Journal of the Formosan Medical Association (2020) 119, 1093e1100

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journal homepage: www.jfma-online.com

Original Article

Bidirectional relationships of psychiatric

symptoms with internet addiction in college
students: A prospective study
Yen-Ju Lin a,b, Ray C. Hsiao c,d, Tai-Ling Liu a,**,
Cheng-Fang Yen a,*

a
Department of Psychiatry, Kaohsiung Medical University Hospital, and School of Medicine and
Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
b
Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai’s Home, Kaohsiung, Taiwan
c
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine,
Seattle, WA, USA
d
Department of Psychiatry, Children’s Hospital and Regional Medical Center, Seattle, WA, USA

Received 4 January 2019; received in revised form 4 May 2019; accepted 5 October 2019

KEYWORDS Background/Purpose: This prospective study evaluated the predictive ability of psychiatric
Internet addiction; symptoms at initial consultation for the occurrence and remission of Internet addiction during
Psychiatric a 1-year follow-up period among college students. Furthermore, it evaluated the predictive
symptoms; ability of changes in psychiatric symptoms for Internet addiction at the initial consultation dur-
College student ing the 1-year follow-up period among college students.
Methods: Five hundred college students (262 women and 238 men) were recruited. The base-
line and follow-up consultations measured the levels of Internet addiction and psychiatric
symptoms using the Chen Internet Addiction Scale and Symptom Checklist-90 Revised,
respectively.
Results: The results indicated that severe interpersonal sensitivity and paranoia symptoms
might predict the incidence of Internet addiction at 1-year follow-up. The college students
with internet addiction did not have significant improvement in the severities of psychopathol-
ogy, whereas those without internet addiction had significant improvement in obsession-
compulsion, interpersonal sensitivity, paranoid and psychoticism during the same period.
Conclusion: Psychiatric symptoms and Internet addiction exhibited bidirectional relationships
in college students during the 1-year follow-up period.

* Corresponding author. Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd, Kaohsiung, Taiwan. Fax: þ886
7 3134761.
** Corresponding author. Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd, Kaohsiung, Taiwan. Fax: þ886
7 3134761.
E-mail addresses: dai32155@gmail.com (T.-L. Liu), chfaye@cc.kmu.edu.tw (C.-F. Yen).

