Electronic Media Use and Symptoms of Attention-Deficit/Hyperactivity Disorder in Greek Adolescents.

BackgroundThis paper explores the widely discussed relationship between electronic media use and sleep quality, indicating negative effects due to various factors. However, existing meta-analyses on the topic have some limitations.ObjectiveThe study aims to analyze and compare the impacts of different digital media types, such as smartphones, online games, and social media, on sleep quality.MethodsAdhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the study performed a systematic meta-analysis of literature across multiple databases, including Web of Science, MEDLINE, PsycINFO, PubMed, Science Direct, Scopus, and Google Scholar, from January 2018 to October 2023. Two trained coders coded the study characteristics independently. The effect sizes were calculated using the correlation coefficient as a standardized measure of the relationship between electronic media use and sleep quality across studies. The Comprehensive Meta-Analysis software (version 3.0) was used to perform the meta-analysis. Statistical methods such as funnel plots were used to assess the presence of asymmetry and a p-curve test to test the p-hacking problem, which can indicate publication bias.ResultsFollowing a thorough screening process, the study involved 55 papers (56 items) with 41,716 participants from over 20 countries, classifying electronic media use into “general use” and “problematic use.” The meta-analysis revealed that electronic media use was significantly linked with decreased sleep quality and increased sleep problems with varying effect sizes across subgroups. A significant cultural difference was also observed in these effects. General use was associated with a significant decrease in sleep quality (P<.001). The pooled effect size was 0.28 (95% CI 0.21-0.35; k=20). Problematic use was associated with a significant increase in sleep problems (P≤.001). The pooled effect size was 0.33 (95% CI 0.28-0.38; k=36). The subgroup analysis indicated that the effect of general smartphone use and sleep problems was r=0.33 (95% CI 0.27-0.40), which was the highest among the general group. The effect of problematic internet use and sleep problems was r=0.51 (95% CI 0.43-0.59), which was the highest among the problematic groups. There were significant differences among these subgroups (general: Qbetween=14.46, P=.001; problematic: Qbetween=27.37, P<.001). The results of the meta-regression analysis using age, gender, and culture as moderators indicated that only cultural difference in the relationship between Eastern and Western culture was significant (Qbetween=6.69; P=.01). All funnel plots and p-curve analyses showed no evidence of publication and selection bias.ConclusionsDespite some variability, the study overall confirms the correlation between increased electronic media use and poorer sleep outcomes, which is notably more significant in Eastern cultures.

Background:In the current era, the use of electronic media in the form of Internet has increased exponentially, particularly among children, and has led to their excessive involvement in Internet. In this context, attention-deficit hyperactivity disorder (ADHD) children were found to have increased tendency for this addiction.Aims and Objectives:The aim is to study and compare Internet addiction between ADHD and normal children and the relation of demographic profile to Internet addiction.Materials and Methods:This was a cross-sectional study including 100 children (50 ADHD cases and 50 normal children without any psychiatric illness as controls) between the ages of 8 and 16 years. A semi-structured pro forma for demographic profile and Internet usage using Young's Internet Addiction Test (YIAT) was used. Statistical analysis was done using SPSS 20.Results:Internet addiction among ADHD children was 56% (54% having “probable Internet addiction” and 2% having “definite Internet addiction”). This was statistically significant (P < 0.05) in comparison with normal children where only 12% had Internet addiction (all 12% had “probable Internet addiction”). ADHD children were 9.3 times more prone to the development of Internet addiction as compared to normal (odds ratio – 9.3). Significant increase in average duration of Internet usage in ADHD children with increasing score of YIAT (P < 0.05) was seen. The incidence of Internet addiction was more in male ADHD children as compared to normal (P < 0.05).Conclusions:ADHD children are more prone to Internet addiction as compared to normal children and thus require preventive strategies.

Objective: Electronic media use is an emerging area of research interest and its relationship with Attention Deficit hyperactivity disorder (ADHD) is neglected in Turkish literature. We therefore aimed to examine its relationship with certain variables and ADHD subtypes. Methods: A total of 360 participants aged between 6-18 years, who attended Bezmialem University, Child and Adolescent Psychiatry outpatient clinic between January 2016 and October 2016, were screened with The Schedule for Affective Disorders and Schizophrenia for School Age Children (KSADS) interview to ascertain diagnosis and a sociodemographic information tool was used to collect the relevant data. Results: The mean age was 9.47±2.67, and 81.9% majority of the sample consisted of males. Exposure to total media (TV, cell phone, tablet, computer) between 2 and 4 hours was reported in 20.6% of the sample, whilst 4-6 hours exposure was reported in 15.8%, 6-8 hours was reported in %11.4, 8-10 hours was stated by 9.4% of the participants and more than 10 hours of exposure to electronic media was reported in 18.2 % of the total sample. More than 2 hours/day computer/tablet use, and more than 4 hours/day cell phone use were significantly associated with academic underachievement, which also became more significant as the time spent with total media gadgets increased. Electronic media use significantly decreased as the household income increased. TV viewing before 2 years of age was significantly associated with heavy use of electronic media, whilst this significance was lost when the age threshold was dropped to 1 year. Total TV viewing in the household was significantly higher among the heavy electronic media users. Regression analysis revealed that exposure to electronic media for 10 hours and above was significantly and independently associated with current family psychiatric illness and low academic achievement. Conclusion: To the best of our knowledge, this is the first study reporting exposure to electronic media in a Turkish clinical sample of children and adolescents with ADHD. Results are in line with the existing international literature and highlights the excessive electronic media use in this clinical population. We recommend a routine screening for electronic media exposure in ADHD minors and increase awareness in their families and education system.

