In our study, the rates of affirmative responses to the 13-item scale used to assess online sexual abuse and risky sexual behaviors were found to be 50% in the ADHD group and 31.6% in the control group. Similarly, when looking at the subtypes of online risky sexual behaviors and abuse, the rate of online sexual victimization was 33.1% in the ADHD group and 17.1% in the control group. The rate of receiving sexual content messages (passive sexting) was 38.1% in adolescents with ADHD, while it was 23.9% in the control group. The rates of sending sexual content messages (active sexting) and sexual bullying were higher in the ADHD group (8.5% and 13.6%, respectively); however, these differences were not statistically significant. In the ADHD group, it was found to be 8.5% (n = 10), while in the control group, it was 3.4% (n = 4).
The results of our research indicate that adolescents with ADHD are exposed to a higher rate of online sexual victimization, especially the subtypes of sexual victimization and passive sexting. It is worth noting that there is a lack of studies in the literature comparing the frequency of online sexual abuse and risky online behaviors in individuals with ADHD to a control group. In a study that evaluated 58 adolescents with ADHD, passive sexting was found in 25.8% of the cases, and active sexting was found in 17.2% of them (6). In another study conducted with adolescents with ADHD, the rate of passive sexting was found to be 25%, and the rate of those who felt pressured into engaging in sexual conversations was determined to be 33% (23). In both of these studies, researchers did not compare the findings with a control group. However, they noted that the rates among individuals with ADHD were higher compared to the general population sample, and individuals with ADHD were considered at risk for both active sexting and passive sexting. In the literature, studies conducted with general population samples have reported varying rates of online victimization, active and passive sexting, and experiences of sexual victimization, depending on the sample and methodology of the studies.
As part of the "EU Kids Online Project" conducted in Europe in 2013, the rate of online sexual solicitation was reported as 17% for girls, 10% for boys, and 13% for all adolescents. In 25 European countries, including Turkey, it was found that 41% of children aged 9–16 had been exposed to risky behavior online, 15% had received sexual messages or photos, and 3% had sent such messages (24).
In a meta-analysis conducted in 2018 to investigate sexting behavior among adolescents, studies involving 110,380 participants were analyzed. The prevalence of receiving sexual messages (passive sexting) was found to be 27.4%, while the frequency of sending sexual content messages (active sexting) was determined to be 14.8% (12). When examining studies investigating online sexual victimization among adolescents, reported rates in the literature vary between 13% and 61%. In a meta-analysis conducted with adolescents, the prevalence rate of online sexual victimization was reported as 20.3% (12). In a study that examined online sexual victimization among 1,588 adolescents aged 10–15, it was reported that 35% of the adolescents stated that they had been harassed or encountered unwanted sexual content material on the internet (25). In another study, the rate of online sexual victimization among adolescents aged 9–16 was found to be 19% (26). In a study involving 5,715 children, 32% of the children reported feeling coerced and pressured into online sexual activities within the past year, and 6% of the children reported engaging in online risky sexual behaviors, including active sexting and sexual harassment, at least once in the past year (27). It has been reported that 21% of adolescents followed in child psychiatry clinics in our country have been exposed to online sexual solicitation, and 17.5% of the victims have been diagnosed with ADHD (28).
The literature data and our current findings suggest that the presence of ADHD may increase the risk of online sexual victimization and receiving sexual content messages (passive sexting). However, active sexting and sexual bullying behaviors were not found to be significantly different from the control group. We expected to find higher rates in the ADHD group. However, we believe that the adolescents included in the study may have experienced familial and societal concerns when reporting online risky sexual behaviors, and due to concerns about data privacy, they may have been particularly reluctant to report their actions as perpetrators. Our findings indicate that adolescents diagnosed with ADHD are at risk for online sexual victimization. We believe that clinicians working with these cases should routinely inquire about this situation in clinical assessments, and when developing intervention programs to prevent online sexual victimization, this factor should be considered.
