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 Table of Contents  
SPECIAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 118-125

Problematic internet use among adolescents and the impact of COVID-19 pandemic on mental health: An overview


Department of Psychiatry, Father Muller Medical College, Mangaluru, Karnataka, India

Date of Submission22-May-2022
Date of Decision23-May-2022
Date of Acceptance24-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
S Malarmathi
Department of Psychiatry, Father Muller Medical College, Mangaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_118_22

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  Abstract 

Adolescents are a vulnerable population to problematic Internet use. Although it is considered a behavioral addiction, there is a lack of unified definition and criteria, and the current models are derived from substance dependence and their validity is yet to be established. At present, the Internet has become an integral part of everyday life and further explication is needed on what constitutes problematic Internet use. Unrealistic expectations, the need for excitement, risky behaviors, addictive temptations, and late bedtime in adolescents can lead to addiction. The Internet provides anonymity and at the same time a sense of belongingness and social acceptability to them. The prevalence of Internet addiction (IA) varies across cultures and countries. More than 90% of students stayed at home due to coronavirus disease 2019 pandemic and the technology became necessary to access education and gather information. Flexible daily routine, unlimited Internet access, less parental interference, boredom, and the natural tendency of this age group to use the Internet have led to an increase in IA. Unsupervised screen time and Internet access, lack of identification of at-risk individuals, lack of appropriate interventional strategies, and lack of awareness of mental health have made the scenario more complex, which is often overlooked. Treatment of problematic Internet use is an evolving field and the traditional model of abstinence is not feasible for the management of IA. Cognitive behavioral approaches are promising when combined with other treatments. Psychotropic drugs are found to be effective on comorbid conditions, which, in turn, can help in mitigating the symptoms of IA.

Keywords: Adolescent Internet addiction, coronavirus disease 2019, pandemic, problematic Internet use


How to cite this article:
Joe A, Safeekh AT, Malarmathi S. Problematic internet use among adolescents and the impact of COVID-19 pandemic on mental health: An overview. Arch Med Health Sci 2022;10:118-25

How to cite this URL:
Joe A, Safeekh AT, Malarmathi S. Problematic internet use among adolescents and the impact of COVID-19 pandemic on mental health: An overview. Arch Med Health Sci [serial online] 2022 [cited 2022 Jun 27];10:118-25. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/118/347951


  Introduction Top


“It's funny how humans can wrap their mind around things and fit them into their version of reality”-Rick Riordan

In a time, when the real world is often undifferentiated from the virtual world, it is no wonder that many would rather prefer the latter where they presume that they can have a certain command. The Internet started as a method for government researchers to share information way back in the 1960s. In 1991, the European Organization for Nuclear Research introduced the World Wide Web to the public. A case of addictive use of the Internet in a 43-year-old homemaker was first reported by Kimberly S Young from the University of Pittsburgh in 1996.[1] Much before most of the world knew what the Internet was, in 1997, Ivan K Goldberg, a psychiatrist from New York, played a joke on the American Psychiatric Association for the complexity and rigidity of Diagnostic and Statistical Manual of Mental Disorders (DSM) and concocted something called Internet addiction (IA) disorder. He had unknowingly opened the gates of this new epidemic when many of his colleagues and self-described addicts responded and mailed him for help.[2] Over the last 20 years, the Internet has grown tremendously and has become an integral part of the everyday life of people all over the world. Recent literature shows that more than 60% of the global population use the Internet now. It is an important tool in education, communication, entertainment, and sharing of information but also not without the emergence of clinical cases presenting with symptoms of problematic Internet use. Although IA is considered behavioral addiction, it is not included in DSM-5 or International Classification of Diseases (ICD)-11. There is also a lack of univocal definition and terminology in the presently available literature. The current models borrow criteria from substance abuse disorder, and unfortunately, their validity is yet to be established.[3]


