|Year : 2020 | Volume
| Issue : 4 | Page : 95-99
Guidelines for prevention and treatment of internet addiction in adolescents during home quarantine for the COVID-19 pandemic
Shiqiu Meng1, Ping Dong2, Yaqi Sun3, Yangyang Li1, Xiangwen Chang1, Guangqiang Sun2, Xijuan Zheng1, Yankun Sun2, Yan Sun1, Kai Yuan2, Hongqiang Sun2, Yumei Wang3, Min Zhao4, Ran Tao5, Coreen Domingo6, Yanping Bao1, Thomas R Kosten6, Lin Lu7, Jie Shi1
1 National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
2 Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
3 Department of Psychiatry, the First Hospital of Hebei Medical University, Mental Health Institute of Hebei Medical University, Brain Aging and Cognitive Neuroscience Laboratory, Shijiazhuang, China
4 Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
5 China Youth Psychological Development Base, Beijing, China
6 Division of Alcohol and Addiction Psychiatry, Baylor College of Medicine, Houston, Texas, USA
7 National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University; Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
|Date of Submission||18-Sep-2020|
|Date of Acceptance||10-Oct-2020|
|Date of Web Publication||20-Nov-2020|
Prof. Jie Shi
National Institute on Drug Dependence, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191
Peking University Sixth Hospital, 51 Huayuan Bei Road, Haidian District, Beijing 100191
Source of Support: None, Conflict of Interest: None
The COVID-19 pandemic threatens physical and mental health of adolescents worldwide and has caused increased risks of dependence and addiction on Internet use during home quarantine. Internet addiction has become an important issue in mental healthcare and its prevention and treatment is of great significance for the development of adolescents. We have gathered leading experts in China and developed this guideline to provide references and suggestions to prevent and treat Internet addiction in adolescents during home quarantine and help them get through the pandemic.
Keywords: Adolescents, cognitive behavioral therapies, COVID-19, Internet addiction, prevention, treatment
|How to cite this article:|
Meng S, Dong P, Sun Y, Li Y, Chang X, Sun G, Zheng X, Sun Y, Sun Y, Yuan K, Sun H, Wang Y, Zhao M, Tao R, Domingo C, Bao Y, Kosten TR, Lu L, Shi J. Guidelines for prevention and treatment of internet addiction in adolescents during home quarantine for the COVID-19 pandemic. Heart Mind 2020;4:95-9
|How to cite this URL:|
Meng S, Dong P, Sun Y, Li Y, Chang X, Sun G, Zheng X, Sun Y, Sun Y, Yuan K, Sun H, Wang Y, Zhao M, Tao R, Domingo C, Bao Y, Kosten TR, Lu L, Shi J. Guidelines for prevention and treatment of internet addiction in adolescents during home quarantine for the COVID-19 pandemic. Heart Mind [serial online] 2020 [cited 2022 May 16];4:95-9. Available from: http://www.heartmindjournal.org/text.asp?2020/4/4/95/301134
The following guideline article provides a reference document for schools, families and treatment groups to prevent and treat Internet addiction among adolescents in China and was composed as a joint product of the Committee of Drug Dependence and Abuse of the Chinese Society of Toxicology, the Academic Group of Substance Dependence of the Chinese Society of Psychiatry, the National Institute on Drug Dependence, Peking University, the Peking University Sixth Hospital and Peking University Institute of Mental Health, and the China Youth Psychological Development Base. Because Internet addiction has become a serious problem over the past 10 years in China, South Korea and other parts of eastern Asia and because China has had the most experience in coping with the COVID-19 pandemic, this article may be of great interest to international psychiatrists, physicians, and mental health professionals who provide care to adolescents. The prevalence of this disorder is still evolving in Western countries, and it has also earned recognition as “Internet Gaming Disorder” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and as “Gaming disorder” in the International Classification of Disease, Eleventh Revision (ICD-11).,, During this COVID-19 pandemic, the conditions are optimal for the growth of this disorder among adolescents,,, and early interventions need consideration as the pandemic is moving towards a 2nd year with limited control of its spread in some countries.
