Children and Youth Services Review

The Psychological Distress Mediates the Relationship between Electronic Devices Use
and Insomnia in Adolescents
--Manuscript Draft--

Manuscript Number:

Article Type: Research paper

Section/Category: Children and Youth Services Review, General

Keywords: Electronic devices; Mediation; Adolescents; Psychological distress; Insomnia; Sleep

Corresponding Author: Maysoun Atoum, Ph.D

The Hashemite University
Zarqa, JORDAN

First Author: Maysoun Atoum, Ph.D., RN

Order of Authors: Maysoun Atoum, Ph.D., RN

Sami Al-Rawashdeh, Ph.D., RN

Sajidah Al-Hawamdih, Ph.D., RN

Hadeel Atoum, M D

Dina Atoum, PH

Arwa Almwajeh, RN

Abstract: Background : The relationships among electronic devices (e-devices) use, Insomnia,
and psychological distress are complex.  Purpose : This study aimed to examine the
relationships between e-devices use and the outcomes of Insomnia and psychological
distress with Insomnia and psychological as mediators.  Design : This is a
correlational study utilized cross-sectional data on hours of e-devices use, Insomnia,
and psychological distress from 485 randomly selected Jordanian adolescents. The 
 PROCESS macro for SPSS  developed by Andrew F. Hayes was used for the aim of
this study.  Results:  The hours of e-devices use predicted psychological distress. The
results of mediation analysis showed that the relationship between the hours of e-
devices use and Insomnia was mediated by psychological distress scores (indirect
effect size= .0462 with 95% CI .0095 and .0837). However, the relationship between
the hours of e-devices use and psychological distress was not mediated by insomnia
(indirect effect size= .0247 with 95% CI -.0063 and .0569). Conclusion:   The hours of
e-devices use may exert its effect on Insomnia through psychological distress, which in
turn may lead to Insomnia. The hypothesis that Insomnia may mediate the relationship
between e-devices use and psychological distress is not supported in this data. Further
research on this topic is warranted.

Suggested Reviewers: Kaltrina Kelmendi

kaltrina.kelmendi@uni-pr.edu

Betul Keles
betul.keles@kcl.ac.uk

Dr Mari Hysing
mari.hysing@uni.no

Marc N. Potenza
marc.potenza@yale.edu

Amir H. Pakpour
pakpour_amir@yahoo.com

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Abstract

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4 The Psychological Distress Mediates the Relationship between Electronic Devices
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7 Use and Insomnia in Adolescents
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12 Abstract
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14 Background: The relationships among electronic devices (e-devices) use, Insomnia, and
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17 psychological distress are complex. Purpose: This study aimed to examine the relationships
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19 between e-devices use and the outcomes of Insomnia and psychological distress with Insomnia
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21 and psychological as mediators. Design: This is a correlational study utilized cross-sectional data
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24 on hours of e-devices use, Insomnia, and psychological distress from 485 randomly selected
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26 Jordanian adolescents. The PROCESS macro for SPSS developed by Andrew F. Hayes was
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29 used for the aim of this study. Results: The hours of e-devices use predicted psychological
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31 distress. The results of mediation analysis showed that the relationship between the hours of e-
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34 devices use and Insomnia was mediated by psychological distress scores (indirect effect size=
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36 .0462 with 95% CI .0095 and .0837). However, the relationship between the hours of e-devices
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use and psychological distress was not mediated by insomnia (indirect effect size= .0247 with
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41 95% CI -.0063 and .0569). Conclusion: The hours of e-devices use may exert its effect on
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43 Insomnia through psychological distress, which in turn may lead to Insomnia. The hypothesis
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46 that Insomnia may mediate the relationship between e-devices use and psychological distress is
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48 not supported in this data. Further research on this topic is warranted.
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54 Keywords: Electronic devices; Mediation; Adolescents; Psychological distress; Insomnia; Sleep
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Title Page (with Author Details)

The Psychological Distress Mediates the Relationship between Electronic Devices

Use and Insomnia in Adolescents

Maysoun Atoum, *1 Ph.D., RN. Teacher, maysoun_atoum@hu.edu.jo

Sami Al-Rawashdeh, 1 Ph.D., RN Associate Professor, samiy@hu.edu.jo
Sajidah Al-Hawamdih, Ph.D., RN. Assistant Professor, Independent researcher.
Sajideh75@hotmail.com
Hadeel Atoum MD. Doctor of Medicine, Independent researcher. atoumh@gmail.com
Dina Atoum PH. Faculty of Pharmaceutical sciences, Independent researcher.
dinaatoum96@gmail.com
Arwa Almwajeh, RN, AL-Mafraq Governmental Hospital - Ministry of Health- Jordan.
arwa83jo@gmail.com

*Corresponding author
1
Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite
University, P.O. Box 330127, Zarqa 13133, Jordan.

