Study of Internet addiction in children with attention-deficit hyperactivity disorder and normal control.

BACKGROUND: In the current era, the use of electronic media in the form of Internet has increased exponentially, particularly among children, and has led to their excessive involvement in Internet. In this context, attention-deficit hyperactivity disorder (ADHD) children were found to have increased tendency for this addiction. AIMS AND
OBJECTIVES: The aim is to study and compare Internet addiction between ADHD and normal children and the relation of demographic profile to Internet addiction.
MATERIALS AND METHODS: This was a cross-sectional study including 100 children (50 ADHD cases and 50 normal children without any psychiatric illness as controls) between the ages of 8 and 16 years. A semi-structured pro forma for demographic profile and Internet usage using Young's Internet Addiction Test (YIAT) was used. Statistical analysis was done using SPSS 20.
RESULTS: Internet addiction among ADHD children was 56% (54% having "probable Internet addiction" and 2% having "definite Internet addiction"). This was statistically significant (P < 0.05) in comparison with normal children where only 12% had Internet addiction (all 12% had "probable Internet addiction"). ADHD children were 9.3 times more prone to the development of Internet addiction as compared to normal (odds ratio - 9.3). Significant increase in average duration of Internet usage in ADHD children with increasing score of YIAT (P < 0.05) was seen. The incidence of Internet addiction was more in male ADHD children as compared to normal (P < 0.05).
CONCLUSIONS: ADHD children are more prone to Internet addiction as compared to normal children and thus require preventive strategies.

Children and adolescents these days are getting easy access to Internet. The use of Internet has become a must part of our daily lives. Easy availability of Internet has problems of its own which psychiatrists throughout the world have started to notice recently. This has an addictive potential.

While maximum makes the use of the Internet in a controlled fashion, a progressive loss of the ability to control the frequency and duration of Internet activities emerges in some users. As a consequence, the excessive time devoted to Internet use and the behavioral narrowing can lead to serious psychosocial outcomes. This phenomenon is referred to as “Pathological Internet Use” (PIU) by Petersen[1] or “Internet addiction.”

Studies from different parts of the world suggest that overall prevalence of Internet addiction in adolescents ranges between 2% and 18%.[23456]

Cross-sectional studies on samples of patients with psychiatric disorders report high comorbidity of PIU, for example, affective disorder and attention-deficit hyperactivity disorder (ADHD).[1] Internet addiction is associated with ADHD, depression, and hostility in males, while it is associated with ADHD and depression in females.[7]

Teens with ADHD are at even greater risk for developing this compulsion.[7] Adolescents who are addicted to the Internet are more likely than nonaddicted teens to engage in self-injurious behaviors such as hitting themselves, pulling their own hair, or pinching or burning themselves.[8]

South Korea considers Internet addiction as one of its most serious public health issues. Using data from 2006, South Korean government estimates that approximately 2,10,000 South Korean children (2.1%; ages 6–19) are afflicted and require treatment. About 80% of those needing treatment may need psychotropic medications and perhaps 20%–24% require hospitalization.[9] Results reveal that, based on studies conducted in China, Hong Kong, Taiwan, and Korea, there are about 12% of Asian youth who are addicted to the Internet.[10] China is also greatly concerned about the disorder. As a result, in 2007, China began restricting computer game use; current laws now discourage more than 3 hours of daily game use.[9]

Internet addiction appears to be a common disorder that merits inclusion in DSM-5.[911] Due to the lack of methodological and sufficient research, currently, there are no specific guidelines for the management of PIU.[1]

India has a huge number of Internet users, with an exponential increase of Internet usage and online activity by the younger generation as a principal modality of social interaction in the current era. A study conducted in Gujarat (India) showed that the prevalence of Internet usage among school-going adolescents is 98.9%; however, the prevalence of Internet addiction was 8.7%.[12]

The data of Internet addiction and associated elements still are not robust. This study aims at examining Internet addiction in normal and ADHD children and its relation to sociodemographic variants in an Indian setting.