  Challenges in Conceptualization Top


The Internet which started as a means for communication has become an essential part of the personal, social, and economic development of the current society. Merely spending excessive time online cannot be considered addiction as a professional gamer who earns by streaming his gameplay or a YouTuber who is always online posting videos for his livelihood cannot be termed as someone with IA disorder. The scope of the Internet is changing rapidly, making it difficult for researchers to keep up. Some people postulated that the Internet is a vehicle, not the target. It is after all a medium, not an activity by itself. What is done online counts; spending excessive time online shopping is different from the one who is gaming excessively. A student who is suffering from IA cannot be kept away from using it as it is needed for various educational purposes. Hence, absolute abstinence as in the case of substance abuse may not be possible here as the Internet has already become an inextricable part of our lives.[4] Multidimensional and diverse environment of the Internet questions the validity and makes us wonder if there is any consistency in the concept of IA. It is too general a term to capture all the nuances. Internet connectivity and mobility make it accessible for various needs such as checking the time, social networking, shopping, entertainment, communication, listening to music, watching movies, and education. Given this context, a substantial amount of time is spent on the Internet, which is understandable. A further challenge is to differentiate problematic usage from required usage. Most of the research on IA disorder is focused on Internet gaming disorder, which is included in the appendix of DSM-5 as a condition for further study. There is a need for greater clarity in the theoretical underpinning to define the complexity of IA and validate its characteristics.[5]


  Definition and Terminologies Top


Over time, the definition of IA has been modified to include various aspects of the disorder. Some researchers see excessive Internet use as a part of another mental illness like anxiety or depression rather than a separate entity. Others have defined it more in terms of impulse control disorder. The American Society of Addiction Medicine recently redefined addiction as a chronic brain disorder, making nonsubstance use disorder to be included in addiction. They all share common characteristics such as intense desire, loss of control, tolerance, salience, withdrawal symptoms, and use despite harmful consequences. Some behaviors associated with excessive Internet use were also considered compulsive behavior. Compulsion can be separated from addiction by its ego-dystonic nature. IA was defined as “pathological, obsessive use of the Internet including tolerance and withdrawal” by Goldberg in 1996. Later, Young herself in 2000 defined it as “a psychological dependence on the Internet and is identified by a growing investment of resources on Internet related activities, unpleasant and annoying feelings when offline, an increasing tolerance to the effects of being online, and denial of the controversial behaviors.” Kim et al. in 2015 defined IA as the use of the Internet to such an extent as to cause emotional problems and dependent behavior indistinguishable from those of drug addiction.[6] There is an ongoing dilemma on how best to classify behaviors characterized by excessive use of the Internet in non-work-related activities. Researchers have used different terminologies and concepts such as IA, compulsive Internet use, pathological Internet use, Internet dependency, Internet overuse, and Internet mania when trying to understand problematic Internet use.[7] Shapira et al. argued that the diagnostic criteria derived from substance dependence may not comprehensively capture the problematic Internet use and may lead to imprecise conclusions. They also avoided the term “IA” to a less pejorative term “problematic Internet use.”[8] Problematic Internet use just denotes excessive use of the Internet that results in negative consequences which are benign in nature and further clinical acumen is needed to consider IA, which is at the upper limit of the severity continuum. Despite many studies, researchers still struggle to draw the line between problematic Internet use and addiction.[9] Regardless of the specific terminology used, the harmful consequences of Internet use continue to grow rapidly and need immediate attention.


  Risk Factors Top


Adolescence is the period when one finds his/her own identity and view of life. Conflict with the authority and norms of society can have a detrimental effect on them. Lack of self-confidence, social isolation, boredom, and entertaining videos can lead to excessive Internet use, resulting in addiction. Spending long hours in online chat rooms and gaming can negatively impact the mental health and standard of learning. Unrealistic expectations, the need for excitement, risky behaviors, addictive temptations, and late bedtime can interfere with their ability to solve identity crises, affirm attitudes, develop social skills, and achieve professional goals. Their vulnerability and receptive nature make them seek the Internet as a form of release. New ways of communication through the Internet provide anonymity and at the same time a sense of belongingness and social acceptability.[10] Low extroversion, low emotional lability, and low agreeableness are common personality traits associated with an increased risk of IA. Mood disorders, conduct disorders, ADHD, social phobia, OCD, alcohol and other substance use, and suicidal ideation are some of the common comorbidities associated with IA. These have common etiology and bidirectional causality and can increase the severity of psychopathology. Excessive use of online social networking sites reinforces online rather than offline social networks. Online use of some applications also influences instantaneous gratification by activating the hedonistic dopamine system. Online gaming demands higher commitment and more time from the player contributing to the development of maladaptive behaviors and coping strategies. Recent studies also indicate that the desire for online media usage is higher than that for substance use disorder.[11]