The COVID-19 pandemic not only threatens physical health, but also affects mental state of the public due to the home quarantine policies needed to control the spread of this infection.[,,,,, School closing and home quarantine during the pandemic has changed the lives of adolescents, and given them more time and opportunities to access the Internet and to be stressed by this component of their environment.,, According to recent studies, during the pandemic, 46.8% of the general public reported increased dependence on Internet use, 71.3% of treatment seekers with gaming disorder or excessive use of Internet/gaming reported increased time of Internet use, and COVID-19-related anxiety is associated with severity of problematic smartphone use. Nearly 30% children and adolescents reported that they spent more than 5 h per day online during the pandemic, and this increased exposure and dependence may enhance their risks for Internet addiction.,,
Internet addiction seriously damages the physical and mental health of adolescents, and has been identified as a significant public health threat in many countries. While appropriate or limited Internet use is beneficial, excessive, or uncontrolled Internet use is associated with several maladaptive behaviors. As a syndrome, these behaviors are called Internet addiction or problematic and pathological Internet use that significantly interferes with daily life., Internet addiction involves compulsive use of the Internet leading to impairments in academic, professional and social functions. Its clinical features may include failure to control impulsive Internet use, occurrence of withdrawal symptoms when stopping or reducing Internet use, mental symptoms such as depression, anxiety, self-mutilation, attention deficits, hyperactivity, obsessive-compulsive symptoms, hostile or aggressive behavior, cognitive impairment, and social interaction dysfunction. Moreover, both the DSM-5 and ICD-11 recognize this as a serious disorder that is spreading worldwide, and appears to be facilitated with the measures needed for COVID-19 pandemic control.,,,,
| Possible Causes of Internet Addiction? During Home Quarantine in Adolescents|| |
Adolescents are in a period of rapid physical and mental development, during which they can be impulsive, curious, and reckless, with relatively poor self-control and self-discipline making them more vulnerable to adverse environmental influences. The temptation of novel information, games, and entertainment from online Internet sources fuels their desire for independence, communication, and identity. Internet access provides knowledge information, and a virtual platform for stress relief, relaxation, and social interaction. Sense of satisfaction, pleasure, achievement, and accomplishment in adolescents during home quarantine can become linked to the Internet, and some may develop Internet addiction.
Home quarantine with the loss of school structure and shift to online teaching can lead some adolescents to focus on entertainment instead of taking lessons. Parents correspondingly can become anxious and depressed and cause tension, anxiety, depression, insomnia, and related symptoms in their adolescent children. Overall, poor family relations, and lack of parental supervision may also lead to excessive and inappropriate Internet use by adolescents.
| Suggestions to Prevent Internet Addiction in Adolescents During Home Quarantine|| |
Suggestions for adolescents to prevent Internet addiction during home quarantine
Adolescents need education about the harm of Internet addiction. These harms include reduced physical exercise and more irregular eating and sleep habits. They also develop symptoms of inferiority, anxiety, depression, and negative moods. Impaired daily functioning with Internet addiction commonly includes ignoring school study, work, family, social interactions, and life planning.
Adolescents need to arrange their daily life reasonably during home quarantine, work, and rest regularly, eat properly, ensure a certain amount of exercise, and strictly limit time for recreational use of the Internet and avoid excessive use. They can also learn proactively about emotional regulation strategies such as relaxation training, mindfulness meditation, and cognitive therapies. It also helps to set short-term goals and focus on school studies. If adolescents find it difficult to control themselves from problematic or compulsive use of the Internet, they need to seek help from parents and experts. Targeted early prevention of Internet addiction is also needed for high-risk groups with preexisting attention deficit and hyperactivity disorder (ADHD), depression, anxiety, and substance use disorders.,
Suggestions for schools to prevent Internet addiction in adolescents during home quarantine
While teaching online which increases Internet use in adolescents inevitably, teachers should try to prevent Internet addiction in adolescents by assigning homework that can be accomplished offline, and educating students to reduce recreational Internet use. Schools should include mental health education as a part of online courses, targeting adolescents who have difficulties controlling themselves. Teachers should help adolescents to set overall and incremental achievement goals, to allow quick successes and thereby enhance their sense of self-worth. Besides imparting knowledge, teachers can also improve adolescents' coping with stress and psychological problems including those related to decreased communication between classmates and friends. By inquiring about study and life situations of adolescents, teachers can provide guidance on healthy social interactions and on establishment of proper online relationships.
