IACAPAP Textbook of Child and Adolescent Mental Health

OTHER DISORDERS

Chapter

H.6

PROBLEMATIC INTERNET USE
Jane Pei-Chen Chang & Chung-Chieh Hung

Jane Pei-Chen Chang MD,
MSc
Institute of Clinical Medical
Science, China Medical
University and Departmentof Psychiatry, China Medical
University Hospital, Taichung,TaiwanConflict of interest: None
declared

Chung-Chieh Hung MD
Department of Psychiatry,
China Medical University
Hospital, Taichung, Taiwan‘Age of
Empires III’
computergame.

©

Conflict of interest: None
declared

Microsoft Corporation

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and theuse is non-commercial. Send comments about this e-book or chapter to jmreyATbigpond.net.au
Suggested citation: Chang J P-C, Hung C-C. Problematic internet use. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent
Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

Problematic Internet use

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IACAPAP Textbook of Child and Adolescent Mental HealthThe Internet has become the most popular medium utilized by the general
population, especially by children and adolescents. It is as common forchildren to use a computer as it is to play with their favorite toys. Studies
have shown that the percentage of students using the Internet has increased
dramatically, for example from 24.5% to 79.5% between 1996 and 2001 in the
US (Odell et al, 2000). The number of Internet users who go online regularly
had surpassed 1.5 billion in 2009 ─19% of them in China alone (Flisher, 2010).
Converging modern technologies, such as cellular phones and the Internet, haveallowed people to affordably communicate at long distances as well as facilitating
many tasks, including science, commerce, shopping, paying bills, taking
educational classes, working, and keeping in touch with loved ones. Children andadolescents also use the Internet for socializing and for leisure activities such as
watching movies and television programs, listening to music, and playing online
games. The Internet has made life more convenient, saves time and shortens the
distance between people; as it becomes pervasive in the lives of youth, it presents
risks and opportunities.

Internet gaming addiction
leads to baby’s death. Clickon the picture to watch video.

The negative impact of Internet usage on individuals and their lives is often
underestimated. Brown (2006) suggested that the choice of media individuals
make is influenced by their character and the way they interact with the world;
in turn, the way individuals interact with the media will be incorporated into
their daily life, influence their behavior and views and even the development of
their brain. Children and adolescents are more susceptible to trade off their reallife activities with virtual reality ones. Young people are also more prone to use
the Internet as a form of socialization without realizing the negative impact that
may carry. Thus, when Internet use starts to take up a large portion of children’sand adolescents’ time, affect their mood, and jeopardize academic and social
function and performance, Internet usage may become a problem that may requireintervention.
Excessive Internet use in adults has been associated with failed marriages,
unemployment, neglected children, and sleep deprivation (Young, 1998). Young’s
research on problematic internet usage (PIU) has documented associated symptoms
and problems, including losing control, craving and withdrawal, social isolation,
academic failure, financial problems, job loss, and marital discord. Moreover,spending more than 18 hours a day online may lead to physical problems suchas back pain, eye strain and carpal tunnel syndrome (Young, 1998). Internet
addiction is considered a public health issue in South Korea (Block, 2008), where
10 cardiopulmonary-related deaths in Internet cafes (Choi, 2007) and a gamerelated murder (Koh, 2007) have been reported. In addition, Internet videogames
are now more sophisticated, more violent, and often incorporate multiple players
when compared to online games two decades ago (Anand, 2007). A negative
correlation has been reported between time spent playing Internet games andacademic performance, and a positive association between violent Internet gameplaying and aggression (Anderson & Dill, 2000). Not only does excessive Internet
use has a negative impact on the mental and physical health of children andadolescents with PIU, it might also increase risk of violence in this age group.

World of Warcraft
Dangerous addiction or
cultural phenomenon? Clickon the picture to view.

Is Internet addiction an illness?
Since Internet addiction has not formally been accepted as a disorder yet,
we will use problematic internet use or PIU as the term to designate Internet-related
behaviors that cause significant psychosocial impairment. So, is Internet addiction

