FC09-06 - Adolescent internet behaviors and its correlation to depression, self-harm and suicidal behavior in European pupils

Pathological Internet use has been predominantly studied in junior high/middle school-aged or older children; data from elementary/primary school-aged children, however, are scarce. The current study aimed to examine the prevalence of problematic Internet use, including pathological and maladaptive Internet use, in elementary and junior high school-aged children and the relationships between problematic Internet use and mental health problems and health-related quality of life. The survey was conducted among children who attend national and public elementary and junior high schools in a medium-sized city in Japan; data were received from 3845 elementary school-aged and 4364 junior high school-aged children. Based on the Young's Diagnostic Questionnaire score, the prevalence of pathological and maladaptive Internet use was 3.6% and 9.4% and 7.1% and 15.8% in elementary and junior high school-aged children, respectively. The prevalence of problematic Internet use, including pathological and maladaptive Internet use, consistently increased from the 4th grade to the 8th grade. In addition, the prevalence sharply increased between the 7th grade and the 8th grade. Our study revealed that children with pathological and maladaptive Internet use exhibited more severe depression and decreased health-related quality of life than those with adaptive Internet use. Our results demonstrated that pathological Internet use is not uncommon even in elementary school-aged children and that those with pathological and maladaptive Internet use have severe mental health problems and decreased health-related quality of life, supporting the importance of providing these children with educational and preventive interventions against problematic Internet use and associated risk factors.

1672 – Pathological internet use among european adolescents: psychopathology and self-destructive behaviors

Abstract. Relevance. The progressive growth of pathological Internet use in adolescent populations, associated with impaired neuropsychic and somatic health of Internet-dependent users, is currently an urgent medical and social problem that requires an immediate solution. Goal of research. To study the age, gender and ethnic characteristics of the structure of online behavior among adolescents in Kyzyl (Republic of Tyva). Material and methods. Random samples of 216 adolescents aged 12-18 years – students of general education institutions in the city of Kyzyl (Tuva Republic) – were examined. The prevalence of types of online behavior was assessed: adaptive (AIU), non-adaptive (MIU) and pathological (PIU) Internet use. Indicators were compared in groups by age (12-14 and 15-18 years), gender (boys, girls) and ethnicity (Russians, Tuvans), using the program “Statistica 12 for Windows” (StatSoft Inc., USA). Results. It has been established that adolescents in the younger age group are characterized by a tendency towards a more frequent occurrence of MIU and PIU, among them there is a higher number of people with maladaptive (MIU+PIU) Internet use. Gender-specific characteristics of online behavior include a higher frequency of occurrence of MIU, a tendency towards a higher prevalence of PIU and maladaptive Internet use in girls. Ethnic differences in online behavior include a higher prevalence of PIU and maladaptive Internet use among Tuvan teenagers compared to Russian peers. Conclusion. Our results indicate the need for further research aimed at solving an urgent medical and social problem - timely diagnosis of Internet addictive behavior among the adolescent population of Tuva and prevention of somatic and neuropsychic health disorders associated with PIU in this population.

