Studiu PDF
Studiu PDF
Studiu PDF
Comprehensive Psychiatry
a r t i c l e i n f o a b s t r a c t
Keywords: Aim: The aim of this study is to investigate parental attitudes, perceived social support, emotion regulation and
Adolescent the accompanying psychiatric disorders seen in adolescents who, having been diagnosed with Internet Addiction
Internet addiction (IA), were referred to an outpatient child and adolescent psychiatric clinic.
Parenting
Methods: Of 176 adolescents aged 12–17, 40 were included in the study group. These scored 80 or higher on
Social support
Young's Internet Addiction Test (IAT) and met Young's diagnostic criteria for IA based on psychiatric interviews.
Emotional availability
Emotion regulation Forty adolescents who matched them in terms of age, gender and socio-economic level were included in the con-
trol group. The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL), the Par-
enting Style Scale (PSS), the Lum Emotional Availabilty of Parents (LEAP), the Social Support Appraisals Scale for
Children (SSAS-C), the Difficulties in Emotion Regulation Scale (DERS) and the Toronto Alexithymia Scale-20
(TAS-20) were applied.
Results: The results showed that the parents of adolescents with IA were more frequently inadequate in accep-
tance/involvement, supervision/monitoring and they had less emotional availability. The adolescents with IA
had less perceived social support, greater difficulty in the identification and verbal expression of their feelings
and emotion regulation. Lower parental strictness/supervision, higher alexithymia and the existence of an anx-
iety disorder were found to be significant predictors of IA. Internet addicted adolescents with comorbid major de-
pressive disorder had higher levels of alexithymia and lower levels of emotional availability in their parents.
Conclusion: It can be concluded that strategies for the prevention and treatment of IA in adolescents should focus
on improving the quality of parenting parent-adolescent relationships, enhancing perceived social support and
emotion regulation while reducing the associated psychiatric symptoms in adolescents.
© 2019 Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
1. Introduction have reached 90.7% by 2018 [3]. As Internet use increases, IA also in-
creases. A meta-analysis of data from 31 nationwide studies in seven re-
Internet Addiction (IA) is a condition where functioning is adversely gions of the world found that the overall prevalence of IA was 6%, the
affected due to excessive Internet use and cognitive, psychological or highest prevalence (10.9%) was in the Middle East and the lowest prev-
physical damage arises. IA is defined as staying on the Internet for lon- alence (2.6%) was in Western and Northern Europe [4]. The prevalence
ger than planned, experiencing withdrawal symptoms such as nervous- of pathological Internet use among adolescents in 11 European countries
ness, depression or restlessness when deprived of the Internet was found to be 4.4% [5]. The prevalence of IA in adolescents in Turkey
unsuccessfully attempting to control or stop using the Internet, lying ranged from 1.6% to 19% depending on the region [6,7].
about Internet use and the gradual deterioration of the school, family IA in adolescents is associated with many psycho-social factors. Pa-
and social life of the affected person [1]. rental attitudes, family and peer relationships, level of perceived social
Internet use in the world and Turkey has shown a sustained and rapid support and emotion regulation are among the researched factors. In
growth in recent years. The number of people using the Internet in the these studies, inadequacies in parenting skills (neglectful, rejecting, pro-
world has increased by 1052% between 2000 and 2018 and 54.4% of tective, demanding and authoritarian parenting) [8–12], failure to con-
the world population and 68.4% of people living in Turkey use the Inter- trol, monitor and participate in children's Internet use [5,13–15],
net according to Internet World Statistics data [2]. The maximum in- negative parent-adolescent relationships [16–18], low perceived social
crease in Turkey occurred in young people between the ages of 16 and support [8,11,19,20], alexithymia and difficulties in emotion regulation
24. The 26.6% utilization rate for this age group in 2004 is reported to [21–24] are found to be related to IA in adolescents. However, commu-
nity samples were used in all of these studies, IA was evaluated only by
⁎ Corresponding author. self-report scales and no clinical evaluation was done. Studies evaluat-
E-mail address: devrimak@hacettepe.edu.tr (D. Akdemir). ing parental attitudes/family relationships, perceived social support
https://doi.org/10.1016/j.comppsych.2019.03.003
0010-440X/© 2019 Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Y. Karaer, D. Akdemir / Comprehensive Psychiatry 92 (2019) 22–27 23
and emotion regulation in adolescents with clinically diagnosed Inter- 2.2. Data collection tools
net addiction are quite limited [25–27]. In addition, although comorbid
psychiatric disorders in adolescents with IA are common [27–29], the 2.2.1. Socio-demographic and clinical information form
associations of these comorbidities with the investigated factors have Questions were asked regarding socio-demographic characteristics,
been overlooked. Therefore, the aim of this study is to investigate paren- medical and family history and Internet use habits.