  Prevalence Top


The prevalence of IA often varies depending on the country, ethnicity, accessibility to the Internet, acceptance by the community, sociocultural and economic background, and gender. A Chinese study reported that the prevalence of adolescent IA in males is 30%, whereas in females, it is 21% with an average of 26.5%. The highest ranked online activities were networking (95%), school work (87%), entertainment (82%), gaming (73%), and shopping (34%).[12] While another study on Chinese adolescents reported that the prevalence of problematic internet use was approximately 8.1%. They were more likely to suffer from psychosomatic dysfunction, lack of energy, emotional and behavioral symptoms, and poor social adaptation.[13] A cross-sectional study of Greek adolescents found that the prevalence of potential problematic Internet use was 19.4% and problematic Internet use was 1.5%. It was also associated with the likelihood of hyperactivity and conduct disorder in such adolescents. Male gender, game playing, chat room use, E-mail, and retrieving sexual information were all determinants of problematic Internet use.[14] A survey of high school students in the United States reported an overall prevalence of problematic Internet use of 4% surprisingly without any difference between the genders. It was significantly associated with substance use, depression, and aggression.[15] Addictive Internet use in patients between 8 and 17 years was 11.3% in a German study. This study also suggested the distinct pattern of psychopathology requiring disorder-specific treatment.[16] In a Finnish study, 4.6% of girls and 4.7% of boys met the definition of IA. Among the criteria used for diagnosis, efforts to control time spent on the Internet were commonly met and the use of the Internet to get more and more excitement was rarely met.[17] The highest prevalence was reported in an Indian study of adolescent IA. Moderate Internet use was seen in 47% and severe use in 23% with boys having a higher risk compared to girls.[18] Another systemic review and meta-analysis of Internet use in Indian settings reported that the overall prevalence of IA was 19.9%.[19] The prevalence among the above studies varied from 1.5% to 26.5% due to differences in sample size, study design, type of scales used, and definition of IA.