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IACAPAP Textbook of Child and Adolescent Mental Healthan illness? One current of thought upholds that PIU merits our attention sincechildren and adolescents are more likely to indulge most of their time in Internet
games, activities, and social networking at the expense of their school work andsports, and PIU can arise from involvement in a range of online activities (Beard,
2005; Davis, 2001; Griffiths et al, 2000; King et al, 2009; Young, 1996). Block(2008) has recently highlighted the increasing incidence of Internet addiction
and its high comorbidity with other psychiatric conditions. He also proposed
the inclusion of “Internet addiction disorder” in the forthcoming Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition (DSM-V). David Greenfield(1999) also considers Internet addiction a form of addictive disorder, pointing outthat individuals with PIU tend to show symptoms of withdrawal and tolerance.
Governments such as South Korea have declared Internet addiction a serious
problem and a public health hazard (Block, 2008); Chinese psychologists also
support Internet addiction to be recognized as a formal disorder by the World
Health Organization (Flisher, 2010).
Some experts, however, do not see Internet use as an illness. They perceive
Internet use as a medium for communicating and of avoiding dealing with
underlying problems (Bell, 2009; Shaffer et al, 2000). For example, they believe
depression or social anxiety to be the core issues in problematic Internet use rather
than a new disorder itself (Bell, 2009; Shaffer et al, 2000). Moreover, some forensic
psychiatrists believe that we should treat online gamblers primarily as gamblers
rather than classifying them as Internet addicts (Lenihan, 2007). Therefore, moreevidence is required to clarify whether PIU should be looked upon as a separate
disorder.

Click on the picture to viewa New York Post report on
Internet addiction.

Definition and diagnosis
The first diagnostic criteria for Internet addiction were proposed by Young(1996) − a modified version of the DSM-IV criteria for substance dependence− since there are similarities between the tolerance and withdrawal symptoms ofInternet use and those of substance use. She also developed an Internet Addiction
Box H.6.1 Young’s diagnostic questionnaire for Internet addiction(adapted from Young, 1998)
Diagnosis suggested if there are five or more “yes” answers to:•
Do you feel preoccupied with the Internet (think about previous online activity or
anticipate next online session)?
•
Do you feel the need to use the Internet for increasing amounts of time in order toachieve satisfaction?
•
Have you repeatedly made unsuccessful efforts to control, cut back, or stop Internetuse?
•
Do you feel restless, moody, depressed, or irritable when attempting to cut down orstop Internet use?
•
Do you stay online longer than originally intended?
•
Have you jeopardized or risked the loss of significant relationship, job, educational or
career opportunity because of the Internet?
•
Have you lied to family members, therapist, or others to conceal the extent of
involvement with the Internet?
•
Do you use the Internet as a way of escaping from problems or of relieving a dysphoricmood (e.g. feelings of helplessness, guilt, anxiety, depression)?

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IACAPAP Textbook of Child and Adolescent Mental Health

Questionnaire (Young, 1998) (Box H.6.1). However, evidence of its reliability andvalidity is lacking.
The term “Internet addiction” was changed to the less controversial“problematic Internet use” (PIU) by Shapira et al (2000). PIU can be defined as
showing:• A maladaptive preoccupation with Internet use, experienced asirresistible, for periods of time longer than intended• Significant distress or impairment resulting from Internet use• Absence of other psychiatric pathology that might explain theexcessive Internet use, such as mania or hypomania.
PIU can also be classified into specific and generalized (Davis, 2001). Specific
PIU refers to particular content that exists independently from the Internet, suchas gambling and video games, whereas generalized PIU refers to specific Internet
content including chat rooms, e-mail, and social networks such as Facebook andTwitter.
In our opinion, Internet use should be considered problematic or an
addiction when children or adolescents exhibit the following characteristics:• Salience: prominent use of the Internet• Mood modification: moody when not being able to use the Internet• Tolerance: need to spend more time on the Internet• Withdrawal: feeling agitated and irritable when the Internet is
inaccessible• Conflict: conflict with family and friends when not able to access theInternet• Relapse: fails to stay away from using the Internet after a period of
abstinence from Internet use.

Activities included inproblematic Internet
use (Davis, 2001)
Specific•
Net compulsion(online gambling
addiction)•
Online game playing
addiction
General•
Net compulsion(online shopping
addiction)•
Online research
addiction.
•
Cybersexual addiction•
Cyber-relational
addition (chat rooms:
social networking,e.g., Facebook,
Twitter; personalmessaging; ande-mail addiction).

