His Final Mission: Rabbi Dr. Abraham J. Twerski ZT”L On His Fight Against Internet Addiction Compiled by Yaakov Nadel Quotes

Internet addiction (IA) was introduced as a new disorder in mid-1990s. Since then, there is growing concern about the addictive nature of the Internet. This chapter is a comprehensive review of published seminal, research and review papers, meta-analyses and book chapters/books on IA in adolescents. The conceptualization of IA, epidemiology, phenomenology, screening, diagnoses, treatment and prevention are discussed with relevant references. The concept of IA is at fetal level with no consensus on definition, norms or clinical criteria. Asian countries such as China and South Korea are affected most. A multination meta-analysis estimated an overall prevalence of 6% for IA. Most of the research identifies IA in gaming, gambling, social networking and cybersex. A few assessment tools have been used with no comparability or cultural sensitivity. Diagnostic criteria are proposed based on those used for substance abuse and pathological gambling. The treatments are mainly psychological with a lot of emphasis on cognitive behavior therapy. The Internet is a very versatile and useful tool for children and adolescents, and it is not advisable to ban it totally. The review highlights education of them on sensible Internet use and supports inclusion of IA in international disease classifications.

1. Introduction

The Internet evolved from early 1980s to the modern day revolutionizing the broadcasting, information sharing and connecting individuals worldwide. Today, it has become an in-built part of daily lives of people including children and adolescents. The Internet can be used for many purposes: educational such as teaching, learning and research; business, such as monetary/document exchanges and conference meetings; recreational such as games, online gambling and watching sexually explicit material, and as a mode of connecting people via texting, calling, social websites, chat applications and e-mails. Research has found increasing number of students are using the Internet for their academic activities, for example, one US study showed an increase in the Internet use among students from 24.5% in 1996 to 79.5% in 2001 [1]. However, together with the many benefits come the risks that are inevitably intertwined due to the innate qualities of the Internet.

There is growing concern about the addictive quality of the Internet, and pioneering researchers have introduced the concept of addiction (IA) in mid-1990s [2, 3]. IA has attracted the attention of media and general public increasingly, with the speedy growth in computer use and the Internet access [4]. The Internet today has reached not only the computer, but also the mobile phone and even the wristwatch with many more sophisticated high-tech apparatus with the Internet facility being introduced to the world, incessantly. It is common to find children and adolescents coming from a reasonable socioeconomical background, around the globe, using a personal digital devise like a smart phone, tablet or a laptop with the Internet. It is important to look into how it is like to grow up with such a vast degree of stimulating and inviting attractions from the cyber world on the developing brain.

This chapter explores the conceptualization of IA as an evolving novel theme [3, 5], describes the types of Internet addiction disorders (IAD) and looks into available epidemiology and etiology. Then, a proposal of a neurobiological basis for IA in the developing brain is introduced based on the current knowledge on more established dependences of substances/behaviors such as gambling of the maturing brain. Identification of high-risk children and adolescents and association of IA with other psychiatric disorders such as depression are discussed next followed by an account of the symptoms and signs of varying clinical presentations of IA and diagnosis. Then a review of treatment modalities, proposed so far, and prognosis of and finally prevention strategies for this, most probably, a fastest growing addiction disorder of the world is discussed.

2. The concept of Internet addiction and its controversies

IA was introduced as a disorder by Young in her seminal paper “Internet Addiction: The emergence of a new clinical disorder” in 1996 [2]. She proposed diagnostic criteria for IA based on the existing Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-4) criteria for substance dependence [6]. In 1999, David Greenfield too proposed IA to be a form of addictive disorder [7]. These researchers highlighted that the tolerance and withdrawal symptoms of Internet use and those of substance use have similar features. There are others who suggest that IA is an impulse control disorder or even an obsessive-compulsive disorder. But the symptom overlap with substance and known behavioral addictions supports the notion that IA is an addiction—a behavioral one—for that matter.

An increasing incidence of IA together with its high cooccurrence with other established psychiatric disorders was pointed out later [8]. The proposal to include “Internet addiction disorder” in the 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was brought forward. DSM-5 acknowledged the growing concern about the Internet use and related problems, but they claimed there is “insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions” to identify the behavior as a mental disorder.

