Email updates

Keep up to date with the latest news and content from BMC Medicine and BioMed Central.

Journal App

google play app store
Open Access Highly Accessed Commentary

Internet addiction: a 21st century epidemic?

Dimitri A Christakis

Author Affiliations

Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA

Department of Pediatrics, University of Washington, Seattle, Washington, USA

BMC Medicine 2010, 8:61  doi:10.1186/1741-7015-8-61

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1741-7015/8/61


Received:8 September 2010
Accepted:18 October 2010
Published:18 October 2010

© 2010 Christakis; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Internet addiction, while not yet officially codified within a psychopathological framework, is growing both in prevalence and within the public consciousness as a potentially problematic condition with many parallels to existing recognized disorders. The rapid and unfettered increase in the number of people accessing a relatively unrestricted internet substantially increases the possibility that those suffering with an underlying psychological comorbidity may be at serious risk of developing an addiction to the internet, lending further credence to this hitherto understudied condition. In this commentary, I outline my recommendations for improved diagnosis, study and prevention of internet addiction.

Background

Lee Seung Seop achieved his 15 minutes of fame in a most tragic fashion. The 28-year-old boiler repairman suffered a cardiac arrest following a 50-hour internet gaming binge during which he neither ate nor slept. His death prompted an investigation into the problem of internet addiction in Korea, where current estimates are that 4% of children suffer from the disorder [1]. International estimates for children vary widely, with European prevalence reported at between 1 and 9% [2-6], Middle Eastern prevalence at between 1 and 12% [7-9] and prevalence in Asia reported between 2 and 18% [10-17]. However, these estimates must be interpreted with some caution, as varying scales with questionable validity and conflicting reports make true generalizations difficult. Additionally, the field has been hampered by methodological weaknesses of existing research, among which the most salient has been sampling bias. Many early studies relied on voluntary internet surveys without measurable denominators, convenience samples of internet users or chat room sampling [18,19], but even beyond issues of sampling, there is the thorny debate about whether internet addiction exists at all as an entity. It is currently not a formally recognized disorder, although internet addiction is being considered for the forthcoming DSM-V [20].

Discussion

Regardless of whether internet addiction is codified within a psychopathological framework, it is fair to say that there is, at the least, the potential for a problem. In the absence of formal diagnostic criteria, most researchers currently model problematic internet usage on problematic gambling, extrapolating from one compulsive nonpharmacologically addictive behavior to another. Key components of addiction include preoccupation with the substance or behavior; repeated unsuccessful attempts to reduce it; mood disturbances related to reduction attempts; greater usage than anticipated or desired; jeopardizing employment, relationships or education; or lying about usage. All of these criteria, at least theoretically, can be seen with internet usage. In fact, in most scholarly circles, given the strong theoretical basis to believe that there could be a problem with pathological use of the Internet, the debate is not so much about whether it exists but about just how prevalent it is.

However, it should be noted that there are significant ways in which likening internet addiction to problematic gambling is inadequate. All existing behaviors or substances that have been shown to lead to addiction, such as alcohol, gambling, tobacco or drugs, have structural constraints on their usage either by law or by social etiquette. Consuming alcohol at the office or at school is sure to land one in trouble; conversely, instant messaging or surfing the web is likely not to. Cultural influences both mandate and facilitate that we spend time "online," meaning that teetotalism is not an option. Given our current understanding that there is a genetic predisposition to behavioral addictions, we may be going a long way toward ensuring that the entire susceptible population develops them. Existing research on internet addiction has also highlighted specific subpopulations that are at increased risk, including those with other psychological comorbidities, including attention-deficit/hyperactivity disorder (ADHD), depression and social isolation [21-25]. These risk factors lend further credence to the validity of the disorder, since they have also been associated with other behavioral addictions as well as substance abuse [26-28].

As this generation of youth is leading the transition to a fully wired society [29], they deserve adequate safeguards and protections against the attendant risks of the technological revolution. Here is what is needed, and quickly. First, a definition of internet addiction that is both validated and applicable to children and adolescents alike should be developed. Existing measures designed for adults have not been well validated in adolescents and many of the domains (e.g., interfering with household chores or schoolwork) are of limited applicability to these populations. Second, we need a better scientific understanding of which types of usage pose the greatest risk of addiction. For example, as with television, it is likely that it is not merely the amount of time that is spent online but how it is spent that mediates its effects [30]. Virtual reality games in particular, where participants assume other identities or collaborate with team members all over the globe, may pose the greatest risk of addiction, since frequent and continuous online presence is both vital and expected; moreover, going offline can have penalties associated with it. The profit margin of these new, subscription-based games is based entirely on keeping people playing and therefore paying. Purveyors of these products therefore have a perverse incentive to develop addictive games. Third, effective primary prevention strategies need to be developed, tested and implemented. Limits on screen time of all types are important for all children, but in the advent of ubiquitous access these are increasingly difficult to enforce [31]. Providers, parents and teachers require approaches that are proven effective and that allow for necessary and even healthy internet usage. Fourth, a targeted prevention approach, identifying children at greatest risk for addiction, is also important. Children with preexisting psychosocial morbidities may be at greatest risk, and their internet usage should be more explicitly monitored and regulated by guardians and protectors.