tal attitudes, perceived social support and emotion regulation and the
relationships between these factors and the psychiatric disorders occur- 2.2.2. Hollingshead - Redich scale
ring in adolescents diagnosed with IA who have been referred to a child This scale was translated into Turkish from the Comprehensive As-
and adolescent psychiatric outpatient clinic. sessment of Symptoms and History (CASH) [30]. Based on the occupa-
tional and educational status of the parents, the scale reflects the
highest socio-economic level reached for a certain period of time. Five
2. Materials and methods different socio-economic levels are defined in the scale.
Table 1
The sample selection for the IA and control groups.
IA: Internet Addiction, IAT: Internet Addiction Test, SES: Socio-economic Status.
24 Y. Karaer, D. Akdemir / Comprehensive Psychiatry 92 (2019) 22–27
adaptation to Turkish done by Yılmaz [37]: test-retest reliability and study of the 20-item scale was carried out by Beştepe [45] and the
Cronbach's alpha internal consistency coefficients for high school stu- Cronbach alpha coefficient was found to be 0.81.
dents were 0.82 and 0.70 for the acceptance/involvement, 0.88 and
0.69 for the strictness/supervision, and 0.76 and 0.66 for the psycholog- 2.3. Procedure
ical autonomy subscales, respectively. “Democratic”, “Neglectful”, “Au-
thoritarian” and “Permissive” parenting styles are distinguished from The study protocol was approved by the Institutional Review Board
the intersection of acceptance/involvement and strictness/supervision of Hacettepe University with decision number GO 17/285. Written in-
dimensions [37]. formed consent was obtained from all the adolescents and their parents.
The first investigator completed the IAT by questioning the participants
2.2.7. Lum Emotional Availability of Parents (LEAP) and then assessed the presence of Young's IA diagnostic criteria and
The scale consists of 15 items in which respondents are asked to con- other psychiatric disorders, through a clinical psychiatric interview
sider their parents separately and give a score between 1 and 6 [38]. with the adolescents and their parents. The other scales were filled in
Higher scores indicate higher levels of parental emotional availability. by the adolescents.
In the validity and reliability study of the Turkish version, the Cronbach
alpha coefficients were found to be 0.95 for the mother form and 0.97
2.4. Statistical analysis
for the father form. The item test correlations of the scale were between
0.65 and 0.83 for the mother form; and between 0.76 and 0.86 for the
The statistical analysis of data was carried out using the Statistical
father form [39].
Package for the Social Sciences (SPSS) v15.0 software. In the evaluation
of the data determined by measurement, Student's t-test or Mann-
2.2.8. Social Support Appraisals Scale for Children (SSAS-C)
Whitney U test were used based on whether parametric test assump-
This is a 41-item, 5-point Likert type questionnaire designed to as-
tions were met or not, respectively. The chi-square (χ2) test was used
sess children's and adolescents' perceptions of their social support
to compare the nominal data between groups. The Pearson correlation
from friends, families and teachers [40]. It measures how the child per-
analysis was applied to investigate the relationships between two con-
ceives himself as a loved, concerned, valued and accepted person.
tinuous variables in the groups. Multiple logistic regression analysis was
Higher scores reflect higher levels of perceived social support. The
performed to determine factors predicting IA. The level of statistical sig-
Cronbach alpha coefficient of the scale is 0.93. The Turkish adaptation,
nificance was accepted to be lower than 0.05 in all analyses.
validity and reliability study was carried out by Gökler [41].