Common clinical presentations include a loss of sense of time or neglectof basic needs while using the Internet; becoming angry, restless and moody
Box H.6.2 Ko et al’s (2005) proposed diagnostic criteria for Internet addiction
A. Six or more of:
1. Preoccupation with Internet activities
2. Recurrent failure to resist the impulse to use the Internet
3. Tolerance: a marked increase in Internet use needed to achieve satisfaction.
4. Withdrawal, as manifested by either of the following: a) dysphoric mood, anxiety, irritability, and boredom after
several days without Internet activity; b) use of the Internet to relieve or avoid withdrawal symptoms.
5. Use of the Internet for a period of time longer than intended.
6. Persistent desire and/or unsuccessful attempts to cut down or reduce Internet use.
7. Excessive time spent on Internet activities.
8. Excessive effort spent on activities necessary to obtain access to the Internet.
9. Continued heavy Internet use despite knowledge of physical or psychological problem caused or exacerbated byInternet use.
B. Functional impairment. One or more of:
1. Recurrent Internet use resulting in a failure to fulfill major obligations.
2. Impairments in social relationships.
3. Behavior violating school rules or laws due to Internet use.
C. The Internet addictive behavior is not better accounted for by another disorder.

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4

IACAPAP Textbook of Child and Adolescent Mental Healthwhen unable to use the Internet; needing better and more computer equipment
and software and more time online; showing more negative behaviors associatedwith online activities such as lying and starting arguments, impaired academic
performance and social relationships (Beard et al, 2001).
Ko et al (2005) proposed diagnostic criteria for Internet addiction (Box
H.6. 2) and tested them in 468 Taiwanese high school students and 216 Taiwanesecollege students. These criteria showed good specificity (97%) and sensitivity(86%). However, larger studies on the validity and reliability of the diagnostic
criteria for PIU are still needed.
There are several scales available to evaluate the severity of PIU. The morecommonly used scales include the Problematic Internet Use Questionnaire (PIUQ)(Thatcher et al, 2005), the Internet Addiction Test (IAS) (Young, 1998), theGoldberg Internet Addiction Disorder Scale (GIAD) (Armstrong et al, 2000), theChen Internet Addiction Scale (Yen et al, 2008) (CIAS), and the French Orman
Internet Stress Scale (ISS) (Valleur & Velea, 2002).The characteristics of these scales
are summarized in Table H.6.1.
Epidemiology
No reliable data exist on the global prevalence of this phenomenon.
Estimates vary from country to country and from study to study. It has been
estimated that 1%-18% of adolescents have PIU in both Western and Eastern
societies (Cao et al, 2007; Jang et al, 2008). More specifically, about 1%-2% of
Italian students have moderate to severe PIU (Poli & Agrimi, in press), 1%-12%
of children and adolescents in Middle Eastern countries (Canan et al, 2010) and
2%-18% of children and adolescents in Asian countries appear to have PIU (Cao& Su, 2007). Small scale studies in Korea and China revealed that around 2%(210,000) of South Korean children aged 6 to19 years have PIU and many may
require treatment (Choi, 2007), while around 10 million adolescent Internet users
in China may meet criteria for Internet addiction (Cao & Su, 2007).
Previous studies had shown that adolescents with problematic Internet use
tend to be boys, have poorer academic performance and are more likely to accessInternet at home and Internet cafes than in school settings (Kormas et al, 2011).
Table H.6.1. Scales to measure Internet misuse
ProblematicInternet Use
Questionnaire(Thatcher &Goolam, 2005)

Internet
Addiction
Scale(Young, 1998)

Internet
Addiction
Disorder Scale(Goldberg, 2000)

Internet
Addiction
Scale(Chen, 2005)

Internet Stress
Scale

Quantitative
20 items

Quantitative
20 items

Qualitative
11 items

Quantitative
26 items

Quantitative
9 items

Scoring5-point Likert scale

5-point Likert
scale

Meeting >2 criteria
indicates Internet
addiction

4-point Likert
scale

Score > 4 suggest
addiction risk

Targetpopulation

Adolescents
AdultsAdolescents
AdultsAdolescents
AdultsAdolescents

Scale

Description

Problematic Internet use

H.6(Valleur & Velea,
2002)

