Accepted Article

The bidirectional associations between the family factors and internet addiction among adolescents in a prospective investigation.

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Running title: Family factors predict internet addiction

Chih-Hung Ko, M.D., Ph.D.,1,2,3 Peng-Wei Wang, M.D.,1 Tai-Ling Liu, M.D.,1 Cheng-Fang Yen, M.D. Ph.D.1,3, Cheng-Sheng Chen, M.D.1,3, Ju-Yu Yen, M.D., Ph.D.1,3,4

1

Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Tzyou 1st Rd. Kaohsiung City, Taiwan 807

2

Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, 482 San-Ming Rd. Kaohsiung City, Taiwan 812

3

Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shi-Chuan 1st Rd. Kaohsiung City, Taiwan 807

4

Department of psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan 801

The Corresponding Author: Ju-Yu Yen, M.D., Ph.D. Department of Psychiatry, Kaohsiung Medical University Hospital Kaohsiung Medical University,

100 Shi-Chuan 1st Rd. Kaohsiung City, Taiwan 807 Telephone: 886-7-3121101 Ext. 6822 Fax: 886-7-3134761 E mail: [email protected]

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/pcn.12204

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Abstract Aim

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 one year later in forward regression analysis, followed by not living with mother and allowance to use internet more than 2 hours per day by parents or caregiver (AIU>2H). The inter-parental conflict and AIU>2H 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 one-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, particular 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. 2 This article is protected by copyright. All rights reserved.

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Key words: Internet addiction, family function, inter-parental conflict, prospective

study, adolescents.

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Introduction The impact of the internet on adolescent life and its application has grown

within the past decade1. It provides beneficial information or can deliver cognitive

therapies to adolescents 2,3. However, loss 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 of adolescents. Family plays an influential role involving the mental health of adolescents 8. To understand how the family factors contribute to internet addiction could provide essential information to develop the treatment of internet addiction. Family relationship has been found to be one of the most influential factors of

internet addiction 9, and family dissatisfaction is also associated with internet addiction among adolescents 10,11. Since family is the leading social unit responsible for 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 one 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. The 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. The 4 This article is protected by copyright. All rights reserved.

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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 relationship between family conflict and internet addiction among adolescents. On the other hand, the family conflict associated with internet addiction might further deteriorate the family function. Thus, it is necessary to understand how the 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 hours/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 5 This article is protected by copyright. All rights reserved.

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gender difference of family factors attributed to Internet addiction. However, the

gender 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 1) evaluating whether family factors predict incidence or remission of Internet addiction in young adolescents; 2) exploring the gender difference in the prediction of family factors; and 3) investigating whether the incidence or remission of Internet addiction makes any differences on the family function.

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Methods Sample

Ten junior high schools (4 from urban areas, 4 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 school. A total of 2,293 adolescents (1,179

boys and 1,174 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 (CIAS). The CIAS contains 26 items on a 4-point Likert scale and assesses five dimensions of Internet-related problems with a scoring

range of 26 to 104. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93 22. The two weeks test-retest reliability is 0.83. Correlation analyses hielded significantly postive correlation of totoal sclae and subscale corees of CIAS with weekly hours spent on internet activity 22. Fruther, the receiver operating characteristic curve analysis for the score of CIAS gave an area under curve of 89.6% for diagnosis of Internet addiction 23. According to the diagnostic criteria of Internet addiction 23, a cutoff 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 7 This article is protected by copyright. All rights reserved.

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function, and was originally developed by Smilkstein 25. The Cronbach’s alpha values

reported across studies using Family APGAR have ranged from .80 to .85, and item-to-total correlations ranged from .50 to .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 The Cronbach’s alpha was 0.843

and 2-week test–retest reliability was 0.724 in Chinese version 28. Higher scores

indicate greater satisfaction with family function. We also evaluated the family characteristics those had been found to associate with internet addiction in a previous cross-section study11 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 assess the frequency of getting conflict with parents or caregivers. Inter-parental conflict: adolescents respond to "always" or "frequent" items for the question that assess 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 assess the frequency of regulation on internet use from

parents or caregivers. 8 This article is protected by copyright. All rights reserved.

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Allowed to use internet more than 2 hours per day by parents or caregivers (AIU>2H): adolescents respond to "2-5 hours/day" or "> 5 hours/day" items for the question that assess 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 complete CIAS, family APGAR, and assessments for family

factors in 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 one year later with the t-test, Chi-square analysis, and forward logistic regression. Then, the same statistical method analyzed the boys or 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 one year later with the t-test and Chi-square analysis. All participants were classified as non-addiction group and 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 internet-addiction group and non-addiction group at the follow-up, were defined as incidence group and non-addiction group respectively. Repeated-measure analysis of variance (ANOVA) analysis of family APGAR scores as a function of the time course (within subject effect), the incidence of Internet addiction (incidence group versus non-addiction 9 This article is protected by copyright. All rights reserved.

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group; between subjects effect), and their interaction term was determined with gender and age as covariates, among subjects without Internet addiction at the baseline.

The addiction group at the baseline who were classified as internet-addiction

group and non-addiction group at the follow-up were defined as persistence group or remission group respectively. Repeated-measure ANOVA analysis of family APGAR scores as a function of the time course (within subject effect), the remission of Internet addiction (remission group versus persistence group; between subjects

effect), and their interaction term was determined with gender 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 the SPSS software package.

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Results

A total of 1,801 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 gender between recruited subjects and excluded subjects. A total of 1,630 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 one year later (incidence group) had a higher score of family APGAR (Table 1). Further, adolescents not cared for by parents, did not live with father, did not live with mother, had frequent conflict with parents, experienced frequent inter-parental conflict, or 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 one 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 (Figure 1). Further stratified analysis

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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 Figure 1).