Over the past 10–15 years, research on the growing prevalence of Internet addiction has risen dramatically, spearheaded in the mid-1990s by the work of Dr Kimberly Young 1. Since that time, problematic Internet use prevalence studies have been conducted around the world and illustrate a growing global public health concern worthy of multi-disciplinary attention. Durkee and colleagues 2 deliver a seminal article on the prevalence of maladaptive and pathological Internet use in a large sample of adolescents in 11 European countries. Internet use disorder has been proposed for the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 incorporating criteria similar to those found in substance and behavioral addictions, including urges or pre-occupation to engage in Internet use, withdrawal, tolerance, difficulty controlling time spent online, a disregard of harmful consequences, a loss of other interests, using the Internet to escape from problems, deception regarding use and impairment 3, 4. While the Internet clearly provides adolescents many benefits (e.g. educational access, social networking, a world perspective larger than the classroom), a maladaptive or pathological use of the Internet also seems possible and probable. The fact that maladaptive and pathological Internet use rates were found in 13.5% and 4.4% of students, respectively, raises significant concerns over the potentially deleterious effects of continued use amongst our global youth. Previous research in young adult and adult populations has indicated psychological problems, such as depression and anxiety, and physical problems, such as carpal tunnel syndrome, dry eyes, headaches 5, altered sleep patterns 6 and poor academic performance 7 associated with excessive Internet use. The so-called ‘chicken and the egg’ debate, however, remains as to which condition promotes the other and is a topic in need of study. Although associated with negative consequences in adult users, we know very little about the short- and long-term effects of Internet addiction on the health and well-being of children and youth 8. Identifying predictors of maladaptive use in this population is an extremely important first step in targeting contributing factors which may lead to future consequences. Interestingly, Durkee and colleagues found that limited parental involvement in the students' lives was a predictor of pathology—a logical conclusion as low parental involvement (or perceived involvement) by the student has been associated with substance use and other unhealthy behaviors. This finding underscores the need for public health initiatives targeting parental education and community involvement as these have been successful in reducing risky behaviors, such as illicit substance use and teenage sexual activity 9-11. The article by Durkee et al. prompts us to further explore the factors associated with maladaptive Internet use by examining—longitudinally—harmful outcomes in youth throughout the webbed world. Unfortunately, research exploring potential genetic and environmental predictors of addition development and associated health correlates has been focused largely in substance addiction, absent of other behavioral addiction models 12. With the majority of the world engaging in Internet use and with the potential for significant negative consequences resulting from maladaptive Internet use, one hopes that the scientific examination of health and educational consequences of repetitive, maladaptive Internet use continues to grow. The research by Durkee and colleagues is an important step in advancing the global knowledge of Internet use in adolescents, but more work is needed. Preventative health measures for children and adolescents who have no understanding of a world without the Internet should comprise a public health priority worldwide. Currently, educational directives and preventative measures are largely lacking from clinical guidelines 13 and major public policy initiatives, such as Healthy People 2020 14 have shown limited interest in behavioral addictions in children and adolescents. Large-scale initiatives such as the Saving and Empowering Young Lives in Europe (SEYLE) project (from which the Durkee and colleagues sample is derived) provide a valuable example of research that strives to identify and call attention to the impact of abnormal Internet use. With increasing numbers of Internet-capable devices and of young people accessing the Internet everyday, mental and public health professionals should be on guard. BO has received a research grant from the Trichotillomania Learning Center and honoraria from Oxford University Press and Current Medicine Group, LLC. JG has received research grants from NIDA, the National Center for Responsible Gaming, Forest, Psyadon, and Transcept Pharmaceuticals, and the University of South Florida. JG receives compensation as the Editor-in-Chief of the Journal of Gambling Studies.

To investigate associations between risky and pathologic internet use with depression, deliberate self-harm and suicidal behaviour among a representative sample of German adolescents. A total of 1,435 students (48% boys, 52% girls) from the area of Heidelberg/Germany were recruited during the SEYLE study, a European school-based intervention study and completed an assessment of different questionnaires, including the Young Diagnostic Questionnaire for the assessment of risky and pathological internet use, the Beck Depression Inventory, the Deliberate Self Harm Inventory, and the Paykel Suicide Scale. 80.7% of the students reported regular, 14.5% risky, and 4.8% pathological internet use. The risky and the pathological internet users showed significant higher rates of depression, deliberate self-harm and suicidal behaviour compared to students with regular internet use. Remarkably, there were no significant differences of levels of depression and suicidal behaviour between risky and pathological users. These results suggest that not only pathologic internet use but also risky internet use is associated with symptoms of depression, self-harm and suicidal behaviour. Therefore, more attention should be paid to adolescents with risky internet use for the early recognition of depression, self-harm and suicidality in adolescence.

Background. The study of the prevalence and structure of various types of online behavior, the characteristics of the content consumed by adolescents of different age, sex and ethnic groups is an important area of scientific research.The aim. To study the features of online behavior and the structure of content consumed in Abakan adolescents of various age and sex groups and ethnicity (Russians and Khakasses).Materials and methods. 1400 adolescents of the city of Abakan (Republic of Khakassia) aged 12–18 were examined: 962 (68.7 %) Russians, 438 (31.3 %) Khakasses, 678 (48.4 %) boys and 722 (51.6 %) girls, aged 12–14 years – 39.8 % and 15–18 years – 60.2 %. The type of online behavior was verified using the Chen scale (CIAS). Emotional and behavioral disorders were diagnosed using the SDQ questionnaire. The indicators were compared in groups formed by sex, age and ethnicity. The data were processed using the Statistica 12.0 program (StatSoft Inc., USA).Results. It has been established that the prevalence and structure of online behavior among adolescents in Abakan depends on gender, age and ethnicity. Pathological Internet use (PIU) is more common among Khakasses, more often in the older age group. Regardless of ethnicity, maladaptive online behavior (pathological and maladaptive Internet use) is recorded more often among girls. In the structure of consumed content, gaming addiction prevails, social network addiction is in second place, and the proportion of mixed and undifferentiated Internet addiction is less. Dependence on online games prevails in boys, while dependence on social networks and undifferentiated internet addiction prevail in girls.Conclusion. One of the reasons for the greater prevalence of maladaptive online behavior among Khakasses may be the association of maladaptive Internet use with the presence of emotional disorders and behavioral problems that reach the borderline level and are causally significant factors in the development of Internet addiction. Adolescents with maladaptive online behavior, who have not yet reached the level of formed Internet addiction, are the target group requiring medical and psychological assistance.