Suggestions for parents to prevent Internet addiction in adolescents during home quarantine
Parents can reduce Internet access and prevent Internet addiction in adolescents by limiting their recreational Internet use. Upper limit of time of Internet use excluding that of taking online courses can be set reasonably, and automatic shutdown of Internet access can be used when the limit is reached. Parents can also create website blacklists, or use keyword filtering and software restrictions to protect adolescents from harmful information. Meanwhile, parents should set an example for their children, and spend less time on their phone or on the Internet, and instead communicate more with their children and pay close attention to mood changes of their children. Good family relationships, a warm emotional atmosphere and relaxed communication can prevent development of Internet addiction.,
| Intervention Suggestions for Internet Addiction in Adolescents During? Home Quarantine|| |
Assessment of Internet addiction
Two scales are commonly used to assess Internet addiction. The Internet addiction test has 20 items covering preoccupation, compulsive use, behavioral problems, emotional changes, and impaired functions. Each item is rated on a 5-point scale (1 = rarely to 5 = always), and the total score ranges from 20 to 100, with scores above 50 indicating Internet addiction. Another widely used scale is the Revised Chen Internet Addiction Scale, which contains 26 items with five dimensions: tolerance, withdrawal symptoms, forced Internet access, time management, and interpersonal health. Each item has a 4-point scale, and the total score ranges from 26 to 104, with a score above 63 indicating Internet addiction.
Cognitive behavioral therapies
Cognitive behavioral therapies (CBT) are used for many psychiatric disorders, including Internet addiction. CBT for Internet addiction follows Davis' cognitive-behavioral model of Internet addiction, and a professional psychotherapist typically conducts it. CBT is effective in treatment of Internet addiction, and combining CBT and other treatments such as online support groups and family therapies described below may further lead to augmented effects. During the pandemic, parents can conduct CBT for their children at home under the remote guidance of a psychotherapist.
The basic assumption of cognitive therapies is that cognitive processes are an intermediary between behavior and emotional response. Abnormal behavior and emotional responses are related to maladaptive cognition. The task is to help adolescents discover their inaccurate perceptions and correct them, thereby improving their behavior and emotions. Specific implementations of CBT can include motivational interviewing (MI), daily activity planning and happiness assessment.
Adding MI to CBT has strong empirical support in addictions., Therapists use MI to elicit self-motivational statements, handle resistance to reducing Internet use, examine helpful and unhelpful aspects of Internet use, and explore costs and benefits of changing Internet use in the context of adolescent values. Reminder cards (or “flashcards”) that summarize treatment goal(s) and/or list a self-motivational statement may be useful.
Daily activity planning is also helpful. Parents and adolescents negotiate the activities that adolescents can complete for each hour and each day. Difficulty and requirements of the activities can increase with improvement of abilities and mood of adolescents. This method can not only help adolescents to promote their time management skills, but also disrupt their negative emotions. Preoccupation of adolescents with the Internet may be an obstacle to identifying alternative ways of spending time. Creation of a personal inventory of activities conducted before Internet addiction may be helpful. For adolescents without a history of other interests or hobbies, new activities that cater to their strengths or competencies can be explored.
Happiness assessment is often used in conjunction with daily activity planning. Adolescents are asked to fill out daily activity records. Two columns are added next to each of the activities for evaluation, one column lists scores for mastery or difficulty (0–5-point scale, 0 for the easiest, 5 for the most difficult), and the other column lists scores for happiness (0–5-point scale, 0 means no pleasure at all, 5 means very pleasant). Through assessment, most adolescents may find that there are many more interesting activities, and meanwhile, the assessment can also play a role in testing cognitive distortions.
Behavioral therapies eliminate or correct abnormal behaviors through repetition training of individuals in normal behaviors. The theory holds that we can renormalize abnormal behaviors by retraining individuals (re-learning and reconstructing conditioned reflexes to make individuals adapt to environmental stimuli), and in some ways by changing the environment or adverse stimulation. During home quarantine, behavioral therapies can be regarded as a “parent-child game” to keep adolescents away from Internet addiction. Several specific behavioral therapy techniques are shaping therapy, the token and model methods, relaxation training and cognitive distraction.
Shaping therapy corrects behaviors through rewards (i.e., reinforcement) for attaining goals that increase expected good behaviors until the final desired behavior change is achieved. The critical components are to clearly define appropriate final and intermediate behaviors and find sufficient rewards for reinforcing each step.
