Risk and benefit

Risk exists when something that is valued, including material resources, or one’s physical or emotional health or well-being, is placed in a situation in which it could be lost. Such risks exist in almost every area of life, but in order for a person to consider taking a risk that action must also carry the potential for some benefit.9 Deciding whether or not to take a risk, therefore, depends on whether the individual perceives the potential gain to outweigh the loss that may be incurred. One challenge in determining risk is that each individual will have a different perspective on the importance of the potential loss or gain presented by a given situation. For example, perspectives on whether the gain of peer support that young people may experience in online communities outweighs the risk of being given bad advice or being targeted by abusive dialogue may differ between young people, primary care practitioners and parents.

Decisions about whether a particular risk is worth taking are, therefore, influenced not only by highly individual perceptions of the relative value of what is put at risk compared to what may be gained but also by people’s perspectives on risk. A risk control perspective, for instance associates risk with threat, danger and harm, sees it as desirable to remove or avoid all risk and gives adults a responsibility to prevent children from being exposed to risks.10

A contrasting view, the risk-taking perspective, sees risk as a positive entity, linked to learning, empowerment and self-determination. 9 This view places taking risks, and even experiencing some degree of adverse outcome, as a central part of children’s learning. It considers it important for children and young people to learn to identify risky situations, consider and experiment with different ways of managing these and develop the ability to decide which risks they are prepared to take, and how they will manage the outcomes of those risks.11 The risk-taking perspective views this process as an important part of children and young people learning to develop autonomy and take responsibility for their actions.12 It gives adults a responsibility to enable and support children as they learn through taking risks; some of which will be successful and lead to gains and some of which will inevitably lead to losses. This perspective links with addressing concerns about children’s online safety by developing their abilities to understand online risks and strategies for keeping themselves safe, so as to acquire the skills which they will need as adults.13,14 For example, using social media at any age includes the risk of encountering negative, derogatory or abusive comments, and bullying. A valuable part of children and young people’s learning would, therefore, be seen as being to gain skills in handling such situations, rather than avoiding situations in which there is a risk of this occurring. This may include enabling children to decide whether the benefits they believe they will gain from a particular site outweigh the problems it may bring, to learn how to manage negative comments and to determine the best thing to do when information or requests for information seem unreasonable or worrying. In relation to personal health records, the risk-taking perspective would see the role of adults, including primary care practitioners, as being to work with children and young people on learning how to take responsibility for and control of this access. This could include how to manage any concerns that accessing their records might create, and developing the skills to negotiate with others what information they are prepared to share.

Making such decisions nonetheless requires primary care practitioners to consider at what point they would deem an action unacceptably risky or harmful, compared to what they would see as a reasonable risk, and a learning opportunity for a child or young person. It may also require them to explore these potentially highly individual perspectives with children and their families.

Acceptable risk

Determining which situations constitute good learning experiences and which constitute a failure to protect children from harm is far from easy. This is partly because individuals all have different priorities, beliefs and values that influence what they see as worth risking for the potential gain offered. For example, for someone whose priority is to gain high-quality information, the risk of being given inaccurate information may greatly outweigh the potential benefit of making friends via social media. For others, the reverse will be true. Similarly, perceptions of whether particular situations are harmful or not can be perceived differently by different people: a comment that is seen as intimidating by one person might be viewed as irritating but trivial by another.15

As well as the variability of perceptions of situations, and the value that individuals attach to particular outcomes of risks, people have different general risk-taking propensities, with some more inclined to take risks than others. These very individual characteristics and perceptions will affect adults’ inclination to encourage children or young people to engage in activities which entail risk, a child or young person’s desire to engage in such activities and each party’s perceptions of the riskiness of a given situation.16 It also means that there is no one acceptable risk, or level of risk taking in any element of life, including online activities. However, working with children, young people and their families to explore the potential risks and benefits of situations, what they see as reasonable risk, and why, may be beneficial in enabling them to access online information in a manner with which they feel comfortable and safe. As well as learning about accessing online information, this may enable them to learn about themselves, and how they can decide about and manage risky situations. It may also provide parents and their children with an opportunity to engage in discussions about how to proceed when their views on acceptable risk differ.