https://doi.org/10.1016/j.jfma.2019.10.006
0929-6646/Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1094
Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Introduction
Global rates of Internet use have increased rapidly because
the Internet has become an essential tool for communica-
tion, education, and socializing.1 However, Internet
addiction has become a global mental health problem.2 The
association between Internet addiction and psychiatric
symptoms was investigated abundantly in the 2010s. Re-
searchers have suggested that Internet addiction leads to
difficulty in maintaining real-life interpersonal relation-
ships, impairs everyday activities, worsens academic work,
and hinders occupational functioning.3e5
A meta-analysis of 31 countries revealed a global prev-
alence of 2.6%e10.9% of Internet addiction for all-age
users.6 The estimate of incidence rates of Internet addic-
tion varied in different age cohorts. Ko et al. proposed an
incidence rate of 7.5% in young adolescents during the 1-
year period from Grade 7 to Grade 8,7 while incidence
ranging between 2.5 and 3.6% over the 2-year period in
junior high school students was reported.8 Previous studies
revealed that adolescents are especially prone to develop
Internet addiction.9 Cross-cultural epidemiological studies
on Internet addiction have reported a remarkably higher
prevalence rates among adolescents in Asian compared to
those among adolescents in Western countries.9 Estimated
15.3%e17.9% of college students in Taiwan are addicted to
the Internet.10,11 One of possible etiologies accounting for
the various incidence and prevalence of Internet addiction
among previous studies is the miscellaneous diagnostic in-
struments assessing Internet addiction based on different
conceptual framework. Young et al. proposed Internet
Addiction Diagnostic Questionnaire (IADQ) and Internet
Addiction Test (IAT) as self-reported screening instruments
to measure the extent of involvement with the computer
and Internet addictive behavior.12,13 Generalized prob-
lematic Internet use scale (PIU) was developed to assess
Internet-related cognitions and social functions.14 The
Chen Internet Addiction Scale (CIAS) was validated in
assessing the core symptoms of Internet addiction, as well
as Internet-related social and physical problems.15
A variety of psychiatric symptoms have been proposed to
be associated with Internet addiction. Cross-sectional
studies have reported significant associations of Internet
addiction with depressive symptoms, anxiety,
obsessiveecompulsive symptoms, inattention, hyperactivi-
ty, and aggressive behaviors.16e21 Several cross-sectional
studies have also discovered positive correlations be-
tween Internet addiction and the characteristic traits of
psychoticism, paranoid, and interpersonal sensitivity.22e25
Lee et al. reported that the homozygous short alleles of
the serotonin transporter gene promoter region may
partially account for the association between excessive
Internet users and depressive disorder.26 Pratarelli
Y.-J. Lin et al.
proposed that obsessive self-focused rumination might
cause repetitive use of the Internet.27 Reicher proposed the
deindividuated effect in the Internet which might lower the
threshold for exhibiting socially inhibited behaviors and
further contributed to aggressive behaviors.28 Individuals
with avoidance coping style was positively correlated with
Internet addiction,29 while higher levels of emotional and
avoidant coping were associated with higher levels of
paranoia.30 However, most of previous studies have exam-
ined the relationship between Internet addiction and the
sole dimension of psychiatric symptoms. The review study
determined that multiple dimensions of psychiatric symp-
toms related to Internet addiction.31 Further study using
the scales such as the Symptom Checklist-90-Revised that
measure multiple dimensions of psychiatric symptoms may
provide knowledge to the relationship between Internet
addiction and psychopathology. Moreover, the cross-
sectional design of the previous studies limited the possi-
bility of determining the temporal relationship between
Internet addiction and psychiatric symptoms.
Prospective studies examining the relationship between
Internet addiction and psychiatric symptoms are relatively
scant. A 2-year prospective study determined that
emotional problems, depression, and social phobia at
baseline are predictive of Internet addiction.32 A 9-month
prospective study reported that Internet addiction at
baseline is predictive of depression.33 A 2-year longitudinal
study found that both pathological Internet use symptoms
and emotional problems may contribute to the vicious cycle
that supports the perpetuation of pathological Internet
use.34
Studies on the temporal bidirectionality of the rela-
tionship between Internet addiction and psychiatric symp-
toms are scant. To our knowledge, only one study examined
the temporal bidirectionality of the relationship between
Internet addiction and psychiatric symptoms. Dong and
colleagues (2011) reported that depression, anxiety, and
hostility on the Symptom Checklist-90-Revised (SCL-90-R)
were the sequela but not the precursors of Internet
addiction in a 1-year longitudinal study; however, Internet
addiction in that study was diagnosed through retrospective
assessment. Prospective studies on the bidirectional inter-
action between Internet addiction and psychiatric symp-
toms in the same study group may provide further evidence