The token method also uses an immediate reward system, when adolescents complete expected behaviors. Tokens function like “money” in real life for adolescents to exchange for the items they need or the activities they are interested in. As examples, when young people reduce their time spent online, or finish homework and other things before turning on the computer, they will get tokens, and when a certain number of tokens are reached, they can exchange them for something they really want or to engage in favorite activities.
The model method involves adolescents learning a model behavior by observing the role model, and correct maladaptive behavior. As a simple example, parents should set a good example, and avoid spending too much time online while restricting adolescents from using the Internet, and modify and/or curb excessive use of both their own and the adolescents.
Relaxation training consciously controls one's own psychophysiological activities, reduces the level of arousal, and improves disordered physical functions. By inducing a relaxing physical and mental state, it helps young people abandon inappropriate cognitive models and self-consciousness. An illustration of progressive muscle relaxation training starts with taking a comfortable sitting or lying position, gradually contracting the muscles of each part of the body for 5–10 s from the top to the bottom following prompts, while inhaling deeply and experiencing the feeling of tension. This tension induction is followed quickly and completely by relaxing for 20–30 s while exhaling deeply and experiencing the feeling of relaxation, and then repeating the cycle again.
Cognitive distraction involves helping adolescents to draw their attention away from the Internet-related cues by focusing on other thoughts. The goal is to improve regulation and control of attention. Examples may include focusing on relaxing or pleasant images or on a memory of a positive event. They should practice this skill so that they can easily be able to switch attention to such thoughts in a high-risk situation.
Online support groups
During home quarantine, adolescents with substantial risk factors for Internet addiction, which include poor academic performance, protective parenting style, anxiety/depression symptoms, inter-parental conflict, not living with their mother, and being allowed to use the Internet for more than 2 h/day by parents or caregivers, can benefit from online group psychological interventions. Group interventions include educating young people by providing them comprehensive knowledge and information about the advantages and disadvantages of Internet use, exploring and clarifying the boundaries between Internet use and Internet overuse, and practicing skills for making decisions, setting life goals, communicating, rejecting, and resisting stress. A group setting during home quarantine would use an Internet application such as ZOOM, Adobe-connect, WeChat, or other commercial products to allow group interactions. These groups may be helpful in reducing feelings of shame, guilt, worthlessness, and isolation related to Internet addiction symptoms in adolescents. Group settings are often employed in treating addiction because they foster the supportive, nurturing, and nonjudgmental environment needed for recovery.
Family therapies focus on modifying and adjusting relationships between family members through the supervision of professionals. The process needs to establish a monitoring and evaluation mechanism involving both parents and adolescents. The monitoring and evaluation include time spent online, completion of each specific goal in the plan, and self-experience at different stages of treatment. The evaluation needs to occur at fixed time periods during the weeks of treatment. Implementation of plans is the most important part of the entire intervention, and making these plans requires full discussion with the adolescent about how to achieve the goal of correction. Without obtaining the approval of the adolescent, temporarily reducing Internet overuse will not last long.
Interventions for physical and psychiatric comorbidities with Internet addiction
Adolescents suffering from Internet addiction are prone to physical problems including circadian rhythm disorders, malnutrition, gastric ulcers, and even epilepsy, due to long-term use of the Internet, restricted outdoor activities, and irregular work and rest, especially during home quarantine. Adolescents with severe Internet addiction may also develop lower limb venous thrombosis due to months of sedentary living. Should such medical complications occur, they need to go to a professional institution for treatment as soon as possible.
Psychiatric comorbidities such as ADHD, depression, anxiety, sleep disorders, and social disorders need more attention. If the symptoms are prominent and seriously affect normal life, the parents should seek treatments for the adolescent from specialized institutions, including pharmacotherapy or psychological treatment. Those with mild symptoms often can actively deal with negative emotions by engaging in regular aerobic exercises, relaxation training, mindfulness meditation exercises, and some of the previously indicated therapies. Investigations are needed to monitor mental health status over the long term, and study how prolonged school closure, strict social distancing measures, and the pandemic itself affect the wellbeing of adolescents.
The Internet is a double-edged sword. It provides useful information, insights, and educational materials to cultivate good qualities, but may produce harmful impacts in adolescents with improper use especially during home quarantine for COVID-19. Families, schools and societies need to work together to help adolescents use the Internet properly, prevent or treat Internet addiction, get through the pandemic, and stay physically and mentally healthy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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