Conclusion

In my opinion, the greatest concern facing this field of research is a general complacency toward internet addiction. In some cases, this complacency is born of ignorance. Too many parents are simply unaware of what their children are doing online and what risks it might pose. In the 20th century, commentators spoke of a digital divide. In those days, it existed along economic lines. That divide has narrowed, or even disappeared, but the 21st century digital divide separates parents from their children. In other cases, the complacency is born of skepticism. In much the same way that tobacco proponents pushed back on early research linking smoking to cancer, these skeptics are quick to point out limitations of existing research as a way of casting doubt on the entire field. There is no question that the field of internet addiction research is in its infancy and that the overall quality of existing data is fair to moderate at best, but that should not distract us or prevent us from taking what is an emerging problem seriously.

Abbreviations

DSM: Diagnostic and Statistical Manual of Mental Disorders; ADHD: attention-deficit/hyperactivity disorder.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

DAC is entirely responsible for the content of this article.

References

  1. Jang KS, Hwang SY, Choi JY: Internet addiction and psychiatric symptoms among Korean adolescents.

    J School Health 2008, 78(3):165-171. PubMed Abstract | Publisher Full Text OpenURL

  2. Kaltiala-Heino R, Lintonen T, Rimpela A: Internet addiction? Potentially problematic use of the Internet in a population of 12-18 year-old adolescents.

    Addiction Res Theory 2004, 12(1):89-96. Publisher Full Text OpenURL

  3. Pallanti S, Bernardi S, Quercioli L: The Shorter PROMIS Questionnaire and the Internet Addiction Scale in the assessment of multiple addictions in a high-school population: prevalence and related disability.

    CNS Spectr 2006, 11(12):966-974. PubMed Abstract | Publisher Full Text OpenURL

  4. Siomos KE, Dafouli ED, Braimiotis DA, Mouzas OD, Angelopoulos NV: Internet addiction among Greek adolescent students.

    Cyberpsychol Behav 2008, 11(6):653-657. PubMed Abstract | Publisher Full Text OpenURL

  5. Villella C, Martinotti G, Di Nicola M, Cassano M, La Torre G, Gliubizzi MD, Messeri I, Petruccelli F, Bria P, Janiri L, Conte G: Behavioural addictions in adolescents and young adults: results from a prevalence study.

    J Gambl Stud 2010. PubMed Abstract | Publisher Full Text OpenURL

  6. Zboralski K, Orzechowska A, Talarowska M, Darmosz A, Janiak A, Janiak M, Florkowski A, Gałecki P: The prevalence of computer and internet addiction among pupils.

    Postepy Hig Med Dosw (Online) 2009, 63:8-12. PubMed Abstract | Publisher Full Text OpenURL

  7. Ghassemzadeh L, Shahraray M, Moradi A: Prevalence of internet addiction and comparison of internet addicts and non-addicts in Iranian high schools.

    Cyberpsychol Behav 2008, 11(6):731-733. PubMed Abstract | Publisher Full Text OpenURL

  8. Canbaz S, Sunter AT, Peksen Y, Canbaz MA: Prevalence of the pathological internet use in a sample of Turkish school adolescents.

    Iranian J Public Health 2009, 38(4):64-71. OpenURL

  9. Canan F, Ataoglu A, Nichols LA, Yildirim T, Ozturk O: Evaluation of psychometric properties of the internet addiction scale in a sample of Turkish high school students.

    Cyberpsychol Behav Soc Netw 2010, 13(3):317-320. PubMed Abstract | Publisher Full Text OpenURL

  10. Cao F, Su L: Internet addiction among Chinese adolescents: prevalence and psychological features.

    Child Care Health Dev 2007, 33(3):275-281. PubMed Abstract | Publisher Full Text OpenURL

  11. Deng YX, Hu M, Hu GQ, Wang LS, Sun ZQ: An investigation on the prevalence of internet addiction disorder in middle school students of Hunan province.

    Zhonghua Liu Xing Bing Xue Za Zhi 2007, 28(5):445-448. PubMed Abstract OpenURL

  12. Ko CH, Yen JY, Yen CF, Lin HC, Yang MJ: Factors predictive for incidence and remission of internet addiction in young adolescents: a prospective study.