  Adolescent Internet Addiction and Coronavirus Disease 2019 Pandemic Top


Coronavirus disease 2019 (COVID-19) pandemic has affected normal daily activities with stay-at-home restrictions in more than 130 countries worldwide. People especially adolescents reported a higher incidence of anxiety, depression, phobia, and sleep irregularities during this period. More than 90% of students stayed at home due to lockdown and technology became necessary to access education. Flexible daily routine, unlimited Internet access, less parental interference, boredom, and the natural tendency of this age group to use the Internet have led to an increase in IA. A meta-analysis conducted before the pandemic showed that 13.6% of adolescents were Internet addicted.[20] However, a study done in Taiwan estimated that IA was 24.4% during COVID-19 outbreak. Higher neuroticism, increased impulsivity, higher depressive symptoms, lack of emotions, reduced self-esteem, lower subjective well-being, and lower social support were risk factors for IA. There was an increased participation in social network sites enabling adolescents to form close relationships online, which provided them with a sense of understanding, allowed them to feel secure and reassured them that someone is available online when needed. Poor family function also increased the likelihood of Internet usage to alleviate the stress caused by the family. This study, however, did not remove the possibility of already existing IA even before COVID-19.[21] A study from Indonesia where school from home was implicated as a part of the preventive measure during lockdown noted the circumstances also lead to restrictions in all types of recreational activities. Playing games, social media, and limited interaction with peers contributed to escalated mental health problems, loneliness, traumatic experiences, and sleep disorders. During adolescence, individuals are more comfortable expressing their feeling to their peers than their parents. This friendship with their peers is seen as a source of love, trust, affection, self-esteem, and inclusivity. This is crucial to their emotional development. Researchers argued that the sudden change from offline to online educational methods and lack of supervision can reduce the motivation to study, neglect daily activities, and increase school dropout rates. Uncertainty in the completion of courses, exam schedules, exchange programs, and lack of practical skills caused an increase in stress and anxiety among students. Their families struggled with layoffs, unstable income, and health-care problems, thereby increasing the financial burden during the pandemic. Most of the daily activities were transitioned into the digital arena. The Internet helped us in the dissemination of information about COVID-19, creating awareness among the public, and providing various services. There was also an increase in fake news, rumors, hoaxes, and conspiracies due to the lack of regulation in the information, resulting in an increase in stress and anxiety among the public. Adolescents were more vulnerable to this because of their naivety, immaturity in impulse processing, and their reduced ability in information appraisal. Negative emotions can, in turn, result in maladaptive coping strategies that could progress into IA. The prevalence of IA among adolescents in Indonesia was observed to be 19.3%, which is more than the adult population. Earlier age of Internet use and higher internalizing and externalizing problems are associated with a higher risk of IA. Many adolescents use the Internet to escape reality and get instant gratification.[22] A cross-sectional study from Turkey investigated the prevalence of IA and psychosocial problems among adolescents during COVID-19. Pandemic made adolescents be away from their social environment, school, playing, and hobbies. Internet was increasingly used for different purposes such as communication, online games, doing homework, and information collection. Daily Internet usage also increased from that of the prepandemic period. Psychosocial problems increased during COVID-19 such as anxiety, depression, suicidality, aggression, ADHD, and stress. They, in turn, predicted the risk of IA. The study reported that almost all adolescents (99.7%) were using the Internet, but the prevalence of IA among them was 4.8%. The prevalence of psychosocial problems was 20.7%. This risk was higher when the father was unemployed, lower family income, lower maternal education levels, and daily Internet use for more than three hours. All parents have to be informed about the relationship between psychosocial problems with IA, and these factors have to be considered when planning preventive strategies during pandemics.[23] Problematic use of the Internet is steadily increasing over the past few years even before COVID-19. The pandemic lockdown has further reinforced this behavior globally. There is a significant difference in the prevalence and purpose of Internet use between countries like the Philippines and Turkey. Social media was significantly more among adolescents in the Philippines, whereas online gaming was more in the Turkish sample. Social media provide an alternative to face-to-face communication and provide a way to escape stress and loneliness. Gaming addiction was more common in males across countries. Young people from the Philippines sought escapism more than those from Mexico, India, and Turkey. Turkish population had more scores on loneliness and self-esteem. Results also suggest that poor mental health is a predictor of problematic Internet use, and Internet use may be a coping strategy for those people. The difference across countries can be attributable to cultural differences.[24] A study from China reported quarantine and stress would have aggravated the crisis of IA. Recreational Internet use increased during the pandemic. Perceived pressure, low social support, and mental illness increased the risk of time spent on the Internet.[25] Cross-sectional studies of medical students in seven countries reported that IA was 67.7%. Poor sleep was experienced in 73.5%. Males had higher scores on IA than females. IA was a predictor of sleep hygiene. The increasing popularity of smartphones has increased their use before sleep, resulting in irregular sleep patterns. This also caused poor memory, poor learning abilities, poor concentration, and decision-making capacities.[26] It is indisputable that social media has become an inextricable part of students. The level of stress increased significantly during the pandemic. Restriction in socialization, boredom, financial problems, the uncertainty of the future, hoaxes, coursework and organization, and external distraction were recognized as factors causing stressors in students during the pandemic. Individual stress response depends on personality and social support. Ambivalent and extrovert personalities, impulsivity, and inadequate social support result in higher stress levels. Coping strategies of students during the pandemic included diversion behaviors such as watching movies, listening to music, shopping, and playing online games. Stress increased the use of the Internet as a coping mechanism to enhance happiness.[27] Improper use of the Internet among adolescents has shown an emerging trend in online harassment and victimization. Adolescents who experienced cyberbullying have higher levels of aggression and disregard for social rules and can show similar behavior with a sense of anger and revenge.[28] Social networks now contain an enormous number of personal details. Unsuspecting adolescents can become easy targets for online radicalization, sexual deviance, online dating abuse, spamming, pornography exposure, and online negative user behavior.[29] There are an increasing number of dare-based games online similar to the notorious blue whale challenge, resulting in an alarming number of deaths based on challenges made popular on the Internet or social media. The virtual game world is designed in such a way that achieving each level targets the brain's reward system and compels the user to perform the act again. Online pornography is easily available to adolescents. Inadequate knowledge and confusion often result in abusive sexual behavior, risky sexual practices, objectification of women, and promote impersonal, nonrelational sexual encounters.[30] India has one of the youngest populations globally and is vulnerable to problematic Internet use. Here, children are allowed to use the Internet from an early age, sometimes as early as infants. Parents are not fully aware of the deleterious effect of the Internet on young minds. Access to mobile phones and the Internet is considered fashionable. Unsupervised screen time and Internet access, lack of identification of at-risk individuals, lack of appropriate interventional strategies, and lack of awareness of mental health have made the scenario more complex, which is often overlooked.[19] Common physical problems include fatigue, irregular sleep patterns, increase or decrease in appetite, minimal outdoor physical activity, and somatic complaints such as backache, body ache, and eye pain.[7] Studies also report weakened immunity, obesity, and impaired vision and musculoskeletal and neurological disorders. IA can lead to an elevated risk of e-gambling. Online scams have increased tremendously in the last few years and adolescents can fall prey to such scams.[31] Social media and online gaming are increasingly becoming a large part of teenage culture throughout the United States and other developed countries. IA also contributes to psychosocial problems within the family, leading to disharmony and burden. The goal of life becomes unreachable as the adolescent population loses intrinsic motivation. There can be a loss of the previous role, a decline in family rituals, and a monetary burden on parents. Parents feel stressed and helpless to control the Internet use of their children. Academic decline and lack of interest in studies put immense pressure on the adolescents and they get diverted from their life goals. Adolescents with IA are at higher risk of depression, suicidal ideation, anxiety, schizophrenia, obsessive-compulsive disorder, antisocial/aggressive behaviors, self-harming behavior, substance use, and sleeping disorders.[7] The exact extent of the negative impact of IA on the lives of adolescents worldwide which was worsened by the pandemic is yet to be known.


