PROBLEMATIC INTERNET USE IN
SCHOOLCHILDREN: an outline and guide
for parents & families
Chatswood High School
Monday 29th May, 2017
Dr Philip Tam
BA, MBBS, MA, FRANZCP, Cert Child Psych
Child/ adolescent psychiatrist & lecturer
Researcher-in-Residence, Knox Grammar
Co-founder NiIRA (www.niira.org.au)
[email protected]
Outline of Session:
 General topic overview & historical development
 Current research, literature & controversies
 Main features of a ‘problem user’ and games-design theory
 Brain and psychological changes in PIU
 Children’s use and overuse – practical issues for parents in
the home and the school setting
 Key associations with mental disorders and physical health
 Strategies to address an emerging problem
 Considerations at a schooling, educational and policy level
 Future-focus discussion : challenges and solutions
A brief history of computing & PIU:
 Evolution of computing and Internet largely as a result of WWII and the
Cold War: Norbert Wiener, USA (cybernetics and feedback) ; Alan
Turing, UK (early computer devpt and theory)
 Computer games from 1960s – Spacewar, Pong, Space Invaders, then home
consoles ( Atari and the Playstations). Web-enabled games from late 1990s.
 Early forms of Web present in 1980’s, but major take off in mid-90’s–
HTML, Intel chip, commercial input; further expansion with ‘Web 2.0’ and
rise of Smartphones from 2007.
 The concept of ‘internet addiction’ first described in 1996/7 in the USA by
Prof. Kimberly Young and Dr. J Block : not initially taken seriously
 Emergent concept of ‘digital natives’ vs. ‘digital immigrants’ (Prensky,
2003); political stance on control vs. open society (notably USA).
 Broader psycho-social concerns on privacy, security, cybercrime, and
cybersafety
A suitable & concise definition :
 Problematic internet use is:
‘ The pervasive, long-term usage by a person of ICT
and related technologies, which results in a
clinically significant impact in that persons daily
functioning or role/expectation, and which persists
despite efforts in the client, or in the social circle, to
reduce that usage.’
Note that PIU is a complex, ‘end point’ behaviour of a range of
underlying psychiatric/ psychological stressors – and may be a
‘disorder’ in itself in advanced cases
… a big Thank You !!
Current Research and Debate:
 Following the initial Case Reports, formal prevalence studies done
in USA & East Asia, then in Europe.
 Emergence of treatments clinics in late 1990’s in S Korea/ China
 Regarded as a major public health problem across E Asia - deaths
 Clear increase in research volume in the 2000’s; no less than 4
internt’l, dedicated Journals
 Questionnaire development:
- Goldberg 1996 (DSM addictive criteria)
- Young DQ 1998 ( mod. Pathol. Gambling) – 5/8 items positive
- DSM 5 international working group ( Addiction - 2014) –
‘Consensus Criteria for IGD’
… Hard, if not impossible, to devise the ‘perfect’ q’naire
Some key features of an ‘internet addict’:
- Playing increasing hours to get the same ‘hit’
- Going online as soon as wake up
- Impact on daily routines & broader
responsibilities/ duties; disengagement from
family
- Impact on sleep, appetite, social domains
- Lack of insight, minimising & low ability to
accept others’ POV - especially parents
- Irritability, anger, even aggression when
confronted or when restricted in usage/ access
eg. in class, or at home
Current Research Findings:
 Varied data collection methods (internet-based, school, clinics)
 All have inherent biases, and highly dependent on strictness of
criteria employed
 Generally show 2-5% fulfil the criteria for addiction, up to
10% ‘at risk’
 Three longit. studies published to date (Lam 2010, Gentile
2011, Ciarrochi 2015) – focus on outcomes
 Recent focus on assoc. mental health issues, parenting styles
 Australian youth among highest consumers of social media,
worldwide (Nielsen polling 2016); also gaming among highest
and ICT use in education ranked as highest
Brain changes and neuroimaging :
 A small, but increasing number of studies are emerging
 IGD cases controlled to ‘normal’ users; largest had n=50
 Key areas of interest WM tract changes; limbic system dysfunc;
inhibitory/ salience/ risk appraisal loops; multi-tasking and
distraction effects on ‘deeper’ learning and understanding
 Too early to draw clear conclusions, but they do indicate
potentially important changes and cravings in the brain – similar
to that seen in other addictions.