When comparing male and female cases in terms of exposure to online sexual victimization and engaging in online risky sexual behaviors in adolescents diagnosed with ADHD, the rate of being an online sexual victim was significantly higher in females. In other words, girls with ADHD are significantly more likely to be online sexual victims. No significant differences were found between the two genders in terms of passive sexting, active sexting, and online sexual bullying rates. Looking at the literature, studies conducted with general population samples have similarly identified female gender as a risk factor for being an online sexual victim. In a study conducted in 2018 with 11,193 adolescents aged 14–16, the rate of online sexual victimization was reported as 35.5% for girls and 19.9% for boys (29). In another study, it was reported that 13.7% of female adolescents and 9.2% of male adolescents were victims of online sexual victimization that started with flirting (30). In a study conducted in Germany in 2008, online sexual victimization was reported at a rate of 5.6% among males and 19.1% among females (31). Literature on the relationship between sexting and gender reveals mixed findings. While some studies suggest that girls are more likely to receive sexual content messages, other studies indicate that gender has no significant effect, with both genders exhibiting similar patterns of sexting behavior. Additionally, there are studies suggesting that boys may engage in sexting (both sending and receiving) more frequently than girls. This variability in findings may be influenced by cultural, demographic, and social factors, as well as the specific methodology of each study (12, 32). Adults, particularly young and unemployed men, have been reported to be more commonly associated with sexual harassment in studies conducted on this topic (33). Our findings appear to be consistent with the literature. Literature data indicates that girls are more frequently victims of online sexual acts, while boys tend to engage in riskier sexual behaviors at a higher rate. The curiosity of adolescent girls about romantic relationships and sexual matters increases their risk of becoming victims of online sexual abuse (26, 34). We believe that the fact that the rates of sending sexual content messages (active sexting) and online sexual bullying were not higher in boys compared to girls in our sample may be related to the composition of our sample, which consists of individuals with ADHD. It is possible that ADHD increased the likelihood of these risky sexual behaviors for both genders, which could have equalized the gender differences.
The participants in our study consisted of adolescents aged 12–18. When evaluating their exposure to online sexual victimization and engagement in online risky sexual behaviors, they were asked whether they had experienced these behaviors at any point in their lives. As a result, the average age of those who answered "yes" to any of these 13 questions was found to be higher than those who answered "no" to all questions. This result suggests that the likelihood of exposure to online sexual victimization and engaging in risky sexual behaviors increases with age. Although our study did not classify adolescents with ADHD based on age, the grouping based on their school grade level provides some insight into the age group. Since our findings evaluated behaviors that occurred at any point in life, they do not allow us to determine at which stage of adolescence or in which age range the risk is higher.
The most comprehensive studies on internet use and online risky sexual behaviors in adolescents, the YISS-1, 2, and 3 studies, when examined by age group, show that online sexual victimization rates in the 10–12 age group were 12%, 9%, and 5%, respectively, while in the 16–17 age group, these rates were 35%, 44%, and 54%, respectively (35). In a study investigating sexting behavior, it was reported that 3% of 12-year-old children and 32% of 18-year-old adolescents had participated in sexual content messaging (36).
A study conducted in Turkey reported that 21.6% of individuals who experienced online sexual victimization were middle school students, while 78.4% were high school students (28).
Both in studies from the literature and in our own research, it is observed that online sexual victimization and receiving sexual content messages (passive sexting) tend to increase with age (28, 35). The increase in the frequency of becoming a victim of online sexual victimization with age is thought to be associated with several factors. As children grow older, they tend to have less supervision, spend more time online, use the internet for social functions like social media and messaging, become more interested in sexual and emotional matters, and engage in increased risk-taking behaviors. These factors can collectively contribute to the higher likelihood of experiencing online sexual victimization as they get older (37).
In the study, it was found that 51.7% of the adolescents diagnosed with ADHD had moderate/poor academic performance (scoring 69 or lower), while this rate was only 20.5% in the voluntary control group. It is widely accepted that ADHD directly affects academic performance, leading individuals to perform below their true cognitive potential. Among adolescents diagnosed with ADHD, those with moderate/poor school performance had higher rates of online sexual victimization and sending sexual content messages (active sexting). Similarly, in the literature, online sexual victimization victims have been found to have lower academic performance (38). Since both our study and the studies in the literature are cross-sectional, it does not allow us to establish a causal relationship between academic performance and online sexual victimization. Nevertheless, we believe that it would be appropriate to target cases with lower academic performance in prevention efforts.