"A person who never made a mistake never tried anything new." -Albert Einstein THE BEGINNING In 1995, when the New York based psychiatrist Dr. Ivan Goldberg posted a sincere-looking but satirical note on the online psychiatric bulletin board PsyCom.net (no longer available now) taking a dig at the rigid diagnostic criteria of the newly released 4th edition of the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association (APA) by "creating" a fictitious disorder called Internet addiction disorder (IAD) and cooking up its "diagnostic criteria" as per DSM style for substance dependence, little did he know that he had opened the proverbial Pandora's box.[1] He and his bulletin board were flooded with people narrating their tales of woe of "remaining caught in the Net" and seeking help for their condition. This was one condition he did not intend to create (he himself did not believe that there could be a true "addiction" to Internet but rather excessive or pathological use), but there it was whatever name you gave it! In 1995, a clinical psychology student Ms Kimberly Young, then in Rochester, USA, got interested in the psychological factors behind computer use and independently conceived of "addictive use of the Internet" as a pathological condition.[2] It is interesting to hear of this story from the author herself 20 years later: "Internet addiction began as a pet project in a young researcher's one bedroom apartment in Rochester, New York. I was that young researcher. It was in 1995, and a friend of mine's husband was seemingly addicted to AOL Chat Rooms spending 40, 50, and 60 h online at a time when it was still $2.95/h to dial into the Internet. Not only did they suffer financial burdens but also their marriage ended in divorce when he met women in online chat rooms."[3] The rest, as they say, is history, with her first illustrative case report published in 1996 having been cited 755 times, and her first definitive research article titled, "Internet addiction: Emergence of a new clinical disorder," published in 1998, having been cited a phenomenal 3144 times as on December 15, 2015![4] In 1995, a clinical psychologist Mark Griffiths, working at Nottingham Trent University, Nottingham, UK, who had been interested in research on gambling, computer use, and use of various machines or technology by humans in general for a few years at that time, published an article named, "Technological addictions."[5] The next year, in 1996, he published on Internet addiction, conceptualized by him as a subset of the broader term technology addiction.[6] This was the beginning, 20 years ago. As the freelance writer Michael OReilly, reporting in Canadian Medical Association Journal in 1996, (who, himself, interestingly, declared that "he may be at risk for developing IAD") titled his article as "Internet addiction: A new disorder enters the medical lexicon," where he mentioned Young's still unpublished research on Internet addiction.[7] Truly, a PubMed search on "Internet addiction" pegs this short report as the very first article included in PubMed on the topic. THE ACCOLADES… Now, in 2015/6, as on December 15, 2015, there are 1561 articles cited in PubMed on "Internet addiction." What is more interesting is a look at the acceleration rate of publication. While there were only three articles in 1996, there were 32 in 2005, 275 in 2014, and 296 (and still counting) in 2015! Thus, while the growth rate of publications was not hugely impressive in the first decade of its life, Internet addiction is now a robust young adult in its postteen year with a sizeable growth spurt in its second decade. Not many "new" terms can boast of such growth in just 20 years in the PubMed! As an aside, it is to be noted that the term "Internet addiction" has many competing contenders; some of the important ones are pathological Internet use, problematic Internet use (PIU), compulsive Internet use, Internet use disorder (IUD), and pathological use of electronic media among others. Pathological Internet use or PIU is often a favored term these days, but we have stuck to the original term because it is still very popular certainly with the social media but also in medical/psychological scientific research, and especially because we wanted to place this editorial in a historical perspective. Hence, what kinds of articles are being published on Internet addiction over the past decade or so? This is no place (and space) for a comprehensive review on the topic. Suffice it to say that, in addition to individual research articles from America, Europe, Asia, and Oceania, there are now a number of published narrative and even a few systematic reviews on almost every aspect of Internet addiction, including its concept and historical perspective,[89] diagnostic criteria,[10] epidemiology,[11] psychosocial and neuropsychological aspects,[1213] neurobiological aspects,[1314151617] and management, both pharmacological and nonpharmacological.[1819] It appears that the issue is, at least partly, resolved, and that we have sufficient power in our knowledge base to conceptualize, detect, diagnose, characterize, treat, and prognosticate something called Internet addiction. Twenty years … and we are quite there. Well, not quite, yet. …AND THE BRICKBATS The first jolt came from APA in their widely publicized 5th edition of the DSM (DSM-5) published in May 2013.[20] Although the much-awaited and much-hyped category of "behavioral addictions" was indeed kept in its re-formulated category, "Substance-related and addictive disorders," the sole diagnostic category kept in its final version under behavioral addictions was gambling disorder, which was a slightly tweaked version of the earlier pathological gambling, shifting its parental home from impulse control disorders of DSM-IV (there is no broad category of impulse control disorders any more in DSM-5) to addictive disorders in DSM-5. Despite early speculations and expectations, Internet addiction did not find a home under behavioral addictions. Instead, and almost as a consolation prize, one particular subtype of Internet addiction, called Internet Gaming Disorder, has been entertained in the DSM-5, but only as a tentative "Condition for Further Study" that "requires further research before they might be considered formal disorders," in its Section III called Emerging Measures and Models. The second jolt, and the one more important from an international perspective including India, comes from the forthcoming 11th revision of the International Classification of Diseases (ICD-11) by the World Health Organization (WHO). A recent article from the WHO Working Group on Classification of Obsessive-Compulsive and Related Disorders, while deliberating on this area as a "key controversy," concluded that, "based on the limited, current data, it would therefore seem premature to include it in the ICD-11."[21] Consequent to this stand, the very recently released Beta Draft of the entire ICD-11 (where Mental and Behavioral Disorders is coded as 07) sticks to its previous model of separate groups for "disorders due to substance use" (which has, by definition, no mention of any behavioral addictions but only substance use related disorders), and "impulse control disorders," which continues to house pathological gambling but has also added "compulsive sexual behavior disorder," a contender for the behavioral addictions, under impulse control disorders. Internet addiction, in any of its avatars, is nowhere in sight.[22] This is certainly a big disappointment for the advocates and champions of behavioral addictions, technological addictions, including Internet addictions. Let alone classifying it as an addictive disorder, ICD-11 Beta Draft refuses to recognize Internet addiction as a disorder in the first place! Why is it so? And, what can be done? To our mind, there is a hierarchical series of questions that need to be answered to get a grasp on the issue. Each successive question builds on its predecessor, assuming that the question hierarchically one step above is answered in the affirmative. THE FOUR CARDINAL QUESTIONS The first and foremost question: Is Internet addiction better conceptualized as a "disorder" or as a continuum of normal behavior (after all, Internet use is an essential part of everyday life of a vast proportion of people worldwide, and steadily increasing – we all are Internet "dependent" in much the same way we are dependent on so many basic things in life)? Although heavily debated already, the simple answer to this question can be borrowed from ICD-11 Working Group: "Where there is a continuum between normal and pathological behavior, associated impairment may become a key determinant of whether or not behavior is disordered. An additional important consideration, from a public health perspective, is whether efficacious treatments are available."[21] As abundantly documented in the literature over the past 20 years, excessive, uncontrolled, and inflexible Internet use behavior can indeed lead to severe functional impairment in some persons. Further, consider the definition of a mental and behavioral disorder as espoused in the Beta Draft of ICD-11: "Mental and behavioral disorders are recognizable and clinically significant behavioral or psychological syndromes that are associated with distress or interference with personal functions."[22] Many (but not all) cases of Internet addiction would satisfy this definition. As in many other psychiatric disorders, there would be a large "gray area," but that only proves that there is indeed a "white" ("normal") and a "black" (pathological or disordered) area as well. From a public health perspective, this is an important question because of its policy implications. There is also some evidence that at least nonpharmacological interventions (especially cognitive behavioral therapy for Internet addiction) can be useful though much more research is needed. And that would only be feasible, once we initially and tentatively agree that indeed there can be a disorder for which we are seeking a treatment! The second important question we ask is, assuming that some cases of these excessive, uncontrolled, and inflexible Internet use behavior indeed is a mental and behavioral disorder: Is this pattern of behavior an addictive disorder? There are actually three sublevels of criticism or question in this: How can there be an addiction to something which is not as tangible a thing as drugs? Why is it not better explained by simply as a manifestation of other underlying disorders such as depression, anxiety, or social phobia? Why is it not better conceived as, say, an impulse control disorder (as done for pathological gambling or the new category of compulsive sexual behavior disorder), or an obsessive-compulsive spectrum disorder? As to the response to the first sublevel of this question/critique, our take is: Epistemologically, "addiction" to psychoactive substances was a later development in history. The Latin root of the word "addiction" – addicere – simply meant "to adjudge, sentence, doom, assign, confiscate, or – importantly – enslave."[23] Thus, "addicted" would simply mean "being sentenced, doomed, or enslaved." The object of this transitive verb could be theoretically anything, from drugs to playing poker. On a neurobiological note, it is the brain learning or memory of a rewarding experience that is the basis of dopaminergic-based positive reinforcement which defines the early stages of addiction, rather than which specific stimulus (whether cocaine or social networking online) triggered that experience.[24] Once continued for a while, this early mechanism paves the way for a delayed-onset recruitment of nondopaminergic anti-reward mechanisms that provides negative reinforcement for a particular behavior which perpetuates that behavior in a compulsive manner.[24] Finally, at a behavioral level, addiction (as opposed to pharmacological dependence on a substance) is always with regard to a core behavior. Even in case of substances, what characterizes substance dependence is the pathological pattern of "use" of the substance (please note: Use refers to a particular behavior). For example, take the definition of alcohol dependence as in the ICD-11 Beta Draft: "Alcohol dependence is a disorder of the regulation of alcohol use, arising from repeated or continuous use of alcohol. Characteristic features are a strong drive to use alcohol, impaired ability to control its use, and giving increasing priority to alcohol use over other activities. Often individuals develop tolerance and experience withdrawal symptoms when cutting down or stopping, or use alcohol to prevent or alleviate withdrawal symptoms. Use of alcohol increasingly becomes a central focus of the person's life and relegates other interests, activities, and responsibilities to the periphery. Continuation of alcohol use despite adverse consequences is a common feature."[22] Now, let us do a little fun experiment. Try substituting the word "alcohol" with "Internet" in this definition and see what comes out of it! The second level of this second question/criticism is partly true. There is a documented large comorbidity between the putative behavioral addictions (including Internet addiction) and other psychiatric disorders, particularly depressive and anxiety and bipolar disorders.[25] However, that is true for many psychiatric disorders and certainly true for substance use disorders in general. The fact that alcohol dependence is heavily comorbid with depression does not make the former identical with the latter! If at all, such a pattern lends credence to the similarity of these behavioral disorders with addictive disorders.[26] Of course, Internet addiction should not be diagnosed if such behavior is exclusively contained within the boundaries of a bipolar, depressive, or anxiety episode and spontaneously resolves after the resolution of such conditions. Coming to the third level, the very nature of these behavioral disorders, we land in a debate that goes to the very heart of concept and nosology of psychiatric disorders. Substance use disorders too, from time to time, have been conceptualized as impulse control disorders, obsessive spectrum disorders, compulsive spectrum disorders, or combinations of these.[27] Impulsivity in decision making and behavior, obsession-like repeated preoccupation, and a compulsion-like quality in repeated use of substances, all are important components of the process of addiction, but addiction as a gestalt has characteristics beyond each of these individual phenomena; otherwise, all substance use disorders would have been consumed under any of these too. Thus, we take on this matter at the moment (admittedly incomplete and one that will require a lot more research to settle) is that pathological or PIU, after a certain threshold of severity and functional impairment, can be conceptualized as an addictive disorder. However, we suggest that the name of the condition be changed to "Internet Use Disorder (IUD)." This term retains the three cardinal characteristics:First, it is a disorder; second, it is concerned with a particular core behavior of using the Internet as a medium (for whatever purpose); and third, Internet) the target "object" (in a metaphorical sense, not as a substance but as a vehicle or medium) of use. The third question, assuming that the two above have been answered, is: If PIU is indeed best conceptualized as an addictive disorder (i.e. IUD, as a behavioral addiction), what is the person addicted to? Is it the Internet as a medium, any of the many actions using the software applications of the Internet (e.g., online gambling, gaming, social networking, relating, watching a particular content such as pornography or scientific literature search, buying, etc.), or to a particular gadget of technology that hosts the Internet (e.g., smartphones, tablets, laptop, or desktop computers)? Many authors now contend that there are two distinct forms of IUD – one specific (where the addictive behavior is predominantly focused on a particular application of the Internet) and another generalized (where there is no such focus).[928] Some researchers even have theorized about the different psychological and neurobiological pathways of these two subtypes.[13] In this regard, we would reiterate that it is the pathological use of the Internet that is the main concern at hand, not what specific purpose it is used for. Much more commonly, users of the Internet (both "normal" and "pathological") use it for a narrow set of specific purposes. Indeed, normal users use the Internet for much more varied purposes, while pathological users tend to narrow down their focus on specific activities (gaming, gambling, sex, chat, buying, etc.) to the exclusion of others. This is reminiscent of the "narrowing of repertoire" characteristic originally espoused for a "dependence syndrome" by Edwards and Gross.[29] Only a handful of persons with IUD do not have any predominant focus; however, even in them, an apparently aimless surfing of the Internet itself is an activity which, however, "useless" in the value-laden sense it may be, is actually a use of the Internet! Thus, the conceptualization of IUD obviates the question of whether one is addicted to the Internet as a source for gratifying other needs or addicted to the Internet as a medium (or to a gadget that hosts that medium), so long as the use of the Internet is the object of the addictive behavior. This view suggests that there is one IUD, with varied subtypes or specifiers based on the specific applications or even lack of any specific one (which may be thought of as "not otherwise specified" in the standard nosological tradition). The fourth question, assuming that we conceptualize IUD as a unifying concept with varied "subtypes" based on specific applications of the Internet, is: How to diagnose such a condition? There is a plethora of screening and diagnostic instruments (21 instruments as mentioned in reference 11) based upon the authors' own theoretical understanding of the issue. Unfortunately, these instruments often provide very different estimates of Internet addiction or PIU, ranging from <1% to 27%.[11] Of course, sample nature and sample selection also play a significant role in explaining such wide intervals. However, coupled with such heterogeneous instruments, such figures undermine the confidence in the concept and diagnosability of the condition. The answer to this question has to build on at least partial resolution of the above questions. INDIAN SCENE: A SKETCHY VIEW There is a trickle of Indian research in this area. Although the first published article was published more than a decade ago,[30] not many published articles are available in peer-reviewed journals. It is beyond the scope and space of this article to critically review all these, but two characteristics are commonly seen:First, often the samples are self-selected or convenience samples, likely to be drawn from accessible college students; second, an almost exclusive use of Young's Internet Addiction Test. It is interesting to note that two Indian studies compared the prevalence of Internet addiction by using two different diagnostic questionnaires from different constructs of Internet addiction. One study compared questions derived from ICD-10 substance dependence criteria with Young's questionnaire;[31] another recent one compared a more conservative and validated diagnostic criteria set with the latter.[32] Both the studies found a wide disparity between prevalence figures for Internet addiction as estimated by different instruments. The prevalence figures varied widely, from 1.2% to more than 50%! This demonstrates the important point raised in the fourth question above. Why is this issue important for India? India is a country with rapidly increasing Internet connectivity. Starting from August 14, 1995, when Videsh Sanchar Nigam Limited first launched India's first full Internet service for public access,[33] interestingly, again 20 years later as of September 2015, there were 350 million active Internet users, fuelled by the rapid spread of smartphones and other In by India is to become the second the and second only to this and growth even a conservative of just prevalence of PIU, IUD, or Internet addiction, by whatever name it is will the number of pathological Internet users to This is a number to Thus, there is a clinical and public health perspective to the question of IUD, which are mentioned as the in this in mind, the recently published of on and Emerging an of the Indian Psychiatric by the Section on Substance Use Disorders, an entire on behavioral Some may contend that it is a mistake to clinical on that nosological at nosological A In a series article in the Indian Journal of and titled as "Internet addiction disorder: or into sufficient research might over time at it a the Internet to the of many but "Internet addiction" as of now more questions than can be a decade with and an scientific literature in hand, we are in with the second but no longer with the There are people out there who are because of their use of the Internet. need and at least some of can be There is evidence to suggest that Internet addiction (or what we to IUD, in with substance use disorders of DSM-5) can no longer be considered a there are still many questions to be answered, and it is the nature of to answer a few questions while agree that we need to the use of the term as opposed to its scientific use, and to estimates of the condition by use of instruments of This is to the concern of or of any behavior with or as a medical disorder. the same time, however, this concern our and to diagnose and for who are indeed in need of it would be the out with the In this there is to be some this way or that way before we can the between and is we need to of the to Einstein in the There is new that we are – each one of the questions above has been and with often upon the perspective. The on these will require a series of What we to do was to the key questions in a hierarchical the and make our stand, however, or it may be, with the that we would to be The purpose is to further in this important to some of a and to ask the question that the

