INTRODUCTION

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, mal-adaptive or addictive internet usage which is a condition also known by terms such as Problematic Internet Use (PIU), internet addiction, internet dependence, and pathological internet use.[2]

Particularly among adolescents, the internet is observed to be increasingly adopted as a readily accessible means for information retrieval, entertainment, and socialization.[3] As adolescents allocate ever increasing time periods for internet use, the risk for developing mal-adaptive internet use (MIU), including potential PIU and PIU, is inherent.[4] Beard and Wolf defined PIU as use of the internet that creates psychological, social, school, and/or work difficulties in a person's life.[5]

The proposed criteria for PIU initially included: (1) An uncontrollable use of the internet, (2) internet use which is markedly distressing, time consuming or resulting in social, occupational, or financial difficulties, and (3) internet use not solely present during hypomanic or manic clinical episodes.[6] Hence, PIU is conceptualized as an individual's inability to control his/her use of the internet, thus causing marked distress and/or functional impairment.[7] Potential PIU is defined as internet use which fulfils some of the PIU criteria.[8]

Worldwide, the prevalence of PIU among adolescents and young adults has been observed to range between 0.9%[9] and 38%.[10] International estimates of adolescent PIU vary widely. In Europe, the prevalence has been reported to be between 1% and 9%[11], in the Middle East the prevalence is between 1% and 12%,[12] and in Asia the prevalence has been reported to be between 2% and 18%.[13] As one of the common mental health problems among Chinese adolescents, PIU is currently becoming more and more serious.[14]

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. High-risk Internet users have inappropriate dietary behavior and poor diet quality, which could result in stunted growth and development.[15] PIU was also associated with other potential addictive personal habits of smoking, drinking alcohol or coffee, and taking drugs.[16] Internet use in adolescents was associated with more severe psychiatric symptoms,[17] and interpersonal problems.[18]

METHODS

RESULTS

Among the study population (n = 605), there were 396 (65.5%) male students and 209 (34.5%) female students. The mean age ± standard deviation (SD) of adolescents with PIU did not significantly differ from that of their normal Internet user counterparts (16.9 ± 0.3 years vs. 16.49 ± 0.8 years, F = 2.4, P = 0.09). Approximately 2.6% (16) were identified as PIUs and males comprised 87.5% among them, while 110 (18.2%) were identified as potential PIUs and most of them were males (70%). Mostly of PIUs their fathers have professional work (93.7%) and their mothers were housewives (68.7%). Beginning age of Internet use was earlier among PIU students than normal Internet users (12.2 ± 1.9 vs. 13.25 ± 1.9, F = 3.5, P = 0.03). With respect to the locations of Internet access, most of the participants owned and frequently used computers in their homes and adolescents with PIU were significantly more likely to access the Internet via their own home portal as compared to normal Internet users [Table 1].

Table 1. Socio-demographic characteristics based on level of internet addiction among the students

As shown in Table 2, PIU was significantly associated with a series of variables: Low social friends (62.8% vs. 19.8%, X² = 40.6, P = 0.001), bad family relations (43.8% vs. 20.3%, X² = 5.2, P = 0.07), irregular bedtime (62.5% vs. 2.5%, Fisher's Exact Test = 189, P = 0.0001), and bad personal hygiene (50% vs. 16.7%, X² = 26.7, P = 0.0001). Moreover, the proportion of adolescents with PIU reporting excellent academic performance was lower than that among normal Internet users (6.5% vs. 20.9%, X² = 16.2, P = 0.03).

Table 2. Lifestyle patterns based on the level of internet addiction among the students

Most of PIUs answered that their dietary habits had been changed to have small meal sizes, a poor appetite, and faster eating speeds than normal Internet users (X² = 43.4, P = 0.001, X² = 32.6, P = 0.001, and X² = 13.01, P = 0.01, respectively). PIUs had a higher percentage of skipping breakfast (62.5% vs. 33.4%, X² =6.6, P = 0.03) as shown in Table 3.

Table 3. Dietary habits based on the level of internet addiction among the students

Table 4 showed the percentage of some physical and emotional symptoms among adolescents with PIU, potential PIU, and normal Internet use. Compared with normal Internet use, adolescents with PIU were more likely to suffer from physical symptoms; weight gain (31.2% vs. 15.9%, X² = 8.5, P = 0.01), joint stiffness (12.5% vs. 2.9%, X² = 6.3, P = 0.04), lack of physical energy (43.7% vs. 24.6%, X² = 14.9, P = 0.001), back pain (62.5% vs. 39.5%, X² = 5.7, P = 0.05), eye strain (62.5% vs. 34.03%, X² = 18.6, P = 0.0001), and emotional symptoms; feeling sad (25% vs. 5.6%, X² = 22.1, P = 0.001), feeling excited (68.7% vs. 12.1%, X² = 85.1, P = 0.001), euphoric (18.7% vs. 5.4%, X² = 17.7, P = 0.001), and anxious (6.25% vs. 8.03%, X² = 9.17, P = 0.01).