Conflict of interest: None to declare

Authorship statement: All authors have contributed sufficiently in writing this manuscript in
terms of data collection, analysis, interpretation, and writing. All authors agree with the content
of the manuscript.

Authors' contributions: Dr. Atoum collected the data and wrote the introduction, Methods, and
implications sections. Dr. Al-Rawashdeh and Mrs. Almwajeh analyzed the data and wrote the data
analysis, the results, and the abstract sections. Dr. Al-Rawashdeh also critically revised and
proofread the final version of the paper. Dr. Sajideh and Dr. Hadeel Atoum wrote the discussion
and conclusion sections.

Acknowledgments: The researchers would like to acknowledge the input of all students who
participated in the current study.

Funding: The authors attest that they have not received funding for the work that resulted in this
article or its preparation.

Data availability statement: Data available upon reasonable request from the authors
 2

The Psychological Distress Mediates the Relationship between Electronic Devices

Use and Insomnia in Adolescents

Abstract

Background: The relationships among electronic devices (e-devices) use, Insomnia, and

psychological distress are complex. Purpose: This study aimed to examine the relationships

between e-devices use and the outcomes of Insomnia and psychological distress with Insomnia

and psychological as mediators. Design: This is a correlational study utilized cross-sectional data

on hours of e-devices use, Insomnia, and psychological distress from 485 randomly selected

Jordanian adolescents. The PROCESS macro for SPSS developed by Andrew F. Hayes was

used for the aim of this study. Results: The hours of e-devices use predicted psychological

distress. The results of mediation analysis showed that the relationship between the hours of e-

devices use and Insomnia was mediated by psychological distress scores (indirect effect size=

.0462 with 95% CI .0095 and .0837). However, the relationship between the hours of e-devices

use and psychological distress was not mediated by insomnia (indirect effect size= .0247 with

95% CI -.0063 and .0569). Conclusion: The hours of e-devices use may exert its effect on

Insomnia through psychological distress, which in turn may lead to Insomnia. The hypothesis

that Insomnia may mediate the relationship between e-devices use and psychological distress is

not supported in this data. Further research on this topic is warranted.

Keywords: Electronic devices; Mediation; Adolescents; Psychological distress; Insomnia; Sleep

 3

Introduction

Electronic devices (e-devices); such as computers, smartphones, and tablets) use has

become a fully integrated part of people's lives. In adolescents, e-devices use has become an

essential part of their contemporary life and one of the adolescents' most popular leisure time

activities (The World Bank, 2016). Although reasonable use of e-devises is beneficial in

improving cognitive skills such as intellectual, attentional control, and problem-solving skills

(Hisam et al., 2018; Nuyens, Kuss, Lopez-Fernandez, & Griffiths, 2019; Ozcetin, Gumustas,

Cag, Gokbay, & Ozmel, 2019), in the recent years e-devices use has become a growing concern

for the issue of addiction and has earned increased consideration from researchers and public

health practitioners. The (World Health Organization, 2015) reported that excessive e-device use

is possibly a type of behavioral addiction that presents as a repetitive pattern of behavioral

action, similar to the compulsive-impulsive spectrum disorder (Block, 2008). (Block, 2008).

Gaming disorders, closely related to excessive e-device use, have recently been included as a

new disorder in the WHO's 11th Revision of the International Classification of Diseases (WHO,

2018). The increased time adolescents spend using e-devices has raised concerns about its

possible negative effect on adolescents' physical and psychological well-being health (Lemola,

Perkinson-Gloor, Brand, Dewald-Kaufmann, & Grob, 2015; Zhao, Feng, Garg, & Kelly, 2019),

as well as in Jordan (Atoum, Al-Rawashdeh, Atoum, Atoum, & Atoum, 2021).

Sleep disorders are among the significant outcomes of excessive e-devices use (Wang et

al., 2021). Systematic reviews and meta-analyses studies showed a positive relationship between

excessive e-devices use and sleep disorders, including Insomnia (Alimoradi et al., 2019; Bartel,

Gradisar, & Williamson, 2015; Carter, Rees, Hale, Bhattacharjee, & Paradkar, 2016).These

symptoms cause severe troubles in adolescents' daily lives, including regular sleeping habits
 4

(Herlache, Lang, & Krizan, 2018), delayed bedtimes, and late wake-up times may additionally

lead to rhythm desynchronization and influence school performance (Herlache et al., 2018).

Good sleep is essential for learning ability, memory processes, emotional regulation, and related

behaviors (Curcio, Ferrara, & De Gennaro, 2006; Kobayashi, Takahashi, Deshpande, Shimbo, &

Fukui, 2012). Furthermore, restoring sleep among adolescents is strongly correlated with better

physical, cognitive, and psychological well-being (Brand & Kirov, 2011).