Adolescence is a time of increasing vulnerability for poor mental health, including depression. Sleep disturbance is an important risk factor for the development of depression during adolescence. Excessive electronic media use at night is a risk factor for both adolescents' sleep disturbance and depression. To better understand the interplay between sleep, depressive symptoms, and electronic media use at night, this study examined changes in adolescents' electronic media use at night and sleep associated with smartphone ownership. Also examined was whether sleep disturbance mediated the relationship between electronic media use at night and depressive symptoms. 362 adolescents (12-17 year olds, M = 14.8, SD = 1.3; 44.8% female) were included and completed questionnaires assessing sleep disturbance (short sleep duration and sleep difficulties) and depressive symptoms. Further, participants reported on their electronic media use in bed before sleep such as frequency of watching TV or movies, playing video games, talking or text messaging on the mobile phone, and spending time online. Smartphone ownership was related to more electronic media use in bed before sleep, particularly calling/sending messages and spending time online compared to adolescents with a conventional mobile phone. Smartphone ownership was also related to later bedtimes while it was unrelated to sleep disturbance and symptoms of depression. Sleep disturbance partially mediated the relationship between electronic media use in bed before sleep and symptoms of depression. Electronic media use was negatively related with sleep duration and positively with sleep difficulties, which in turn were related to depressive symptoms. Sleep difficulties were the more important mediator than sleep duration. The results of this study suggest that adolescents might benefit from education regarding sleep hygiene and the risks of electronic media use at night.