However, DSM-5 has introduced the condition Internet gaming disorder with some proposed criteria under “Emerging Measures and Models” heading for future study. The DSM-5 work group has reviewed many articles about online gaming, and they found some behavioral similarities of Internet gaming to other addiction behaviors which are established as disorders, namely gambling disorder and substance use disorders. The proposed criteria for Internet gaming disorder focus on preoccupation and behaviors, which mainly consume most aspects of life, withdrawal, tolerance, lack of control of use and marked deterioration of the function. The criteria are mostly as proposed by early researches on Internet addiction disorder [2].

Lack of consensus on a definition for IA, which is even blurred subcategory of Internet use (i.e., gaming, social media, cybersex, etc.), makes it difficult to derive prevalence data. Also, there is little or no knowledge of natural histories of cases. Thus, limited scientific research from around the globe has hindered IA earning a place as a disorder in DSM-5 [6].

However, in parts of the world where Internet gaming has an apparent high prevalence, relevant governments such as Chinese have accepted Internet gaming as an established “addiction” and South Korea have identified IA as a problem at governmental level and declared it a serious public health hazard [8]. Such highly affected Asian countries have developed separate treatment units for Internet gaming addiction, in hospitals (e.g., China, Korea). There are an increasing number of researchers looking into the diagnosis of IA, and many researchers agree that the criteria to identify Internet addiction are like in any addiction with craving and compulsion to use despite the knowledge of the harm, loss of control in terms of initiation, continuation and conclusion of the use and withdrawal features such as mood symptoms and distress. In the case of children, however, the knowledge of harm may not be relevant due to the level of cognitive development. For example, a Taiwanese study has proposed diagnosis criteria for Internet addiction and when tested on a group of adolescents found them to be of high specificity and sensitivity [9]. The criteria of Ko et al. are more organized than what is introduced by Young in 1998 [10] with the former following the pattern of International Classification of Diseases 10th version (ICD 10) by World Health Organization (WHO) [11]. However, we need larger multicenter international collaborative studies to understand the prevalence, etiology and the course of IA before we adopt criteria proposed based on local studies as the validity and reliability of the diagnostic criteria have to be ensured. Mental healthcare professionals in many countries particularly in Asia and Europe are increasingly urging the authorities such as World Health Organization to identify IA as an independent disorder [12].

3. Controversies

The Internet is undoubtedly a very useful commodity. Can we consider liberal use of the Internet as an illness at all? Is it unwanted pathologization of changing times? A disadvantage of such a labeling could be the stigmatization of the Internet, which has many important and versatile uses. One may wonder whether there is any underlying pharmaceutical company agenda in pushing this as a diagnosis!

One controversial view is based on the argument that there is no “chemical substance” as such, to get addicted to. However, American Society of Addiction Medicine (ASAM) has defined addiction as a chronic brain disorder, which is not limited to substance use [13].

A strong argument against an independent disorder of IA is brought up by some researchers who believe existing and well-established disorders such as depression or social anxiety are the root causes of driving people to misuse the Internet [14, 15]. They argue that IA therefore is not a new disorder but a consequence of a more primary problem in mental health. Others (e.g., Some Forensic Psychiatrists) suggest that we should consider problematic Internet use, and the same way we consider the online gamblers as gamblers but not as Internet addicts [16].

More and more younger age groups are using the Internet with wider prevalence of the availability of the Internet. It is wondered how young is too young for children to go online. Some question the demarcation between passionate high involvement and problematic use or addiction [17]. Some experts in the field bring the argument whether we are pathologizing a common behavior [18, 19]. It is also relevant to keep in mind the discrepancies in cultural beliefs and attitudes toward the Internet use in different parts of the world. In southeast Asia, for example, parents appear to believe any behavior that takes time away from family or educational pursuits as abnormal [20]. This may partly explain the highly inflated prevalence rates of IA in countries such as Taiwan and South Korea [21].

4. Terminology in Internet addiction

Currently, some have settled into a less controversial term for the problem of IA, the “problematic Internet use” (PIU) [22, 23]. A large European Union-funded multicountry study used the terms Internet addictive behavior (IAB) for IA and dysfunctional Internet behavior (DIB) for problematic use of the Internet [24]. Compulsive Internet use (CIU) is another term used [25]. A more recent European study involving 11 countries has adopted the terms pathological Internet use (PtIU) and maladaptive Internet use (MIU) [26]. The salient features of addiction and problem use are more or less the same though the terminology used by different researchers is different. Addiction to the Internet basically implied a craving for the Internet use for uncontrollably long periods with impairment of functionality in the absence of any other disorders accounting for the condition and problem use was when one not meeting addictive features but nevertheless there are problems in bio psychosocial aspects in life. This chapter uses the terms IA and problem use for simplicity and clarity.