In our study, the presence of ADHD was considered as a risk factor for online sexual victimization alone. Among our patients, 66.9% had mixed type ADHD, 29.7% had ADHD-PI, and 3.4% had ADHD-HI. In our study, no significant relationship was found between the type of ADHD diagnosis and online sexual victimization or online risky sexual behaviors. Among the patients, 11.9% were newly diagnosed, while 17.8% had been diagnosed with ADHD for more than 5 years. According to our data, the rates of being an online sexual victim, receiving sexual content messages (passive sexting), and sending sexual content messages (active sexting) decrease as the duration of diagnosis of ADHD increases. Similarly, in ADHD patients who do not use medication or use it irregularly, online sexual victimization, receiving sexual content messages (passive sexting), and sending sexual content messages (active sexting) are significantly higher. Early diagnosis of ADHD patients and long-term follow-up allow for the management of their treatment and the management of their complaints under the guidance of clinical specialists. Adolescents who are newly diagnosed have not received any intervention for a long time and are at risk in many ways, including functional impairments and online risky behaviors. Our findings suggest that early diagnosis of ADHD and initiation of appropriate treatment and regular medication use are protective against online sexual victimization and online risky sexual behaviors. We believe that medical treatment for ADHD reduces the core symptoms such as inattention, hyperactivity, and impulsivity and related symptoms, thus protecting the adolescent.
In our study, 21.2% of adolescents diagnosed with ADHD do not use any medication, while 37.3% have been using medication for more than 2 years, and the most commonly used medication is extended-release methylphenidate, with 48.3%. Online sexual victimization and receiving sexual content messages (passive sexting) were significantly higher in non-users of ADHD medication and users of short-acting methylphenidate. Studies have shown that methylphenidate treatment in patients diagnosed with ADHD is successful in treating risky behaviors and risky sexual behaviors (39, 40). In the literature, it is mentioned that methylphenidate treatment reduces risky sexual behaviors, but there is no specific study addressing online sexual victimization, which is a form of sexual exploitation that does not involve physical contact (41). Short-acting methylphenidate has a duration of action of 4 hours and may not adequately meet the dopamine requirements due to its phasic release. In patients using extended-release methylphenidate, these risky behaviors decrease. The phasic release and the inability of short-acting methylphenidate to meet dopamine needs throughout the day may be one of the reasons it is not sufficiently protective against online sexual victimization (42).
As is known, comorbid conditions are quite common in individuals with ADHD. In our study, 66.9% of patients diagnosed with ADHD had at least one psychiatric comorbidity. The most common comorbid diagnoses were as follows: 27.1% had Oppositional Defiant Disorder (ODD), 24.6% had an anxiety disorder, 19.5% had Conduct Disorder (CD), and 15.3% had a depressive disorder. In individuals with ADHD, the presence of comorbid conditions such as CD was associated with passive sexting (receiving sexual messages). Among adolescents with ADHD, those with comorbid anxiety disorder were found to have a higher incidence of passive sexting and online sexual bullying behaviors. Those with an additional diagnosis of depression exhibited a higher incidence of all subtypes of online sexual victimization and risky sexual behaviors. Comorbid diagnoses of obsessive-compulsive disorder (OCD) and Oppositional Defiant Disorder (ODD) did not show a significant relationship with any subtype of online sexual victimization or risky sexual behaviors. Only the presence of any comorbid condition in adolescents with ADHD was statistically significant with one subtype of online sexual bullying. Since our study is cross-sectional, it is not possible to establish a cause-and-effect relationship between these comorbid disorders and exposure to online sexual victimization and the display of online risky sexual behaviors. The presence of these comorbid conditions may make adolescents more prone to such behaviors, but it is also possible that comorbid mental disorders may develop in individuals who have been exposed to or engaged in such behaviors. Nevertheless, we recommend that clinicians working with these cases exercise extra caution, especially in the presence of the comorbid conditions mentioned above. In the literature, it has been reported that the presence of psychiatric comorbidities accompanying ADHD affects the individual's functionality, the course of the clinical condition, treatment response, and quality of life (43–45). The presence of comorbid diagnoses in individuals with ADHD leads to more severe psychopathological outcomes, behavioral disorders, and increased risky behaviors in these adolescents (46, 47). While there is no study specifically examining the relationship between comorbid diagnoses in ADHD and online risky sexual behaviors, there are studies indicating that comorbid diagnoses increase the frequency of offline risky sexual behaviors (41, 48, 49). It is also reported that ADHD can lead to risky sexual behaviors in adolescents, such as early sexual activity, unwanted pregnancies, sexually transmitted diseases, and frequent partner changes (41, 48). A study also indicates that risky sexual behaviors are more closely associated with comorbid conditions such as Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and substance abuse, rather than the severity of ADHD itself (41). In particular, the co-occurrence of Oppositional Defiant Disorder (ODD) with ADHD has been directly associated with risky sexual behaviors in the literature (41). The higher prevalence of receiving sexual messages (passive sexting) in adolescents with comorbid ODD may be attributed to increased family conflict in these cases, leading to reduced parental supervision. This decreased supervision could contribute to problematic internet use and a higher likelihood of receiving sexual messages (passive sexting). When examining the relationship between online sexual victimization and the diagnosis of depression and anxiety disorders, there is a study in the literature that demonstrates this connection (50). In our study, adolescents with comorbid depression in addition to ADHD exhibited a higher frequency of risky online behaviors and all subtypes of online sexual victimization. Similarly, those with comorbid anxiety disorders showed a higher prevalence of receiving sexual messages and engaging in online sexual harassment. Comorbid depression and anxiety disorders may act as risk factors for sexual victimization and risky sexual behaviors in individuals with ADHD, but they could also be outcomes of these behaviors. Further longitudinal studies are needed to explore this relationship in more depth.