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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 mother or father, were not cared for by parents, had frequent adolescent-parental conflict or inter-family conflict, or had AIU>2H, were more likely to have internet addiction one 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. Since the inter-parental conflict might cause distress to adolescents and impair their competence 36,37, they will experience an emotional difficulty, such as depression. It might limit the emotional resource of parents to play an adequate role to support the adolescents. Adolescents might get support from online interaction 38 to attenuate their emotional distress. However, adolescents who turn to online relationships were more lonely 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

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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, 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, 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

popular media for

adolescents to get support and resources 38. Adolescents with poor family function might seek support and resources from the internet. However, if they get resources from risky strangers or a rewarding game, the risk of getting risky behavior or addiction to the internet might increase. On the other hand, adolescent behavior affects parenting behavior 42. This

presenting study demonstrated that adolescents become addicted to the internet

decreased their family function. 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 one 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 the parents cope with the problem, parents will experience frustration and sustain

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conflict with the adolescents. These reciprocal negative interactions will deteriorate the 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, since 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 one year later in this study. Since internet activities such as online gaming are designed

to attract users to use them 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 good 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 hours/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 mother or father were more likely to

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have internet addiction one year later in this study. It indicated that parents play an extremely vital role in regulation of internet use and 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 behavior problem of adolescents. Since 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 and monitoring their children’s internet use than

do other caregivers, particular in adolescent boys. There are several limitations of this study to be considered when interpreting

the findings. Firstly, 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. Secondarily, the family APGAR scale measures satisfaction with family function, but not measures family function directly. Thirdly, there are several confounders not controlled in this study, such as the economic status. Conclusion This presenting result suggests that family function and factors play an

influential predictive factor for internet addiction among adolescents. The

intervention for preventing Internet addiction should promote the family function, particularly among boy adolescents. Furthermore, the incidence of Internet addiction deteriorates the family function. To promote the family function is essential among

adolescents with Internet addiction. Family conflict, particularly inter-parental

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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 hours/day in the summer vacation is also necessary to prevent Internet addiction.

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Acknowledgements The study was support by a grant from Kaohsiung Municipal Hsiao-Kang

Hospital (KMHK-98-001) and Kaohsiung Medical University Hospital (KMUH99-9R-50).

Declaration of interest: no conflict of interest declared.

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Figure 1 The progression of family satisfaction in prospective study among subjects without Internet addiction in the first investigation. Footnote: Non-addiction group: subjects without Internet addiction in follow-up investigation; incidence group: subjects with Internet addiction in follow-up investigation.

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Table 1 The association between family factors and courses (incidence, remission, persistence) of Internet addiction. Adolescent without IA at first Adolescents with IA at first (Mean±SD) (Mean±SD) Non-addiction Incidence Remission Persistence (N=1494) (N=136) X2 or t (N=88) (N=83) X2 or t Age 12.31±0.46 12.32±0.47 0.38 12.33±0.47 12.37±0.53 0.57 Family APGAR 9.08±3.74 8.14±3.86 -2.81** 7.36±3.81 7.57±3.70 0.35 (1st) Family APGAR 8.40±3.81 6.55±3.77 -5.43*** 6.91±4.20 7.23±3.45 0.55 (follow-up) Gender Boys 692 (46.32) 90 (66.18) 19.69*** 62 (70.45) 66 (79.52) 1.86 Girls 802 (53.68) 46 (33.82) 26 (29.55) 17 (20.48) Not cared for by parents No 1243 (83.20) 101 (74.26) 6.88** 73 (82.95) 64 (77.11) 0.92 Yes 251 (16.80) 35 (25.74) 15 (17.05) 19 (22.89) Not living with father No 1269 (84.94) 105 (77.21) 5.63* 73 (82.95) 71 (85.54) 0.22 Yes 225 (15.06) 31 (22.79) 15 (17.05) 12 (14.46) Not living with mother No 1340 (89.69) 112 (82.35) 6.90** 73 (82.95) 65 (78.31) 0.59 Yes 154 (10.31) 24 (17.65) 15 (17.05) 18 (21.69) Adolescent-parental conflict No 1429 (95.65) 125 (91.91) 3.92* 80 (90.91) 72 (86.75) 0.75 Yes 65 (4.35) 11 (8.09) 8 (9.09) 11 (13.25) Inter-parental conflict No 1413 (94.58) 121 (88.97) 7.07** 83 (94.32) 77 (92.77) 0.17 Yes 81 (5.42) 15 (11.03) 5 (5.68) 6 (7.23)

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Family alcohol No 35 (2.34) 6 (4.41) Yes 1459 (97.66) 130 (95.59) Family smoke No 22 (1.47) 3 (2.21) Yes 1472 (98.53) 133 (97.79) Regulation of internet use No or occasional 716 (47.93) 77 (56.62) Frequent 778 (52.07) 59 (43.38) Allowed to use internet more than two hours/day No 808 (54.08) 57 (41.91) Yes 686 (45.92) 79 (58.09)

2.18

0 (0.00) 88 (100.00)

3 (3.61) 80 (96.39)

3.24

0.44

0 (0.00) 88 (100.00)

2 (2.41) 81 (97.59)

2.15

3.77

46 (52.27) 42 (47.73)

46 (55.42) 37 (44.58)

0.17

7.41**

26 (29.55) 62 (70.45)

19 (22.89) 64 (77.11)

0.98

Family APGAR: the score of family APGAR scale; 1st: in the first investigation; follow-up: in the follow-up investigation one year later; Adolescent-parental conflict: frequent conflict with parents; Allowed to use internet more than two hours/day: in the summer vacation before entering the junior high school. *: p

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

This study aimed at evaluating the effect of family factors on the occurrence of Internet addiction and determining whether Internet addiction could m...
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