for the reciprocal relationships between Internet addiction
and multidimensional psychiatric symptoms and serve as
the basis for prevention programs.
This study evaluated the prediction of psychiatric
symptoms at the initial consultations for the occurrence
and remission of Internet addiction during a 1-year follow-
up period among college students. Furthermore, it evalu-
ated the prediction of changes in psychiatric symptoms for
Internet addiction at the initial consultation during the 1-
Psychiatric symptoms and Internet addiction
year follow-up period among college students. We hy-
pothesize that psychiatric symptoms at baseline predict the
occurrence and nonremission of Internet addiction 1 year
later and that Internet addiction predicts exacerbation of
psychiatric symptoms 1 year later.
Methods
Participants
Through advertising, 500 college students between 20 and
30 years old (262 women and 238 men) were recruited and
participated in this study. Their mean age was 22.1 years
(standard deviation [SD]: 1.8 years). Informed consent was
obtained from all participants prior to assessment. The
study was approved by the Institutional Review Board of
Kaohsiung Medical University Hospital.
Measures
Chen Internet Addiction Scale
We used the self-administrated Chen Internet Addiction
Scale (CIAS) to assess the severity of participants’ Internet
addiction in the month preceding the study.15 The CIAS
contains 26 items rated using a four-point Likert scale with
scale scores ranging from 26 to 104.15 High scores indicate
severe Internet addiction. The internal reliability (Cron-
bach’s a) of the CIAS in the present study was .93. A 67e68
cut-off point on the CIAS has the highest diagnostic accu-
racy and acceptable sensitivity and specificity.35 Accord-
ingly, those with CIAS scores of 68 were assigned to the
Internet addiction group.
Symptom Checklist-90-Revised
The SCL-90-R is a self-report scale designed to measure the
general psychopathology associated with the constructs of
somatization, obsessionecompulsion, interpersonal sensi-
tivity, depression, anxiety, hostility, phobic anxiety, para-
noid ideation, psychoticism, and sleep and appetite
problems.36 The SCL-90-R consists of 90 symptom state-
ments that participants use to rate severity on the basis of
their experiences during the preceding week. Each item is
rated on a five-point scale of distress (0e4), ranging from
“not at all” to “extremely.” High scores on the SCL-90-R
indicate that participants have severe psychiatric symp-
toms. The validity of the Chinese-language version of the
SCL-90-R for assessing the neurotic symptomatology of pa-
tients in Taiwan was established.37
Study process and statistical analysis
During the initial assessment, all participants were invited
to complete the CIAS and SCL-90-R. The participants were
invited to again complete the CIAS and SCL-90-R 1 year
later. Depending on the initial and follow-up CIAS scores,
the participants were assigned to one of four groups
(Fig. 1). Participants deemed nonaddicted in the initial
assessment were stratified into group I or II on the basis of
subsequent nonaddiction or addiction status, respectively.
The remaining participants, who were initially deemed
1095
Internet addicts, were stratified into group III or IV based on
remission or continuation of the behavior, respectively. A
chi-square and a t tests was used to evaluate the difference
in gender and age between groups I and II and between
groups III and IV, respectively. A p < .05 was considered
significant for these two tests. The relationships between
the incidence of Internet addiction and psychiatric symp-
toms at the initial consultation for the members of groups I
and II were investigated by Mann-Whitney U test. The re-
lationships between the remission of Internet addiction and
psychiatric symptoms at the initial consultation for the
members of groups III and IV were also investigated by
Mann-Whitney U tests. Because of multiple comparison of
nine dimensions of psychopathology on the SCL-90R, a
p < .006 (.05/9) was considered significant for Mann-
Whitney U tests.
Additionally, we aspired to evaluate whether changes in
psychiatric symptoms during the 1-year period differed
between college students with and without Internet
addiction at the initial consultation. A Wilcoxon signed
ranks test was used to evaluate the change in psychiatric
symptoms on the SCL-90-R between the initial and follow-
up consultation for all participants in the Internet addiction
and nonaddiction groups based on their classification in the
initial consultation. A p < .006 was considered significant
for Wilcoxon signed ranks tests. All statistical analyses
were performed using SPSS 20.0 (SPSS Inc., Chicago, IL,
USA).
Results
A total of 324 college students (65.8%, 169 women and 155
men) underwent follow-up assessment 1 year later. Of 176
participants who did not receive the follow-up assessment,
96 (54.5%) were disconnected, 48 (27.3%) refused partici-
pating in the follow-up assessment, and 32 (18.2%) had
motivation but were not able to participate in the follow-up
assessment due to work or army service. No difference in
gender was found between participants who received and
did not receive the follow-up assessment (p Z .884),
whereas participants who received the follow-up assess-
ment were older than those who did not receive the follow-
up assessment (p Z .047). No difference in the proportion
of internet addiction was found between participants who
received and did not receive the follow-up assessment
