Bidirectional associations between family factors and Internet addiction among adolescents in a prospective investigation

Authors

  • Chih-Hung Ko MD, PhD,

    1. Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
    2. Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung City, Taiwan
    3. Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung City, Taiwan
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  • Peng-Wei Wang MD,

    1. Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
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  • Tai-Ling Liu MD,

    1. Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
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  • Cheng-Fang Yen MD PhD,

    1. Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
    2. Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung City, Taiwan
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  • Cheng-Sheng Chen MD, PhD,

    1. Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
    2. Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung City, Taiwan
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  • Ju-Yu Yen MD, PhD

    Corresponding author
    1. Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
    2. Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung City, Taiwan
    3. Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
    • 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: yenjuyu@cc.kmu.edu.tw

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Abstract

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, inter-parental 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 addiction among boys. The prospective investigation demonstrated that the incidence group had more decreased scores on family APGAR than did the non-addiction 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.

The 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 adolescents 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 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 monitoring[16] 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 significantly 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 APGAR Index

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 study[11, 29] and the family regulation on Internet use. The definition of family characteristics associated with Internet use are:

  • 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.

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.

Study procedure and statistical analysis

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-Internet-addiction 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 non-addiction 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 non-addiction group at the follow up were defined as the persistence group or the remission group, respectively. 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).

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.

Table 1. Association between family factors and courses (incidence, remission, persistence) of IA
 Adolescent without IA at first (mean ± SD)Adolescents with IA at first (mean ± SD)
Non-addiction (n = 1494)Incidence (n = 136)χ2 or tRemission (n = 88)Persistence (n = 83)χ2 or t
  1. *P < 0.05; **P < 0.01; ***P < 0.001.
  2. 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.
  3. IA, Internet addiction.
Age12.31 ± 0.4612.32 ± 0.470.3812.33 ± 0.4712.37 ± 0.530.57
Family APGAR (1st)9.08 ± 3.748.14 ± 3.86−2.81**7.36 ± 3.817.57 ± 3.700.35
Family APGAR (follow-up)8.40 ± 3.816.55 ± 3.77−5.43***6.91 ± 4.207.23 ± 3.450.55
Sex      
Boys692 (46.32)90 (66.18)19.69***62 (70.45)66 (79.52)1.86
Girls802 (53.68)46 (33.82) 26 (29.55)17 (20.48) 
Not cared for by parents      
No1243 (83.20)101 (74.26)6.88**73 (82.95)64 (77.11)0.92
Yes251 (16.80)35 (25.74) 15 (17.05)19 (22.89) 
Not living with father      
No1269 (84.94)105 (77.21)5.63*73 (82.95)71 (85.54)0.22
Yes225 (15.06)31 (22.79) 15 (17.05)12 (14.46) 
Not living with mother      
No1340 (89.69)112 (82.35)6.90**73 (82.95)65 (78.31)0.59
Yes154 (10.31)24 (17.65) 15 (17.05)18 (21.69) 
Adolescent–parental conflict§      
No1429 (95.65)125 (91.91)3.92*80 (90.91)72 (86.75)0.75
Yes65 (4.35)11 (8.09) 8 (9.09)11 (13.25) 
Inter-parental conflict      
No1413 (94.58)121 (88.97)7.07**83 (94.32)77 (92.77)0.17
Yes81 (5.42)15 (11.03) 5 (5.68)6 (7.23) 
Family alcohol      
No35 (2.34)6 (4.41)2.180 (0.00)3 (3.61)3.24
Yes1459 (97.66)130 (95.59) 88 (100.00)80 (96.39) 
Family smoking      
No22 (1.47)3 (2.21)0.440 (0.00)2 (2.41)2.15
Yes1472 (98.53)133 (97.79) 88 (100.00)81 (97.59) 
Regulation of Internet use      
No or occasional716 (47.93)77 (56.62)3.7746 (52.27)46 (55.42)0.17
Frequent778 (52.07)59 (43.38) 42 (47.73)37 (44.58) 
Allowed to use Internet more than 2 h/day      
No808 (54.08)57 (41.91)7.41**26 (29.55)19 (22.89)0.98
Yes686 (45.92)79 (58.09) 62 (70.45)64 (77.11) 
Table 2. Predictive value of family factors for Internet addiction 1 year later with forward logistic regression model
 WaldExp(β)P95%CI
  1. Allowed to use Internet more than 2 h/day in the summer vacation before entering junior high school. Score of family APGAR scale.
  2. CI, confidence interval.
Sex17.792.23<0.0011.537–3.243
Age (years)0.131.070.720.735–1.563
Inter-parental conflict7.652.310.011.276–4.181
Not living with mother4.251.660.041.025–2.692
More than 2 h/day3.921.440.051.004–2.078
Among girls    
Age (years)0.940.710.330.35–1.42
Inter-parental conflict4.352.510.041.06–5.94
More than 2 h/day4.131.880.041.02–3.45
Among boys    
Age (years)1.301.310.250.83–2.07
Not cared for by parents4.951.760.031.07–2.90
Family APGAR4.310.940.040.89–1.00