  Management Top


Although IA is widespread across the world, it is not yet recognized as a mental disorder in DSM-5 or ICD-11. Diagnosing and managing this disorder may be a great challenge as it is more common among younger individuals, especially adolescents in a pandemic-affected world. Accepting the fact that adolescents who use the Internet inappropriately can become addicted to it is the primary step toward management. In 2009, the first treatment facility for online addiction in the United States was opened in Fall City, Washington. Soon, the first hospital-based IA treatment center in the United States was opened at the Bradford Regional Medical Center in Pennsylvania in 2013. Treatment of IA is an evolving field, and the traditional model of abstinence is not feasible for the management of IA. There is a paucity of evidence-based research on IA.[32] Like all other disorders, detailed clinical history is the primary step in formulating a treatment plan. Some of the common scales used for IA are the Generalized Problematic Internet Use Scale by Caplan in 2002, IA Test by Young in 1998, IA Scale by Nichols and Nicki in 2004, Problematic Internet use scale by Morahan-Martin in 2000, Problematic Internet use diagnostic– Interview by Bread and Wolf in 2001, and the Internet-Related Problem scale by Armstrong in 2000.[33],[34] Problematic Internet Use Questionnaire is a self-reporting scale developed to access problematic Internet use with good psychometric properties. It is a 5-point Likert scale where a score from 6 to 30 indicates increased problematic use and consists of 3 subscales (i.e., obsession, neglect, and control disorder). The scale also has two short versions (9- and 6-item), with proven validity and reliability in the adult and adolescent groups.[35]


