You are on page 1of 6

Longer term effect of randomized, controlled

group cognitive behavioural therapy for Internet


addiction in adolescent students in Shanghai

Ya-song Du, Wenqing Jiang, Alasdair Vance

Objective: The aim of the present study was to evaluate the therapeutic effectiveness of
group cognitive behavioural therapy (CBT) for Internet addiction in adolescents.
Method: A total of 56 patients, who met Beard’s diagnostic criteria for Internet addiction, aged
12–17 years, were divided randomly into an active treatment group (n = 32) and a clinical
control group (n = 24). Participants in the active treatment group were treated with an eight-
session multimodal school-based group CBT while participants in the clinical control group
received no intervention. Internet use, time management, emotional, cognitive and behav-
ioural measures were assessed for both groups at baseline, immediately after the intervention
and at 6 month follow up by investigators blind to the participants’ group status.
Results: Internet use decreased in both groups while only the multimodal school-based
group CBT evinced improved time management skills and better emotional, cognitive and
behavioural symptoms.
Conclusions: Multimodal school-based group CBT is effective for adolescents with Inter-
net addiction, particularly in improving emotional state and regulation ability, behavioural
and self-management style.
Key words: group cognitive behavioural therapy; Internet addiction, randomized controlled
trial.

Australian and New Zealand Journal of Psychiatry 2010; 44:129–134

The Internet has become one of the most common, addiction, have emerged, especially in the adolescent
expeditious and important communication tools of our population [1–5]. Internet addiction was initially
global society. Despite its manifest benefits, a particular described by Young as a variant of pathological gambling
set of behavioural overuse problems, termed Internet without an associated alcohol and/or substance depen-
dence disorder [2]. Beard and Wolf outlined some modi-
Alasdair Vance, Professor (Correspondence) fications to Young’s approach that enhanced the validity
Academic Child Psychiatry Unit, Royal Children’s Hospital, University and reliability of the Internet addiction diagnosis [1].
of Melbourne, Gatehouse Street, Parkville, Vic. 3052, Australia. Email:
avance@unimelb.edu.au These criteria have become established in the field.
Ya-song Du, Professor
Recently, the American Psychiatric Association recom-
mended that three or more of seven key criteria are
Department of Child and Adolescent Psychiatry, Shanghai Mental
Health Center, Shanghai Jiao Tong University, Shanghai, China; required for a diagnosis of Internet addiction disorder.
Academic Child Psychiatry Unit, Royal Children’s Hospital, University These include being preoccupied with the Internet (thinks
of Melbourne, Murdoch Children’s Research Institute, Melbourne,
Victoria, Australia about previous online activity and/or is anticipating the
Wenqing Jiang, Child and Adolescent Psychiatrist next online session); spending increasing amounts of
Department of Child and Adolescent Psychiatry, Shanghai Mental time on the Internet in order to feel satisfied; making
Health Center, Shanghai Jiao Tong University, Shanghai, China unsuccessful attempts to control, cut back or stop Internet
Received 27 February 2009; accepted 10 June 2009. use; social, occupational, recreational activities decreased,

© 2010 The Royal Australian and New Zealand College of Psychiatrists


Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on April 8, 2016
130 GROUP CBT FOR ADOLESCENT INTERNET ADDICTION