Adolescents5IACAPAP Textbook of Child and Adolescent Mental Health

Individuals with PIU are also more likely to use Internet to converse in chat rooms,
play interactive games, and access sexual information, and are less likely to use
Internet for educational purposes (Kormas et al, 2011). Adolescents with PIU also
have more behavior problems such as hyperactivity, conduct problems and worse
overall psychosocial maladjustment than their peers (Kormas et al, 2011).
Pathophysiology
Researches have shown that some of the behavioral and neural characteristics
of individuals with PIU are similar to those of individuals diagnosed withpathological gambling and substance use disorders (Ko et al, 2009). This is further
supported by a recent functional magnetic resonance imaging study where a cueinduced online gaming urge activated similar brain areas as those activated bycraving for drugs in people with substance addiction (Ko et al, 2009). Increased
activation in the orbitofrontal cortex in gain trials and decreased activation in theanterior cingulate cortex in loss trials have been described in individuals affectedwith PIU (Dong et al, in press). Individuals with PIU also exhibit poorer executive
control and poorer impulse control than non-affected individuals; for example
affected individuals had longer reaction times and more response errors than theircounterparts in the Stroop Test (Dong et al, 2011).
Interaction between environmental and genetic factors appears to play
an important role in the development of PIU (see Figure H.6.1). The current
understanding of addiction suggests that some individuals may be more susceptible
to PIU than others due to their genetic vulnerabilities, but other factors are needed
for those individuals to eventually develop Internet addiction or problems with
Internet use.
Another hypothesis suggests that children and adolescents with PIU initiallyengage in Internet activities by trying to solve a problem, avoid stress or cope withan unwanted feeling, such as anxious or depressive mood (Lin & Tsai, 2002).
Addiction to the Internet may then develop during this process.

Negative
Consequences of PIU•
Impaired academic
performance•
Impaired social
interaction/family
relations•
Decreased selfperceived acceptanceby peers•
Increased drinking in
males•
Lower self-worth infemales
PIU-associatedpsychiatric
symptoms andcomorbidity•
Hostility•
Depression, irritability
or mood changes•
Phobic anxiety•
Daytime sleepiness or
sleep deprivation
Risk factors for PIU•
Greater hours per
week spent online•
Increased need forsocial network•
Low self-esteem•
Poor quality of family
relationships•
Loneliness

Figure H.6.1. Pathophysiology ofproblematic Internet use
Like for most psychiatric disorders, it is hypothesizedthat PIU follows the bio-psycho-social model.
Individuals who develop Internet addiction may havegenetic vulnerability for addictive disorders (e.g.,
substance use disorders, pathological gambling)
and other psychiatric conditions such as ADHD anddepression. The risk for PIU may also increase when
individuals experience rewarding experiences throughInternet activities such as online gaming.

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Onset of PIU is most likely during late childhood and early adolescence(Pridgen, 2010). Adolescence is a period of biological, psychological and socialchange and navigating these changes is stressful for many youth. Adolescents withemotional and behavioral disorders are also more vulnerable to the negative effects
of Internet use (Pridgen, 2010). Furthermore, affected youth often deny theirproblems with Internet use, denial being one of the main factors in maintaining
PIU. Denial enables adolescents to continue engaging in Internet usage in spite ofobvious negative consequences; it is also a way to protect themselves from seeingor feeling things that are unpleasant. Owing to denial, the impact of one’s Internet
usage is seldom fully appreciated until the consequences become serious.
Some studies suggest that children and adolescents with ADHD (Yoo etal, 2004), depression, and those who are socially isolated (Armstrong et al, 2000)
are at higher risk of PIU. PIU shares some risk factors with impulsive-compulsive
spectrum disorders and addictions such as pathological gambling and substanceuse disorder (Yen et al, 2008). A recent US study of Internet use among youngadolescents and adults showed that most males used the Internet on a weekly basis,
while most females had not played more than a single Internet game in a year
(Padilla-Walker et al, 2010). They also found that Internet video game playing,regardless of gender, tends to associate with negative social behaviors such asrecreational drugs use, alcohol drinking, and impaired interpersonal relationships.
Internet use for chat rooms, shopping, entertainment, pornography, andvideogames are further associated with drinking, illicit drugs use, greater numberof sexual partners and lower self-worth. Moreover, playing violent Internet games
is associated with having more sexual partners and poorer quality of interpersonal
relationships in this group. On the other hand, when Internet use is for academic
purposes, there is a positive correlation with less substance use, greater self-worth,and better parent-child relationships (Padilla-Walker et al, 2010).