2.2.10. Toronto Alexithymia Scale (TAS-20) The duration of Internet use was 480 (Min: 60 - Max: 1020) min/day
This scale was originally developed by the University of Toronto in in the study group and 120 (Min: 10 - Max: 300) min/day in the control
1985 and consisted of 26 items and four factors. It was then rearranged group (Mann-Whitney U test, U = 56.5, p b .01). There was a strong
by Taylor et al. [44] to include 20 items and three factors: “Difficulty positive correlation between the duration of daily Internet use and the
Identifying Feelings”, “Difficulty Describing Feelings” and “Externally- IAT scores (Pearson correlation analysis, r = 0.734, p b .01) over the
Oriented Thinking”. It is a 5-point Likert type scale and higher scores in- whole group. No significant correlation was found between age and
dicate higher levels of alexithymic features. The validity and reliability the IAT scores (r = 0.034, p N .05).
Table 2
Socio-demographic variables in the study and control groups.
Table 3 Table 4
Psychiatric diagnoses in the study and control groups. PSS, LEAP, SSAS-C, DERS and TAS-20 scores in the study and control groups.
Psychiatric diagnoses IA group Control Statistics Scales IA group Control group Statistics
group Mean ± SD Mean ± SD
According to the K-SADS-PL, 39 (97.5%) adolescents in the study NS: Not Significant (p N .05), *p b .05, **p b .01, IA: Internet Addiction, PSS: Parenting Style Scale,
group and 31 (77.5%) adolescents in the control group had at least one LEAP: Lum Emotional Availability of Parents, SSAS-C: Social Support Appraisals Scale for Chil-
dren, DERS: Difficulties in Emotion Regulation Scale, TAS-20: Toronto Alexithymia Scale.
psychiatric diagnosis during the evaluation (χ2 = 7.31, p b .01). The
mean number of psychiatric diagnoses was 3.2 ± 1.5 in the study
group and 1.5 ± 1.2 in the control group (t = −5.69, p b .01). In the The model explained 36.5% of the variance (Nagelkerke R2 = 0.365)
study group, the mean number of psychiatric diagnoses was signifi- and the overall prediction success was 72.5% (72.5% for no IA and
cantly higher in females (3.5 ± 1.2) than in males (2.2 ± 1.6; t = 72.5% for IA). The PSS-Strictness/supervision scores, total TAS-20 scores
2.80, p b .01). The current psychiatric diagnoses for the two groups are and the presence of any anxiety disorders were significant predictors of
given in Table 3. IA. Lower parental strictness/supervision, higher alexithymia and the
presence of an anxiety disorder were found to be associated with IA in
3.3. Differences between IA and control groups adolescents (Table 5).
Table 5
Predictors of IA in adolescents.
Lower Upper
IA: Internet Addiction, PSS: Parenting Style Scale, TAS-20: Toronto Alexithymia Scale.
well as over-intrusive and punitive [11–13]. Their families' communica- alexithymia was higher only in Internet addicted adolescents with ac-
tion, cohesion, intimacy and relationships were considered weak and companying major depressive disorder. Other studies have reported
conflict was high [14,16,17,49]. In this case, adolescents who cannot that the emotional awareness of adolescents [55] and the emotional
find emotional responsiveness, adequate care and attention in their availability of their parents [56] are lower in adolescents with depres-
families, who are not properly supervised and monitored, and who do sion symptoms. As a result, the higher alexithymia and the lower emo-
not have access to open communication tend to use Internet more. tional availability of parents might make the adolescents susceptible to
These results show that promoting parenting skills and strengthening both IA and depression. These results indicate that the parent-
the quality of the parent-adolescent relationship are crucial in adolescent relationship and the adolescents' emotion recognition and
preventing and treating IA in adolescents. expression skills should be better evaluated in adolescents with IA and
Adolescents with IA in this study were found to have lower per- accompanying symptoms of depression.