given up or employment threatened by Internet use [1]. 30 in each group. Power calculations based upon previous Internet
Recent studies in China have shown Internet addiction to overuse self-rating scale studies yielded moderate effect sizes
have the highest point prevalence in adolescence compared (d = 0.55–0.85; d = M1-M2/σpooled, where spooled = s 2 ⫹s 2 / 2 and
1 2
M1 and M2 represent means in untreated and treated patient groups,
to other life stages [3–5]. Further, there is a significant
respectively) suggesting that 60 young people (30 active group) and
positive correlation between the level of emotional and
30 clinical control participants were required for an experimental
behaviour problems and the severity of Internet addiction. power of 0.80. There were 28 boys and four girls (mean age of
These problems include increased social anxiety, increased 15.39 ± 1.69 years) in the active group and 17 boys and seven girls
irritability, increased hyperactivity, impulsiveness and (mean age of 16.63 ± 1.23 years) in the control group. The two groups
aggression, increased interpersonal sensitivity, increased did not differ in age, gender composition or educational level. The
difficulties making and maintaining friendships and multimodal school-based intervention was completed in the active
decreased self-esteem. In addition, decreased organizational group schools while there was no school-based intervention in the
and strategizing ability and time management skills char- control group schools.
acterize the adolescents with Internet addiction [6,7].
To date, group cognitive behavioural therapy (CBT) Measures
has been shown to be effective in aiding adolescents with
Internet addiction; in particular, a multimodal school- Beard’s Diagnostic Questionnaire for Internet addiction
based intervention [8–10]. This involves (i) group CBT for
This scale has eight items in all, with a dichotomous (Yes/No) Lik-
adolescent students with Internet addiction; (ii) psychoed-
ert scale [1]. Internet addiction is diagnosed when all of the first five
ucation for teachers on the recognition and psychological items and at least one of the next three items are met.
treatment of Internet addiction; and (iii) group cognitive
behavioural parent training delivered at the same time as
Internet Overuse Self-Rating Scale
for the adolescent Internet addiction group [8–10].
Improved impulse control, emotional stability and This scale consists of 20 items in all and uses a 4 point Likert scale
decreased Internet addiction behaviours have been shown [5,6]. The higher the score, the more severe the participant’s Internet
addiction. Validity and reliability are adequate for China.
immediately after the multimodal school-based interven-
tion. A maintenance effect for this intervention, however,
has not been demonstrated as yet. The purpose of the Time Management Disposition Scale
present study was therefore to investigate whether a ran- The Time Management Disposition Scale (TMDS) has 44 items in
domized, controlled trial of this multimodal school-based all, with three specific factors: the ‘worth of time’, ‘control over time’
intervention is effective at 6 months after its delivery. and ‘efficacy of time’ [11]. The higher the score, the better time man-
agement reported. Validity and reliability are adequate for China.

Methods
Strength and Difficulties Questionnaire (Chinese edition)
Participants This scale has 25 items in all and uses a 3 point Likert scale supporting
five factors: ‘emotional symptoms’, ‘conduct problems’, ‘hyperactivity
and attention deficit problems’, ‘peer relationship problems’ and ‘pro-
Fifty-six adolescent students with Internet addiction, according to
social behaviour’ [12]. For the first four factors, the lower the score,
the Beard and Wolf criteria [1], were recruited from 10 secondary
the better, and for the last factor the higher the score, the better. Valid-
schools in Shanghai, selected at random from the 100 available second-
ity and reliability are adequate for China.
ary schools. These students were spending approximately 6.53 ± 1.68 h
per day using the Internet online. The Principal of each school gave
permission for their school to be part of the study. Teachers in each Screen for Child Anxiety Related Emotional Disorders
school gave information about the study to students in their classes. (SCARED)
This information was taken home by the students and read by them and The Screen for Child Anxiety Related Emotional Disorders (SCARED)
their parents/guardians. If the students and their parents/guardians consists of 41 items in all and uses 3 point Likert sale supporting five factors:
expressed interest in being involved, they met with the study staff at ‘somatic/panic’, ‘generalized anxiety’, ‘separation anxiety’, ‘social anxiety’
their school for a screening session. A total of 224 students took part and ‘school anxiety’ [13]. The higher the score, the higher the level of a
in these screening interviews. Students were excluded if they had evi- given anxiety factor in a child. Validity and reliability are adequate for
dence of any comorbid medical disorder, pre-existing psychiatric dis- China.
order and/or were taking any psychoactive medication.
Thirty-two students were randomly allocated to the multimodal
Procedure
school-based intervention, while 24 students were randomly placed
in the control group. A random number generator computer program
The multimodal school-based intervention and control groups
was used to achieve randomization. We aimed to recruit 60 children,
were established through random ascertainment of first, the schools to