Click on the picture to watch
an interview with DavidGreenfield PhD on Internet
and video game addiction

What is the Internet Doing to
our Brains?
Click on the picture to view
Dr Paul Howard Jones
discuss the scientific findings
about what technology isdoing to us (26 minutes)

TIM

Tim, a 15 year-old boy, was brought to the psychiatric clinic by his parents due to his spending excessive
time on the Internet and deterioration in his daily activities, performance at school and relationships with peers.
Tim was first introduced to the Internet at school when he was working on an assignment in 3rd grade. In thelast 2 years, he had joined online social networks such as Facebook and MySpace, where most of his friends
share their activities and thoughts. He also prefers using text messages to telephone calls when he wants tocommunicate with his friends. He enjoys online role-playing games and often feels obligated to be online when
his game-partners are also online. He spends more than 12 hours per day (90 hours per week) online, evencutting down his sleeping time. His grades have dropped recently and he has started to skip classes to be on
the Internet. He feels happier and more empowered when online –he does not have to think about his gradesand problems. Tim finds schoolwork increasingly difficult. He has more arguments with his parents, and quarrels
are often associated with his Internet use. Thus, he has started lying to them about the hours he spends online.
He feels restlessness, irritable and unhappy when at school or somewhere else away from the computer. Whenhe first walked into the clinic, he told the psychiatrist “I know I should cut down on the hours I spend online andconcentrate on my school work, but I just can’t. I feel so anxious and joyless when not online.” Tim feels his life isa failure, and that his parents dislike him. He had thought about suicide, but says he does not have the courage
to do it. Tim’s depressed mood had worsened in the previous 2 months, since the beginning of the new semester.
The psychiatrist diagnosed Tim with depression and problematic Internet use.

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TREATMENT
There are currently no treatments for PIU that are supported by evidence,
which is not surprising considering that it is not yet an officially accepted diagnosis.
No pharmacologic or psychotherapeutic intervention has received adequate testingin randomized controlled trials. Most interventions suggested for PIU are based on
personal clinical experience, small anecdotal studies or trials without randomized
double blind design. A recent systematic review showed several limitations inavailable clinical trials (King et al, 2011). These include:• Inconsistencies in definition and diagnosis•

Lack of randomization and blinding•

Lack of adequate control groups, and•Insufficient information concerning recruitment, sample characteristics,
and treatment effect size.

These shortcomings are highlighted in Table H.6.2, which summarizes thecharacteristics of Internet addiction treatment studies currently available.
While there is no agreement on the diagnostic criteria for Internet addiction
or PIU, there seems to be a demand for treatment for these problems, especially in
China, Taiwan, and South Korea (King et al, 2011). Interventions for PIU range
widely from boot-camp style programs in Eastern countries to clinics specializing in
the psychological treatments including CBT, family and group therapy, social skills
training, and addiction counseling (King et al, 2011). Programs often extrapolate
treatments used for substance abuse.
Before going into details about intervention, a careful clinical evaluation
and assessment of comorbid conditions is essential. For example, a depressed child
may start leading a virtual life to boost his self-esteem at the expense of offline
interactions and duties, hence treating the depression will be a priority in thischild’s treatment plan.
There has been no double-blind placebo-controlled study on thepharmacotherapy for PIU. Thus no specific medication can be recommended at
this stage, although a wide range of them has already been tried, as summarizedin Table H.6.2. The only randomized controlled study published so far allocated
56 adolescents aged 12 to 17 years into either active treatment (8-sessions ofmultimodal school-based group CBT) or no treatment (Du et al, 2010). While
Internet use decreased in both groups, the active treatment group improved morein the areas of time management, emotional, cognitive, and behavior symptoms.
Children and adolescents affected with PIU may benefit from family based
interventions, although there is no evidence so far that this is the case (Yen et al,2007). For example, family therapy may help to improve communication within
the family and teach Internet techniques to monitor Internet use better (Yen et al,2007). Ironically, PIU may also improve with online educational programs (Kinget al, 2011). There are several online services, mostly based on the ‘12 step’ selfhelp treatment philosophy.
Although other management options, such as intensive and expensive
residential treatments, have received much attention from the media and the
public in some countries, there are no empirical data about their effectiveness.

Problematic Internet use

H.6

Behavioral strategies forclinicians and self- help
tips for dealing with PIU
•

•

•

•

•

•

•

•

Help patients
identify their patternof Internet use using
a logbook.
Set clear, specificgoals with thepatients.
Limit and shorten
Internet usage time.
External prompts,
such as timers may
be helpful to remindthem when it is time
to log off.
Negotiate acomputer free day
once each week.
Write down negative
consequences ofInternet use on
reminder cards andencourage patientsto carry and readthem.
Help patients makea list of hobbies orinterests they used
to enjoy.
Increase time spend
on sports, hobbies
and other nonInternet activities
Join a PIU support
group.