Psychological distress also was associated with negative outcomes e-devices use

(Atwood, Beckert, & Rhodes, 2017) and with sleep problems (Bhandari et al., 2017; Elhai,

Dvorak, Levine, & Hall, 2017; Fang, Tu, Sheng, & Shao, 2019; Vernon, Modecki, & Barber,

2017). However, no concord on the predictive role of psychological distress in developing sleep

disorders, especially in adolescents, with an inadequate number of longitudinal studies (Lovato

& Gradisar, 2014). Additionally, Insomnia has shown associations with psychological distress

(Bhandari et al., 2017; Elhai et al., 2017; Fang et al., 2019; Vernon et al., 2017), and predicted

the onset and relapse of depression(Fang et al., 2019). Studies that highlight the relationships

between e-devices use, sleep disorders and psychological distress was limited. These

relationships are complex especially among adolescents' populations. Research has identified

that the onset of puberty is an indicator for the development of both psychological distress and

sleep problems (Jeppesen et al., 2015; Lovato & Gradisar, 2014; Maalouf & Brent, 2012). The

time-course of developing Insomnia and other psychological distress overlaps, primarily when

excessive e-devices are used. Therefore, psychological distress may mediate the relationship

between the duration of e-devices use and Insomnia, or the Insomnia may mediate the

relationship between the duration of e-devices use and the development of psychological

distress. Many previous studies have demonstrated that Insomnia may be a potential mechanism
 5

explaining the relationship between e-devices and psychological distress among adolescents

(Kim et al., 2019; Lee, Y. J., Cho, Cho, & Kim, 2012; Zhao et al., 2019). This paper aimed to

clarify these relationships by examining these possibilities in a random sample of adolescents

from Jordan. This will assist in achieving a better understanding and guide the development of

early intervention and prevention strategies.

Methods

Design:

This study is a cross-sectional correlational study. A multiple‐ stage cluster random

sampling technique was employed to choose the study participants. Two secondary schools (one

for males and one for females) were randomly selected from a list of all government schools in

the five educational districts in Amman, Jordan's capital. Then, two classes from each ninth-,

10th-, and 11th-grade levels in each school were randomly selected. The final sample consisted

of 235 male and 250 female students drawn out of 1,210 males and 1,380 female students in the

selected schools. The required sample size was calculated using the G*Power 3.1.9.7 with a

small effect size of .05, statistical significance (α) of .05, a power level of 0.90, and 7 predictors.

The required sample size was about 373 students. We requested 120 additional participants to

overcome the expected non-response rate of about 30 % related to having the consent of both

students and their parents.

Procedure

Data were collected during the academic year of 2018/2019. Before data collection, the

Ethics Committee of the Institutional Review Board (IRB) at the university where the first author

is working (reference# 5/2/2018/2019) approved the study. In addition, the Ministry of

Education-Jordan approved this study. The study was briefly explained to the students and their
 6

parents, and written consent was obtained from both parties. All participants were assured of

their right to participate, refuse, and draw at any time without any consequence.

Measures

Psychological distress. The short form of the Arabic version of the Depression Anxiety

Stress Scale-21 (DASS-21) was used to measure psychological distress. The scale measures the

depression, anxiety, and stress dimensions, with dimension score is calculated by summing the

responses of the seven pertinent items (Lovibond & Lovibond, 1995). The responses are rated

on a scale ranged between 0="Did not apply to me at all" to 3="Applied to me very much, or

most of the time. “An example of the item is "I found it difficult to relax. The dimensions scores

are summed and then multiplied by two to represent the total score of psychological distress,

which could range between 0 and 126. The higher scores represent severe psychological distress.

The validity and reliability of the DASS-21 questionnaire in measuring the psychological distress

among adolescents have been provided in several studies(Ali & Milstein, 2012; Singh,

Junnarkar, & Sharma, 2015). In the current study, Cronbach's reliability alpha was 0.71, 0.63,

0.67, and 0.83 for the stress, anxiety, depression subscales, and the total scale scores,

respectively.

Sleep and Insomnia. Sleep related measures assessment included the average of hours

slept per day (the duration of the nap, if taken during the day, is added to the hours of sleep at

night), the perception of the adequacy of the sleep (yes, no), and Insomnia. Insomnia was

measured using the Insomnia Severity Index (ISI). The ISI is a widely used self-report

questionnaire consisting of 7-item to measure Insomnia's nature, severity, and effect on a 5-point

Likert scale ranging from 0 "not at all" to 4 "very severe." The total scores were calculated by
 7

summing the responses of the items and so the total scores range between 0 and 28, with a higher

score indicating severe Insomnia. The respondents were classified into no signs of Insomnia,

mild Insomnia, moderate Insomnia, and severe Insomnia, based on the cutoff scores of 0–7, 8–

14, 15–21, and 22–28, respectively (Morin, Belleville, Bélanger, & Ivers, 2011). The ISI has

shown excellent psychometric properties and was validated in adolescents (Bastien, Vallières, &

Morin, 2001; Chung, Kan, & Yeung, 2011; Morin et al., 2011). The Arabic version of the ISI has

shown excellent psychometric properties (Ahmed, 2015; Suleiman & Yates, 2011). In the current

study, the ISI had a Cronbach's alpha of 0.717.