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on April 8, 2016


Y-S. DU, W. JIANG, A. VANCE 131

Table 1. Internet Overuse Self-Rating Scale


Before intervention After intervention Six months later
Mean ± SD Mean ± SD Mean ± SD
Active group (n = 32) 40.57 ± 19.50 23.14 ± 11.88∗∗∗ 18.71 ± 12.01∗∗∗
Control group (n = 24) 30.38 ± 14.06 21.40 ± 13.26∗∗ 20.69 ± 14.94∗∗
Paired t-test before and after the intervention and at 6 months follow up: ∗∗p < 0.01, ∗∗∗p < 0.001.

receive Beard’s Diagnostic Questionnaire for Internet addiction, and sec- of their professional development. Each workshop contained didactic
ond, the adolescents and schools to be in the active versus the control teaching, analysis and discussion of case examples and reflective role
groups. The immediate post-intervention assessment was conducted plays.
blind to the individual’s group status, as was the 6 month follow up
assessment. All students, their parents and teachers attended and Statistical analysis
completed all sessions.
SPSS 11.5-derived paired t-tests were used to examine the relation-
ship between continuous variables (SPSS, Chicago, IL, USA). The
Multimodal school-based intervention
effect sizes of variables that significantly differed were calculated using
the Cohen’s d statistic: the range for a small effect is 0.20–0.50; for a
(1) Group CBT was delivered to adolescent students with Internet
medium effect it is 0.50–0.80; and for a large effect it is ≥0.8 [14].
addiction: 6–10 students with Internet addiction participated in an
Paired t-tests rather than analysis of covariance were used because
eight-session group CBT run by two child and adolescent psychia-
of the potential for baseline values to not be equal between groups
trists. Each session lasted 1.5–2 h. In each session of group therapy,
[15]. Hence, ANCOVA could mislead. Therefore, even though paired
a different topic was discussed. These topics included how to recog-
t-tests have a higher variance, they remain unbiased in such circum-
nize and control your feelings; principles of healthy communication
stances.
between parents and children; techniques for dealing with relation-
ships developed via the Internet; techniques for dealing with content
experienced via the Internet; techniques for controlling your impulses;
techniques for recognizing when addictive behaviour is occurring; Results
and how to stop addictive behaviour. The last session was a review
session. The Internet Overuse Self-Rating Scale did not differ between the
(2) Group cognitive behavioural parent training was delivered at active and the control groups at baseline, immediately after the inter-
the same time as adolescent group CBT. Topics covered were prin- vention or at 6 month follow up. Both groups decreased immediately
ciples and techniques for recognizing your child’s feeling states; prin- after the intervention and at 6 month follow up compared to before the
ciples and techniques for good communication between family intervention. The active group effect sizes both immediately and at
members; problem-solving principles and techniques; principles 6 month follow up, however, were large (Cohen’s d = 1.08, 1.35) com-
and techniques for controlling your own feelings and behaviour; and pared to those of the control group (Cohen’s d = 0.66, 0.67; Table 1).
principles and techniques for managing adolescents with Internet The active and control groups did not differ at baseline or immedi-
addiction. ately after the intervention, but did have higher scores on all subscales
(3) Psychoeducation for delivered to teachers regarding the recogni- of the TMDS at 6 month follow up. Effect sizes were predominantly
tion and psychological treatment of Internet addiction. This treatment small on all the subscales (Cohen’s d = 0.41–0.54). The active group
package contained all the elements of both the adolescent and parent decreased immediately after the intervention and at 6 month follow
groups. It was delivered to teachers through workshops that were part up compared to before the intervention on the ‘efficacy of time’ and

Table 2. Time Management Disposition Scale


Before intervention After intervention Six months later
Mean ± SD Mean ± SD Mean ± SD

Worth of time Study group (n = 32) 32.68 ⫾ 8.87 35.53 ⫾ 8.02 36.30 ⫾ 8.70
Control group (n = 24) 33.76 ⫾ 7.30 32.92 ⫾ 7.35 32.88 ⫾ 7.87
Efficacy of time Study group (n = 32) 28.21 ⫾ 6.96 33.60 ⫾ 7.51∗∗ 34.48 ⫾ 6.79∗∗
Control group (n = 24) 30.62 ⫾ 5.46 32.90 ⫾ 6.80 31.01 ⫾ 5.95
Control over time Study group (n = 32) 64.95 ⫾ 14.18 76.08 ⫾ 16.19∗∗ 76.09 ⫾ 16.93∗∗
Control group (n = 24) 67.86 ⫾ 13.46 69.97 ⫾ 13.04 69.28 ⫾ 12.61

Paired t-test before and after the intervention and at 6 months follow up: *p < 0.05, **p < 0.01.

