliness, poor academic performance, being bullied, interpersonal problems, anxiety and depression.

Different forms of addiction

Cyber-relational

Excessive tendency to establish relationships with people met online, which quickly becomes over-involving and individuals neglect their relationships with friends and family members.

Info overload

Characterized by an increased search for information on the web, many of them unnecessary, like short entertainment videos in youtube and social media. 

Cybersexual 

There is frequent use of adult-videos and virtual sex sites and engage in adult-only chats. 

Gaming

Excessive involvement in games and online activities such as gambling, compulsive shopping, etc.

The internet provides many opportunities but there is a downside. Some people suffer from diminished control over their use, and there are many reports of people gaming or watching series for days without rest. Given the increased use of the internet in this era of social distancing and remote working, it is important to assess harm caused by online addictive behaviors. The outcomes of the disorder could be academic decline, interpersonal relationship problems, family conflict, sleep deprivation, physical health problems like neck stiffness, loneliness, suicidal tendencies, aggression, depression, social withdrawal, cybercrimes and future decline in workplace competitiveness. 

For objective assessment, the Internet Addiction Test (IAT) is applied by professionals. WHO recommends no screen time for children less than one year old, no more than an hour for 2-5 year-olds, with less time preferred, which can be doubled in weekdays under observation. It is similar for adolescents and adults, no more than an hour a day of screen time. Instead, involvement in social interaction and physical activity is encouraged.

On excessively using the internet, children and adolescents first become unable to prioritize or keep schedules, avoid work or procrastinate, then develop symptoms of depression or anxiety, and may even appear agitated when forced to stop by a caregiver. Therefore, internet and gaming-addicted children and adolescents urgently need an early and effective treatment and prevention program. But there is prevalence of parents’ unwillingness to accept internet addiction as a mental disorder, or parents’ misunderstanding that pharmacological treatment is harmful for gaming-addicted youth.

Treatment for internet addiction is comprehensive and multimodal. Psychosocial interventions include cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), reality therapy (RT), and multi-level counseling (MLC) programs, solution-focused brief therapy (SFBT), which are delivered via individual-session psychotherapy, family-based therapy or group-based supportive psychotherapy. The 20-20-20 rule (take a 20-second break every 20 minutes and view something 20 feet away is beneficial. Medical management is for the treatment of the co-occurring anxiety, depression or ADHD.

As a preventive strategy against this addiction, we should focus on raising awareness and training parents, teachers, and other supporters early on, for early intervention. The rule of thumb is to establish healthy internet use habits early in life, which can prevent children from becoming the victims of internet gaming disorder and scholars from scrollers.

The author is a resident doctor at Department of Psychiatry, Patan Academy of Health Sciences

The recent news of sexual exploitation of children in a care home in Kathmandu has stirred-up the society. It is a most cruel and tragic occurrence and a serious infringement of a child’s rights to health and protection. But it is not the first news and my prayers would be futile if I wished it to be the last. Similar incidents have occurred in the past in different parts of Nepal, neighboring countries and in the world. Though a heinous act against humanity which spreads rage for a few days, the incident repeats. It has been so for ages. The easy access to the news and information sharing might have made the perpetrator think twice and increased awareness on child sexual exploitation in the public.

The World Health Organiaztion (WHO) defines Child Sexual Abuse (CSA) as “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society”. It ranges from fondling, inappropriate touch to sexual penetration. Studies have shown that one in five women and one in 13 men reported being sexually abused as a child. CSA is a silent health emergency that is prevalent everywhere. Generally, it goes unnoticed, under-reported and poorly managed as it is surrounded by a culture of silence and stigma. Some victims do not recognize that their experience was CSA until adulthood. The main contributing factors are poverty, family separation or being orphaned at a young age, lack of awareness, armed conflicts, among others. Poverty and lack of awareness could be the factor for the recent event in Kathmandu. 

Though it looks unreal, CSA often occurs in places normally considered safe: Homes, schools, places for leisure activities. Children lack maturity to understand and report sexual abuse. In addition, they are coerced, sworn to secrecy or threatened by the perpetrator. The habitual perpetrator is usually someone who is known and trusted by the child, is within or close to the family or who has authority over the child. They include fathers, stepfathers, grandfathers, uncles, brothers, cousins, domestic servants, teachers, peers, family friends, employers and others.

There are numerous short-term and long term consequences of CSA affecting physical, mental and social health. Some to list are physical injury, sexually transmitted infections (e.g. HIV/AIDS), unwanted pregnancy and unsafe abortion with its complications, regressive behaviors like bed wetting and thumb sucking, emotional trauma, depression, anxiety, phobia, posttraumatic stress disorder (PTSD), substance use, suicide attempts, poor school performance, rejection by family and society, family disharmony leading to poor parenting and abusive behaviour by the victim in the later life.

The assessment part along with management is very sensitive. The taboo against talking with children about sexuality makes the tasks of prevention programs challenging and discourages sexually abused children from disclosing their abuse. Most of the times, children are inappropriately inquired or examined by the family members for the possible sexual abuse which can be counter-productive, that they will not open up even with the specialists. First thing to be done is reassurance and safety of the child by removing them from being in contact with the perpetrator. These may necessitate measures such as making alternative living arrangements for the child, with relatives/extended family, with whom the child feels safe and comfortable. We should respond in a sensitive manner and prevent re-traumatizing victims. 

The government of Nepal has OCMC (One-stop Crisis Management Center) in all the districts. The main aim of the OCMC is to provide comprehensive care for the victim, from examination, psychosocial counseling, management and placement in safe-house if required, all free of cost and from within the same place. Confidentiality throughout the process of management and speedy trial of offenses against children by OCMC has encouraged victims to reach those centers and seek help. If not able to visit OCMC due to threat to life, they can even call the center (phone numbers are available on the internet). In addition, there is a toll-free number (1098) to report child abuse.

Prevention strategies include improving children’s understanding of their bodies, appropriate and inappropriate touch, and who they could reach out to if they have concerns about someone’s behavior, along with body safety training programs in school or community. Strong preventive law and policy and its implementation at the grass-roots is necessary. Everybody in the society should be responsible to identify the children in stress, their change in behavior and report any suspicious activity to concerned authorities.  We should not make judgmental comments, always take it seriously what the child is saying, and assure them that they did the right thing in telling. We should tell the child that he or she is not to blame for the sexual abuse and offer them comfortable and protected environment. 

It is equally inhumane, to involve in the act of sexual exploitation or not to involve in the act of prevention!

The author is a resident doctor at the Department of Psychiatry, Patan Academy of Health Sciences, Lalitpur