Practically, perceptions of online risk may also be influenced by the confidence that individuals have about using the internet.17,18 Health care professionals are likely to have varying degrees of confidence in using online resources.1 Similarly, families may have differing levels of knowledge and confidence in this area. As well as debating more general issues of risk, primary care practitioners may, therefore, find it helpful to utilise available guidance on online safety as a reference point to discuss what can, and cannot, be done to reduce unnecessary risks online.4 This may also be a useful start point from which professionals can initiate discussions about how to tailor such advice to a particular child or young person’s cognitive and emotional developmental level, and how, over time, they can be helped to learn to manage their own online safety. In general terms, a public health approach to child protection in which prevention and early intervention are key has been recommended.19 In relation to online activities, this approach might include primary care practitioners being aware of, and open to discussing, the risks and benefits of using the Internet to access health-related information with children, young people and their parents.

Whilst these considerations apply to all children and young people, there are some additional issues which those who work with children and young people who have long-term health needs may need to weigh up in discussing the use of online resources.

Children with long-term conditions and vulnerability

Vulnerability is usually associated with the notion of an individual being at risk of harm from a danger or threat, and in need of protection because of this.20 Children are generally perceived as being more vulnerable than adults, and those who have long-term health conditions are often regarded as more vulnerable than their peers. For instance, disabled children are at greater risk than their peers of suffering abuse or maltreatment.21,22 Thus, children, and particularly those with additional heath needs, are generally seen as being in need of some degree of protection from harm.

Affording children protection from harm is a part of a parent and professional’s duty. However, rather than seeing vulnerability as a weakness or deficit, which adults must manage for children, vulnerability, be it because of age, health, experiences or personality can be regarded as a common human trait, as everyone is at some time vulnerable in some way.23 Huta and Hawley24 suggest that rather than being viewed negatively, vulnerability, if managed positively and supportively, can give people the opportunity to develop strategies which will improve their long-term strength, confidence and safety. In addition, as all people are at some time vulnerable, rather than being avoided, people should be encouraged to recognise their vulnerabilities, learn to manage them effectively, and thus increase their self-awareness and control over their lives.20 This has links with the risk-taking perspective, in that rather than avoiding situations where they are vulnerable, people are encouraged to recognise their vulnerabilities and determine how they can best manage them. This perspective suggests that primary care practitioners who work with children and young people should not only acknowledge and understand but also enable children to recognise and take control of their vulnerabilities, including those related to online activities. It sees professionals as having a key role in enabling children, young people and their families to determine how they can manage their vulnerabilities so that, as adults, they are less likely to suffer harm than they would otherwise be.

The desire to attribute blame when something goes wrong can, nonetheless, mean that professionals are inclined to adopt a risk avoidance stance, wherein advice is geared at avoiding risk, rather than enabling children and young people to learn about it.11,25,26 In contrast, the risk-taking perspective would encourage professionals to engage in open dialogue with parents, children and young people about the risks and benefits of seeking information and support online. This would include discussion of the many interpretations of risk, risk taking and how children and young people can be enabled to learn about managing online risks and making appropriate choices. This may include identifying: what each individual’s child’s vulnerabilities are, how these relate to online activities, whether online activities will increase or decrease their vulnerabilities in particular ways, whether the perceived risks are definite risks, potential risks, highly likely or marginally likely. It is also useful to consider whether the short-term apparent safety of risk avoidance creates longer term dangers or harms. Discussing worst case scenarios, how the risk of these compares to the benefit of a particular activity, and how each worst case scenario might be avoided or managed may also help children, young people and families to make decisions about their online activities.