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on April 8, 2016


132 GROUP CBT FOR ADOLESCENT INTERNET ADDICTION

Table 3. Strengths and Difficulties Questionnaire (Chinese version)


Before intervention After intervention Six months later
Mean ± SD Mean ± SD Mean ± SD
Emotional symptoms Active group (n = 32) 3.30 ⫾ 2.23 2.35 ⫾ 1.74∗ 1.77 ⫾ 1.93∗∗
Control group (n = 24) 3.13 ⫾ 2.47 2.96 ⫾ 2.22 2.33 ⫾ 2.26
Conduct problems Active group (n = 32) 3.53 ⫾ 1.90 2.73 ⫾ 1.72∗ 2.42 ⫾ 1.80∗∗
Control group (n = 24) 3.00 ⫾ 1.64 2.79 ⫾ 1.59 2.29 ⫾ 1.60
Hyperactivity and attention-deficit Active group (n = 32) 5.16 ⫾ 2.80 3.54 ⫾ 2.50∗∗ 3.61 ⫾ 2.27∗∗
problems Control group (n = 24) 3.56 ⫾ 2.19 4.04 ⫾ 1.85 3.21 ⫾ 2.08∗
Peer relationships Active group (n = 32) 3.50 ⫾ 1.46 2.71 ⫾ 1.37∗ 2.56 ⫾ 1.70∗
Control group (n = 24) 2.75 ⫾ 1.48 3.08 ⫾ 1.14 2.83 ⫾ 1.37
Prosocial behaviours Active group (n = 32) 6.41 ⫾ 2.18 7.25 ⫾ 1.83∗ 7.42 ⫾ 1.94∗
Control group (n = 24) 6.42 ⫾ 2.15 6.96 ⫾ 1.94 7.04 ⫾ 2.24

Paired t-test before and after the intervention and at 6 months follow up: ∗p < 0.05, ∗∗p < 0.01.

‘control over time’ TMDS subscales. Effect sizes were predominantly Discussion
medium for the two follow up time points on the two subscales (Cohen’s
d = 0.70–0.91). In contrast, the control group did not differ on any of The Internet Overuse Self-Rating Scale is similar to
the TMDS subscales from baseline to immediately after the interven- Young’s Internet Addiction Screening Scale [2] in
tion to 6 month follow up (Table 2). number and content of items. Interestingly, both the
The active and control groups did not differ at baseline, immediately active group and the control group improved over time,
after the intervention or at 6 month follow up on the emotional symp-
with no difference evident between them. This implies
toms, conduct problems or prosocial behaviour scales of the Strength
that regardless of the multimodal school-based inter-
and Difficulties Questionnaire (SDQ) (Chinese version). The active
group, however, had more hyperactivity and attention deficit problems
vention, Internet addiction behaviour has the potential
and peer relationship problems at baseline than the control group, to change and improve. There was a larger effect size
although the groups did not differ on these measures immediately after evident, however, in the active group over time, which
the intervention or at 6 month follow up. The active group decreased suggests that changes in associated emotional, cogni-
immediately after the intervention and at 6 month follow up compared tive and behavioural problems may have had an influ-
to before the intervention on the emotional symptoms, conduct prob- ence. Such an association has been suggested in
lems, hyperactivity and attention deficit problems and peer relationship previous treatment studies [8–10].
problems scales. Further, they demonstrated a similar pattern of increase In contrast, the TMDS showed only that the multi-
in the prosocial behaviour scales from baseline to 6 month follow up. modal school-based intervention group had an improved
In contrast, the control group did not differ on any of the SDQ (Chinese
use of time (‘efficacy of time’) and control over time
version) scales from baseline to immediately after the intervention to
usage (‘control over time’) at the 6 month follow up.
6 month follow up. The active group effect sizes were uniformly small
(Cohen’s d = 0.44–0.59), except for the emotional symptoms, conduct
This suggests that the multimodal school-based inter-
problems and hyperactivity and attention-deficit problems scales at vention did uniquely aid the improved Internet addic-
6 month follow up, and the hyperactivity and attention-deficit problems tion behaviour. Internet addiction adolescents’ valuing
scale immediately after the intervention, which were medium (Cohen’s of time (‘worth of time’), however, did not differ
d = 0.73/0.60/0.61/0.61, respectively; Table 3). between the two groups. This implies that their assess-
The active and control groups did not differ at baseline, except for ment of time’s value is not related to their efficient use
the school anxiety subscale of the SCARED, for which the active of time and control over its use. Recent studies have
group reported higher levels of school anxiety. In contrast, the active shown that time management is positively correlated
group demonstrated lower scores on all scales compared to the control with a given individual’s feeling of happiness in
group, immediately after the intervention and at 6 month follow up,
life and self-satisfaction, and negatively correlated
except for the school anxiety scale immediately after the intervention.
with anxiety and depression [16]. It has also been
Effect sizes were predominantly small immediately after the interven-
tion (Cohen’s d = 0.4–0.48) and medium at 6 month follow up
reported that one’s attitude toward time is
(Cohen’s d = 0.61–0.79). The active group decreased immediately congruent with one’s personality and/or temperament
after the intervention and at 6 month follow up compared to before characteristics [17].
the intervention on all the SCARED subscales. Effect sizes were pre- Consistent with these reported associations, we
dominantly medium (Cohen’s d = 0.62–0.93). In contrast, the control found that only the active group demonstrated
group did not differ on any of the SCARED scales from baseline to decreased emotional (particularly anxiety), hyperac-
immediately after the intervention to 6 month follow up (Table 4). tive and inattentive, conduct and peer relationship

