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

Background: The influence of adverse childhood experiences (ACEs) on an individual’s health is substantial. However, the associations between ACEs, problematic internet use (PIU), and health-related quality of life (HRQOL) in adolescents remain underexplored. Objective: To assess the association between ACEs and HRQOL in Chinese adolescents and to evaluate the mediating role of PIU in this association. Method: A sample of 6,639 adolescents (3,457 boys and 3,182 girls) aged between 11–20 years (mean [SD] age: 14.5 [1.6] years) were recruited from 6 junior and senior middle schools using a proportional sampling approach in a cross-sectional study. Data on ACE exposure was collected through the short form of Childhood Trauma Questionnaire, the ACE-International Questionnaire, and two additional questions. HRQOL was assessed by the Pediatric Quality of Life Inventory version 4.0. The associations between ACEs and HRQOL were estimated using linear regression models. Mediation analysis was further conducted to explore the possible mediating role of PIU in the association between ACEs and HRQOL. Results: Our study collected 13 different ACEs. We found that adolescents exposed to any ACE had significantly lower scores in all HRQOL dimensions, psychosocial health summary scale, and total scale, than those without such exposure. Specifically, adolescents with ≥ 3 ACE exposure had a total scale score that was 14.70 (95%CI: 15.53 to 13.87) points lower than their non-exposed counterparts. Mediation analysis identified PIU as a significant mediator, with the proportion of the total effect attributable to PIU ranging from 14.38% for social functioning to 17.44% for physical functioning. Conclusions: Exposure to ACEs was associated with poorer HRQOL in Chinese adolescents, underscoring the importance to prevent ACEs and their negative impacts on adolescent well-being. These findings also highlighted the need of promoting appropriate internet use among adolescents exposed to ACEs, in order to avert potential impairment in their HRQOL. HIGHLIGHTS Adolescents with adverse childhood experiences have poorer health-related quality of life. The association between adverse childhood experiences and health-related quality of life shows a dose–response pattern. Problematic internet use partially mediates the associations between adverse childhood experiences and health-related quality of life in adolescents.

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.

Influence of resilience on health-related quality of life in adolescents

General Problematic Internet Use (GPIU) is a dysfunctional use of Internet handling and management in general. In contrast, Internet Gaming Disorder (IGD) is a specific behaviour linked to online videogames. Both problems are becoming common in adolescents, but they have hardly been studied simultaneously, and the joint relationship of the two constructs with Health-Related Quality of Life (HRQoL) is unknown. The general objective of this study is to analyse the relationship between GPIU and IGD and their association with HRQoL. The study is analytical and cross-sectional with 2,024 participants (46.4% boys, n = 939) from 16 schools of 7 Spanish regions. The mean age and standard deviation were 14.20±1.42, with a range of 11-18 years. The Spanish versions of the KIDSCREEN-10, the Revised Generalized and Problematic Internet Use Scale 2 and the Internet Gaming Disorder Scale were used. Of the total sample evaluated, 15.5% of the participants had high levels of GPIU, and 3.3% of video game players presented IGD. The dimensions of GPIU are strongly associated with those of IGD. HRQoL correlated significantly and negatively with all the dimensions of GPIU and IGD (p <.001). Participants who reported problems with GPIU or IGD, individually or conjointly, had significantly lower scores in HRQoL than those with no problems.

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

The primary aim of this study was to examine associations between problematic Internet use, depression and sleep disturbance, and explore whether there were differential effects of problematic Internet use and depression on sleep disturbance. A total of 1772 adolescents who participated in the Shantou Adolescent Mental Health Survey were recruited in 2012 in Shantou, China. The Chinese version of the Internet Addiction Test (IAT) was used to evaluate the prevalence and severity of Internet addiction. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI), a 10-item version of the Center for Epidemiologic Studies Depression Scale (CESD-10), and other socio-demographic measures were also completed. Multiple regression analysis was used to test the mediating effect of problematic Internet use and depression on sleep disturbance. Among the participants, 17.2% of adolescents met the criteria for problematic Internet use, 40.0% were also classified as suffering from sleep disturbance, and 54.4% of students had depressive symptoms. Problematic Internet use was significantly associated with depressive symptoms and sleep disturbance. The correlation between depressive symptoms and sleep disturbance was highly significant. Both problematic Internet use (β = 0.014; Sobel test Z = 12.7, p < 0.001) and depression (β = 0.232; Sobel test Z = 3.39, p < 0.001) had partially mediating effects on sleep disturbance and depression was of greater importance for sleep disturbance than problematic Internet use. There is a high prevalence of problematic Internet use, depression and sleep disturbance among high school students in southern China, and problematic Internet use and depressive symptoms are strongly associated with sleep disturbance. This study provides evidence that problematic Internet use and depression have partially mediating effects on sleep disturbance. These results are important for clinicians and policy makers with useful information for prevention and intervention efforts.