 Concern over young age of exposure and developmental impacts
 Key question is: are these changes permanent?
….If so, should there be closer regulation of heavy gaming/ ICT?
What children really crave in development?
 Rapid/instant feedback is highly reinforcing
 Commercial/ consumer priming: ‘akrasia’ and the
‘disorders of affluence’
 The ‘holy Trinity’ of attraction:
CONNECTION
AGENCY
REWARD
…..and the ‘effort/reward ratio’
 Psychoanalytical: substitute parent; attachment object
 Or, conversely: the ‘secret Zone’ in identity exploration
 Apeirophilia : innate desire for ‘touching the infinite’
 Apeirophilia in
Representational Art :
 Apeirophilia in
Representational Art :
Caspar David Friedrich
‘The Wanderer above the
Mists’ (1818)
Core Gaming principles: the ‘3 Fs’
- FLOW
- FIERO
-FRUSTRATION or
‘FUN FAILURE’
…think of examples of ‘successful games’ !
The ‘Aristotlelean Principle’ ( or
‘engagement curve’ in Flow Psychology)
( – adap. M. Csikszentmihalyi 1990 )
2015 game software revenue. Source: App
Annie
4%
Mobile games $34.8
billion
22%
41%
Computer games
$29 billion
Console games
$18,5 billion
34%
Handheld gaming
devices $$3 billion
Core principles in Social Networking :
 Similar to gaming, SN offers intense reward/ feedback
loop:
the ‘Hyperpersonal Effect’ , plus the ‘Online
disinhibition effect’
 Now an indispensible form of ‘social currency’, espec. in
females: note recent RSPH study on soc media and M Health
 The Zeigarnik Effect – need of our working models for
closure….social media as ‘The Never-Ending Story’ /
endless feedback loop
 SN differs from Gaming in that it can enhance one’s ‘real
life’ socialising, vs. a ‘virtual space’ in gaming: note no
deaths reported from ‘social media addiction’
Bronfenbrenner’s ‘Ecological Model’ of social interactions
(1979):
:
Principles of assessment in
the household and at school
Examining the problem (1):
what are parents reporting and noticing?
 Negative impact on homework, motivation etc
 Spending more time on own; in bedroom etc
 Their ‘personality seemed to change’ over time
 Initially referrals seemed to be nearly all male; now many
females with similar features
 Peak age of clinical referral around 15-17
 Problems often unamenable to reason: lead to anger and
violence
Examining the problem (2):
what are teachers noticing?
 Negative impact on Grades
 Distracted in the class – multitasking; covert gaming/ browsing
 Dozing in class, tired or arriving late
 Ceasing to attend school altogether in extreme cases
 Broader social-role and activity impacts
 Parents raising it as an issue with schools
Examining the clinical problem (2)
- a proposed ‘4-level model’ :
note : early-warning signs important in progression
Level Descriptor
Impacts
Treatment
1
Mild/early
Internal effects, localised
difficulties
Parents/carers
and self-help
2
Moderate
Now noticeable to others,
increasing concerns in some
areas eg. on Grades, sleep
School
Counsellor/
primary
3
Clinical
Co-morbidity likely with other Clinical
disorders; treatment
Psychologist/
indicated / sought
secondary
4
Pathological
Significant psycho-social
impacts, loss of functioning,
inpatient treatment
Psychiatric/
tertiary
Examining the clinical problem (4):
Associated co-morbidities ....
anxiety
anomie
Asperger’s
depression
ADHD
Boredom
Examining the clinical problem (5):
 Schools and individual teacher styles will vary widely in ICT usage
and monitoring , as will parental monitoring
 Note both +ve and –ve aspects of internet usage
 Concept of a ‘sentinel illness’
 The ‘enabler’ (drug use analogy)
 Alongside mental health issues, organisation/ motivation/
procrastination difficulties are common
 All the above are dependent on age, relations issues; bear in mind
gender differences in usage.