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on April 8, 2016


Y-S. DU, W. JIANG, A. VANCE 133

Table 4. Screen for Child Anxiety Related Emotional Disorders

Before intervention After intervention Six months later


Mean ± SD Mean ± SD Mean ± SD

Somatic/panic Study group (n = 32) 7.37 ⫾ 4.80 4.21 ⫾ 3.61∗∗ 3.56 ⫾ 3.56∗∗
Control group (n = 24) 5.81 ⫾ 4.57 5.79 ⫾ 4.46 6.77 ⫾ 4.63
Generalized anxiety Study group (n = 32) 7.11 ⫾ 4.53 4.68 ⫾ 3.84∗∗ 3.98 ⫾ 3.74∗∗
Control group (n = 24) 5.46 ⫾ 4.52 6.49 ⫾ 3.61 6.28 ⫾ 4.46
Separation anxiety Study group (n = 32) 3.87 ⫾ 2.60 2.64 ⫾ 2.99∗ 2.42 ⫾ 1.81∗
Control group (n = 24) 2.92 ⫾ 2.38 3.75 ⫾ 2.27 3.75 ⫾ 2.45
School anxiety Study group (n = 32) 2.47 ⫾ 1.81 1.29 ⫾ 1.60∗∗ 1.09 ⫾ 1.06∗∗
Control group (n = 24) 1.58 ⫾ 1.47 1.33 ⫾ 1.27 1.88 ⫾ 1.54
Social anxiety Study group (n = 32) 7.04 ⫾ 4.22 5.45 ⫾ 3.55∗ 4.72 ⫾ 3.17∗
Control group (n = 24) 6.67 ⫾ 3.57 8.12 ⫾ 3.72 6.50 ⫾ 3.59

Paired t-test before and after the intervention and at 6 months follow up: ∗p < 0.05, ∗∗p < 0.01.