(p Z .819).
Of the 268 participants in groups I and II who had no
Internet addiction at the initial consultation, 20 (7.5%)
were deemed to have Internet addiction at the follow-up
consultation (group II). Of the 56 individuals in groups III
and IV who had Internet addiction at the initial consulta-
tion, 26 (46.4%) were classified as free of Internet addiction
at the follow-up consultation (group III).
Comparisons of the demographic characteristics and
SCL-90-R psychiatric symptoms between groups I and II are
presented in Table 1. The results reveal that compared with
group I, group II had more severe interpersonal sensitivity
and paranoia on the SCL-90-R at the initial assessment,
indicating that severe interpersonal sensitivity and para-
noia symptoms on these SCL-90-R subscales might predict
the incidence of Internet addiction at 1-year follow-up.
1096
All participants
Initial assessment
Non addiction
Follow-up assessment
Non addiction Internet addiction
Group I (n = 248) Group II (n = 20)
Figure 1 Participants were assigned to one of four addiction groups. The participants deemed nonaddicted at baseline
assessment were stratified into groups I and II based on the follow-up evaluation as nonaddicted or addicted, respectively. The
participants deemed addicted initially but who had remitted on follow-up were assigned to group III, whereas those who remained
addicted were assigned to group IV.
Comparisons of the demographic characteristics and
SCL-90-R psychiatric symptoms between groups III and IV
are presented in Table 1. The participants in group III were
younger than those in group IV. However, no dimension of
psychiatric symptoms was significantly associated with
Internet addiction remission.
The results of SCL-90-R score comparison between the
initial and follow-up consultations among the participants
with and without Internet addiction at the initial consul-
tation are shown in Table 2. The results of Wilcoxon signed
ranks test revealed that the severities of obsession-
compulsion, interpersonal sensitivity, paranoid and psy-
choticism in the nonaddiction group significantly decreased
from the initial and follow-up consultations, whereas the
severities of all dimensions of psychopathology in the
internet addiction group did not improve significantly from
the initial and follow-up consultations.
Discussion
This prospective study examined the bidirectionality of
psychopathology and Internet addiction among college stu-
dents in Taiwan. The results indicated that severe inter-
personal sensitivity and paranoia symptoms on these SCL-90-
R subscales might predict the incidence of Internet addiction
at 1-year follow-up. The severities of obsession-compulsion,
interpersonal sensitivity, paranoid and psychoticism in the
nonaddiction group significantly decreased during the one-
year period of follow-up, whereas the severities of all di-
mensions of psychopathology in the internet addiction group
did not improve significantly during the same period.
Effects of psychopathology on internet addiction
development
In accordance with the results of previous studies,7,24 the
present study determined that high interpersonal sensitivity
Y.-J. Lin et al.
Internet addiction
Non addiction Internet addiction
Group III (n = 26) Group IV (n = 30)
predicted the development of Internet addiction in the 1-
year follow-up period. College students with high interper-
sonal sensitivity exhibited low self-esteem, high sensitivity
to criticism, reliance on others, and high insecurity in inter-
personal relationships.38 Moreover, problematic Internet
users exhibited higher interpersonal sensitivity, asocial
behavior, unassertiveness, criticism, and distrust than those
without Internet problems.38 College students with high
interpersonal sensitivity have feelings of inadequacy, infe-
riority and self-doubt.39 They obtained more support and
self-confidence from the Internet rather than face-to-face
interaction and may indulge in the virtual world and isolate
themselves from the outside environment.38 Previous studies
showed that individuals with Internet addiction have more
often personality disorders than those without.40
Furthermore, the scale of interpersonal sensitivity was
higher in those with cluster B and cluster C personality dis-
order.41 Ko et al. suggested that low interpersonal sensitivity
predicted remission of Internet addiction in adolescents.7
Further research is warranted to examine the effect of
psychotherapy for modification of interpersonal sensitivity
to prevent the development of Internet addiction.
The present study determined that baseline paranoid
ideation predicted the development of Internet addiction 1
year later. Paranoid ideation is associated with excessive
fear or anxiety.42 Regarding the neurobiology of the
development of paranoia, Corlett et al. reported the
aberrant prediction error in fronto-striatal learning systems
and inappropriate engagement of the brain’s fear system.43
Moreover, a review of neuropsychological and neuro-
imaging findings of Internet addiction identified fronto-
striatal loops as a main neural correlates of addictive
behavior.44 In accordance of previous studies, individuals
with avoidance coping style was positively correlated with
Internet addiction,29 while higher levels of emotional and
avoidant coping were associated with higher levels of
paranoia.30 However, the present study assessed self-
reported paranoid ideation on the SCL-90-R but not
Psychiatric symptoms and Internet addiction 1097