ObjectiveWith the prevalence of electronic media use among Chinese adolescents and concerns regarding its potential negative consequences on their health and development, this study investigated the relationship between physical exercise and electronic media use. Utilizing data from the China Education Panel Survey, we examine the impact of physical activity on adolescents’ electronic media use.MethodsA simultaneous equation model, including two-stage least square and three-stage least square, was employed to estimate the impact of physical activity on electronic media use among adolescents. Self-control theory and media addiction theory were also used to analyze electronic media use in adolescents. Descriptive statistics were used to analyzed the data.ResultsChinese adolescents dedicated a substantial amount of time, averaging 2.95 hours per day, to electronic media activities. Increasing physical activity demonstrated an effective means to reduce electronic media use. Furthermore, the impact of physical activity on electronic media use exhibited urban-rural stratification, with family factors related to social class status primarily influencing electronic media use among urban students, while physical activity has a more pronounced influence among rural students.ConclusionsPromoting physical activity represents a compelling and effective strategy for curbing excessive electronic media use among Chinese adolescents, particularly in rural areas where physical activity has a stronger influence. In addition, controlling media entertainment and recreation time and enhancing social cohesion can help to weaken media interest. While changing the social class status of families in urban areas may be difficult in the short term, parents should be aware that physical exercise is an effective way to reduce their children’s use of electronic media. Our findings suggested that promoting physical activity may be a promising strategy for reducing excessive electronic media use among Chinese adolescents, particularly in rural areas where physical activity has a stronger influence.