PIU and Physical Health:
- Key relevant domains are sleep, weight, and physical
activity
 Sleep: clear, strong recent evidence on suboptimal
adolescent amount; link with m. illness
 Weight: well-established concern. Link with both sleep
and IT overuse, part of broader ‘obesity epidemic’
 Physical activity: ? effect of IT on childrens’ levels of
sport and outdoor engagement. Role of Wii and similar
‘active’ consoles in enhancing is still equivocal
 Myopia ‘epidemic’ espec. In East Asia youth: up to 90% indoor lifestyle, screen (over)use, ‘nature deficit
syndrome’
Children’s sleep and IT usage:
- Sleep medicine now a major clinical area
eg. Circadian Rhythm Disorders/ Delayed Sleep-Phase Disorder
- Emission spectrum from IT is at UV end : wake drive
highly susceptible. ? Use of sleep Apps eg. F.Lux
- Psychological aspects of ‘sleep hygiene’: bedroom as a
restful space, not for ‘entertainment’ ; ability to process
the day’s info
- UK youth sleep clinics report massive increase in adol
sleep problems. Largely attributed to ICT nighttime use
PIU and the physical “health triangle”
PIU
Sleep
Appetite/
weight
Principles of management in
the home :
Emerging treatment models :
 Every case is unique, though many share core features
 CBT (group and individ.); behavioural; insight-oriented approaches
- CBT-IA (K Young, 2011)
 Major & growing self-help literature ( ? industry)
 Key considerations:
- service provider/ specialist input
- individual vs. ‘evidence- based’
- out vs. in-patient
- exogenous vs. endogenous drivers
Addressing the clinical issues (1) :
 Clearly, no ‘one size fits all’ strategy will suffice
 Optimise, and teach, healthy usage at an early age ( ie. Primary
School) and upskilling of teachers and s/c’s
 Address motivation, procrastination & avoidance issues robustly
 Consider whole-school policies/ contracts; involve parents
 The “Healthy Digital Diet” programme:
- student surveys and focus groups; parents survey and workshop;
teacher prof. development; Healthy Digital Diet monthly podcasts ; Termly peerreview discussion groups; optimise ‘positive computing’ in class
Addressing the clinical issues (2) :
 Will usually require a sensitive & holistic hx and family appraisal,
leading to informed Formulation
 Most commonly, an underlying ‘cause(s)’ of the PIU
- > these can be effectively treated ( psychology / psychiatry)
• CBT (both individ. and group) shown to be effective, including l/t
 Medication may be part of Tx ( eg. SSRI; ? Naltrexone, Ritalin )
 Do not hesitate to refer to a MH specialist if worsening
 Lack evidence as to longer-term outcomes / progression / crossaddictions
Addressing the clinical issues (3) :
 Once a detailed ‘internet inventory’ is taken, target specific and
agreed computer and gaming habits/ behaviours
 Family involvement ( age-appropriate) and good modelling
 Aim not to cease all ICT use, but have a balanced, controlled use
 Must also replace ‘internet time’ with a viable healthy alternative
 May use web-monitoring programmes, with consent
 Try to observe the “ Three T’s” - timing ; task-focussed ;
tolerance of uncertainty
Potential Role of School Counsellor:
- S/Cs very well-placed to have central role in complex cases:
-At the ‘coal face’
- Can liaise with families, as well as Education
- ‘Gatekeeping’ role to formal mental health
- Key is trust, rapport, full understanding of technical ‘lingo’
- Use of the IMPROVE tool in assessment
- My own research indicates major concerns/ desire to learn on
PIU: survey of over ~ 100 s/c’s around Sydney
- Part of the broader ‘Educating Generation Wi-Fi’ challenge (
Greg Whitby, Parramatta – recent textbook)
Figure 1 – Respondents’ familiarity with the Internet
and technology
60.0
50.0
Percentage
40.0
30.0
20.0
10.0
.0
Find technology
intimidating and frightening
Series1
3.1
I have learnt a little about
it, enough to get by day-today
38.5
I’m a ‘digital immigrant’
A proud ‘digital native’
55.4
3.1
- This reflects the average age of school counsellors being >56
Figure 2 - Level of interest in area of
Internet/Technology Overuse
70.0
60.0
Percentage
50.0
40.0
30.0
20.0
10.0
.0
Series1
Intrigued but have other
priorities
12.3
Interested; equal priority
with existing issues
64.6
Actively seek information
No response/ NA
21.5
1.5
- This reflects the dynamic role of School Counsellors and the need
for them to be competent with a range of disorders and problems.
.
Figure 3 - Year that Internet/Technology
Overuse problems were first seen.
