Bidirectional associations between family ... - Wiley Online Library

Psychiatry and Clinical Neurosciences 2015; 69: 192–200

doi:10.1111/pcn.12204

Regular Article

Bidirectional associations between family factors and Internet addiction among adolescents in a prospective investigation Chih-Hung Ko, MD, PhD,1,2,3 Peng-Wei Wang, MD,1 Tai-Ling Liu, MD,1 Cheng-Fang Yen, MD PhD,1,3 Cheng-Sheng Chen, MD, PhD1,3 and Ju-Yu Yen, MD, PhD1,3,4* 1 Department of Psychiatry, Kaohsiung Medical University Hospital, 2Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, 3Department of Psychiatry, Faculty of Medicine, College of Medicine, and 4Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan

Aims: This study aimed at evaluating the effect of family factors on the occurrence of Internet addiction and determining whether Internet addiction could make any difference in the family function. Methods: A total of 2293 adolescents in grade 7 participated in the study. We assessed their Internet addiction, family function, and family factors with a 1-year follow up. Results: In the prospective investigation, interparental conflict predicted the incidence of Internet addiction 1 year later in forward regression analysis, followed by not living with mother and allowance to use Internet more than 2 h per day by parents or caregiver. The inter-parental conflict and allowance to use Internet more than 2 h per day also predicted the incidence in girls. Not cared for by parents and family APGAR score predicted the incidence of Internet

HE IMPACT OF the Internet on adolescent life and its application has grown within the past decade.1 The Internet provides beneficial information and can deliver cognitive therapies to adolescents.2,3 However, loss of management of Internet use could result in negative consequences among adolescents.4 Previous reports have found that 1.4–17.9% of ado-

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*Correspondence: Ju-Yu Yen, MD, PhD, Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Shi-Chuan 1st Rd, Kaohsiung City 807, Taiwan. Email: [email protected] Received 9 January 2014; revised 20 March 2014; accepted 11 May 2014.

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addiction among boys. The prospective investigation demonstrated that the incidence group had more decreased scores on family APGAR than did the nonaddiction group in the 1-year follow-up. This effect was significant only among girls.

Conclusions: Inter-parental conflict and inadequate regulation of unessential Internet use predicted risk of Internet addiction, particularly among adolescent girls. Family intervention to prevent inter-parental conflict and promote family function and Internet regulation were necessary to prevent Internet addiction. Among adolescents with Internet addiction, it is necessary to pay attention to deterioration of family function, particularly among girls. Key words: adolescents, family function, Internet addiction, inter-parental conflict, prospective study.

lescents had Internet addiction across both Western and Eastern societies.5–7 This suggests that Internet addiction is a serious mental health issue for adolescents. Family plays an influential role involving the mental health of adolescents.8 An understanding of how family factors contribute to Internet addiction could provide essential information on how to develop treatment for Internet addiction. The family relationship has been found to be one of the most influential factors on Internet addiction,9 and family dissatisfaction is also associated with Internet addiction among adolescents.10,11 As the family is the leading social unit responsible for the socialization of children and adolescents, impaired

© 2014 The Authors Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology


Family factors and Internet addiction 193

family function has a significant impact on behavioral problems of adolescents, such as substance use disorder.12 A previous report demonstrated that low family function predicted Internet addiction 1 year later.13 This supports the notion that low family function results in risk of Internet addiction among adolescents. Thus, family function plays a vital role in developing Internet addiction and deserves further evaluation. Adolescents with Internet addiction rated parental rearing behaviors as being over-intrusive, punitive, and lacking in responsiveness.14 Parenting attitudes, family communication, family cohesion, and family violence exposure are all associated with Internet addiction.15 High adolescent–parental conflict and inter-parental conflict are also associated with Internet addiction.11 However, families need to regulate the Internet use of adolescents with Internet addiction. Withdrawal symptoms might create conflict between adolescents and other family members. Furthermore, inconsistent rules of regulation between parents might result in further conflict, and these conflicts might make adolescents perceive a poor parental attitude or communication model. Thus, prospective investigation is necessary to confirm the causal correlation between family conflict and Internet addiction among adolescents. On the other hand, family conflict associated with Internet addiction might further deteriorate family function. Thus, it is necessary to understand how family function changes in the course of Internet addiction. Family monitoring16 is associated with Internet addiction. Previous studies have also suggested that Internet use of more than 20 h/day predicts the risk of Internet addiction,13,17 so it is reasonable to regulate the Internet use of adolescents to prevent Internet addiction. In the summer before entry to junior high school, the regulations for Internet use loosen. However, the no-limit use of the Internet might increase the risk of Internet addiction later. Thus, it is necessary to investigate whether the regulation for Internet use could prevent Internet addiction in a prospective study. Furthermore, parental alcohol use was associated with Internet addiction in a previous study,11 particularly among adolescent boys.18 A prospective study is also necessary to understand its predictive effect on Internet addiction. Internet addiction is more prevalent among adolescent boys than among girls.19 Additionally, family factors appear to play a different role in addictive behavior between adolescent boys and girls.20 For