Neuropathic Pain Is Associated with Poor Health-Related Quality of Life in Adolescents with Sickle Cell Disease

It is essential to determine contributors around impairment in health‐related quality of life (HRQoL) in patients with cirrhosis aiming at improving health care and therapeutic strategy. Studies simultaneously incorporating disease severity based on biochemical parameters and other physical/psychological effects (i.e., sleep disturbance and frailty) are heterogeneous and the subject of the present study. We analyzed and compared HRQoL, using the EuroQol Group 5 Dimension (EQ‐5D) questionnaire and the utility index retrieved, in patients with cirrhosis and across groups stratified by sleep disturbance or frailty phenotype. Sleep disturbance and frailty were determined by the Pittsburgh Sleep Quality Index (PSQI) and Frailty Index, respectively. Multiple linear regression was implemented to clarify contributors of poor HRQoL. In this cohort of 227 patients with mean age of 61.7 years and 47.2% male, more than half of the study population represented impairment in HRQoL in at least one domain, according to EQ‐5D. Furthermore, sleep disturbance and frailty have proved to be independently associated with poor HRQoL in two separate regression models, whereas conventional scoring systems such as Child‐Pugh classification and Model for End‐Stage Liver Disease are not closely relevant. Intriguingly, not all health domains within EQ‐5D correlated well with PSQI and Frailty Index, with the exception of usual activities. Pain and anxiety/depression were the most frequently affected HRQoL domains even in patients without sleep disturbance or frailty. Conclusion: Impaired HRQoL is prevalent in patients with decompensated cirrhosis. Sleep disturbance and frailty are independently associated with poor HRQoL. It is imperative to timely intervene with these symptoms and deliver tailored health care.

AimTo study health related quality of life (HRQOL) and depressive symptoms in adolescents with chronic fatigue syndrome (CFS) and to investigate in which domains their HRQOL and depressive symptoms differ from those of healthy adolescents.Background and objectiveSeveral symptoms such as disabling fatigue, pain and depressive symptoms affect different life domains of adolescents with CFS. Compared to adolescents with other chronic diseases, young people with CFS are reported to be severely impaired, both physiologically and mentally. Despite this, few have investigated the HRQOL in this group.MethodThis is a cross-sectional study on HRQOL including 120 adolescents with CFS and 39 healthy controls (HC), between 12 and 18 years. The Pediatric Quality of Life Inventory™, 4.0 (PedsQL) was used to assess HRQOL. The Mood and Feelings Questionnaire assessed depressive symptoms. Data were collected between March 2010 and October 2012 as part of the NorCAPITAL project (Norwegian Study of Chronic Fatigue Syndrome in Adolescents: Pathophysiology and Intervention Trial). Linear and logistic regression models were used in analysis, and all tests were two-sided.ResultsAdolescents with CFS reported significantly lower overall HRQOL compared to HCs. When controlling for gender differences, CFS patients scored 44 points lower overall HRQOL on a scale from 0–100 compared to HCs. The domains with the largest differences were interference with physical health (B = −59, 95 % CI −54 to −65) and school functioning (B = −52, 95 % CI −45 to −58). Both depressive symptoms and being a patient were independently associated with lower levels of HRQOLConclusionThe difference in HRQOL between CFS patients and healthy adolescents was even larger than we expected. The large sample of adolescents with CFS in our study confirms previous findings from smaller studies, and emphasizes that CFS is a seriously disabling condition that has a strong impact on their HRQOL. Even though depressive symptoms were found in the group of patients, they could not statistically explain the poor HRQOL.