5. Types of Internet addiction disorders

One very common online activity among adolescents is recognized as online gaming. Many attractive single- and multiplayer games are being marketed among the youth worldwide. (e.g., World of Warcraft Clash of Clans, Slither.io, Clash Royale, Pokemon). Virtual communities created by some of the games could be more appealing for an adolescent than the real communities; the gamer can become an avatar of anybody he or she wishes; some games are designed in such a way gamers can buy cars and mansions and have a virtual second life. People spend/invest a whole lot in the second life at the cost of a deteriorating real life. Author, going by her clinical experience, wonders whether the adolescents with low self-esteem who are not recognized in real life might gain a lot of recognition from other fellow gamers in the online community as great warriors. However, this hypothesis needs to be explored through proper research. A US study has found Internet gaming to be associated with alcohol and recreational drug abuse and poor interpersonal relationships with no gender differences [27]. Research has found online gaming addiction to be associated with aggression, low sociability and self‐efficacy, and a lower satisfaction with life [24]. The gamers with these risk factors engage in intense use and are of all age groups. It should be interesting to see the nature of these associations, whether these negative characteristics in the adolescents lead to IA or IA results in these traits. Such knowledge can provide us with interventions in terms of prevention of IA. No clear answer is evident from available data at present.

Another type of internet use, which is popular among adolescents, is social networking using applications such as viber, whatsapp, instagram, facebook, twitter, my space etc. and chat rooms/e-mail. A child or an adolescent will be very much overwhelmed by the amount of online connections he or she can have through these connecting apps. Notifications popping up will invariably distract the youth from homework or any other academic activity. Being connected with around the world friends 24 × 7 could be an around the clock distraction and disturbance. Author recalls one of her patients, a 16-year-old schoolgirl who receives 14,000+ text messages via Viber per day. Her life revolved around receiving and sending texts to her boyfriend and friends and would become aggressive toward family and property when the parents attempted to limit the Internet time. Another grave risk involved in social media sites is children and adolescents getting exposed to unknown adults who may abuse the “online friendship” and bring harm on the young.

Cybersex is also an attractive type of Internet activity among adolescents. Premature exposure to various aspects of sexuality and exposure to adverse sexual activity may hinder the healthy psychosexual development in children and adolescents. Problem use of Internet pornography by adolescents has been associated with alcohol, illicit drugs, greater number of sexual partners, poor interpersonal real-life relationships with partners and poor self-worth [27].

Online gambling is the most studied type of IA. It is found to be highly addictive among adults, yet there are not enough studies to know the situation among adolescents. However, it is reasonable to state that going by available data and author’ s clinical experience, social networking and gaming are strongly associated with problem use of the Internet.

Watching videos/movies was not related to problem use of the Internet according to one study [24]. Yet the evidence is not conclusive to derive a definite idea about this type of Internet activity.

Males are found to have been engaging in gaming significantly more compared to females, whereas more females tend to spend time in social media at a significantly higher rate than males. Children and adolescents tend to indulge in these online attractions at the expense of their school work and real-life relationships with friends/family and sports. Researchers have found that IA or problem use can arise from involvement in a range of online activities [2, 23, 28–30].

6. Epidemiology of Internet addiction

Researchers have looked into the prevalence of IA. As discussed above, being an evolving concept there are very few empirical studies and even fewer meta-analyses on IA. Further, it is difficult to compare and contrast available studies due to the vast differences in the methodology as a result of the ill-defined and poor consensual concept of IA. The considerable lack of unanimity in terminology is apparent in studies, and prevalence rates mentioned here are from studies that use many different terms for IA.

IA is reported more commonly in Asian countries and in males aged 12–20. The available research on game addiction centers mostly on young males worldwide. There is some evidence to believe that the onset of IA is probably in late childhood/early adolescence [31]. There are many reports in countries such as China and South Korea. A few European and American studies are also available. The researchers who make an effort to educate the authorities and public in USA claim that IA is a silent epidemic in United States, at present. There are a fewer African studies mainly from South Africa that indicate a lower prevalence estimate compared to other countries of the world. One study reported the figure as 1.67–5.29% [32]. A meta-analysis from 31 nations from seven world regions (North America, Oceania, North & West Europe, South & East Europe, Middle East, Asia and South America) revealed an overall prevalence estimate of 6% in IA. The results showed that the adverse real-life living conditions such as poor satisfaction with life, greater overall pollution, lower national income and greater time spent in traffic were directly proportional to the IA. Middle East had the highest individual world region prevalence estimate of IA, the figure being 10.9% [33].

