Problematic Internet use in Chinese adolescents and its relation to psychosomatic symptoms and life satisfaction

The Internet has become an important tool for social interaction, information, and entertainment [1]. However, as the Internet has moved into homes, schools, Internet cafes, and businesses, there has been a rapidly growing public awareness of the potential adverse effects arising from excessive, maladaptive or addictive Internet usage [2, 3], which is a condition also known by terms such as problematic Internet use (PIU), Internet addiction, Internet dependence and pathological Internet use. Beard and Wolf defined PIU as use of the Internet that creates psychological, social, school, and/or work difficulties in a person's life [4].

As an important period between childhood and adulthood, adolescence is encompassed by alterations in physical, psychological, and social development [5]. During this developmental stage, more time is spent with peers and adults to face the variant social environment where more conflicts arise. The presence of relatively immature cognitive control [6, 7], makes this period a time of vulnerability and adjustment and may lead to a higher incidence of affective disorders and addiction among adolescents [8, 9]. Thus, adolescents are worthy of special consideration. International estimates of adolescent PIU vary widely. In Europe the prevalence has been reported to be between 1% and 9% [10, 11], in the Middle East the prevalence is between 1% and 12% [12, 13] and in Asia the prevalence has been reported to be between 2% and 18% [14–16]. According to the 27th China Internet development statistical report, as of 30 December 2010, there were 457 million people in China with access to the Internet. Of those, the group aged 10~29 years was the largest (57.1%) [17]. As one of the common mental health problems among Chinese adolescents, PIU is currently becoming more and more serious [18].

The negative impacts of PIU have progressively emerged. Recently, numerous studies had shown indulging in the use of the Internet is associated with a variety of problems. Kim et al [19] reported high-risk Internet users have inappropriate dietary behaviour and poor diet quality, which could result in stunted growth and development. Frangos et al [20] reported that PIU was also associated with other potential addictive personal habits of smoking, drinking alcohol or coffee, and taking drugs. Seo et al [21] found there were statistically significant positive correlations between Internet addiction and interpersonal problems (r = 0.43, P < 0.001). Ko et al [22] found that after controlling for the effects of shared associated factors, adolescents with Internet addiction were more likely to display aggressive behaviours. Kelleci et al [23] reported that Internet use in adolescents was associated with more severe psychiatric symptoms. Morrison et al [24] found that those who regard themselves as dependent on the Internet report high levels of depressive symptoms.

Although many studies on the associations between PIU and physical and psychological health have been carried out, some questions remain. First, some studies have recruited participants on-line or used a convenience sample [25, 26]. These studies have inherent biases, which make it difficult to accurately assess the prevalence of PIU as well as the relationship between psychiatric symptoms and PIU. Second, many studies were often restricted and either referred to local or regional samples [27] which could not really be generalized, or examined only a part of the child and adolescent age spectrum [28]. Third, information on the effects of PIU on life satisfaction is limited.

For these reasons, we carried out a large-scale, cross-sectional study in China. The main purpose was to investigate the prevalence of PIU among adolescents aged 10 to 24, and to test the relationships between PIU and psychosomatic symptoms and life satisfaction. This study will contribute to our understanding of PIU among Chinese adolescents and help in designing educational policies to prevent PIU.

The information provided here may help us better understand the prevalence of PIU and the relationships between PIU and psychosomatic symptoms, life satisfaction among Chinese adolescents. This study showed that 8.1% of the total study population, including 8.3% of junior high school subjects, 9.0% of senior high school subjects and 6.9% of college subjects, had PIU, which were consistent with many previous studies[34, 35]. Lam et al [34] reported that 10.8% were diagnosed as Internet addicted users among high school students, and Ni et al [35] identified 6.4% of 3 557 first-year university students as Internet addicted. During adolescence, high school students usually experience dramatic serious problems than do individuals of other ages if they engage in problem behaviours. Thus, there is increasing evidence that PIU among high school students is emerging due to easy access to the Internet [12, 36], similar to the current study which shown PIU may be more severe among high school students in China. The rate of Internet addiction among adolescents varies widely, from 1.0% to 36.7% [10–16, 37]. There could be many reasons for this. First, different social and cultural contexts, as well as differing definitions and criteria for measuring Internet addiction, make it difficult to effectively compare findings. Second, the cut-off criteria for most studies were set without clinically established diagnostic validity. However, the current study used the YIAT to establish good diagnostic validity for the cut-off point. Finally, prevalence rates have varied widely depending on the sample. The above-mentioned most studies were limited by relatively small or unrepresentative samples, whereas the present study examined a nationwide sample of adolescents and confirmed the prevalence of PIU within adolescents aged 10 to 24.

