Pathological Internet use and psychopathology among European adolescents

Sammanfattning: Background: Internet use and accessibility has grown exponentially across the globe. The highest rates are noted in adolescents and youth. The swift development of technological improvements combined with interactive and enticing online activities has demonstrated to be unprecedented. As a result, the endless possibilities of the Internet become exceptionally appealing, whereby the risk of excessive use becomes elevated. Excessive use of the Internet is a strong precursor for subsequent pathological Internet use (PIU). Considered to be a subtype of a behavioural addiction, the construct of PIU is closely related to the biopsychosocial model of addiction. This suggests that there are genetic, biological, psychological and social components involved in the complex pathways of PIU development. Thus, initiatives that adopt such a multifaceted approach are critically needed in order to attain a better understanding of PIU and related factors. Objectives: The primary aim of this thesis is to improve our knowledge of adolescent PIU by utilising a multifactorial approach. The objective of Study I is to estimate the prevalence of PIU and assess its potential link with demographic and social factors. The objectives in Studies II and III are to ascertain the correlations between PIU, psychopathology and suicidality, while Study IV investigates the association between PIU and health risk-behaviours. The objective of Study V is to evaluate the preventive effect of mental health action in schools on PIU and related psychosocial impairments. Methods and materials: The studies in this thesis were conducted within the framework of the FP7 European Union project: Saving and Empowering Young Lives in Europe (SEYLE). SEYLE is a randomised controlled trial (RCT) assessing the efficacy of mental health interventions based on different strategies and approaches. Adolescents were recruited from randomly-selected schools across study sites in eleven countries, including Austria, Estonia, France, Germany, Hungary, Ireland, Israel, Italy, Romania, Slovenia and Spain, with Sweden serving as the coordinating centre. PIU was measured using Young’s Diagnostic Questionnaire (YDQ). Social factors, health risk-behaviours, psychopathology and suicidality were measured using validated psychometric instruments. Apposite statistical models were applied in each study in order to assess the respective outcomes of interests. Results: Findings for each study are described accordingly: Study I comprised a sample of 11,956 adolescents (female/male: 6731/5225; mean age: 14.9 ±0.89). The overall prevalence of PIU was 4.4%. Prevalence rates of PIU were significantly higher in males than females (5.2% versus 3.8%). Adolescents in Israel had the highest prevalence of PIU, whereas Italy had the lowest. A significant correlation between mean hours online per day and male gender were observed. In terms of online activities, Internet gaming was significantly associated with males, while social networking was significantly correlated with females. Students not living with a biological parent, low parental involvement and parental unemployment showed the strongest association with PIU. Study II was a systematic review and meta-analysis. An electronic literature search was conducted using the following databases: MEDLINE, PsycARTICLES, PsychINFO, Global Health, and Web of Science. PIU and known synonyms were included in the search as well as psychopathology (i.e. depression, anxiety, symptoms of attention deficit and hyperactivity disorder (ADHD), obsessive-compulsive symptoms, social phobia and hostility/aggression). Effect sizes for the correlations observed were identified from either the respective publication or calculated using Cohen’s d or R2. The potential effect of publication bias was assessed using a funnel plot model and evaluated by Egger’s test based on a linear regression. Twenty articles met the pre-set inclusion and exclusion criteria: 75% reported significant correlations of PIU with depression, 57% with anxiety, 100% with symptoms of ADHD, 60% with obsessivecompulsive symptoms, and 66% with hostility/aggression. The majority of studies reported a higher rate of PIU among males than females. Depression and symptoms of ADHD appeared to have the most significant and consistent correlation with PIU. Study III comprised a sample of 11,356 school-based adolescents (M/F: 4,856/6,500; mean age: 14.9). Results showed that suicidal behaviours (suicidal ideation and suicide attempts), depression, anxiety, conduct problems and hyperactivity/inattention were significant and independent predictors of PIU. The correlation between PIU, conduct problems and hyperactivity/inattention was stronger among females, while the link between PIU and symptoms of depression, anxiety and peer relationship problems was stronger among males. The association between PIU, psychopathology and self-destructive behaviours was stronger in countries with a higher prevalence of PIU and suicide rates. These findings ascertain that psychopathology and suicidal behaviours are strongly related to PIU. This association is significantly influenced by gender and country suggesting socio-cultural influences. Study IV involved a sample of 11,931 adolescents who were included in the analyses: 43.4% male and 56.6% female (M/F: 5179/6752), with a mean age of 14.89±0.87 years. Adolescents reporting poor sleeping habits and risk-taking actions showed the strongest associations with PIU, followed by tobacco use, poor nutrition and physical inactivity. Among adolescents in the PIU group, 89.9% were characterized as having multiple risk-behaviours. The significant association observed between PIU and risk-behaviours, combined with a high rate of cooccurrence, underline the importance of considering PIU when screening, treating or preventing high-risk behaviours among adolescents. Study V included a sample of n=2,831 school-based adolescents. The sample comprised 47.1% male and 52.9% female adolescents (M/F: 1333/1498), with a mean age of 14.83±0.90 years. In order to avoid contamination from the SEYLE interventions, only those who were in the control group were included in this study. Mental health action in schools (MHAS) was defined as adolescents reporting to have received mental health education at their school and was approached by a teacher to discuss psychosocial issues prior to baseline assessment. Outcomes showed that adolescents exposed to MHAS had a 50 percent lower risk for the onset of PIU compared to the unexposed group. When analysing psychosocial impairments, results showed that adolescents in the MHAS group also exhibited a significantly lower incidence of ≥30 percent for emotional distress, depression and coping problems. Conclusion: Significant correlations between PIU and health risk-behaviours, psychopathology and suicidality were observed among European adolescents. Given the momentous proclivity of evidence-based research, it is clear that PIU is a condition that merits international recognition as a potential disorder. Implementing evidence-based mental health action in schools appear to be effective in the overall risk-reduction of PIU. Of course, the level of efficacy, in terms of prevention efforts, is dependent on the structure of the respective intervention. It is, therefore, critical that an international accord is reached in order to develop a standardized approach to ascertain the nomenclature, taxonomy and diagnostic criteria of PIU. The future direction of PIU research must focus on this fundamental issue in order to legitimize and advance our knowledge and understanding of this condition.