ceived social support, especially from their friends, than adolescents This study has several strengths and limitations. Although most of the
who did not have IA. There are studies reporting that IA is negatively re- studies investigating IA in adolescents used school-based samples, this
lated to perceived social support in adolescents [11,19,20,46]. In other study was carried out in adolescents with a psychiatric referral. Thus,
studies, different from the findings of this study, as a source of perceived the findings of this study can contribute to the treatment of clinically re-
social support, the family is related to IA, but not friends [19,46]. How- ferred adolescents with IA. However, the recruitment of a control group
ever, friendship is increasingly becoming important in meeting social from a clinical sample might have underestimated the findings and
needs during healthy adolescence, and friends play a crucial role in prevented more robust results. Therefore, the lack of a healthy control
the emotional and social development of adolescents. When adoles- group is a limitation. In this study, the diagnoses of IA and other psycho-
cents fail to make close friendships, they feel more lonely and their pathologies were based not only on self-report scales filled in by the ado-
self-esteem decreases. Therefore, it can be considered that adolescents lescents but also on clinical psychiatric interviews. However, establishing
who do not get enough social support from their friends use Internet a cause-and-effect relationship between IA and the variables investigated
more to meet their social needs, to develop alternative social relation- were not possible due to the cross-sectional design of the study. It might
ships and to increase their self-esteem. be another limitation that an evaluation of parental psychopathology was
In this study, it was found that adolescents with IA had more diffi- not performed in this study. Furthermore, the fact that the sample has a
culty in identifying and describing emotions, understanding emotional high female-to-male ratio limits the generalizability of the results. In
reactions, controlling their impulsive behaviors in response to negative order to better explain the results of this study, follow up studies includ-
emotional experiences and were less able to use effective emotion reg- ing parental assessment and larger samples are required.
ulation strategies than adolescents without IA. In addition, deficiencies In conclusion, the prevalence of IA in this clinical sample was found
in identifying and describing emotions, namely alexithymia, signifi- to be high. The adolescents with IA showed more comorbid psychiatric
cantly predicted IA. In a few studies available in the literature, the diffi- disorders; less perceived social support; more difficulty in identification
culties in adolescents' emotion regulation are shown to be related to IA and verbal expression of their feelings and emotion regulation. Their
[21,22,50]. Adolescents with IA also have inadequate prefrontal cogni- parents were more frequently inadequate in acceptance/involvement,
tive control to suppress their negative emotions, which may result in supervision and monitoring and were less emotionally available.
impulsivity [51]. In a recent study, it has been shown that a good Lower parental strictness/supervision, higher alexithymia and an anxi-
parent-adolescent relationship can reduce IA by increasing the emotion ety disorder were significant predictors of IA in adolescents. Internet
regulation skills of adolescents [50]. In addition, in school-based studies addicted adolescents with comorbid major depressive disorder had
with adolescents, alexithymia and especially the difficulty in identifying higher levels of alexithymia and lower levels of parental emotional
emotions were shown to be associated with IA [24,52]. These results availability. Considering the high prevalence of IA, it might be advisable
emphasize that adolescents' emotion recognition, expression and regu- to include Internet use measurements in routine psychiatric evalua-
lation skills might be important targets in preventing and treating IA. tions, both in clinical and community samples. These results also
The adolescents with IA in this study were more likely to have anx- show that interventions for the prevention and treatment of IA in ado-
iety disorders, particularly separation anxiety disorder, specific phobias lescents should focus on improving parental skills and enhancing the
and obsessive-compulsive disorder and disruptive behavior disorders, quality of parent-adolescent relationships, perceived social support
particularly oppositional defiant disorder and conduct disorder. How- and emotion regulation in order to reduce the associated psychiatric
ever, the high prevalence of comorbidities in adolescents with IA symptoms of adolescents. Future studies should explore the implica-
(97.5%) in this study should be interpreted with caution, since most of tions of these interventions.
the patients in our sample were referred to the outpatient clinic with
psychiatric symptoms other than IA. Indeed, it has been shown that Disclosure statement
the presence of an anxiety disorder increases the risk of IA 5.7 times.
In line with this finding, anxiety has been found to predict IA in adoles- No competing financial interests exist.
cents in recent studies [6,53,54]. These data emphasize the necessity for
a careful evaluation to diagnose IA in adolescents with anxiety symp-
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