Data Analysis

Statistical Package for Social Sciences (SPSS) version 25 was used in analyzing data

with 0.05 as the significance level. Descriptive statistics such as frequency (percentage) and

mean (±standard deviation) as appropriate to the level of measurement, were used to summarize

the subjects' demographic and clinical characteristics. The PROCESS Macro version 3.5.3 for

SPSS developed by Dr. Andrew F. Hayes was used for the mediation analysis in this study

(Hayes, 2018). The PROCESS mediation analysis was done while controlling the variables of

age, gender (0=male 1=female), number of family members, income, and Body Mass Index

(BMI). The PROCESS mediation analysis was done using bootstrapping of 5000 samples and

95% as the level of confidence for all confidence intervals in output.

Results

The Subjects Sociodemographic and Clinical Characteristics

The subjects' mean age was 16.1 (±0.77) years (Table 1). About half of the subjects were

females and under the poverty line of JD 814 (≈ $1140). The average number of family members
 8

was 4.76 (±1.26) members, with the majority having four members. The majority of subjects

were non-smokers and had a normal BMI.

The subjects had a high mean of daily e-devices of 5.26 (±4.0) hours. They had

moderately low total psychological distress scores (DASS-21, mean was 42.52 ±20.29),

indicating a mild distress level. Regarding the subjects' sleep, the subjects had a good mean (8.63

hours ± 2.01) of total hours of sleep /day and a mean Insomnia score of 8.76 ±4.6, indicating a

subthreshold Insomnia. Most subjects were categorized in either the "no Insomnia" group or the

"mild Insomnia" group.

Please insert Table 1 here.

Table 2 shows the correlation among subjects' characteristics and main study variables.

The hours of e-devices use had a weak but significant positive correlation with psychological

distress scores. There was no significant association between the hours of e-devices and

Insomnia. The psychological distress scores had a significant positive association with Insomnia,

indicating an increase in psychological distress scores is associated with increased (worse)

Insomnia. The other correlations are presented in Table 2.

Please insert Table 2 here.

Mediation role of psychological distress on the relationship between the hours of e-devices

use and Insomnia

The results of the regression analyses indicated that the hours of e-devices use were not a

significant predictor of the Insomnia scores (model 1, Table 3A) but, the hours of e-devices use

was a significant predictor of psychological distress (model 2, Table 3A). Insomnia was

significantly predicted by psychological distress only when both psychological distress and e-

devices use entered simultaneously into the regression model (model 3, Table 3A). Using
 9

PROCESS macro for SPSS, we conducted a post-hoc mediation analysis using bootstrapping

(the number of bootstrap samples for percentile bootstrap confidence intervals was 5000 with a

confidence interval (CI) of 95%; Table 3B). The result showed that the relationship between the

hours of e-devices use, and Insomnia was mediated by psychological distress scores with an

effect of .0552 and CI for the completely standardized indirect effect(s) of X on Y were .0173

and .0925.

Please insert Table 3A here

Please insert Table 3B here

Mediation role of Insomnia on the relationship between the hours of e-devices use and

psychological distress

The results related to examining the role of Insomnia as a mediator of the relationship

between the hours of e-devices use and psychological distress are presented in Table 4A. The

number of hours of e-devices use was a significant predictor of psychological distress (model 1,

Table 4A). The Insomnia scores were not predicted by the hours of e-devices use (model 2).

When both Insomnia scores and hours of e-devices use entered simultaneously into the

regression model (model 3, Table 4A), both were significant predictors of psychological distress.

The post-hoc mediation analysis using bootstrapping (Table 4B) showed that the relationship

between the hours of e-devices use and psychological distress was not mediated by Insomnia (the

effect was .0247 and CI for the completely standardized indirect effect(s) of X on Y were (-.0064

and .0578).