  Pharmacological Management Top


Although pharmacological management is generally indicated only if IA has comorbid psychiatric conditions such as anxiety or depressive disorder, selective serotonin-reuptake inhibitors are found to be effective in primary IA by few researchers. Dell'Osso et al. studied the effect of escitalopram on 14 subjects with impulsive-compulsive Internet usage disorder (ICIUD). All the participants showed improvement in symptoms during the open-label escitalopram phase.[36] Another study used bupropion on 12 subjects diagnosed with substance dependence with Internet gaming disorder. There was a decrease in craving for Internet video gameplay, total game play time, and cue-induced brain activity in the dorsolateral prefrontal cortex after 6 weeks of sustained-release treatment.[37] Use of methylphenidate on 62 children with attention-deficit hyperactivity disorder with video game-playing addiction showed decreased Internet usage after 8 weeks of treatment.[38] Mood stabilizers also improved the symptoms of IA. In addition to these studies, there are some case reports of patients treated with citalopram, quetiapine, and naltrexone, showing improvement in symptoms.[32]


  Nonpharmacological Management Top


Motivational interviewing

This client-centered counseling approach is predominantly used for alcohol dependence and is now found to be useful in persons with IA to deal with the ambivalence of denial associated with IA. It is a technique that includes psychoeducation, reflective listening, affirmations, and summarization to enhance intrinsic motivation to control Internet use. However, there are no randomized control studies to show its efficacy on IA.

Reality therapy

This therapy emphasizes that IA is a preference that adolescence makes over other activities. The management includes helping the adolescents to expand their ability to develop skills like handling time and offering alternative measures to deal with problematic Internet use. A study done in Korea by Kim where reality therapy was used for treating IA in 25 college students showed a reduction in Internet use and improved self-esteem.[32]

Acceptance and commitment therapy

It is a type of psychotherapy that emphasizes acceptance as a way to deal with negative thoughts, feelings, symptoms, or circumstances. Acceptance and commitment therapy (ACT) has been used to treat persons with IA. Twohig and Crosby in 2010 treated six males with IA using ACT. The result showed a reduction in watching Internet pornography and they maintained remission at 3 months of follow-up. The study by Firouzkouhi et al. in 2021 in Tehran on 40 secondary school students with IA using ACT showed a decrease in both IA and interpersonal difficulty. The improvement persisted beyond 1 month. Another study from Tehran conducted by Dousti et al. in 2015 on 30 high school students reported that ACT reduced physical aggression, verbal aggression, anger, and hostility in the participants. ACT is considered to be one of the important approaches toward dealing with IA.[39]

Cognitive behavior therapy

Cognitive behavior therapy (CBT) is a short-term problem-focused therapy that is being considered an effective treatment for IA. This helps the patients to see the association between thought-action and feeling and the interplay which leads to psychopathology. CBT has shown to be efficient in impulse control disorders. Young treated 114 patients with IA using CBT and found improvement in symptoms. A study done by Gao on 29 middle school students with IA using CBT found an improvement in psychological functioning. Ting in 2018 conducted an 8-week CBT session on Chinese college students with mobile phone dependence, which resulted in a decrease in mobile phone dependence, obsessive-compulsive symptoms, and interpersonal sensitivity.[40] Despite CBT being used extensively for the management of IA, the clinical evidence for the efficacy is lacking. However, a multimodal approach where CBT is combined with psychotropic drugs, family intervention, behavioral therapy, group work, and casework has shown promising results.[7] A specialized kind of CBT called CBT-IA was developed to address the issues of patients with IA. CBT-IA is a comprehensive three-phase approach that includes behavior modification to control compulsive Internet use, cognitive restructuring to identify, challenge, and modify cognitive distortions that lead to addictive use, and harm reduction techniques to address and treat comorbid issues associated with the disorder.[41]

Support groups

Adolescents with IA seek social support from the outside world in case they are deprived of the same from the family. In some, virtual community becomes a means to seek support, validation, and approval, thereby compensating for the deficit. Very few online support groups are available to address and help the person with IA at present. IA support group is one such group run by the Center for Online Addiction in the USA. However, such services are not available in the rest of the world.[33]