Previous studies identified gender as a risk factor for PIU [1, 34], and our results are in agreement with them. One explanation for this may be that males are more likely to play online games, engage in cybersex, view cyberporn, and gamble online, all of which are associated with addictive Internet use [38]. This study showed that the frequency spent using the Internet per week was associated with PIU. One explanation for the association between frequency of Internet usage and PIU is that it may be as much a symptom as it is a cause.

The present results showed that adolescents with PIU had more severe psychosomatic symptoms than those without. This finding also corresponds to analogous investigations of excessive Internet use [39, 40], which has been reported that extensive Internet use may bring forth a heightened level of psychological arousal, possibly resulting in online users experiencing health problems. Psychosomatic symptoms in adolescence might be important signals of mental health and this should be taken seriously in school health and in general primary care.

Teenagers tend to use the Internet as a medium for socialising, but PIU can result in individuals spending ever-increasing amounts of time in online activities, leading to social withdrawal, self-neglect, poor diet and family problems. The consequences of PIU are insidious, becoming apparent after months of PIU and eventually engulfing all aspects of the individual's life. Teenagers with PIU have reportedly become physically aggressive when parents try to remove them from the computer. Late night use of the Internet can cause sleep deprivation and fatigue, which can adversely affect academic performance and can result in reversed sleep pattern and poor academic performance [41].

In the long term, problematic Internet use can cause serious health problems. Repetitive strain injury and back ache are common complaints. There have been at least 10 reports from China of users collapsing and dying following several days of uninterrupted online video game playing [41]. A sedentary life-style can increase risk of deep vein thrombosis and pulmonary embolus, eventually leading to obesity and its associated complications [42, 43]. Similar to the study results above, our study found adolescents with PIU were more likely to suffer from physical symptoms, such as lack of physical energy, physiological dysfunction and weakened immunity.

In addition, the current study found adolescents with PIU were more likely to suffer from emotional symptoms, behavioural symptoms and social adaptation problems, meanwhile adolescents with PIU had significantly lower scores on total and all dimensions of life satisfaction. Adjusted for the demographic and Internet-related factors, all dimensions of psychopathological symptoms and life satisfaction were significantly associated with PIU. Given the essential role of the Internet in communication, recent other studies also have examined the influence of Internet use on psychological well-being. Several cross-sectional questionnaire and interviewing studies claim the underlying psychopathology of Internet addiction, including attention deficit and hyperactivity disorder (ADHD), depression, social anxiety, and substance dependence [44–48], in adolescents and college students. There are several possible mechanisms explaining this association. A co-morbid mental disorder may result in, contribute to, or exacerbate the symptoms of PIU. PIU may lead to, contribute to, or exacerbate the symptoms of various mental disorders. There may be underlying biological, psychological, and sociological mechanisms shared by PIU and various mental disorders.

In the information age, Internet use is becoming increasingly significant in the acquisition of information and the sharing of knowledge. Internet use is now considered to form part of the culture of adolescents, and hence studying Internet use and its negative aspects is tremendously important to the creation of a sound youth culture. This requires studies on the relationships between PIU and physical and psychological health. This present study has demonstrated that PIU was common among Chinese students, and PIU was significantly associated with psychosomatic symptoms and life satisfaction. Effective measures are needed to prevent the spread of this problem and interventions to prevent the effects of PIU on psychosomatic symptoms and life satisfaction should be conducted as early as possible.