Table 4. Physical and emotional health problems caused by internet use among students

Determinants of potential PIU and PIU: The multinomial logistic regression analysis [Table 5] indicated that father's professional work, poor family relation, male gender, and limited social friends were independently associated with potential PIU and PIU.

Table 5. Multinomial logistic regression analyses for identifying the determinants of internet addiction among students

DISCUSSION

The Internet is extremely an important social and communications tool, and is changing our daily lives at home and at work. There is no doubt that some Internet users develop problematic behavior.[21] There is no an epidemiological study on PIU neither in general nor in adolescence in Egypt. In light of these findings, this study was conducted in order to assess the prevalence of PIU among high school students and to determine the personal, clinical, family, and social characteristics of PIU among adolescents.

The study participants were 605 high school students. Most of the participants owned and frequently used computers in their homes. Three types of Internet users were identified in this study: Normal, potential PIUs, and PIUs. The prevalence of PIU among adolescents was 2.6%, which is closely related to that reported by some other studies of Internet use among students worldwide; such as PIU was 1% in Greece[1], 4% in South Korea,[22] 3.1% in Finland,[23] 4.2% in Lebanon,[24] and 4.6% in Australia.[25] Its lower percentage may be attributed to the limited access of computer/Internet access among urban Egyptian youth. However, marked international variances regarding the prevalence rates of PIU may also be attributed to a measurement bias incurred by a lack of international consistency regarding both the definition and assessment of PIU[26] and to different samples and social contexts. Furthermore, among the study population examined about 18.2% of adolescents were identified with potential PIU which is slightly lower than what found in another study; that approximately one-fifth (19.4%) of adolescents were identified with potential PIU.[4]

Empirical studies have suggested gender as a predictive factor of PIU. Previous study has found that male Internet users were more subject to PIU.[1] In contrast, another study contended that females were more prone to PIU than males.[27] However, one study found no gender differences in relation to internet addiction (IA).[28] This study supports the general literature that males tend to be more subject to PIU and the explanation for this may be that males are more likely to play online games, engage in cybersex, and gamble online.

According to Korean scientists, the causes of PIU do not have only habitual bases, but also demographic and socioeconomic.[11] The present study partly confirmed this by the finding that parents’ work and students who have higher number of siblings were more in danger of PIU.

This study shows that PIU adolescents at were much more likely to have interpersonal problems, as PIU was significantly higher among adolescents had poor social friends and family relations. Researchers state that widespread use of the Internet among the adolescents makes them feel alone, causes problematic behaviors, and leads to poor family and friends relationships.[29] High parent-adolescent conflict predicted PIU in adolescents; as adolescents with a higher conflict level with their parents refused to obey the supervision of their parents, including the rules set for Internet use.[30]

High-risk Internet users reported more irregular sleep patterns and more episodes of sleep disturbance than no risk Internet users. This is consistent with a previous study of Korean adolescents that showed that PIU was associated with insomnia, apnea, and nightmare.[31] 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.[32]

In this study, PIU is more among adolescents who had skipping breakfast habit. This finding seems reasonable since PIU stay up late at night and may get up too late for breakfast.[33] The high frequency of snaking could be related to skipping meals, more frequent snacking was observed in PIUs than normal internet users. Moreover, the favorite snacks of our participants were fast food, which are nutritionally poor foods with high calories provided by fats and simple sugars but with few other nutrients such as vitamins and minerals. Thus PIUs have improper dietary behaviors that could impact their growth and development. This is matched with a study found that PIU had the lowest meal regularity, reflected by a higher rate of snaking than in normal Internet users.[15]

Children and adolescents carry a much higher risk for negative effects of PIU than adults due to incomplete developmental processes. Our study found adolescents with PIU were more likely to suffer from physical symptoms, such as lack of physical energy (students may look overly tired or sleep in class because of all-night Internet sessions), change of sleep pattern,[34] back strain, and eye strain from the long periods of sedentary computer use. This risk was reported to increase by excessive Internet and computer use.[35] PIUs may be depressed, withdrawn, or anxious as a result of both the physical and psychological toll of the PIU.[36]

Frequently and increasingly PIUs cut themselves off from their family, friends, and social activities and choose to spend most of their time alone. This study shows that father's professional work, and poor family relation were the most contributing risk factor of PIU, these results may suggest a relationship between a poor social support system and PIU.[37]

Some potential limitations have also been identified in this study. First, this study was a cross-sectional study, therefore, we could not confirm causal associations between PIU and its consequences. Second, the questionnaire was self-reported and is subject to recall or report bias. Third, since the survey was administered during class time, it is possible that some students, especially those had PIU, were absent from class when the questionnaire was administered. Therefore, the survey may have under-represented PIU by failing to record the responses of those who are so consumed by the Internet that they rarely leave their rooms, thus leading to an underestimation of the prevalence of PIU. Future studies should attempt to determine implementation of preventive measures, and the development of treatment approaches for PIU.

CONCLUSION

PIU is not rare among Egyptian high school students. Adolescents with PIU had an augmented likelihood to report poor social and familial relationships, and enhanced risk for some physical and emotional health problems.