Family therapy

Family therapy and couple therapy are recommended if children have IA and family seems to be a contributing factor to the condition. Consistent parenting, limit setting, and differential reinforcement can be practiced by parents to control the behavior. The Qualitative study on Practitioner's views on Family involvement in the Treatment Process of Adolescent IA by Camilla Kin Ming Lo et al.[42] in 2020 shows that healthy parenting practices involving appropriate parental monitoring behaviors and strong emotional support are associated with a lower risk of IA in adolescents. In a study on multifamily group therapy for adolescent IA by Liu et al. in 2014, a significant difference was noted both in the decline and proportion of adolescents with IA. The six-session multifamily group therapy was effective in reducing IA behaviors among adolescents and could be implemented as part of routine primary care clinic services in similar populations. As family support system is critical in maintaining the intervention effectiveness, fostering positive parent–adolescent interaction, and addressing adolescents' psychological needs, it should be included in preventive programs for IA in the future.[32],[43]


  Other strategies Suggested by Young Top


  • Practice the opposite: Creating a new schedule of Internet use can weaken the old schedule of Internet use among adolescence. For example, if the adolescent has a habit of accessing the Internet just after arriving from school, now he/she should get access to the Internet at night or in the morning hours
  • External stoppers: These can be used to curb the time on the Internet. Adolescents can use an external stopper like an alarm clock to give a cue to terminate the online session
  • Setting goals: Short-term realistic goals could be of great help to decrease Internet time, thereby having intrinsic motivation. Assisting adolescents to set precise, achievable goals concerning the amount of time spent online is one such activity. If the patient remains online all day, a schedule should be set with brief sessions of Internet use followed by a brief session of discontinuation
  • Abstinence from certain applications: The abstinence model is not realistic as our existence revolves around the Internet and has become an integral part of our lifestyle. However, access to certain apps such as online games, Facebook, and series can be completely restricted which are most appealing and the client feels unable to resist. Whereas, access to other online use should be encouraged and can be used as an alternative activity
  • Reminder cards: Flashcards containing the disadvantages such as financial, psychological, academic, and physical harm should be listed along with the advantage of abstaining from the Internet. This should be read when the patient has cravings to use the Internet
  • Personal inventory: A personal inventory can be prepared by the client about all the activities he/she is not performing because of excessive Internet use like not engaging in outdoor activity, playing games, visiting friends and relatives, and not having meals with parents. This also can be used as a reminder when the patient has a craving.[44]



  Prevention Strategies Top


The universal prevention techniques that can be implemented for problematic Internet use are monitoring and regulating harmful content (live streaming suicide, erotic content) online by the service providers. Releasing official guidelines and legal enforcement of the minimum age may also prove to be effective. Limiting access to the Internet and stricter regulations such as blocking certain sites and reducing screen time can be helpful. In South Korea, minors can have late-night entry to Internet cafés only on parental requests.[45] In 2022, collaborative work by several institutions and committees in China composed the guidelines for people with IA, parents, and school authorities. Parents play a key in educating adolescents about IA. They can enhance cohesiveness, warmth, values, and conscience in children. Certain family rituals and outdoor and social activities should be constantly practiced as a part of daily life. Adaptive behavior should be positively reinforced, whereas maladaptive behaviors should be immediately addressed. Parental control on mobile or computers would give leverage to control adolescent behavior. Adolescents should continue to have daily activities which they followed before the pandemic and parents should act as role models for the adolescent by not engaging on the Internet excessively and can encourage communication in the family enhancing psychosocial competencies. School authorities can initiate mental health programs in the school curriculum to educate students about IA and its associated consequences. School teachers should be encouraged to provide offline homework assignments for online classes. The school counselor can keep vigilance on vulnerable adolescents for any mental health issues. Adolescents need to build skills to handle stress and to reach out to the concerned person when needed.[46]


  Conclusion Top


IA is still being extensively studied and the debate goes on about whether or not to designate it as a mental disorder. Adolescents are a vulnerable population and the pandemic further predisposed them to IA. Not many empirical evidence-based treatments for IA are available at present. Cognitive behavioral approaches are promising when combined with other treatments. There is no proven role for psychotropic medication in IA, but psychotropic drugs are found to be effective on comorbid conditions, which, in turn, can help in mitigating the symptoms of IA. Further research is needed for better conceptualization, developing diagnostic criteria, understanding of adolescent IA, and planning effective treatment interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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