Internet addiction (IA), also referred to as Internet use disorder, is a serious problem all over the world, especially in Asian countries. Severe IA in students may be linked to academic failure, attention-deficit hyperactivity disorder (ADHD), and forms of social withdrawal, such as hikikomori. In this study, we performed a survey to investigate the relation between IA and ADHD symptoms among college students. Severity of IA and ADHD traits was assessed by self-report scales. Subjects were 403 college students (response rate 78%) who completed a questionnaire including Young's Internet Addiction Test (IAT) and the Adult ADHD Self-Report Scale-V1.1. Out of 403 subjects, 165 were male. The mean age was 18.4 ± 1.2 years, and mean total IAT score was 45.2 ± 12.6. One hundred forty-eight respondents (36.7%) were average Internet users (IAT < 40), 240 (59.6%) had possible addiction (IAT 40-69), and 15 (3.7%) had severe addiction (IAT ≥ 70). Mean length of Internet use was 4.1 ± 2.8 h/day on weekdays and 5.9 ± 3.7 h/day on the weekend. Females used the Internet mainly for social networking services while males preferred online games. Students with a positive ADHD screen scored significantly higher on the IAT than those negative for ADHD screen (50.2 ± 12.9 vs 43.3 ± 12.0). Our results suggest that Internet misuse may be related to ADHD traits among Japanese youth. Further investigation of the links between IA and ADHD is warranted.