Simple SummaryHealth-related quality of life in the adolescent stage is of vital importance because it provides the adolescent with an impression of his or her functional capacity, allowing him or her to examine, discover, and distinguish sensations and concerns. This indicator provides information on the person’s state of health. The EQ-5D-Y questionnaire was used to measure health-related quality of life, due to its simplicity and ease of use. Therefore, the aim of the present study was to describe the perceived quality of life in Peruvian school adolescents. Despite the increase in health-related quality of life studies, there is little research on the Latin American population. For this reason, it would be important to have normative data in Peru in order to estimate the impact on health-related quality of life in adolescents, since it allows comparisons of health-related quality of life between the general population and the pathological population. The results have shown that there are differences in the EQ-5D-Y between ages, as well as between weight groups established according to body mass index. In conclusion, adolescents have perceived favorable health-related quality of life sensations and the EQ-5D-Y has shown to be a feasible and useful questionnaire, in addition to having internationally recognized and validated cross-cultural characteristics.(1) Introduction: There is a growing interest in health-related quality of life (HRQOL) in adolescent population. The EQ-5D-Y is a generic HRQOL instrument that allows adolescents to understand the health status of different levels of physical, mental, and social health. This study was carried out with an adolescent population in Peru. The main objective of this article is to report the normative values of the EQ-5D-Y questionnaire in Peruvian adolescents. (2) Methods: The EQ-5D-Y questionnaire was administered to Peruvian adolescent students. A total of 1229 young people participated in the survey. The EQ-5D-Y score was reflected as a function of sex and age. (3) Results: The mean utility index of the EQ-5D-Y for the total sample was 0.890; this rating was significantly better for males at (0.899) and females at (0.881). The ceiling effect was higher for adolescent males with (47.3) females (40.7). (4) Conclusions: The results of the present study provide evidence that schooled adolescents show a positive perception of HRQOL.

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.

Background and aimsThis large-scale study aimed to test (a) associations of problematic Internet use (PIU) and sleep disturbance with suicidal ideation and suicide attempts among Chinese adolescents and (b) whether sleep disturbance mediates the association between PIU and suicidal behavior.MethodsData were drawn from the 2017 National School-based Chinese Adolescents Health Survey. A total of 20,895 students’ questionnaires were qualified for analysis. The Young’s Internet Addiction Test was used to assess PIU, and level of sleep disturbance was measured by the Pittsburgh Sleep Quality Index. Multilevel logistic regression models and path models were utilized in analyses.ResultsOf the total sample, 2,864 (13.7%) reported having suicidal ideation, and 537 (2.6%) reported having suicide attempts. After adjusting for control variables and sleep disturbance, PIU was associated with an increased risk of suicidal ideation (AOR = 1.04, 95% CI = 1.03−1.04) and suicide attempts (AOR = 1.03, 95% CI = 1.02−1.04). Findings of the path models showed that the standardized indirect effects of PIU on suicidal ideation (standardized β estimate = 0.092, 95% CI = 0.082−0.102) and on suicide attempts (standardized β estimate = 0.082, 95% CI = 0.068−0.096) through sleep disturbance were significant. Conversely, sleep disturbance significantly mediated the association of suicidal behavior on PIU.Discussion and conclusionsThere may be a complex transactional association between PIU, sleep disturbance, and suicidal behavior. The estimates of the mediator role of sleep disturbance provide evidence for the current understanding of the mechanism of the association between PIU and suicidal behavior. Possible concomitant treatment services for PIU, sleep disturbance, and suicidal behavior were recommended.

