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Problematic Internet Use in Adolescents: an Overview for Primary Care Providers Jasmine Atwal, M.D., Nicole Klaus, Ph.D., A.B.P.P., Rebecca Daily, M.D

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Problematic Internet Use in Adolescents: an Overview for Primary Care Providers Jasmine Atwal, M.D., Nicole Klaus, Ph.D., A.B.P.P., Rebecca Daily, M.D Kansas Journal of Medicine 2012 Problematic Internet Use Problematic Internet Use in Adolescents: An Overview for Primary Care Providers Jasmine Atwal, M.D., Nicole Klaus, Ph.D., A.B.P.P., Rebecca Daily, M.D. University of Kansas School of Medicine-Wichita Department of Psychiatry and Behavioral Sciences Introduction Technology use is playing an iated with psychosomatic symptoms such as increasingly important role in the daily lives lack of physical energy, weakened of adolescents. As many adolescents readily immunity, and lower life satisfaction.8 incorporate the internet into their lives, it is Excessive internet usage can be defined as important to be aware of the negative greater than or equal to 35 hours per week. 4 consequences that can stem from High levels of electronic media use by problematic internet use. adolescents, including internet overuse, is Problematic internet use is characterized related to poor sleep patterns and increased by an excessive preoccupation with internet daytime sleepiness, decreased level of use and a difficulty controlling urges and functioning during the day, and fatigue.9-11 behaviors related to the internet. 1 This Excessive time spent on the internet preoccupation with or use of the internet increases the opportunity to be victimized causes significant distress or impairment in through unwanted sexual solicitation, social, occupational, or other important exposure to pornography, and cyberbullying. areas of functioning.2 Though there is no One study 12 showed that 9% of youth listing of problematic internet use in the reported unwanted sexual solicitation, 11% Diagnostic and Statistical Manual of Mental of youth reported an online harassment Disorders (DSM-IV-TR),3 many articles experience (cyberbullying), and 23% of have proposed ways to identify when youth reported unwanted exposure to internet use has become a problem. pornography. Unwanted exposure to Problematic internet use in adolescents pornography can occur inadvertently while can manifest in different behaviors, using a search engine, opening an email, or including online gambling, internet-enabled surfing the web. Experiences with unwanted sexual behavior, excessive online gaming, sexual solicitation include unwelcome and excessive online socialization (i.e., sexual comments, requests for offline emailing, messaging, social network site contact (e.g., telephone, in-person meeting, usage).4,5 Heavy internet use has been etc.), or other unwanted sexual experiences. correlated with poor academic performance, Of note, solicitation may occur from other depression, social phobia, and attention- minors. Although the rate of unwanted deficit/hyperactivity disorder. 6,7 Primary online sexual solicitation is decreasing, care providers are often the first to intervene online harassment, or cyberbullying, is when problems arise with adolescents, and increasing.12 awareness of problematic internet use is Cyberbullying includes online threats or more important than ever. abusive, dishonest, and offensive material posted where the victim or others can see. 13 Effects of Problematic Internet Use Given the anonymous nature and lack of Problematic internet use can impact the face-to-face contact in online communi- health of adolescents negatively. Prob- cation, online bullies may become more lematic internet use in adolescents is assoc- brazen in their bullying attempts. In 108 Kansas Journal of Medicine 2012 Problematic Internet Use traditional forms of bullying, victims can go similar mechanisms in problematic internet home and escape the threats. However, with use and substance use. 19 cyberbullying, the victim may receive threatening electronic communication wher- Evaluation ever he or she is. In addition, cyberbullying Diagnostic criteria for problematic does not require the aggressor to be large in internet use do not appear in the DSM-IV- physical stature or popular in social status. TR.3 Various instruments have adapted Cyberbullying can reach a much larger DSM-IV-TR criteria for substance abuse or audience than traditional bullying,14 can dependence or DSM-IV-TR criteria for result in significant distress to victims, and pathological gambling.20 There are at least should be taken seriously. 