BackgroundSleep is essential for child and adolescent health and well-being. There is an increasing interest in whether electronic media use affects children and young adolescents’ sleep. Prior reviews have focused on a school-aged population. Moreover, it is crucial that research continuously addresses the processes of technology and media use and the implication on sleep. This systematic review examines the evidence of electronic media use related to sleep among 0–15-year-olds.MethodsSearches were carried out in four databases (CINAHL, Web of Science, EMBASE, and Medline). Inclusion criteria included age ≤ 15 years, and intervention, cohort, or cross-sectional studies from western countries. Methodological quality was rated using the Quality Assessment Tool for Quantitative Studies by two independent reviewers. Data was extracted using a standardized data extraction form. Synthesis was done by summarizing results across studies by age groups of 0–5, 6–12, and 13–15 years within four sleep domains: Bedtime and sleep onset; Sleep quality; Sleep duration; Daytime tiredness.ResultsThe search identified 10,719 unique studies, of which 109 fulfilled inclusion and exclusion criteria and were assessed for methodological quality. In total, 49 studies were included in the review. The study designs were randomized controlled trials (n = 3), quasi-experimental studies (n = 2), prospective cohort studies (n = 15), and cross-sectional studies (n = 29). Evidence for an association between electronic media use and sleep duration was identified, with stronger evidence for 6–15-years-olds than 0–5-year-olds. The evidence for a relationship between electronic media use and other sleep outcomes was more inconclusive. However, for 6–12-year-old children, there was evidence for associations of electronic media use with delayed bedtime and poor sleep quality. For 13–15-year-olds, there was evidence for associations between screen time and problems falling asleep, and between social media use and poor sleep quality.ConclusionsOverall, electronic media use was generally associated with shorter sleep duration in children and adolescents. Studies with stronger research design and of higher quality are needed to draw solid conclusions about electronic media’s impact on other sleep outcomes. Public awareness and interventions could be promoted about the potential negative impact on children’s sleep of electronic media devices that are used excessively and close to bedtime.

BackgroundParticipation in electronic media use among 2–3 year olds is high and associated with adverse health and developmental outcomes. This study sought to test the feasibility and potential efficacy of a family-based program to decrease electronic media (EM) use in 2–3-year-old children.MethodsFamily@play was a six-session pilot randomised controlled trial delivered to parents of 2–3 year-old children from August to September 2012 in a community environment in the Illawarra region of New South Wales, Australia. Development of program content was guided by Social Cognitive and Family Systems Theories. The primary outcome was children’s electronic media use. Secondary outcomes included children’s time in sitting, standing and stepping. Data collectors were blinded to group allocation. Parents completed comprehensive process evaluation measures and participated in focus group discussions following completion of the program. Regression analyses were undertaken and effect sizes calculated using principles of intention to treat.ResultsTwenty-two participants (n = 12 intervention; n = 10 control) provided complete baseline data; complete data from 16 participants (n = 6 intervention; n = 10 control) were available post-intervention. Process evaluation results were high, showing the acceptability of the program. Compared with children in the control group, there were greater decreases in total EM use among children in the intervention group (adjusted difference [95 % CI] = −31.2 mins/day [−71.0–8.6] Cohen’s d = 0.70). Differences for other outcomes were in the hypothesised direction and ranged from small for postural (sitting, standing, stepping) outcomes to moderate to large for individual electronic media (e.g. TV viewing, DVD/video viewing).ConclusionsThis is the first family-based study to engage families of 2–3 year old children outside the United States and target multiple EM behaviours. Family@play was shown to be a feasible and acceptable intervention to deliver to families of 2–3 year old children. Potential efficacy is evident from moderate to large effect sizes. A larger trial is warranted to test the efficacy of the program.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12612000470897).