The far eastern countries such as China report 10.2% of moderate users and 0.6% of severely addicted [34]: South Korea have found 1.6% [35], 3.5% [36], 4.3% [37], 10.7% [38] and 20.3% [39] of adolescents with IA. In Taiwan, 17.9% of students were found to be addicted to the Internet [40].

A European Union‐funded research project was carried on among adolescents in Greece, Germany, the Netherlands, Iceland, Poland, Romania and Spain [24]. The Internet addiction was detected in 1.2% of the total sample, and 13.9% have been found to have problematic Internet use. Less affluent countries of the sample, Spain, Romania and Poland, have showed a higher prevalence of problem use, while Germany and Iceland have shown the lowest. The problem use was associated more commonly with boys, older adolescents and those who had parents with low level of education. The problem users have shown lower psychosocial well‐being.

A more recent research on the prevalence of Internet addiction on a large number of adolescents from 11 European countries has showed that the overall prevalence of problematic Internet use was 4.4%, and rates were higher in males than in females (5.2% versus 3.8%) and differed between countries (χ(2) = 309.98; d.f. = 20; P < 0.001). A significant correlation between problem use and mean hours online and male gender were found [26].

The Indian subcontinent is seemingly overtaking other nations with 53% of Indians connected to the Internet every waking hour according to a recent study conducted in 10 countries by a global management consulting firm AT Kearney Global Research based in London. India has made several attempts to contribute to available knowledge base on IA and related problems in adolescents. One 2013 cross-sectional study conducted among 987 adolescents in Mumbai has revealed 74.5% as moderate users, 24.8% as possible addicts and 0.7% as addicts. Males in comparison with females were significantly more addicted [41]. Many such local researches are available online, yet a national figure on prevalence of IA or problem use is not yet available in India where one of the leading and fastest growing information technology industries prevails.

A preliminary survey was conducted on the Internet use in a convenient sample of 179 adolescents from schools in central Sri Lanka by author and her team to derive a general idea about the Internet use among adolescents and the views of their significant adults on the Internet [42]. Sri Lanka is a middle-income developing country in South Asia where the Internet is promoted at large scale by multinational companies for competitive prices. No published studies are available on the Internet use among children and adolescents in Sri Lanka. The survey found that 91.06% of the sample was using the Internet with no sex difference; 2.79% of parents and 3.3% of teachers liked students using the Internet; and 45% of each adult group had a neutral view (Table 1). This is interesting as for some parents and teachers in Sri Lanka believe the Internet is a bad influence on the young that entices them into pornography and risky relationships. The Internet is not affordable to many young Sri Lankans yet, but mobile phone packages with Internet facility are coming up increasingly enabling the children and adolescents to use the Internet unsupervised by adults. Out of the sample, 68.7% used the Internet for social media and 55.6% was watching films and videos (Table 2).

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7. Etiology

Many children and adolescents are engaging in the Internet use for academic pursuits as well as recreation. But not all will end up being addicted to or problem users of the Internet. The pertinent question what makes a particular adolescent becomes a victim of IA is the question we should try and find an answer. However, like the etiology of any other mental and psychosomatic disorder in psychiatry, the answer is not that simple. After reviewing the attempts made by researchers to come up with a model to understand IA and its management, the author believes that the well-known biopsychosocial model of disease is a feasible and logical explanation for IA, too.

The genetic factors play a part in addictions, and therefore, biological vulnerability is considered to contribute for IA too. The psychological component with cognitive errors, negative effects and personality traits also accounts for the condition. Here, it is noteworthy that personality is again determined by the genetic composition of the individual. Finally, the social factors such as affordability and availability of the devices and networks, the attitudes of the parents and schools about the Internet and the nature of the education system (i.e., whether students are requested to use a lot of online activities for school work as in most high schools in North America) and the inert qualities of the Internet itself that attract youngsters are also contributing for IA.

Researchers have wondered whether different types of Internet addictions (i.e., cybersex, social networking, gaming, etc.) have same underlying mechanisms or not. Apparently, all the types have common features of the well-established signs and symptoms of addiction, pleasure generating quality and the ability to go anonymous if necessary. Yet it is only speculation until scientific evidence is available on underlying pathophysiology.