BackgroundPersistent pain has a high prevalence among adolescents. Pain has been shown to reduce all aspects of the adolescent’s health-related quality of life (HRQOL). In adult patients with pain, self-efficacy has been shown to mediate the relationship between pain intensity, disability and depression. However, little is known about whether self-efficacy acts as a mediating variable in the relationship between persistent pain and HRQOL sub-scale scores in a school-based population of adolescents.ObjectivesTo describe the experience of pain, HRQOL and self-efficacy, and to explore the association between pain intensity, general self-efficacy and HRQOL in adolescents with persistent pain by testing self-efficacy as a possible mediator.MethodsThe study participants were 78 adolescents with persistent pain, aged 16–19 years, who were recruited from five high schools in southern Norway. All participants completed an electronic survey consisting of the Lubeck Pain Questionnaire, which included a visual analogue scale (VAS) measuring pain intensity, the General Self-Efficacy Scale (GSE) and the KIDSCREEN-52 Questionnaire measuring HRQOL. Statistical analyses were conducted using the PROCESS macro for SPSS developed by Andrew Hayes.ResultsAll participants reported pain in multiple locations, of which the head was most common (88.5%). Mean (SD) pain intensity score of the participants was 5.4 (1.8). The study sample had poor HRQOL, with mean (SD) scores for several sub-scales ranging from 45.2 (21.0) to 91.0 (13.3) on a 0–100 scale. The associations between pain intensity and the HRQOL sub-scales of physical well-being, psychological well-being, mood, self-perception, autonomy and school environment were mediated by self-efficacy. The highest degree of mediation and, thus, the largest indirect effect was estimated for the HRQOL sub-scale physical well-being (67.2%).ConclusionsThis school-based sample of adolescents with persistent pain had impaired HRQOL. Up to 67% of the reduction in the HRQOL sub-scale scores for physical well-being, psychological well-being, mood, self-perception, autonomy and school environment could be explained by the mediating variable self-efficacy. Thus, future pain-management interventions that aim to increase HRQOL in school-based populations of adolescents with persistent pain should consider promoting self-efficacy and providing more targeted interventions.Trial registrationClinicalTrials.gov ID NCT03551977.

To examine potential risk factors for poor health-related quality of life (HRQOL) among adolescents with epilepsy by using the newly developed QOLIE-AD-48. Risk factors were derived from sociodemographic, social, academic, and epilepsy- and health-related domains. The QOLIE-AD-48 was administered to 197 English-speaking adolescents (age 11-17 years from >20 sites in the United States and in Canada). The self-report instrument yields an overall HRQOL score and eight subscale scores. Other data were obtained from family interviews, physician reports, and health records. Multiple regression analyses were conducted to study risk factors for impairment of HRQOL. Older adolescents (age 14-17 years), those with more severe epilepsy and more symptoms of neurotoxicity, and those living in households with lower socioeconomic status were more likely to report poor overall HRQOL. Risk factors in the eight HRQOL domains were found as follows: (a) Epilepsy Impact: older age in adolescence, more severe epilepsy and neurotoxicity, more hospitalizations during the past year, and fewer hours of extracurricular activities; (b) Memory and Concentration: longer duration of epilepsy, special education classes, and history of repeating a grade in school; (c) Attitude Toward Illness: older age, female gender, and more severe epilepsy and neurotoxicity; (d) Social Support: younger age, male gender, and fewer hospitalizations in the last year; (e) Stigma: lower socioeconomic status and special-education classes; and (f) Health Perceptions: older age, female gender, and lower socioeconomic status. None of the factors examined was significantly associated with HRQOL in (g) Physical Functioning or (h) School Behavior subscales. We identified several risk factors for poor HRQOL outcomes in adolescents with epilepsy. Age, increased seizure severity, and neurotoxicity were most consistently associated with poor HRQOL across domains. Older adolescents, independent of epilepsy severity, reported worse overall HRQOL than did their younger counterparts. Older adolescents also were more likely to perceive a greater negative impact on life and general health, and had more negative attitudes toward epilepsy. Adolescent boys and girls may show different sensitivities to various quality-of-life domains.

The internet has been a breakthrough for adolescents in many ways, but its use can also become dysfunctional and problematic, leading to consequences for personal well-being. The main objective is to analyze profiles related to problematic internet use and its relationship with health-related quality of life (HRQoL). An analytical and cross-sectional study was carried out in a region of northern Spain. The sample comprised 12,285 participants. Sampling was random and representative. Mean age and standard deviation was 14.69 ± 1.73 (11–18 years). The Spanish versions of the Problematic and Generalized Internet Use Scale (GPIUS2) and of the Health-Related Quality of Life (KIDSCREEN-27) were used. Four profiles were detected (non-problematic use, mood regulator, problematic internet use, and severe problematic use). The prevalence of these last two profiles was 18.5% and 4.9%, respectively. Problematic internet use correlated negatively and significantly with HRQoL. The severe problematic use profile presented a significant decrease in all dimensions of HRQoL. Analyses were carried out to extract a cut-off point for GPIUS2 (52 points). The results and practical implications are discussed.