Internet addiction and health-related quality of life in adolescents: The mediating role of sleep disturbance

Problematic internet use (PIU) and problematic social-media use have been associated with depressive symptoms and suicidal behaviors among university students, with limited Mediterranean evidence. This study examined their associations with stressful life events, depressive symptoms, and suicidal behaviors. A cross-sectional anonymous online survey conducted among undergraduates at the Cyprus University of Technology. Participants completed Internet Addiction Test-20 (IAT-20) to assess PIU risk, Bergen Social Media Addiction Scale (BSMAS) to assess problematic social-media use, Center for Epidemiologic Studies Depression Scale (CES-D) to assess depressive symptoms, Life Events Scale for Students (LESS-36) to assess stressful life events, and Suicidal Behaviors Questionnaire-Revised (SBQ-R) to assess suicidal behaviors. Correlation and multivariable linear regression analyses examined associations with depressive symptoms and suicidal behaviors. 1002 students completed the survey (45% response rate); 67.7% were female. PIU risk was minimal (51.1%), mild (38.6%), and moderate (10.3%). BSMAS and LESS-36 scores correlated with depressive symptoms (ρ = 0.47; ρ = 0.30) and suicidal behaviors (ρ = 0.24; ρ = 0.31; all p < 0.001). Adjusted analyses showed depressive symptoms were associated with female gender, mild-moderate PIU, problematic social-media use, and stressful life events. Suicidal behaviors were associated with male gender, non-Cypriot nationality, family history of mental illness, screen time, mild-moderate PIU, stressful life events, and depressive symptoms. Problematic internet and social-media use and stressful life events were associated with depressive symptoms and suicidal behaviors; longitudinal research is needed to clarify temporal relationships.

Indonesian adolescents spend too many hours using the internet. It leads to negative impacts, including problematic internet use (PIU). Few studies have found that social factors from parents and peers contribute to how they use the internet. Regardless, they still found inconsistencies regarding whether parents or peers, if investigated together, had the highest impact on their maladaptive internet use. This study aimed to examine the contribution of adolescent attachment to parents and peers to adolescents’ maladaptive internet use in terms of PIU. This research is using accidental sampling. The subjects were 237 adolescents (91 male) aged 12-24 years (M=15.03) from the Jabodetabek area. Data was collected using Google Forms. The PIU was measured using IPIUS (Indonesia Problematic Internet Use), and adolescents’ attachment was measured using IPPA (Inventory of Parent and Peer Attachment). Multiple regression with the stepwise model is applied to investigate the contribution of attachment to PIU. This paper argues that parent and peer attachment contributes significantly to adolescents’ PIU, and this parent attachment has a higher influence than peer attachment. This implies that optimizing parents’ role in attachment behavior could still impact adolescents’ internet behavior.

Internet Addiction Disorder: Personality characteristics and risk of pathological overuse in adolescents

Rising global rates of pathological Internet use (PIU) and related psychological impairments have gained considerable attention in recent years. In an effort to acquire evidence-based knowledge of this relationship, the main objective of this study was to investigate the association between PIU, psychopathology and self-destructive behaviours among school-based adolescents in eleven European countries. This cross-sectional study was implemented within the framework of the European Union project: Saving and Empowering Young Lives in Europe. A representative sample of 11,356 school-based adolescents (M/F: 4,856/6,500; mean age: 14.9) was included in the analyses. PIU was assessed using the Young’s Diagnostic Questionnaire. Psychopathology was measured using the Beck Depression Inventory-II, Zung Self-Rating Anxiety Scale and Strengths and Difficulties Questionnaire. Self-destructive behaviours were evaluated by the Deliberate Self-Harm Inventory and Paykel Suicide Scale. Results showed that suicidal behaviours (suicidal ideation and suicide attempts), depression, anxiety, conduct problems and hyperactivity/inattention were significant and independent predictors of PIU. The correlation between PIU, conduct problems and hyperactivity/inattention was stronger among females, while the link between PIU and symptoms of depression, anxiety and peer relationship problems was stronger among males. The association between PIU, psychopathology and self-destructive behaviours was stronger in countries with a higher prevalence of PIU and suicide rates. These findings ascertain that psychopathology and suicidal behaviours are strongly related to PIU. This association is significantly influenced by gender and country suggesting socio-cultural influences. At the clinical and public health levels, targeting PIU among adolescents in the early stages could potentially lead to improvements of psychological well-being and a reduction of suicidal behaviours.Electronic supplementary materialThe online version of this article (doi:10.1007/s00787-014-0562-7) contains supplementary material, which is available to authorized users.