problems, with a commensurate increase in manifest study. This research was funded by the Shanghai
prosocial behaviour, over time. This is an important Mental Health Center. Professor Yasong Du has
finding for the multimodal school-based intervention received research funding from Xi’an-Janssen
because Internet addiction is known to have a Pharmaceutical, Eli Lilly, and Shanxi Ruifulai
greater-than-chance association with anxiety, espe- Pharmaceutical.
cially social anxiety, and impulsiveness, hyperactiv-
ity and inattention [18–20]. Interestingly, all these
symptom domains demonstrated a large effect size References
improvement only with the multimodal school-based
1. Beard K, Wolf E. Modification in the proposed diagnostic criteria
intervention.
for Internet addiction. Cyberpsychol Behav 2001; 4:377–383.
In summary, the multimodal school-based interven- 2. Young KS. Internet addiction: the emergence of a new clinical
tion did lead to an improved emotional state and regula- disorder. Cyberpsychol Behav 1998; 1:237–244.
tion ability, behavioural and self-management style in 3. Zhu Y, Du Y. Emotional correlation of Internet addiction among
the adolescents identified with Internet addiction. The middle-school students in Shanghai. Shanghai Arch Psychiatry
2006; 18:69–71.
generalizability of these findings, however, are limited 4. Huang L, Du Y. Research on psychological characteristics of
by the absence of pre-existing comorbid conditions Internet overuse in young people. Chin J Health Psychol 2007;
such as high- and low-prevalence psychiatric disorders 1:30–33.
and language learning disorders (reading/spelling/arith- 5. Cao F, Su L. The factors related to Internet overuse in middle
school students. Chin J Psychiatry 2006; 39:141–144.
metic/writing), verbal and visuospatial IQ data and key 6. Jiang W, Du Y. The relationship between Internet overuse in middle
motor, speech and language developmental milestones school students in Shanghai and time management disposition.
data. Such information could allow us to examine the Shanghai Arch Psychiatry 2006; 18:129–133.
possible differential response of adolescents with Inter- 7. Chak K, Leung L. Shyness and locus of control as predictors of Inter-
net addiction and Internet use. Cyberpsychol Behav 2004; 7:559–570.
net addiction in the context of these key comorbid con- 8. Yang FR, Hao W. The effect of integrated psychosocial intervention
ditions and developmental risk factors. This should on 52 adolescents with Internet addiction. Chin J Clin Psychol
be a focus of future randomized, controlled studies 2005; 13:343–346.
9. Yu YZ. Feasibility of group psychological interventions in amelio-
of Internet addiction, along with investigation of
rating the Internet addictive behavior of teenagers. Chin J Clin
younger and older cohorts from different developmental Rehabil 2005; 20:81–83.
periods. 10. Yang R, Shao Z. Comprehensive intervention for Internet addiction
in middle school students. Chin Ment Health J 2005; 19:457–459.
11. Huang X, Zhang Z. The compiling of the adolescence Time Man-
agement Disposition Scale. Acta Psychol Sin 2001; 33:338–343.
Acknowledgements 12. Du Y, Kou J. A study of the Strengths and Difficulties Question-
naire (SDQ). Psychol Sci 2006; 29:1419–1421.
13. Jiao M, Du Y. The clinical application of screening for anxiety related
The authors would like to acknowledge the hard work emotional disorders. Shanghai Arch Psychiatry 2005; 17:72–74.
of the staff of the Shanghai Mental Health Center and 14. Cohen J. Statistical power analysis for the behavioral sciences, 2nd
the adolescents and their families who took part in this edn. Hillsdale, NJ: Lawrence Erlbaum Associates, 1988.

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on April 8, 2016


134 GROUP CBT FOR ADOLESCENT INTERNET ADDICTION

15. Senn S. Cross-over trials in clinical research. Chichester: Wiley, 18. Chak K, Leung L. Shyness and locus of control as predictors of Internet
2002. addiction and Internet use. Cyberpsychol Behav 2004; 7:559–570.
16. Morahan-Martin J, Schumacher P. Incidence and correlates of 19. Wang L, Tong H. The relationship between Internet addiction in
pathological Internet use among college students. Comp Hum university students and social support, social anxiety and self-
Behav 2000; 16:13–29. harmony. Health Psychol J 2003; 11:94–96.
17. Tsai CC, Lin SS. Analysis of attitudes toward computer networks 20. Yoo HJ, Cho SC, Ha J. Attention deficit hyperactivity symptoms
and Internet addiction in Taiwanese adolescents. Cyberpsychol and Internet addiction. Psychiatry Clin Neurosci 2004; 58:
Behav 2001; 4:373–376. 487–494.

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on April 8, 2016