PROBLEMATIC INTERNET USE AMONG ADULT JAPANESE PSYCHIATRIC PATIENTS

BackgroundMany studies reported the high prevalence of problematic internet use (PIU) among adolescents (13–50%), and PIU was associated with various psychiatric symptoms. In contrast, only a few studies investigated the prevalence among the adult population (6%). This study aimed to investigate the prevalence of PIU and psychiatric co-morbidity among adult psychiatric patients.MethodsThree hundred thirty-three adult psychiatric patients were recruited over a 3-month period. Two hundred thirty-one of them completed the survey (response rate: 69.4%, 231/333; Male/Female/Transgender: 90/139/2; mean age = 42.2). We divided participants into “normal internet users” and “problematic internet users” using a combination of Young’s Internet Addiction Test (IAT) and the Compulsive Internet Use Scale (CIUS). Demographic data and comorbid psychiatric symptoms were compared between the two groups using self-rating scales measuring insomnia (Athens Insomnia Scale, AIS), depression (Beck Depression Inventory, BDI), anxiety (State-trait Anxiety Inventory, STAI), attention deficit hyperactivity disorder (ADHD) (Adult ADHD Self-report Scale, ASRS), autism (Autism Spectrum Quotient, AQ), obsessive-compulsive disorder (OCD) (Obsessive-Compulsive Inventory, OCI), social anxiety disorder (SAD) (Liebowitz Social Anxiety Scale, LSAS), alcohol abuse, and impulsivity (Barratt Impulsive Scale, BIS).ResultsAmong 231 respondents, 58 (25.1%) were defined as problematic internet users, as they scored high on the IAT (40 or more) or CIUS (21 or more). The age of problematic internet users was significantly lower than that of normal internet users (p < 0.001, Mann–Whitney U test). The problematic internet users scored significantly higher on scales measuring sleep problems (AIS, 8.8 for problematic internet users vs 6.3 for normal internet users, p < 0.001), depression (BDI, 27.4 vs 18.3, p < 0.001), trait anxiety (STAI, 61.8 vs 53.9, p < 0.001), ADHD (ASRS, part A 3.1 vs 1.8 and part B 3.5 vs 1.8, p < 0.001), autism (AQ, 25.9 vs 21.6, p < 0.001), OCD (OCI, 63.2 vs 36.3, p < 0.001), SAD (LSAS, 71.4 vs 54.0, p < 0.001), and impulsivity (BIS, 67.4 vs 63.5, p = 0.004).ConclusionsThe prevalence of PIU among adult psychiatric patients is relatively high. As previous studies reported in the general population, lower age and psychiatric comorbidity were associated with PIU among adult psychiatric patients. More research is needed to determine any causal relations between PIU and psychopathological illnesses.

Aboujaoude's review of problematic Internet use is a timely contribution to the literature on a poorly understood behaviour that has apparently caught the attention of the media more than that of mental health professionals. And, while psychiatrists and clinical psychologists seem to be sceptical about many aspects of the problematic Internet use, concern in the community about the adverse effects of the Internet use seems to be growing exponentially. This revolves mainly around two issues. The first is the impact of violent video games and other violent online content; the second is what has increasingly been referred to as "Internet addiction". The focus of this commentary will be on the latter issue. The problem starts with terminology, as the appropriate name for the condition or behaviour often labelled "Internet addiction" is not clear. Progress in this area can hardly be made without first reaching a consensus as to what terms to use. "Internet addiction" is a troublesome term, not only because of its pejorative connotations, but also because there is no evidence that this is really an addictive disorder, i.e., that it is characterized by the hallmarks of substance addiction such as tolerance and withdrawal. If adopted without sufficient evidence, "Internet addiction" will clearly be an arbitrary term. It is appropriate to be cautious and retain more descriptive and "neutral" terms, such as problematic (or problem) Internet use. Other terms have also been proposed, e.g., "pathological use of electronic media" 1, but "Internet addiction" still seems to dominate the literature and professional jargon. The terminological rigour should go hand in hand with conceptual clarity. A part of the reason for the ongoing struggle with terminology is the lack of clarity about the key features of problematic Internet use. Several features have been proposed, but many of them seem to overlap and boil down to the basic two characteristics. The first pertains to the aspects of Internet use, described as excessive or compulsive, along with preoccupation with and loss of control over the Internet use. The second refers to various adverse consequences of spending too much time on the Internet, such as neglecting social activities, relationships, health and work or school duties, and altering sleep and eating habits in a detrimental way. Further research is needed to ascertain more precisely to what extent these features characterize problematic Internet use. Problematic Internet use appears to be too heterogeneous as a concept. It has been suggested that it consists of at least three subtypes: excessive gaming, problematic sexual behaviour, and e-mail/text messaging 2. The Internet may also be used excessively and with negative consequences to gamble, shop, or chat. These different purposes of using the Internet may be associated with different patterns of use, different underlying psychopathology, and different adverse consequences. It may then be inappropriate to lump together all the instances of problematic Internet use and perhaps more useful to consider online gambling as a manifestation of pathological gambling, Internet-related problematic sexual behaviour as a feature of a sexual or some other disorder, and so on. In accordance with this approach, we have formulated and tested preliminary criteria for problem video game use 3, but these require further study. "New" disorders or patterns of behaviour may be no more than alternative expression of various psychopathological entities. Accordingly, it has been debated whether addictive disorders, including problematic Internet use, represent primary conditions in their own right or whether they can be better understood as a manifestation of some underlying psychopathology or poor coping, that is, a "secondary addiction" 4,5. Various mental and other disorders often co-occur with problematic Internet use, which suggests that in many cases the latter may be conceived of as being related to the former. The co-occurring conditions and corresponding dimensions of psychopathology include depressive and bipolar disorders, anxiety disorders (especially social anxiety disorder, generalized anxiety disorder, and obsessive-compulsive disorder), sleep disturbance, substance use disorders, impulse control disorders, attention deficit and hyperactivity disorder, personality disorders and traits (especially borderline, narcissistic, antisocial, and avoidant), and psychotic disorders. Several issues should be addressed when elucidating whether and when problematic Internet use is primary or secondary. First, prospective studies need to ascertain the sequence in the development of problematic Internet use and psychiatric disorders. Second, it is important to understand to what extent the relationship between problematic Internet use and the associated psychopathology is specific. Finally, treatment of individuals with problematic Internet use crucially depends on whether an underlying condition accounts for problematic Internet use, as that condition should then be targeted by treatment. There have been calls to conceptualize problematic Internet use as a mental disorder, include it in the DSM-V, and classify it as a "compulsive-impulsive spectrum disorder" 2. However, doing so seems premature in view of the following: a) it is not yet clear whether and how problematic Internet use can be distinguished from a pattern of behaviour usually labelled by others as undesirable or disturbed; b) the boundary between normal and problematic Internet use has not been established; c) it remains to be ascertained whether problematic Internet use possesses conceptual validity, including distinct presentation and sociodemographic and neurobiological correlates, internal homogeneity, and sufficient longitudinal stability with distinct course, prognosis, and response to treatment. Not endowing problematic Internet use with the status of a mental disorder would prevent its psychiatric reification at the time when so little is known about it, while fostering an open-minded attitude towards further research.