MATERIALS AND METHODS

Study design and setting

It was a cross-sectional study carried out in the psychiatry and pediatric outpatient department (OPD) of a tertiary care teaching municipal hospital, after obtaining institutional ethics committee approval. In the psychiatry OPD, a child clinic runs, especially to address the psychiatric issues in children and adolescents.

Study participants

A total of 100 children, aged 8–16 years, who had access to Internet usage, were included in the study. Fifty consecutive children from pediatric OPD who were ruled out for ADHD and other psychiatric comorbidities according to the DSM-5 criteria were included as controls. Fifty consecutive children from child psychiatry clinic, diagnosed with ADHD according to the DSM-5 criteria, were taken in the second group. Any child having any unstable or chronic disabling physical condition was excluded from the study. The diagnosis of ADHD was further objectively supported through Conners' Rating Scales for ADHD. Children with any other psychiatric morbidity or chronic/unstable medical illness were excluded from the study. A written informed consent from the parents of the child and assent from the child were taken before commencing the study. Interview was conducted by a single interviewer in a single setting.

Materials

Semi-structured pro forma: To capture the demographic and pattern of Internet usage details

Young's Internet Addiction Test (YIAT.): Developed by Dr. Kimberly Young, it is a validated and reliable measure of addictive use of the Internet. Cronbach's α is >0.9.[131415] YIAT is a twenty-item questionnaire that assesses Internet use in terms of the degree of preoccupation, inability to control use, extent of hiding or lying about online use, and continued online use despite negative consequences of behavior.[16] Each item asks respondent the level of selected symptoms/psychological states which are scored as – does not apply (0), rarely (1), occasionally (2), frequently (3), often (4), and always (5). The total score measures the Internet usage as an average user (score 20–49), frequent problems (score 50–79), and significant problems (80–100). As defined in other studies, we defined the “Internet addiction” group as YIAT score ≥50 and the “Internet nonaddiction” group as YIAT score ≤49 and Internet addiction can be further subgrouped into ‘probable internet addiction with frequent problem’ group (when score is 50-79), and ‘definite internet addiction with significant problems' (score 80-100).[1]

Conners' Parent Rating Scales-Revised Short (CPRS-R:S): To assess the severity of ADHD, the CPRS-R:S was completed for the patients. CPRS-R:S which has been used in this study has 27 questions and 5 subscales including opposition, cognitive problems, inattention, hyperactivity, and ADHD index.[17] Internal coefficients have been reported in a range of 75%–90%, and test–retest reliability coefficients with the 8-week interval have been achieved in a range of 60%–90%.[18]

Statistical analysis

Descriptive statistics, Pearson's Chi-square test, and one-way ANOVA were used to analyze the variables.

RESULTS

Sociodemographic and Internet usage pattern

The demographic profile and Internet usage pattern of the participants were assessed. The sample had a male preponderance that is 74%, of which 43% had ADHD and rest (31%) were controls. More than half of them belonged to the age group of 11–13 years (52%), followed by 39% belonging to 14–16 years and rest in 8–10 years' category. Sixty-nine percent of them belonged to nuclear family. Home was the most common place of Internet usage (78%); school, cyber cafe, and friend's house were other places where children used Internet. Most of them (55%) used Internet alone without any supervision.

Comparison of Internet addiction between attention-deficit hyperactivity disorder and control group

Mean YIAT score of ADHD sample was 50 and of normal children 30; this difference was statistically significant (P = 0.001). The sample mean for ADHD children pointed more toward “probable Internet use” and that of normal children toward “average use.”

Studying the distribution of the participants based on the grading of YIAT score, a large number (56%) of ADHD children were found in Internet addiction range as compared to the number in normal group (12%); the difference was statistically significant (P < 0.001). ADHD children were found to be 9.3 times more prone (odd's ratio) to get addicted to the Internet as compared to normal children.

Distribution of sample based on Young's Internet Addiction Test

The mean duration of hours of Internet usage in the normal and ADHD group based on their categories of YIAT scores is depicted in Table 1. The scores in the ADHD group show that children having higher scores on YIAT have higher mean duration of Internet usage, and the difference among the various subgroups is statistically significant (P = 0.002). However, in the control group, the difference is not significant (P = 0.667). The average duration of time spent on Internet is higher in definite Internet addicts, i.e., 21 hours/week as compared to probable Internet addicts, where it was 12.53 hours/week.