25.0
Percentage
20.0
15.0
10.0
5.0
.0
Series1
2012
2011
2010
2009
2008
2007
2006
10.8
21.5
23.1
13.8
4.6
7.7
12.3
Don't see a
problem
6.2
- Over 55% of responses have seen PUI be observed in the last 3 years.
- Only 6% have not seen PUI as a problem.
Figure 4 – Approx. number of cases of
Internet/Technology Overuse seen in Counselling role
60.0
50.0
Percentage
40.0
30.0
20.0
10.0
.0
Series1
1 or 2
18.5
3-10
52.3
10-20
13.8
20-50
1.5
More than 50
12.3
No Repsonse
1.5
- 52% of responses indicated they saw between 3 -10 cases, a relatively large
number (12% ) saw over 50 cases. No one indicated they have not seen any
cases of PIU.
Figure 5 - Changes in presentations of
Internet/Technology Overuse over time
Pretty much stayed the same in
the time I have known them
1% 2%
5%
Problems have got a little more
frequent, but not any more
‘serious’ or entrenched
Problems are both a bit more
frequent, and more serious
6%
21%
Problems are a lot more common,
but no more serious
Problems are a lot commoner, and
also more serious
57%
8%
Haven’t seen any/ enough to make
a reasoned judgement
No response/ NA
General agreement that the problem is a) increasing and b) getting more
serious.
Figure 6 - Conceptualisation of Internet/Technology
Overuse problems by respondents
40
35
30
25
20
15
10
5
0
AC - A novel
A symptom, or B - A purely
social and
D - I’m unsure
‘entity’ or
‘secondary
behavioural condition in its at the moment
effect’ of an
underlying
phenomenon
own right
problem
Combination response
11
5
6
2
Single/primary response
26
1
6
14
E- Other
No response/
NA
All of the
above
5
1
1
Mostly seen as secondary issue – tech use seen as an escape? From what?
Trat the source, by harnessing technology! Respondents also indicated not
sure of conceptualisation.
Figure 7 - Conditions believed to be underlying
the Internet/Technology Overuse problems
Childhood depression
8%
Anxiety
8%
Bullying or self-esteem issues
29%
9%
Family Issues
Obsessive-compulsive problems
14%
12%
3%
All are of equal significance and I
cannot rank them
I haven’t seen enough to make a
reasoned judgement
No response/ NA
17%
Even spread of Anxiety, Depression and Bullying as well as Family issues seen
as issues underlying PUI. 17% said all were significant and 30% did not respond
and 12% said they hadn’t seen enough cases to judge.
Figure 8 - Ease of addressing PIU
40.0
35.0
30.0
Percentage
25.0
20.0
15.0
10.0
5.0
.0
Series1
Problem could
be resolved
easily and
effectively
Problem could
only partially be
addressed
Problems were
very difficult to
resolve or treat
1.5
23.1
33.8
I quickly
referred the
child on, so
cannot
comment
3.1
The cases varied
widely so
outcome were a No response/ NA
mixture of the
above
23.1
9.2
Combination
6.2
A third of responses indicated difficulty in addressing cases, over a fifth used
a mixture of approaches. Nearly 10 % did not respond.
Figure 9 – Treatment or referral options used
40.0
35.0
30.0
Axis Title
25.0
20.0
15.0
10.0
5.0
.0
fully resolve the
issues ‘in house’
Series1
4.6
get the family to
be involved in
assisting
33.8
refer to private
psychologist
Other
No response/ NA
All
Combinations
15.4
15.4
12.3
1.5
16.9
- Important role of family as much of the tech use occurs at home and on
private devices. Combination of treatments also used (as expected). Private
referrals popular, but again may be the case in other presenting problems.
Figure 10 – Most common presenting
problem on respondents caseload (top rank)
45.0
38.5
40.0
35.0
30.0
25.0
21.5
18.5
20.0
15.0
12.3
10.0
5.0
3.1
3.1
1.5
1.5
.0
Depression
No response/ NA
Anxiety
School Bullying
Family Issues
Cyberbullying
Unable to rank
Internet and
Technology
Overuse
- Anxiety and depression, then family problems main presenting
issue
Figure 11 - Modalities and approaches used to treating
the Internet/technology Overuse problem
50
45
40
35
Percentage
30
25
20
15
10
5
0
12.0
BSetting
firm
and
clear
limits
and
boundar
ies on
usage
25.0
0
0
ASimply
talking
to and
supporti
ng the
child
Combination of options selected
Single/primary response
CAddressi
ng any
underlyi
ng
problem
eg.
depressi
on
DEnlisting
support
of
families
in limitsetting
ENothing
I tried
worked
FOther
No
respons
e/ NA
All of
the
above
28.0
28.0
6.0
1.0
.0
.0
11
18
7
7
46
11
- Problematic question; many no responses. Many used combination of
techniques. Again it is clear that parental involvement and boundaries are
deemed as important.