Table 1 Comparisons between groups I and II and groups III and IV of demographic characteristics and psychiatric symptoms.
Group I (n Z 248) Group II (n Z 20) p Group III (n Z 26) Group IV (n Z 30) p
n (%) or mean (SD) n (%) or mean (SD) n (%) or mean (SD) n (%) or mean (SD)
Gendera
Female 129 (50.0) 11 (55) .797 15 (57.7) 14 (46.7) .410
Male 119 (48.0) 9 (45) 11 (42.3) 16 (53.3)
Age (years)b 22.3 (2.0) 22.4 (1.9) .729 21.6 (1.2) 22.6 (1.9) .019
SCL-90-Rc
Somatization 4.7 (5.6) 7.6 (6.6) .026 9.8 (8.7) 10.9 (9.5) .705
Obsession-compulsion 8.1 (5.8) 10.9 (4.9) .015 13.8 (6.7) 14.1 (7.1) .915
Interpersonal sensitivity 6.2 (5.4) 9.2 (5.0) .006 9.5 (6.7) 11.3 (7.5) .370
Depression 7.3 (6.5) 10.3 (5.3) .010 14.0 (8.2) 13.7 (9.0) .687
Anxiety 5.5 (4.8) 6.1 (3.9) .306 10.1 (6.6) 10.3 (7.3) .961
Hostility 2.7 (3.2) 3.5 (4.1) .441 5.0 (4.1) 5.5 (5.1) .875
Phobia 1.7 (2.5) 2.5 (2.1) .026 4.5 (4.4) 4.0 (4.2) .740
Paranoid 3.4 (3.6) 6.1 (4.1) .001 5.5 (4.4) 6.4 (4.2) .365
Psychoticism 3.7 (4.1) 5.3 (3.3) .015 5.5 (4.8) 6.4 (5.1) .519
SCL-90-R: Symptom Checklist-90-Revised.
Group I and II: The participants deemed nonaddicted at baseline assessment were stratified into groups I and II based on the follow-up
evaluation as nonaddicted or addicted, respectively.
Group III and IV: The participants deemed addicted initially but who had remitted on follow-up were assigned to group III, whereas those
who remained addicted were assigned to group IV.
a
Chi-square test.
b
t test.
c
Mann-Whitney U test.