Table 1

Gender distribution and average duration of Internet usage with respect to Young's Internet Addiction Test scores in attention-deficit hyperactivity disorder and control groups

Comparison based on gender shows that the number of male ADHD children (n = 25) in “frequent problem” category on YIAT scores is more as compared to normal children (n = 3), and this difference is statistically significant (P = 0.008), suggesting that male ADHD children probably have higher propensity toward Internet addiction. However, in case of female children, no considerable difference was observed [Table 1].

Considering the distribution as per the age [Table 2], there is statistically significant difference between the ADHD and the control group in the nonaddicted range of YIAT scoring, i.e., score <50 (P < 0.05). The number of children beyond the age group of 11 years (i.e., 11–16 years) using Internet was although high, but it was not problematic or addictive use. This could be attributed to the understanding of how to use Internet according to the needs after a certain age. Similarly, the distribution of ADHD sample in the age group of 11–16 years is higher (although not statistically significant difference) than the control group in the probable Internet addiction range (i.e., frequent problems). This result could be attributed to the lack of judgment and impulsivity seen in ADHD children.

Table 2

Age-wise distribution of grading of Young's Internet Addiction Test score in the study groups

Similarly, no statistically significant comparison was observed in family type, place of Internet use, and usage (alone/accompaniment/supervision) with grades of YIAT score.

DISCUSSION

In line with previous studies,[7192021] we found that Internet addiction was higher in children who had ADHD (in the age group of 8–16 years), such that they are 9.3 times more prone to get addicted to Internet as compared to normal children. One such study including more than 2000 seventh graders having similar findings suggested certain plausible explanations for it: children with ADHD have lack of self-control and require instant gratification, which is provided by Internet through option to surf multiple participants simultaneously.[7] Furthermore, Internet and social media temporarily provide an emotionally and socially safe platform to children to escape from their daily hassles and obligations, becoming a faulty coping mechanism for their stress and fears.

Previous literature also suggests that Internet addiction in ADHD children can also be attributed to behavioral and cognitive dysregulation. Behavioral dysregulation was observed in the form of deficits of attention, planning, working memories, self-monitoring, and judgment.[222324] Internet provides an ever-changing, multimodal means of instant gratification with minimal delay fits into the cognitive model of ADHD children hypothesized by Sonuga-Barke.[25] In addition, excessive Internet usage is maintained over a long period through stimulatory effects on reward and sensitization as ADHD children are hypothesized to have low dopamine availability in the brain reward system, which is overcome to an extent by dopamine secreted at reward center following the instant gratification.[26]

We found that male ADHD children had a greater propensity for Internet addiction, which is in accordance with previous studies.[19] This suggests that ADHD or specifically male ADHD is a potential risk factor for Internet addiction.

Considering the duration of time spent on Internet, we found it higher in definite Internet addicts, which is in accordance with earlier studies.[212728] A recent study having the similar sample groups as ours showed similar findings.[29] The prolonged hours of Internet use in ADHD children further reinforce the inattention, quick responsiveness, and instant rewards. Dalbudak and Evren found that severity of Internet addiction was related to the severity of the ADHD symptoms and suggested impulsivity as the mediator in this relationship.[30]

Thus, taking into prior consideration of ADHD features increasing Internet addiction and later consideration of prolonged hours of Internet use consolidating inclination to impulsive, rapid, and hyperfocused reactivity, it could be inferred that ADHD features and Internet addiction may share a bidirectional relationship.

CONCLUSIONS AND IMPLICATION

It is apparent that Internet addiction is higher in children with ADHD, especially boys, as compared to normal children. Thus, it seems imperative to watch out for Internet use and possible addiction in ADHD children. The converse is also true that if a parent complains of excessive Internet use, then it should alert a clinician to probe for comorbid ADHD. However, longitudinal studies with larger sample involving multiple sites including the possibility of constructive Internet use in ADHD children to understand complex tasks and social cues could be explored and would give more generalizable results. Furthermore, studies on limit setting, as far as time is concerned, may help understand their specific needs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.