Please insert Table 4A here

Please insert Table 4B here

Discussion
 10

The present study examined the relationship among e-devices use, Insomnia, and

psychological distress with Insomnia and psychological as mediators. Our finding revealed that

the relationship between hours of e-devices use, and Insomnia is mediated by psychological

distress, but the relationship between the hours of e-devices use and psychological distress scores

was not mediated by Insomnia. The current findings support the proper use of e-devices by

adolescents as it has shown that the excessive e-devices use is associated with more

psychological distress and insomnia. The significant effect of the duration of hours of e-devices

use on psychological distress in our study is in line with many previous studies (Lange et al.,

2017; LeBourgeois et al., 2017; Schweizer et al., 2017). This study may contribute to a better

understanding of the interrelations among modifiable lifestyle factors and potentially guide the

development of early intervention and prevention strategies. However, having insignificant

mediation effect of Insomnia on the relationship between the hours of e-devices use and

psychological distress scores does not exclude the importance of maintaining good sleep during

adolescence to as having a good sleep minimizes the psychological problems and prevent the

onset of psychological distress.

Regarding the pathway, our results revealed that the e-devices activities were indirectly

associated with Insomnia through psychological distress. Furthermore, two meta-analyses

showed a significate negative effect of e-device duration on young adolescents' sleep (Bartel et

al., 2015; Carter et al., 2016). Additionally, adolescents with Insomnia are more likely to report

comorbid psychological distress such as depression and anxiety than those without sleep

problems (Elhai et al., 2017; Hysing, Mari, Lundervold, Posserud, & Sivertsen, 2016).The

adolescents in our study have duration of e-devices use (five hours) higher the recommended

duration of a maximum of two hours (Paruthi et al., 2016). This high duration is consistent with
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findings of many previous studies among adolescents (Buabbas, Hasan, & Buabbas, 2021;

Stiglic & Viner, 2019) and the dependence of adolescents on e- devices use (Chaput et al., 2014;

Hysing, M. et al., 2015; Kappos, 2007; SUGANUMA et al., 2007). In addition, adolescents in

our study have moderate level of psychological distress similar to some previous research studies

(Jeong, Kim, Yum, & Hwang, 2016; Samaha & Hawi, 2016) but a higher level than those

reported by others (Mishra, Srivastava, Tiwary, & Kumar, 2018; Ostovar et al., 2016). For

example, subjects in our study had higher psychological distress than Indians (Mishra et al.,

2018) and Malaysian adolescents (Latiff, Tajik, Ibrahim, Abubakar, & Ali, Shirin Shameema

Binti Albar, 2016) but lower than those reported by Buabbas & Hasan (2021). It could be from

the influence of culture, which may interpret the differences between psychological distress

among the population, society, heredity, environmental factors (Putul, Kahua, Choudhury, &

Shobhana, 2018).

In our study, hours of e-devices predicted adolescent psychological distress, similar to

findings reported by many previous studies (Al Salman, Al Debel, Al Zakaria, Shafey, &

Darwish, 2020; Ramón-Arbués et al., 2020). Excessive use of e-devices provokes adverse

psychological problems (Elhai et al., 2017; Madigan, Browne, Racine, Mori, & Tough, 2019;

Neophytou, Manwell, & Eikelboom, 2021; Stiglic & Viner, 2019). E-devices can be solitary

activities, reducing adolescents' opportunities to engage in face-to-face social contact. Moreover,

these relieving of social deprivation and isolation have unique effects on the brain and behavioral

development, which sequentially are implicated in psychological problems (Orben, Tomova, &

Blakemore, 2020). Excessive e-devices use can cause an imbalance in the gamma-aminobutyric

acid (GABA) brain chemistry, which correlates with developing depression and anxiety (Seo

HS, Jeong EK, Choi SW, Kwon YA, Park HJ, Kim IS, 2017). This cycle could further initiate or
 12

worsen psychological well-being and trigger further e-devices addiction (Yen, Lin, Chou, Liu,

& Ko, 2019), as it could be used as a coping mechanism (Avci & Kelleci, 2016; Domingues‐

Montanari, 2017; Vidal, Lhaksampa, Miller, & Platt, 2020). Further, it was suggested that family

relationships, economic conditions, and academic school pressure were related to real

psychological distress. The reason may be that the use of e-device was not linked to the

biological clock of the sample and its effect was not evident in this regard, although those

adolescents sleep less than recommended (Paruthi et al., 2016).

Subjects who use e-devices for approximately 5 hours per day can cause severe trouble in

psychological wellbeing and sleeping habits (Herlache et al., 2018), while others indicate that

those problems are common among those who use e-devices for more than 6 hours (Lee, J. J. et

al., 2020). In conclude to support healthy e-devices usage, strategies aimed at relieving the

harmful psychological effect of e-devices use on psychological distress might benefit from those

aimed at enhancing sleep quality.

The literature suggests a complex bidirectional relationship between sleep problems

including Insomnia and psychological disorders (Cousins et al., 2011; Fang et al., 2019).