Individual, home social and physical environment correlates of electronic media (EM) use among children were examined and pattern of differences on school and weekend days. Youth (n = 298) aged 11 to 12 years self-reported time spent using EM (TV, video/DVD, computer use, and electronic games) on a typical school and a weekend day, each dichotomized at the median to indicate heavy and light EM users. Anthropometric measurements were taken. Logistic regression examined correlates of EM use. In total, 87% of participants exceeded electronic media use recommendations of ≤ 2 hrs/day. Watching TV during breakfast (OR = 3.17) and after school (OR = 2.07), watching TV with mother (OR = 1.96), no rule(s) limiting time for computer game usage (OR = 2.30), having multiple (OR = 2.99) EM devices in the bedroom and BMI (OR = 1.15) were associated with higher odds of being heavy EM user on a school day. Boys (OR = 2.35) and participants who usually watched TV at midday (OR = 2.91) and late at night (OR = 2.04) had higher odds of being a heavy EM user on the weekend. Efforts to modify children's EM use should focus on a mix of intervention strategies that address patterns and reinforcement of TV viewing, household rules limiting screen time, and the presence of EM devices in the child's bedroom.

Background: Electronic media use is an important avenue for reaching stigmatized populations. We examined Internet access and use of sexually related electronic media among men who have sex with men (MSM) in 4 cities in Tanzania. Methods: A questionnaire was administered to 231 MSM in Dar es Salaam, Mwanza, Arusha, and Tanga regarding electronic media type, times of use, type of use and frequency of use of sexually-related media. Results: Mean age was 25.7 years, and 52% had completed high school. Half had access to the internet through personal electronic devices, a further quarter had access through work, 10% through friends’ devices, and only 2% had no access to the internet. Most frequently used electronic devices were personal computer followed by work smartphone, with work computer a close third. These patterns were consistent for both seeking other men for sex and finding sexual health information. All respondents had accessed sexual material electronically at some time. Substantial logged-in time was reported each week seeking/chatting with potential sexual partners (median = 48 hr), looking at “porn” (median = 24 hr), and searching for health information (median = 7 hr). Over 98% indicated that they would use an anonymous/confidential online service for HIV and sexually transmitted infection testing. The majority (79%) had found sexual partners throughout the Internet in the last 24 hours, and 52% sought sexual health education online 2–3 times per week. Peak search time was evenings, increasing during weekends. Discussion: For Tanzanian MSM in cities, sexual electronic media use is high and includes work devices. Sexual health information seeking, and openness to electronic counseling and testing was almost universal. Electronic sites for sexual health access should be explored and evaluated.

Introduction: Repeated use of social network is said to cause addiction. Attention deficit hyperactivity disorder (ADHD) is disorder found in childhood. Studies have shown that such children continue to have the symptoms of ADHD as adults. The aim of this study was to find the prevalence of social networking addiction and Internet addiction and their relationship with ADHD. Also, to assess the relationship between perceived stress and sociodemographic factors with social networking and internet addiction. Material and Methods: A cross-sectional study was conducted among 150 undergraduate and postgraduate students of BMCRI after ethical clearance. Medical students who gave consent were included through stratified random sampling. Those who were taking treatment for psychiatric illness were excluded. Scales like the Young Internet addiction test (IAT); Bergen's Facebook Reporting Scale, ADHD Self-Reporting Scale, and Wender Utah Brief Rating Scale for ADHD, and Cohen Perceived Stress Scale (PSS) for perceived stress have been used. Results: The mean age was found to be 21.56 ± 3 years. 62.6% were males and 37.33% of were females. The prevalence of Internet addiction was found to be 23.3% (n = 35), with 2% (n = 3) were having severe addiction, 6.6% (n = 10) were having moderate Internet and 14.6% (n = 22) having mild internet addiction according to modified Young's criteria (2011). The prevalence of social networking addiction as per the Bergen Facebook Addiction Scale (BFAS) score was 4.66% and adult ADHD was 15%. There was a strong positive correlation (0.76) between Internet Addiction and Facebook addiction scores and between BFAS score and IAT score. A moderate positive correlation (0.46 and 0.47) between Internet addiction and Facebook addiction with perceived stress and ADHD and IAT score with PSS score and ASRS score, weak positive correlation with PSS score and ASRS score was observed. Conclusion: A significant proportion of medical students develop Internet addiction and minority develops social network addiction. Furthermore, perceived stress and ADHD scores are positively correlated with internet and social networking addiction.