example, the lack of parental attention associated with tobacco smoking among adolescent girls, and the loss of one or both parents associated with that among boys.21 Further, parental problem drinking is associated with Internet addiction among boys but not girls.18 This may indicate a sex difference of family factors attributed to Internet addiction. However, the sex difference in the prediction of family factors on Internet addiction has not been examined in a prospective design. Thus, we hypothesize that family factors will predict the incidence or remission of Internet addiction, and furthermore, that addiction to the Internet will contribute negatively to family function. This study aimed at: (i) evaluating whether family factors predict incidence or remission of Internet addiction in young adolescents; (ii) exploring the sex difference in the prediction of family factors; and (iii) investigating whether the incidence or remission of Internet addiction makes any differences on family function.

METHODS Sample Ten junior high schools (four from urban areas, four from suburban areas, and two from rural areas) in southern Taiwan were recruited for this study. All students in the eight randomly selected classes of each school participated in the investigation. Research assistants explained the goal and procedure of the study to the students in the classrooms with permission from the school. A total of 2293 adolescents (1179 boys and 1174 girls) signed their consent to participate in the initial investigation. The mean age of the participants was 12.36 ± 0.55 years at the baseline. The study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital.

Instruments Chen Internet Addiction Scale The Chen Internet Addiction Scale (CIAS) contains 26 items on a 4-point Likert scale and assesses five dimensions of Internet-related problems with a scoring range of 26–104. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93.22 The 2-week test–retest reliability is 0.83. Correlation analyses yielded sig-


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nificantly positive correlation of total scale and subscale scores of CIAS with weekly hours spent on Internet activity.22 Further, the receiver–operator curve analysis for the score of CIAS gave an area under the curve of 89.6% for diagnosis of Internet addiction.23 According to the diagnostic criteria of Internet addiction,23 a cut-off point marked by the scores 63/64 has the highest diagnostic accuracy (87.6%) and accepted sensitivity (67.8%) and specificity (92.6%).24 Accordingly, those with CIAS scores of 64 or more were classified into the Internet addiction group in this study.

Family smoking: families smoke every day. Parental regulation of Internet use: adolescents respond to ‘always’ or ‘frequent’ items for the question that assesses the frequency of regulation on Internet use from parents or caregivers. Allowed to use Internet more than 2 h/day by parents or caregivers (AIU > 2H): adolescents respond to ‘2–5 h/day’ or ‘>5 h/day’ items for the question that assesses the duration of Internet use approved by parents or caregivers before entry to junior high school.

Family APGAR Index

Study procedure and statistical analysis

The Family APGAR Index measures satisfaction with family function, and was originally developed by Smilkstein.25 The Cronbach’s alpha values reported across studies using Family APGAR have ranged from 0.80 to 0.85, and item-to-total correlations ranged from 0.50 to 0.65.26 The score of Family APGAR correlated with the previously validated instrument the Pless–Satterwhite Index (r = 0.64).26 This study used the Chinese-translated version that ranged from ‘never’ (0) to ‘always’ (3), with a total score range of 0–15.27 Cronbach’s alpha was 0.843 and 2-week test– retest reliability was 0.724 in the Chinese version.28 Higher scores indicate greater satisfaction with family function. We also evaluated the family characteristics that had been found to be associated with Internet addiction in a previous cross-sectional study11,29 and the family regulation on Internet use. The definition of family characteristics associated with Internet use are:

The participants completed all questionnaires in the initial assessment. They were then invited to complete the same questionnaires 12 months later. All participants who had completed CIAS, family APGAR, and assessments for family factors in the first investigations were recruited in the statistical analysis. Participants classified into the non-Internetaddiction group in the first investigation were selected to examine the predictive values of baseline family factors for the occurrence of Internet addiction 1 year later with the t-test, χ2 analysis, and forward logistic regression. Then, the same statistical method analyzed the boys and girls separately. On the other hand, participants classified as Internet-addicted in the first investigation were selected to examine the association between baseline family factors and remission of Internet addiction 1 year later with the t-test and χ2 analysis. All participants were classified as the nonaddiction group or the addiction group based on the result of the first investigation and were analyzed separately. The non-addiction group at the baseline, who were classified as the Internet-addiction group or the non-addiction group at the follow up, were defined as the incidence group and the non-addiction group, respectively. Repeated-measure ANOVA of family APGAR scores as a function of the time course (within subject effect), the incidence of Internet addiction (incidence group vs non-addiction group; between subjects effect), and their interaction term was determined with sex and age as covariates among subjects without Internet addiction at the baseline. The addiction group at the baseline who were classified as the Internet-addiction group and the nonaddiction group at the follow up were defined as the persistence group or the remission group, respec-

• Not cared for by parents: families other than parents cared for the adolescents. • Not living with father: adolescents did not live with their father. • Not living with mother: adolescents did not live with their mother. Adolescent–parental conflict: adolescents respond to ‘always’ or ‘frequent’ items for the question that assesses the frequency of conflict with parents or caregivers. Inter-parental conflict: adolescents respond to ‘always’ or ‘frequent’ items for the question that assesses the frequency of experiencing conflicts between adolescents’ parents and caregivers. Family alcohol use: families use alcohol more than three times a week.




tively. Repeated-measure ANOVA of family APGAR scores as a function of the time course (within subject effect), the remission of Internet addiction (remission group vs persistence group; between subjects effect), and their interaction term was determined with sex and age as covariates among subjects with Internet addiction at the baseline. A P-value less than 0.05 was considered significant for all analyses, performed using SPSS (SPSS, Chicago, IL, USA).

significant for girls, but not for boys (Table 3 and Fig. 1).

RESULTS A total of 1801 adolescents (910 boys and 891 girls) completed CIAS, family APGAR, and assessments for family factors and were included in the main analysis. There was no significant difference in sex between recruited subjects and excluded subjects. A total of 1630 participants (782 boys and 848 girls) were classified as having no Internet addiction at the baseline. Among them, subjects who became addicted to the Internet 1 year later (incidence group) had a higher score of family APGAR (Table 1). Further, adolescents not cared for by parents, those who did not live with their father, those who did not live with their mother, those who had frequent conflict with parents, those who experienced frequent inter-parental conflict, and those who had AIU > 2H were more likely to be classified in the incidence group at follow up. In addition, regression analysis revealed that inter-parental conflict was the first variable entering the model that predicted the incidence of Internet addiction 1 year later, followed by not living with mother and AIU > 2H (Table 2). Further stratified analysis demonstrated that inter-parental conflict, followed by AIU > 2H, predicted the incidence of Internet addiction among girls. Not cared for by parents and family APGAR score predicted incidence of Internet addiction among boys. The analysis demonstrated that there was no significant association between family factors and remission of Internet addiction. The repeated measure two-way ANOVA demonstrated that the interaction term of the time course and incidence effect significantly predicted the APGAR score among subjects without Internet addiction at the baseline (Table 3). It indicated that the incidence group decreased more on APGAR scores than did the non-addiction group during the period of follow up (Fig. 1). Further stratified analysis demonstrated that the effect of the interaction term of time and incidence effect to APGAR score was only

DISCUSSION This is the first prospective study to evaluate the association between Internet addiction and family factors. In the prospective analysis, adolescents who had lower family function, did not live with their mother or father, were not cared for by their parents, had frequent adolescent–parental conflict or interfamily conflict, or had AIU > 2H, were more likely to have Internet addiction 1 year later. Further forward regression analysis demonstrated that inter-parental conflict was the most predictive factor, followed by not living with mother, and AIU > 2H. Social control theory claims that a tendency toward deviance manifests when the bond between an individual and society is weakened.30 The social bond may be weakened when the parent–adolescent relationship becomes impaired.31 Thus, family relationships play an extremely vital role in behavioral problems of adolescents as the result of this presenting study. Inter-parental conflict is associated with both internalizing and externalizing problems of adolescents,32 such as depression or alcohol use.33,34 It has also predicted emotional distress and risky behaviors in a prospective study.35 This presenting study supports the notion that inter-parental conflict contributes to Internet addiction of adolescents. As the interparental conflict might cause distress to adolescents and impair their competence,36,37 they will experience emotional difficulty, such as depression. It might limit the emotional resource of parents to play an adequate role in supporting the adolescents. Adolescents might get support from online interaction38 to attenuate their emotional distress. However, adolescents who turned to online relationships were lonelier than others.39 This might result in a vicious cycle. Thus, without a healthy support system from the real world, inter-parental conflict would result in adolescent escapism with correspondent heavy Internet use and risk of Internet addiction. Previous reports suggest that supportive parent– child relationships could attenuate the negative effect of inter-parental conflict on adolescents.32 Social control theory indicated that when adolescents are close to their parents, they feel obligated to act in non-deviant ways in order to please their parents.38,40 However, a previous study demonstrated that adoles-