Objective: This study examined the differences between noninternet addiction, problematic Internet use, and pathological Internet use and their association with stress and depression among preuniversity students in a public university in East Malaysia. Methods: It was a cross-sectional study using the self-administered questionnaire that consists of sociodemographic information, the Internet addiction test (IAT), patient health questionnaire (symptoms of depression), and Perceived Stress Scale-10. Data were analyzed using the IBM SPSS software version 23. Results: Two hundred and sixty-six respondents participated in the study (response rate of 95.7%). About 12% of the respondents reported having a high level of perceived stress and 69.9% with moderately severe and severe depression. For the Internet addiction profile, 21.4% reported being problematic Internet users and 21.4% were pathological Internet users. Multinomial logistics regression analysis showed no significant effect from gender, perceived stress, and depression on problematic Internet addiction. On the outcome of pathological Internet addiction compared to noninternet addiction (reference category), male has higher pathological Internet addiction as compared to female (odd ratio = 2.78); those who have moderately severe-to-severe depression are more likely to be pathological Internet addiction as compared to noninternet addiction (1/0.325 = 3.07). Conclusion: The study revealed that problematic and pathological Internet use is prevalent in our sample, and pathological Internet addiction was associated with the symptom of depression and gender. Early intervention and detection of problematic internet use may prevent the development of maladaptive coping responses that lead to Internet addictive use.

"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

To investigate the prevalence of pathological internet use (PIU) and maladaptive internet use (MIU) among adolescents in 11 European countries in relation to demographic, social factors and internet accessibility. Cross-sectional survey. The 7th Framework European Union (EU) funded project, Saving and Empowering Young Lives in Europe (SEYLE), is a randomized controlled trial (RCT) evaluating interventions for risk behaviours among adolescents in Austria, Estonia, France, Germany, Hungary, Ireland, Israel, Italy, Romania, Slovenia and Spain, with Sweden serving as the coordinating centre. A total of 11 956 adolescents (female/male: 6731/5225; mean age: 14.9 ± 0.89) recruited from randomly selected schools within the 11 study sites. Internet users were classified by gender into three categories: adaptive, maladaptive and pathological, based on their score in the Young Diagnostic Questionnaire for Internet Addiction (YDQ). The overall prevalence of PIU was 4.4%; it was higher among males than females (5.2% versus 3.8%) and differed between countries (χ(2) = 309.98; d.f. = 20; P < 0.001). PIU correlated significantly with mean hours online and male gender. The highest-ranked online activities were watching videos, frequenting chatrooms and social networking; significantly higher rates of playing single-user games were found in males and social networking in females. Living in metropolitan areas was associated with PIU. Students not living with a biological parent, low parental involvement and parental unemployment showed the highest relative risks of both MIU and PIU. Across a range of countries in Europe, using the Young Diagnostic Questionnaire for Internet Addiction yields a prevalence of 'pathological internet use' of 4.4% among adolescents, but varies by country and gender; adolescents lacking emotional and psychological support are at highest risk.

Maladaptive Internet use is defined as Internet addiction disorders (IAD), which can lead to psychological problems and sleep disorders. Although many studies on the correlation between Internet addiction, psychiatric symptom levels, and sleep disorders have been conducted in recent years, there is no meta-analysis to substantiate the connection between these variables. We systematically searched databases including Web of Science, PubMed, Embase, and the Cochrane Library to collect relevant studies using keywords associated with Internet addiction, psychological problems, and sleep disorders. All comparable studies that provided sufficient data (e.g., correlation coefficients) were included in our analysis. 41 studies were included, and the results indicated that IAD was associated with psychological problems and sleep quality at moderate to low levels (depression: r = 0.39, 95%CI = 0.34-0.45; SMD = 1.34, 95%CI = 0.81-1.86; OR = 0.86, 95%CI = 0.46-1.26; anxiety: r = 0.30, 95%CI = 0.23-0.37; OR = 0.90, 95%CI = 0.29-1.52; stress: r = 0.34, 95%CI = 0.29-0.38; OR = 1.76, 95%CI = 0.37-3.16; sleep problems: r = 0.26, 95%CI = 0.19-0.33). This meta-analysis reveals that IAD is positively associated with depression, anxiety, and sleep problems, which indicates that individuals with IAD have an increased risk of depression, anxiety, and sleep problems. Hence, high attention should be paid to Internet addictive behaviors, and preventive and treatment measures should be adopted timely. The publicly accessible registration record can be found at: https://www.crd.york.ac.uk/prospero/.