15 One study 16 of 13 instruments designed to diagnose adolescents found that that 42.5% of the problematic internet use, 20 such as such as victims of cyberbullying felt frustrated, the Internet Addiction Disorder Diagnostic almost 40% felt angry, and 27% felt sad. In Criteria,21 Young’s Internet Addiction Test,22 this study, 31.9% of respondents said and the Chen Internet Addiction Scale.23 cyberbullying affected them at school, while In general, internet use is considered 26.5% said cyberbullying affected them at problematic when it begins to interfere with home. daily responsibilities, grades, relationships, Youth who experienced traditional or mood, and physical health. The primary care cyber forms of bullying, as either a bully or physician may find it useful to screen a victim, were more likely to attempt suicide routinely for problematic internet use and than those who had not experienced such may ask the following questions, as adapted forms of peer aggression.17 The perpetrators from those proposed by Shaw et al. 1: of cyberbullying also are at risk for psycho- • Do you feel overly preoccupied with logical, behavioral, and social problems, accessing the internet? such as poor emotional bonds with their • Do you feel that your internet use is caregivers, substance use, delinquent excessive, inappropriate, or poorly behaviors, and themselves being subject to controlled? 18 peer victimization on and offline. • Has your usage of the internet ever been The effects of problematic internet use overly time consuming, caused you to may extend to the central nervous system. feel upset or guilty, or led to serious 19 One study compared adolescents who problems in your life (e.g., financial or spent around 10 hours per day on the legal problems, academic problems, or internet with controls who spent less than relationship loss)? two hours per day on the internet. Results Problematic internet use may be inter- showed that long-term problematic internet related with existing comorbidities; there- use resulted in structural alterations in the fore, it is difficult to determine whether this brain in adolescents with excessive internet can be classified as a separate disorder.5 use. Such changes included reduced gray Nevertheless, recognition of the manifest- matter volume in regions such as the right ations of problematic internet use remains dorsolateral prefrontal cortex, right supple- important. mentary motor areas, and left rostral anterior cingulate cortex. Impairment in these Prevention and Treatment regions results in decreased cognitive There are no widely-accepted evidence- control. Abnormalities were consistent with based treatments for problematic internet previous substance abuse studies, suggesting use. As mentioned, problematic internet use 109 Kansas Journal of Medicine 2012 Problematic Internet Use may coincide with already-present psych- Cognitive behavioral therapy is effective iatric comorbidities. In fact, problematic in managing problematic internet use. Young internet use may be predicted by the et al.30 investigated 114 adults with presence of depression, attention-deficit/ problematic internet use who were treated hyperactivity disorder, social phobia, and with cognitive behavioral therapy (CBT). hostility.6 One of the various screening tools This study showed that most clients for problematic internet use is warranted managed their presenting symptoms by the when such symptoms are present. eighth CBT session and during the six- Social anxiety may predict problematic month follow-up had sustained these results. internet use, as socially anxious people may Young 31 suggested the following feel that online communication is safe and strategies to achieve recovery from poses less risk for negative evaluation.24 problematic internet use: One study 25 suggested that aggression, low • Practicing the opposite: identifying the self-control, and narcissistic personality patient's pattern of internet use and traits may predispose individuals to become doing neutral activities during that time. addicted to online games. Overall, the early • Setting external limits: use of external recognition and treatment of psychiatric prompts such as an alarm clock to symptoms, according to established prompt client to log off. treatment guidelines, is crucial in mitigating • Setting time limits and making pre-set 6,26 future problematic internet use. schedules for future use. There is no Food and Drug • Making reminder cards: negative Administration approved medication consequence of internet use are written indicated for the treatment of problematic down on a reminder card and carried at 27 internet use in adolescents. Hadley et al. all times. tested escitalopram in adult patients with • Set task priorities: prior to using internet, problematic internet use. Patients showed a the client should write down priorities of significant improvement of symptoms the internet session to maintain a time- during the 10-week, open-label escitalopram limit and avoid unplanned internet phase. After this phase, subjects were surfing. blinded and randomized to either continue Family involvement is equally important on escitalopram or receive placebo. Both to achieve recovery from problematic groups showed improvement. However, no internet use and the education of
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