Figure 12 - Impact of Internet/Technology Overuse on a
young persons studies/education.
50.0
45.0
40.0
35.0
Percentage
30.0
25.0
20.0
15.0
10.0
5.0
.0
A- Minimal or no
effect
Series1
1.5
B- Some effect
but not enough to
be overly
concerned
26.2
C- Major impact
on their studies
and Grades
D- They almost
ceased attending
school completely
No response/ NA
Combination of
responses
43.1
4.6
10.8
13.8
- 50% claim major to severe impact as a result of PIU.
Figure 13 - Level of Interest in further professional
development on Technology/Internet Overuse
No response/ NA
2%
Combination of
responses
8%
B - Am interested,
but have little time
to do more than a
brief overview
15%
D- I would like
further specific
education in the
area
43%
C- Am
interested, and
will try to read
more on the
topic in free
time
32%
43% indicated wanting specific training in the area, demonstrating the need
for information, clarification and treatment models.
Another 32% indicated they would undertake reading on the topic.
Summary of results:
 School counsellors are actively seeking information on PIU and would like
specific training in the area.
 We are seeing increasing numbers of cases of PIU and the cases are
becoming more serious. These are seen as difficult to treat and require
secondary referral (as would many issues).
 The conceptualisation of PIU is mostly as a secondary effect of an
underlying problem, however that underlying problem was seen as varied or
unknown.
 Family involvement was important in treatment: only a minority required
medical help.
Case vignette and open discussion
 May be an actual specific case, an amalgam of past features, or
a prototype example
 Try to elaborate on the Formulation and associated features
espec education and social
 If relevant, what worked and what didn’t
 Would some of the resources be of use ?
 Future trends and challenges
The psychology of the Internet : ethnocultural considerations
 ‘Western’ vs ‘Eastern’ cultures, values, learning (? simplistic)
 Probable higher intensity, severity and public concern in East
(but note recent multi-centre study – D Gentile et al 2011)
 ‘Hikikomori’ phenomenon in Japan - note predates PIU
 Economic-historical factors; urban living; physical/ metabolic
differences; social pressures on students
......relevancies to Australia – eg. growing number of
international students ; selective-system demographic and
culture ; multicultural pressures
So what should be the role of the
following groups ? :
- schools and education communities
- parents and families
- mental health specialists (public and
private)
- gaming and s. media companies
- government and authority bodies
…so, some conclusions & personal perspectives :
 clearly, a major area of growing educational and public concern
 under-13s remain an under-researched demographic, but likely
very important, espec. in primary prevention
 as yet unclear differences between metropolitan and rural/remote
populations, and gender differences
 e-Sports as major and mainstream ‘player’ in market; changes in
generational attitudes to online time
 likely to require a multi-stakeholder approach (including IT and
computing companies) : ? public policy approaches
 no ‘one size fits all’ approach : “global problems, local
solutions”, within an ever-changing digital and tech landscape
Suggested reading list…
 Cyber Junkie : escape the gaming and internet trap (2010)
-
Kevin Roberts
 Mental Health in the Digital Age (2015) – Starcevic & Aboujaoude Eds.
 ID: the quest for identity in the 21st Century (2008) - Prof Susan Greenfield
 Virtually You: the dangerous power of the E-personality (2012) - Elias Aboujaoude
 Cyburbia: the dangerous idea that’s changing how we live and who we are (2009) James Harkin
 Internet Addiction: a handbook and guide to evaluation and treatment (2010) Kimberly Young & Cris De Abreu (eds.) ; Internet Addiction– a treatment guide (2017)
 Reality Is Broken: why games make us better & can change the world ( 2012) –
Jane McGonigal
 The Video Game Debate (2015) - Kowert & Quandt, Eds.
 PIU in young people : an outline and overview. Tam P, Aust Clin Pscychol June 2016
Thank you!
…. Further
questions and
discussion ?