Adolescents with psychological problems may have difficulty initiating or maintaining sleep and

have difficulty awakening in the morning (Demirci, Akgönül, & Akpinar, 2015; Gottschalk,

2019; Mei et al., 2018). Consequently, spending a lot of the total time in bed awake (Hysing et

al., 2015; King, Delfabbro, Zwaans, & Kaptsis, 2014a; King, Delfabbro, Zwaans, & Kaptsis,

2014b; Lemola et al., 2015), and improved sleep was related to a better psychological well-being

status in adolescents (Cairns, Yap, Pilkington, & Jorm, 2014; Lovato & Gradisar, 2014). Several

possible mechanisms could explain the relationship between Insomnia and psychological distress

among adolescents. First, screen light emitted from e-devices can affect sleeping patterns by
 13

altering adolescents' circadian rhythm and hormone levels of melatonin-suppressing effect,

especially during bedtime (Lemola et al., 2015; Lewy, 2015). Using e-devices in the last hour

before sleeping for a long time at the onset of latency and increasing the lack of sleep cause a

positive correlation between e-device use in bed and Insomnia as a study by (Driller & Uiga,

2019; Fossum, Nordnes, Storemark, Bjorvatn, & Pallesen, 2014).

(Driller & Uiga, 2019; Fossum et al., 2014). Second, a short duration of sleep adversely affects

levels of neurotransmitters that regulate and express emotions of brain function (Goldstein &

Walker, 2014). It is also resulting differences in brain functions (Dutil et al., 2018), including

working memory, inhibitory control, anger, aggression behavior, and development of psychiatric

disorders (Ranum et al., 2019; Rohlf, Holl, Kirsch, Krahé, & Elsner, 2018).Third, sleep

deprivation could be related to increased cortisol response, and dysregulation of cortisol and

pubertal hormone levels among adolescents can cause Insomnia and psychological disorders

(Blake, Trinder, & Allen, 2018; Dolsen, Wyatt, & Harvey, 2019; Minkel et al., 2014). Finally,

Insufficient Sleep can make the preservation of healthy active living more difficult due to

subsequent sleepiness, and daytime impairments pose severe health threats (Owens, Adolescent

Sleep Working Group, & Committee on Adolescence, 2014). The potential pathways linking e-

devices to psychological distress and Insomnia have not been fully realized. Therefore, timely

diagnosis and management of sleep disorders appear critical for growth and development in

adolescents. There is a need to confirm this relationship in a longitudinal study with a larger

sample size in future studies.

Limitations and Implications

Although our study has many strengths such as using reliable and valid tools, fairly large

sample, and use of randomized sampling that may help in generalization of the findings.
 14

Nevertheless, the study's cross-sectional design limits inferring of the cause-effect relationship.

All variables were evaluated through a self-report questionnaire, which may lead to social

desirability bias. It is highly recommended to add objective measures of the variables. Future

studies may benefit from comparing findings from subjective and objective measures. Although

this study was conducted in two randomly selected secondary schools, it could not represent all

adolescent students from both genders in Jordan. Future research should increase the

representativeness of the sample. Further, longitudinal and experimental studies are needed to

allow attribution of causation. Despite these limitations, our study extends the previous results

regarding the relationship between e-devices, sleep problems, and psychological distress by

estimating the mediating effects of sleep on the relationship between e-devices and psychological

distress among adolescents' students. In our study, we do not specify the used e-devices. At the

same time, many authors reported that the positive and negative consequences of e-devices use

are contingent on what kind of digital activity is engaged (Pandya & Lodha, 2021).

The study highlights the need for increasing awareness about the effects of e-devices on

psychological wellbeing and sleep in adolescents, which should regularly assessed and

monitored especially in the Coronavirus era and thereafter where most adolescents become using

e-devices more often and owning at least one e-device. It also highlights the need for further

research on identifying the effective interventions regarding these issues among adolescents and

involving clinicians, teachers, parents, and adolescents to foster proper e-device use and promote

the psychological wellbeing and healthy sleep habits. Students' curriculum should provide the

adolescent students with knowledge about the proper use of e-devices and should improve

students' self-ability to control or monitor the time they use e-devices. Psychoeducation training

programs and crisis interventions for the high-risk target of psychological problems and the
 15

general population, such as time management, problem-solving skills, and finding alternate

events to fill the adolescents' free time.

The finding also emphasized the importance of restricting and limiting the total time

spent on e-devices using software applications to monitor and prevent e-devices addiction

(Sediyono & Ariwibowo, 2017). Although specific software applications were constructed to

help users control their excessive e-devices use, these applications seem to have failed to reduce

actual usage (Zimmermann, 2021). But a real way may be by using parental restricting styles

intervention (Nikken, 2018) and self-regulation as a protective influence on adolescents'

excessive e-devices uses (Chang et al., 2019; Meeus, Eggermont, & Beullens, 2019). In a

systematic review meeting, the recommendations ensure the combination of physical activity,

sedentary time, and sleep duration to improve psychological well-being among adolescents

(Sampasa-Kanyinga et al., 2020). Additionally, based on the current findings, future research

should focus on the interventions related to excessive e-devices use and concentrate on sleeping

problems and psychological distress. Overall, it is crucial to provide strategies at the community

and school levels to avoid excessive e-devices.