    Cyberpsychol Behav 2007, 10(4):545-551. PubMed Abstract | Publisher Full Text OpenURL

  13. Park SK, Kim JY, Cho CB: Prevalence of internet addiction and correlations with family factors among South Korean adolescents.

    Adolescence 2008, 43(172):895-909. PubMed Abstract OpenURL

  14. Song XQ, Zheng L, Li Y, Yu DX, Wang ZZ: Status of 'Internet addiction disorder' (IAD) and its risk factors among first-grade junior students in Wuhan.

    Zhonghua Liu Xing Bing Xue Za Zhi 2010, 31(1):14-17. PubMed Abstract OpenURL

  15. Wu J, Lin G, Lin L: Analysis of the situation of internet use and the related health-risky behaviors among the youngsters in Guangzhou City.

    J Trop Med (Guangzhou) 2007, 7(8):816-818. OpenURL

  16. Xu J, Shen LX, Yan CH, Wu ZQ, Ma ZZ, Jin XM, Shen XM: Internet addiction among Shanghai adolescents: prevalence and epidemiological features.

    Zhonghua Yufang Yixue Zazhi 2008, 42(10):735-738. PubMed Abstract OpenURL

  17. Wang YL, Wang JP, Fu DD: Epidemiological investigation on internet addiction among internet users in elementary and middle school students.

    Chin Mental Health J 2008, 22(9):678-682. OpenURL

  18. Young KS, Rogers RC: The relationship between depression and internet addiction.

    CyberPsychol Behavior 1998, 1(1):25-28. Publisher Full Text OpenURL

  19. Young KS: Internet addiction: the emergence of a new clinical disorder.

    CyberPsychol Behavior 1998, 1(3):237-244. Publisher Full Text OpenURL

  20. Block JJ: Issues for DSM-V: Internet addiction.

    Am J Psych 2008, 165(3):306-307. Publisher Full Text OpenURL

  21. Cao F, Su L: Internet addiction among Chinese adolescents: prevalence and psychological features.

    Child Care Health Dev 2007, 33(3):275-281. PubMed Abstract | Publisher Full Text OpenURL

  22. Widyanto L, McMurran M: The psychometric properties of the Internet addiction test.

    Cyberpsychol Behav 2004, 7(4):443-450. PubMed Abstract | Publisher Full Text OpenURL

  23. Niemz K, Griffiths M, Banyard P: Prevalence of pathological internet use among university students and correlations with self-esteem, the General Health Questionnaire (GHQ), and disinhibition.

    CyberPsychol Behav 2005, 8(6):562-570. PubMed Abstract | Publisher Full Text OpenURL

  24. Ko CH, Yen JY, Chen CS, Yeh YC, Yen CF: Predictive values of psychiatric symptoms for internet addiction in adolescents: a 2-year prospective study.

    Arch Pediatr Adolesc Med 2009, 163(10):937-943. PubMed Abstract | Publisher Full Text OpenURL

  25. Fortson BL, Scotti JR, Chen YC, Malone J, Del Ben KS: Internet use, abuse, and dependence among students at a southeastern regional university.

    J Am College Health 2007, 56(2):137. Publisher Full Text OpenURL

  26. Knop J, Penick EC, Nickel EJ, Mortensen EL, Sullivan MA, Murtaza S, Jensen P, Manzardo AM, Gabrielli WF Jr: Childhood ADHD and conduct disorder as independent predictors of male alcohol dependence at age 40.

    J Stud Alcohol Drugs 2009, 70(2):169-177. PubMed Abstract | PubMed Central Full Text OpenURL

  27. Lopez B, Schwartz SJ, Prado G, Huang S, Rothe EM, Wang W, Pantin H: Correlates of early alcohol and drug use in Hispanic adolescents: examining the role of ADHD with comorbid conduct disorder, family, school, and peers.

    J Clin Child Adolesc Psychol 2008, 37(4):820-832. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  28. Romer Thomsen K, Callesen MB, Linnet J, Kringelbach ML, Moller A: Severity of gambling is associated with severity of depressive symptoms in pathological gamblers.

    Behav Pharmacol 2009, 20(5-6):527-536. PubMed Abstract | Publisher Full Text OpenURL

  29. Lenhart A, Madden M, Hitlin P: Teens and Technology: Youth are Leading the Transition to a Fully Wired and Mobile Nation. Pew Internet and American Life Project; 2005.

  30. Christakis DA, Zimmerman FJ: The Elephant in the Living Room: Make Television work for your Kids. Emmaus, PA: Rodale; 2006.

  31. American Academy of Pediatrics. Committee on Public Education: Media education.

    Pediatrics 1999, 104(2 Pt 1):341-343. PubMed Abstract | Publisher Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1741-7015/8/61/prepub