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Table 1. Association between family factors and courses (incidence, remission, persistence) of IA Adolescent without IA at first (mean ± SD)

Age Family APGAR (1st)† Family APGAR (follow-up)‡ Sex Boys Girls Not cared for by parents No Yes Not living with father No Yes Not living with mother No Yes Adolescent–parental conflict§ No Yes Inter-parental conflict No Yes Family alcohol No Yes Family smoking No Yes Regulation of Internet use No or occasional Frequent Allowed to use Internet more than 2 h/day¶ No Yes

Adolescents with IA at first (mean ± SD)

Non-addiction (n = 1494)

Incidence (n = 136)

χ2 or t

Remission (n = 88)

Persistence (n = 83)

χ2 or t

12.31 ± 0.46 9.08 ± 3.74 8.40 ± 3.81

12.32 ± 0.47 8.14 ± 3.86 6.55 ± 3.77

0.38 −2.81** −5.43***

12.33 ± 0.47 7.36 ± 3.81 6.91 ± 4.20

12.37 ± 0.53 7.57 ± 3.70 7.23 ± 3.45

0.57 0.35 0.55

692 (46.32) 802 (53.68)

90 (66.18) 46 (33.82)

19.69***

62 (70.45) 26 (29.55)

66 (79.52) 17 (20.48)

1.86

1243 (83.20) 251 (16.80)

101 (74.26) 35 (25.74)

6.88**

73 (82.95) 15 (17.05)

64 (77.11) 19 (22.89)

0.92

1269 (84.94) 225 (15.06)

105 (77.21) 31 (22.79)

5.63*

73 (82.95) 15 (17.05)

71 (85.54) 12 (14.46)

0.22

1340 (89.69) 154 (10.31)

112 (82.35) 24 (17.65)

6.90**

73 (82.95) 15 (17.05)

65 (78.31) 18 (21.69)

0.59

1429 (95.65) 65 (4.35)

125 (91.91) 11 (8.09)

3.92*

80 (90.91) 8 (9.09)

72 (86.75) 11 (13.25)

0.75

1413 (94.58) 81 (5.42)

121 (88.97) 15 (11.03)

7.07**

83 (94.32) 5 (5.68)

77 (92.77) 6 (7.23)

0.17

35 (2.34) 1459 (97.66)

6 (4.41) 130 (95.59)

2.18

0 (0.00) 88 (100.00)

3 (3.61) 80 (96.39)

3.24

22 (1.47) 1472 (98.53)

3 (2.21) 133 (97.79)

0.44

0 (0.00) 88 (100.00)

2 (2.41) 81 (97.59)

2.15

716 (47.93) 778 (52.07)

77 (56.62) 59 (43.38)

3.77

46 (52.27) 42 (47.73)

46 (55.42) 37 (44.58)

0.17

808 (54.08) 686 (45.92)

57 (41.91) 79 (58.09)

7.41**

26 (29.55) 62 (70.45)

19 (22.89) 64 (77.11)

0.98

*P < 0.05; **P < 0.01; ***P < 0.001. † Score of family APGAR scale in first investigation. ‡Score of family APGAR scale in follow-up investigation 1 year later. § Frequent conflict with parents. ¶In the summer vacation before entering the junior high school. IA, Internet addiction.

cents with Internet addiction have frequent parental– adolescent conflict.11 This conflict would make adolescents unwilling to follow the regulation of parents. Further, based on Sullivan’s interpersonal theory, a poor parent–child relationship contributes to frustrating interpersonal relationships through

identification, internalization, and introjection. This might then raise the level of social anxiety and increase the level of addiction to the Internet.41 The family APGAR assesses the family functions of adaptability, partnership, growth, affection, and resolve. The Internet has become a popular medium




Table 2. Predictive value of family factors for Internet addiction 1 year later with forward logistic regression model

Sex Age (years) Inter-parental conflict Not living with mother More than 2 h/day† Among girls Age (years) Inter-parental conflict More than 2 h/day† Among boys Age (years) Not cared for by parents Family APGAR‡

Wald

Exp(β)

P

95%CI

17.79 0.13 7.65 4.25 3.92

2.23 1.07 2.31 1.66 1.44