When examining the relationship between the Conners Parent Rating Scale scores and online sexual victimization and risky sexual behaviors in adolescents with ADHD, it was found that adolescents who were victims of online sexual victimization had significantly higher average scores on the Oppositional, Social Problems, and Emotional Lability subscales compared to adolescents who were not victims of online sexual victimization. Previous studies have shown that oppositional behavior in adolescents with ADHD is closely associated with risky behaviors and conduct disorders (41, 51). We believe that oppositional behaviors may predispose individuals to becoming more vulnerable to online sexual victimization due to a lack of control and becoming easy targets in social environments. While it is challenging to establish a cause-and-effect relationship in a cross-sectional study, the high average scores in the Oppositional, Social Problems, and Emotional Lability subscales for online sexual victimization victims suggest that adolescents with ADHD who experience these problems may exhibit them in the online environment, making them more easily noticeable by online sexual perpetrators. It is possible that these perpetrators may exploit these issues, leading to victimization.
When comparing adolescents with ADHD who engaged in receiving sexual messages (passive sexting), sending messages (active sexting), and online sexual harassment to those who did not engage in these behaviors, there were no significant differences in all the subscale scores of the Conners scale. As far as we know, there are no studies in the literature that evaluate online sexual victimization and risky behaviors using the Conners Parent Rating Scale. While some studies suggest that inattention, impulsivity, and hyperactivity are risk factors for online sexual victimization, there is no study that directly compares them with the severity of ADHD symptoms. (51, 52). In a study in the literature that investigated the relationship between ADHD-diagnosed adolescents and problematic internet use and gaming disorder using the Conners Parent Rating Scale, only the inattention subscale score was found to be associated with these behaviors (53). In another study that assessed problematic internet use and negative consequences of the internet in adolescents with ADHD using the Conners Parent Rating Scale, only high scores on the oppositional and restlessness/impulsivity subscales were associated with these issues (54). This situation suggests that online sexual abuse may be related not to the severity of inattention and hyperactivity but to the impact of ADHD symptoms on internet usage patterns and an individual's level of functioning. Another factor that could influence this conclusion is the evaluation of the relationship between online sexual abuse and ADHD severity and symptom levels not through self-report but through parental reporting.
Our study has some limitations. Firstly, due to its cross-sectional nature, it is not possible to establish a cause-and-effect relationship in our findings. Additionally, the assessment of online sexual abuse and risky sexual behaviors may be difficult to determine the temporal relationship with the risk factors we assessed, as individuals may have experienced or exhibited them in their past lives. Our scale for addressing online sexual abuse had binary response options, so the presence or absence of sexual abuse was queried, but its severity, frequency, and timing were not assessed. In future studies, using the scale with a larger patient sample, the relationship between ADHD and sexual risky behaviors can be better understood. Furthermore, we did not inquire about individuals with ADHD engaging in online sexual abuse actions. Given the anonymous and concealable nature of the online environment, categorizing the actions experienced in the virtual realm may be challenging. This limitation is a common issue encountered in all studies related to this topic.
Nevertheless, despite these limitations, our study is particularly valuable as a comparative study conducted in a distinct adolescent group, such as those with ADHD, and it is the first study to examine online sexual risky behaviors and sexual abuse through four sub-parameters. It also addresses the relationship between exposure to online sexual abuse and risky behaviors in ADHD adolescents from various angles, including sociodemographic characteristics and parental assessment.
For these reasons, we believe that our study will make a significant contribution to the literature. In the future, large-scale, multicenter longitudinal studies may help to better understand the temporal relationship between online sexual abuse and risky behaviors with current risk factors. Additionally, we believe that our findings will contribute to the development and evaluation of intervention programs aimed at preventing online sexual abuse and risky behaviors in adolescents.