Websites that offer
help for problematicInternet use
www.netaddiction.com
http://www.
netaddictionrecovery.com
www.onlineaddiction.com.
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IACAPAP Textbook of Child and Adolescent Mental Health

Table H.6.2 Available treatment studies for Internet addiction (adapted from King et al, 2011)
STUDY

TREATMENT(COUNTRY)

DEFINITIONOF INTERNETADDICTION

Du et al, 2010
(China)Beard’s Diagnostic
Questionnaire

8 session CBT vs control

NUMBERCOMMENTS(AGE)
Treatment (n =32) vs clinicalcontrols (n = 24).

The only controlled study
available(12-17)
Han et al, 2009
(South Korea)

Young Internet Addiction
Scale > 50

8 weeks ofmethylphenidate

Han et al, 2010
(South Korea)>4h/day, 30h/week;

6 weeks bupropion
sustained release

Young Internet Addiction
Scale score > 50

62
(8-12)
19(17-29)Kim, 2008(South Korea)

Korean Internet Rating
Scale

5 weeks “reality training”
group counseling vsuntreated controls

25

Shek et al, 2009
(Hong Kong)

Young Internet Addiction
Scale; Chinese Internet
Addiction Scale

15-19 months multimodal counseling

Su et al, 2011
(China)Young’s Diagnostic
Questionnaire: Internet
use of 14+ hr/week

Healthy Online SelfHelping Center (Natural
Environment; Learning
Environment, NonInteractive) vs Control(age notreported)

Young, 2007
(USA)

Internet Addiction Test

12 sessions of CBT

114(age notreported)59

All subjects in the study
had comorbid ADHD

Small sample size (11)and no control group

Limited information (e.g.,age of participants notdescribed)
No control group(11-18)65

Limited information (e.g.,age of participants notreported)

No control group(age notreported)

TIM (continuation)
The psychiatrist worked together with Tim to devise a plan of action. This entailed asking Tim to keep a diary, particularly
noting the time spent online, homework and house duties as well as other activities, and to rate his mood every day. Once abaseline was obtained, they worked on ways to increase participation in activities Tim used to enjoy apart from the Internet.
With Tim’s agreement, his parents were invited to participate in the sessions and encouraged to discuss activities andhobbies they could do with Tim and rewards for time offline. After discussion, it was agreed by Tim and his parents to move
Tim’s computer from his bedroom to a more public space in the lounge room, that Monday would be an Internet free day for
the whole family and a reward for Tim every time he was successful in doing that. Once this was in place, Tim agreed to limit
his Internet use to one hour per day on the remaining weekdays and 2 hours on weekends. After a month of treatment, Tim’s
depressed mood had improved and he had reduced substantially his time online, although with some relapses. He began to
be involved again in outdoor activities with his family and friends and there were fewer arguments at home. Temptations to
use the Internet remained, particularly when frustrated with homework or after arguments with his parents.

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Course and outcome
Due to the ready accessibility of the Internet, and the need to use it in modern
life, relapse rates are high. Many adults with PIU started using the Internet when
they were in grade school and Internet use usually became problematic without theaffected individual being aware of it. However, little is still known about its natural
history. Uncontrolled and anecdotal studies suggest that Internet addiction is often
resistant to treatment and has high relapse rates.
Prevention
Online gaming seems to be a particular problem in many Asian countries,
where much of the online gaming commercial promotion targets children andadolescents. Asian adolescents often face tremendous academic pressure, while
online gaming can temporarily provide a stress-free virtual reality for many. Schools,
governments and health departments should encourage research on this problem
to clarify its causes and promote preventative interventions. For example, South
Korea, a country in which multiplayer online games are very popular, has decided
to introduce a ban from midnight to 6:00AM for Internet use by children andadolescents less than 18 years of age (Block, 2008). The South Korean government
also has a system that slows down the Internet connection of Internet gameplayers who played for more than 6 hours. China is another country experiencing
problems with Internet use. The Chinese government restricts daily Internet gameuse among youth by demanding online game operators to set up a "game fatigue
system" that encourages players under 18 to play less than 3 hours a day since 2007
(Block, 2008).

Click on the picture to watcha news item about Internet
addiction in China

Conclusion
The Internet has revolutionized human life, is here to stay and has many
positive aspects that can enhance youth learning and empowerment. The younger
generations are growing up with and making Internet an integral part of their lives,
however, in a few instances, Internet use becomes problematic. Is this a disorderthat requires treatment or an example of medicalization of a social phenomenon?
Because Internet addiction or problematic Internet use is not recognized by DSMIV and ICD-10, the research evidence is very limited yet. This situation will needto change if we are to provide answers supported by evidence to the questions
posed in this chapter.

Legend of Zelda: Ocarina of Time, one of
the most popular video games

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