8. The neurobiological basis of the Internet addiction

It is known that the developing brains of children and adolescents are more vulnerable to get addicted to rewarding activities. Adolescent period is a period of heightened neuroplasticity that makes this age more susceptible to the effects of addictive drugs [43]. Internet addiction and other similar addictive behaviors too can reasonably be considered to have the same effect as drugs on these vulnerable brains. Based on the available knowledge of neurobiology of addiction, scientists have proposed a neurobiological theory for Internet addiction. The “reward center” or “pleasure pathway” of the brain is responsible for the pleasure experienced by an individual. Neurochemicals associated with pleasure such as dopamine, morphine, like endorphins, and others are released when the brain areas such as nucleus accumbens of the pleasure pathway are activated [44, 45]. Substances of addiction or similar behaviors of addictions are found to activate the pleasure pathway. The receptors involved gets affected when exposed to the chemicals over time, and tolerance and withdrawal develop like in any addiction, needing more and more online input to achieve the same stimulation or “kick” together with continuous engagement in the behavior to avoid withdrawal features [46]. Some activists working on education of public against hazards of the Internet argue, in the genetically vulnerable adolescent or child, lack of love care and affection by the significant adults in his or her life leads to no or minimal activation of pleasure pathways. The children are left alone to fill the emptiness from outside pleasures such as the Internet. That is a theory worth more research as it can be utilized to prevent Internet addiction.

The Internet offers a strong reinforcement for addiction like any other addiction as depicted in Dr. Kimberly Young’s Hand Book on Internet Addiction [47]. In gambling, as psychologists found through their extensive research, a variable ratio reinforcement schedule (VRRS) operates giving the gambler the suspension of unpredictability and varying rewards. It is proposed what happens in Internet addiction is also the same. The computer applications are increasingly developed to engage the user fully and incessantly. The coupling of the online activity with pleasure generating themes (sex, sense of connection through social networks, etc.) will heighten the reinforcement leading to more severe addictions [48].

9. High-risk groups for Internet addiction

Qualitative research has reported how the adolescence itself is a risk factor [49].

The developing brain of adolescents has an innate quality of curiosity and a drive for adventures with risk taking. The Internet also gives answers to almost any query they have, keeps them connected and can be a load of never-ending fun at mere finger tips.

However, certain adolescents are more vulnerable to the addictive quality of the Internet than others. One with deficient real-life social skills may find it easy to have online relationships as there is no pressure of real-life eye-to-eye contacts, gestures and human touch. They may find it boosting to be liked and praised online. They may tend to overuse virtual realities offered by attractions in the Internet to fill the voids of boredom and loneliness of real life. At the press of a key, an “emoticon” expressing the due feeling could be far less distressing and comforting than all the “hard work” of trying to express emotions in real-life relationships for the shy adolescent.

Adolescents who are lacking emotional and psychological support are found to be at highest risk and so are the adolescents with identified emotional and behavioral disorders [31].

It is worth exploring the fact whether the adolescents who face tremendous academic pressure in real life tend to find temporary solace in stress-free virtual reality of being online. This may explain the high prevalence of gaming reported in Asian cultures those give priority to the education of the children even at the expense of the psychological well-being of the children. However, this theory needs empirical support.

It is found that living in metropolitan areas was associated with problem use of the Internet. It is not clear whether it is due to wider availability of the Internet by way of free WiFi in cafes, shops and malls in metropolitan area. Poor adult supervision seems a key element in high-risk adolescents. Students not living with a biological parent, low parental involvement and parental unemployment have shown the highest relative risks of both problem use and addiction of Internet.

Availability of one or several devices to log into the Internet such as smart phones, tablets and even wrist watches at present with wide spread availability of the Internet paves way for increase in the risk of IA.

The Internet-based treatment programs are trialed and used in the management of individuals with autism spectrum disorders. However, there is some concern that, despite its benefits, the Internet has the risk of addictive use in this special group of people [50].

It has been found that doing homework/research was negatively associated with problematic Internet use [24]. A positive correlation was found between Internet use for academic purposes and greater self-esteem, better relationship with parents and less use of substances of abuse [27]. Maybe the studious adolescent does not possess some of the risk factors leading to problem use of Internet to begin with, and it could be the reason for positive findings. This needs more exploration as it may lead us to understand preventive measures.