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

Table 3. Effect of incidence and remission on the change of score in family APGAR in the 1-year follow up
VariablesWithin-subject analysisPartial η2
d.f.Mean squareF
  1. *P < 0.05; **P < 0.01; ***P < 0.001.
  2. Time: follow-up versus initial investigation; sex: boys versus girls; incidence group: incidence group versus non-addiction group; remission: remission group versus persistence group.
  3. IA, Internet addiction.
Adolescent without IA at first    
Time116.832.460.002
Time by age129.884.36*0.003
Time by sex19.611.400.001
Time by incidence155.088.03**0.005
Girls    
Time11.100.180.000
Time by age14.840.810.001
Time by incidence147.807.99**0.009
Boys    
Time125.143.220.004
Time by age132.754.20*0.0015
Time by incidence116.022.050.003
Adolescent with IA at first    
Time10.520.050.000
Time by age10.640.060.000
Time by sex11.150.110.001
Time by remission10.470.040.000
Figure 1.

Progression of family satisfaction in prospective study among subjects without Internet addiction in the first investigation. image, Non-addiction (subjects without Internet addiction in follow-up investigation); image, incidence (subjects with Internet addiction in follow-up investigation).

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 inter-family 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 inter-parental 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 interaction[38] 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 adolescents 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 for adolescents to obtain support and resources.[38] Adolescents with poor family function might seek support and resources from the Internet. However, if they obtain resources from risky strangers or a rewarding game, the risk of dangerous behavior or addiction to the Internet might increase.

On the other hand, adolescent behavior affects parenting behavior.[42] This presenting study demonstrated that when adolescents became addicted to the Internet, their family function decreased. The incidence group had poorer family function than did the non-addiction group at the baseline. The prospective investigation revealed that the family function further deteriorated 1 year later among the incidence group. It is extremely difficult to control the Internet use of adolescents with Internet addiction in the clinical experience. Without resources to help parents cope with the problem, parents will experience frustration and sustain conflict with the adolescents. These reciprocal negative interactions will deteriorate family function as reported in this presenting study. Thus, it is necessary to provide an effective family intervention for family and adolescents as early as possible. Further, as the deteriorating effect of incidence of Internet addiction on family function is significant only in girls, attention to family function should be paid more to adolescent girls with Internet addiction.

Mann proposed ‘availability as a law of addiction’.[43] The duration of time allowed to use the Internet in the summer vacation predicted Internet addiction 1 year later in this study. As Internet activities, such as online gaming, are designed to attract users as frequently as possible, they are highly rewarding. The repeated rewarding experience might result in positive implicit attitude[44] and conditioned behavior. They then result in automatic Internet use and risk of addiction.[45] If adolescents have enough time to use the Internet, they have more chances to get higher scores and grades in the games that might further reward their online gaming. In addition, the heavy Internet use might limit their time to participate in other recreational or social activities.

As the Internet is a necessary tool for most modern students, determination of the optimal level of limitation is difficult. Some online activities or information are beneficial to adolescents. The regulation of Internet use should not be too rigorous to prevent experience of these beneficial online experiences. Online gaming has contributed to Internet addiction in previous reports.[13, 17] It would be reasonable to limit online gaming to less than 2 h/day in the summer vacation before entry to junior high school. On the other hand, it is not necessary to keep this limitation on online information or resources that benefit adolescents.

The adolescents who did not live with their mother or father were more likely to have Internet addiction 1 year later in this study. This indicated that parents play an extremely vital role in the regulation of Internet use and in supporting adolescents. Based on social learning theory, social control theory[31] and interpersonal theory,[46] parental attitude, behavior, monitoring, and interaction have a great impact on the behavioral problem of adolescents. As the mother usually plays a more prominent (parenting) role involving regulation of Internet use in Asian countries, living with the mother is a stronger factor to protect adolescents from Internet addiction than living with the father. Furthermore, to be cared for by caregivers other than parents increases the risk of Internet addiction among adolescent boys. It indicates parents play an effective role in both caring for and monitoring their children's Internet use than do other caregivers, particularly in adolescent boys.

There are several limitations of this study to be considered when interpreting the findings. First, the diagnosis of Internet addiction and family function relies solely on self-reported data. In future, data from informants, such as parents and teachers, might be provided to support the self-reported scale. Second, the family APGAR scale measures satisfaction with family function, but does not measure family function directly. Third, there are several confounders not controlled for in this study, such as economic status.

Conclusion

This presenting result suggests that family function and factors play an influential predictive factor for Internet addiction among adolescents. Intervention for preventing Internet addiction should promote family function, particularly among male adolescents. Furthermore, the incidence of Internet addiction deteriorates family function. The promotion of family function is essential among adolescents with Internet addiction. Family conflict, particularly inter-parental conflict, predicts the risk of Internet addiction. Interventions to attenuate family conflict and to educate adolescents in how to cope with inter-parental conflict are necessary, particularly for adolescent girls. Lastly, for non-essential Internet use, such as online gaming, imposing a limit of no more than 2 h/day in the summer vacation is also necessary to prevent Internet addiction.

Acknowledgments

The study was supported by a grant from Kaohsiung Municipal Hsiao-Kang Hospital (KMHK-98-001) and Kaohsiung Medical University Hospital (KMUH99-9R-50). No conflict of interest is declared.

Ancillary