Conclusion
This study found that the relationship between the hours of e-devices use, and

psychological distress was not mediated by Insomnia and that the relationship between e-devices

use and Insomnia was mediated by psychological distress. The hours of e-devices use,

psychological distress, and Insomnia was mediated. Throughout the consequences of prolonged

e-devices, use a strict need for teaching healthy habits to limit the total time spent on e-devices,

especially knowing that e-devices technology is here to stay and grow up with time.

A collaborative team from parents, educators, policymakers, and health professionals to

prevent harmful effects of excessive e-devices. Based on the findings of this study, the following
 16

recommendations are suggested to avoid the detrimental impacts of hours of e-devices use and

psychological distress. First, parents should limit the hours of e-devices use; second, schools

should educate students about the effects of e-devices use. Third, conducted further research on

e-device effects, especially psychological effects.

 17

Table 1. Demographic and clinical characteristics of the subjects (N=485).

Characteristic Mean ±SD or n (%)
Age, Years 16.1 ±0.77
15 years 111 (22.9)
16 years 230 (47.4)
17 years 132 (27.2)
18 years 12 (2.5)
Gender, Female 250 (51.5)
Number of Family Members, 4.76±1.26
3 Members 79 (16.3)
4 Members 154 (31.8)
5 Members 117 (24.1)
≥ 6 Members 135 (27.8)
Family Income, JD 745.98±214
≤ 814 (below the poverty line) 243 (50.1)
>814 242 (49.9)
BMI 21.38±3.94
Underweight (<19) 122 (25.2)
Normal (19-25) 297 (61.2)
Overweight (>25) 66 (13.6)
Smoking status,
Non-smokers 437 (90.1)
Smokers 48 (9.9)
Hours of e-devices use/day 5.26±4.0
Total Psychological distress scores (DASS-21) 42.52±20.29
Total Insomnia Severity Index scores 8.76±4.6
No Insomnia (0–7) 222 (45.8)
Subthreshold/mild (8–14) 212 (43.7)
Moderate Insomnia (15-21) 48 (9.9)
Severe Insomnia (>22) 3 (0.6)
Total hours of sleep time (including naps)/day 8.63± 2.01
SD = standard deviation; DASS 21= Depression Anxiety Stress Scale-21; MSPSS=
Multidimensional Scale of Perceived Social Support
 18

Table 2: correlation among subjects' characteristics and main study variables (N=485).

1 2 3 4 5 6 7
1 Age --
2 Gender .176** --
3 Number of family members .125** .048 --
4 Income -.143** .012 -.038 --
5 BMI .090* -.021 .086 .057 --
6 Hours of e-devices use .099* .074 -.029 .008 .009 --
7 Total DASI-21 .202** .144** .149** -.041 .107* .160** --
8 Insomnia scores .090* .026 -.016 -.073 .060 .077 .386**
* Correlation is significant at the 0.05 level (2-tailed); ** Correlation is significant at the 0.01 level (2-tailed)
 19

Table 3A. Standard multiple linear regression analyses with the psychological distress scores as a mediator of the relationship
between the Hours of e-devices use (independent variable) and Insomnia scores as dependent variable (N=485).
Model/ Predictors B S. Error β t p LLCI ULCI
1. Outcome: Insomnia (dependent variable)
Hours of e-devices use .0786 .0524 .0684 1.4994 .1344 -.0244 .1816
Age .4160 .2821 .0696 1.4744 .1410 -.1384 .9703
Gender (ref=female) .1112 .4244 .0121 .2621 .7934 -.7227 .9452
Number of family members -.1140 .1675 -.0312 -.6807 .4964 -.4431 .2151
Income -.0015 .0010 -.0685 -1.4914 .1365 -.0034 .0005
Body Mass Index .0696 .0534 .0596 1.3026 .1933 -.0354 .1745
2
F(6, 478) =1.699 R=.1445 R =.0209 P= .1192
2. Outcome: Psychological distress (the mediator)
Hours of e-devices use .7140 .2223 .1409 3.2124 .0014 .2773 1.1508
Age 3.7958 1.1966 .1440 3.1721 .0016 1.4445 6.1471
Gender (ref=female) 4.2172 1.8001 .1039 2.3428 .0195 .6802 7.7543
Number of family members 1.9645 .7104 .1219 2.7655 .0059 .5687 3.3603
Income -.0022 .0042 -.0235 -.5325 .5946 -.0104 .0060
Body Mass Index .4434 .2265 .0861 1.9571 .0509 -.0018 .8885
F(6, 478) =8.3591 R=.3082 R2=.0950 P= .0000
3. Outcome: Insomnia (dependent variable)
Hours of e-devices use .0152 .0491 .0132 .3096 .7570 -.0813 .1117
DASS-21 .0887 .0100 .3915 8.8738 .0000 .0691 .1084
Age .0791 .26544 .0132 .2992 .7649 -.4404 .5986
Gender (ref=female) -.2630 .3959 -.0286 -.6645 .5067 -1.0409 .5148
Number of family members -.2883 .1566 -.0789 -1.8417 .0661 -.5960 .0193
Income -.0013 .0009 -.0593 -1.3961 .1647 -.0031 .0005
Body Mass Index .0302 .0497 .0259 .6077 .5437 -.0675 .1279
F(7, 477) = 12.943 R= .3995 R2=.1596 P= .0000
B= Unstandardized & β=Standardized coefficients; LLCI & ULCI = Lower limit & upper limit confidence interval (CI); CI =95%
 20