through face-to-face interviews and thus could not deter-
mine the real characteristics of the paranoid ideation that
the participants reported. Paranoid ideation may make
college students feel unsafe when they go outside and
interact with others. The Internet may provide them an
environment in which they feel comfortable and can
decide with whom they wish to interact and in what ac-
tivities they wish to participate. Thus, the risk of devel-
oping Internet addiction may increase among college
students with high paranoid ideation.

Table 2 Psychiatric symptoms on Symptom Checklist-90-Revised at the initial and follow-up consultations among the par-
ticipants with and without Internet addiction at the initial consultation: Wilcoxon signed ranks test.
Initial investigation Follow-up investigation Z p
Mean (SD) Mean (SD)
Internet addiction group (n Z 56)
Somatization 10.4 (9.0) 8.4 (9.2) 1.869 .062
Obsession-compulsion 13.9 (6.9) 11.7 (8.3) 2.223 .026
Interpersonal sensitivity 10.5 (7.1) 9.2 (6.6) 1.432 .152
Depression 13.9 (8.6) 12.9 (10.5) -.738 .460
Anxiety 10.2 (6.9) 8.9 (7.6) 1.912 .056
Hostility 5.3 (4.7) 4.6 (4.7) 1.269 .204
Phobia 4.2 (4.3) 3.5 (4.3) 1.285 .199
Paranoid 6.0 (4.3) 5.3 (4.9) -.973 .330
Psychoticism 6.0 (5.0) 6.7 (6.7) .816 .415
Non-Internet addiction group (n Z 268)
Somatization 4.9 (5.7) 4.0 (5.4) 2.605 .009
Obsession-compulsion 8.3 (5.7) 7.1 (6.2) 4.088 <.001
Interpersonal sensitivity 6.4 (5.4) 4.9 (5.0) 5.112 <.001
Depression 7.6 (6.5) 6.8 (7.4) 2.493 .013
Anxiety 5.6 (4.8) 5.4 (5.6) 1.041 .298
Hostility 2.8 (3.3) 2.5 (3.5) 1.847 .065
Phobia 1.8 (2.5) 1.5 (2.5) 2.652 .008
Paranoid 3.6 (3.7) 2.8 (3.8) 4.624 <.001
Psychoticism 3.9 (4.0) 3.2 (4.4) 3.571 <.001
1098
Effect of internet addiction on psychopathology
Normally, the skills of interpersonal interaction, social
cognition and communication mature with age in early
adulthood as the brain grow45,46; as time go by, the in-
dividuals may develop ability and accumulate experiences
to analyze the interpersonal and intrapersonal stimuli and
cope with them efficiently. The individuals may establish
their confidence to manage multidimensional difficulties
encountered in daily lives and therefor feel less anxious
toward unknown. The matureness may partially account for
the result of the present study that the severities of
obsession-compulsion, interpersonal sensitivity, paranoid
and psychoticism in the nonaddiction group significantly
decreased in follow-up consultations. However, the sever-
ities of all dimensions of psychopathology in the internet
addiction group did not improve significantly 1 year later.
Internet addiction may reduce the opportunities for college
students to engage in face-to-face social activities and
further compromise Internet users’ ability to learn what
others think, how to interact with peers maturely, how to
behave in a socially acceptable manner, and how to develop
empathy. In addition, evidence of decreased brain func-
tional connectivity in circuits linking cortical to subcortical
regions was found in adolescents with Internet addiction.47
College students with Internet addiction may be less
mature in both brain functional connectivity and personality
construction than those without Internet addiction.
Limitations
This study had several limitations that should be considered
when interpreting the results. First, the study data were
exclusively self-reported. Therefore, using only one data
source may have influenced our findings and resulted in
shared-method variance. Second, SCL-90-R is more useful
for measuring static mental states than psychiatric di-
agnoses. Hence, we could not infer from our result the
bidirectionality of the relationship between Internet
addiction and psychiatric diagnoses as previous studies do.
Third, the number of members of the Internet addiction
group was relatively small. This highlights the necessity of
large perspective studies with longer follow-up periods.
Fourth, we did not assess the content of the Internet ac-
tivity. In addition, present study utilized only two assess-
ments since the ideal methodological approach to tackle
bidirectional relationship often demand three or more
assessments.
Conclusion
This prospective investigation in college students demon-
strated that severe interpersonal sensitivity and paranoia
symptoms might predict the incidence of Internet addiction
at 1-year follow-up. The college students with internet
addiction did not have significant improvement in the se-
verities of psychopathology during the one-year period of
follow-up, whereas those without internet addiction had
significant improvement in obsession-compulsion, inter-
personal sensitivity, paranoid and psychoticism during the
same period. Intensive screening should be emphasized for
Y.-J. Lin et al.
college students with psychiatric symptoms to prevent the
development of Internet addiction. Furthermore, strategies
implemented for early intervention in Internet addiction
are therefore critical to college students for improving
their psychological symptoms.
Funding sources
This study was supported by Kaohsiung Medical University
Hospital (Grant No. KMUH103-3M38). The funding supported
conduction of the study, collection of data, and preparation
of original study report. No funding was available for
writing manuscript or publishing article.
Authors’ contribution
YJL: Study concept and design, obtained funding, study
supervision.
RCH: Study concept and design, analysis and interpretation
of data.
TLL: Analysis and interpretation of data, statistical
analysis.
CFY: Study concept and design, analysis and interpretation
of data, statistical analysis, obtained funding, study
supervision.
All authors had full access to all data in the study and take
responsibility for the integrity of the data and the accuracy
of the data analysis.
Ethics approval and consent to participate
The study was approved by the Institutional Review Board
of Kaohsiung Medical University Hospital.
Consent for publication
Not applicable.
Declaration of Competing Interest
The authors have no conflicts of interest relevant to this
article.
Acknowledgments
This study was supported by Kaohsiung Medical University
Hospital (Grant No. KMUH103-3M38).
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jfma.2019.10.006.
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