Table 3B. The PROCESS macro post-hoc mediation analysis using bootstrapping of the effect of psychological distress scores
as a mediator on the relationship between hours of e-devices use and Insomnia scores.
Effect Effect S. Error t p LLCI ULCI c_ps c_cs
Total effect of X on Y .0786 .0524 1.4994 .1344 -.0244 .1816 .0171 .0684
Effect S. Error t p LLCI ULCI c'_ps c'_cs
Direct effect of X on Y .0152 .0491 .3096 .7570 -.0813 .1117 .0033 .0132
Effect Bootstrap Bootstrap Bootstrap
SE LLCI ULCI
Indirect effect(s) of X on Y .0634 .0222 .0204 .1081
Partially standardized .0138 .0048 .0044 .0233
indirect effect(s) of X on Y
Completely standardized .0552 .0190 .0173 .0925
indirect effect(s) of X on Y
The number of bootstrap samples was 5000; CI=confidence interval; CI was 95%; LLCI= Lower limit CI; ULCI= Upper limit
CI; c_ps; c_cs; c'_ps; c'_cs
 21

Table 4A. Standard multiple linear regression with Insomnia as a mediator of the relationship between the Hours of e-devices
use (independent variable) and psychological distress as dependent variable (N=485).
Model/ Predictors B S. Error β t p LLCI ULCI
1. Outcome: Psychological distress (dependent variable): see model 2 Table 3A
2. Outcome: Insomnia (the mediator): see model 1 Table 3A
3. Outcome: Psychological distress (dependent variable)
Hours of e-devices use .5886 .2066 .1161 2.8486 .0046 .1826 .9946
Insomnia 1.5965 .1799 .3619 8.8738 .0000 1.2430 1.9501
Age 3.1316 1.1123 .1188 2.8155 .0051 .9460 5.3173
Gender (ref=female) 4.0397 1.6695 .0996 2.4196 .0159 .7591 7.3202
Number of family members 2.1465 .6591 .1331 3.2567 .0012 .8514 3.4416
Income .0001 .0039 .0013 .0311 .9752 -.0075 .0078
Body Mass Index .3323 .2105 .0645 1.5788 .1150 -.0813 .7459
F(7, 477) =19.5796 R= .4724 R2=.2232 P= .0000
B= Unstandardized & β=Standardized coefficients; LLCI & ULCI = Lower limit & upper limit confidence interval (CI); CI =95%

Table 4B. The PROCESS macro post-hoc mediation analysis using bootstrapping of the Insomnia as a mediator on the
relationship between hours of e-devices use and psychological distress scores.
Effect Effect S. Error t p LLCI ULCI c_ps c_cs
Total effect of X on Y .7140 .2223 3.2124 .0014 .2773 1.1508 .0352 .1409
Effect S. Error t p LLCI ULCI c'_ps c'_cs
Direct effect of X on Y .5886 .2066 2.8486 .0046 .1826 .9946 .0290 .1161
Effect Bootstrap SE Bootstrap LLCI Bootstrap ULCI
Indirect effect(s) of X on Y .1255 .0847 -.0311 .2981
Partially standardized indirect 0062 .0042 -.0015 .0148
effect(s) of X on Y
Completely standardized indirect .0247 .0164 -.0064 .0578
effect(s) of X on Y
 22

The number of bootstrap samples was 5000; CI=confidence interval; CI was 95%; LLCI= Lower limit CI; ULCI= Upper

limit CI; c_ps; c_cs; c'_ps; c'_cs

 23

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psychopathology: The mediating role of sleep disruptions. Journal of Clinical Child & Adolescent Psychology, 46(2), 269-283.

Vidal, C., Lhaksampa, T., Miller, L., & Platt, R. (2020). Social media use and depression in adolescents: A scoping review.

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1 1
2
3
4 The Psychological Distress Mediates the Relationship between Electronic Devices
5
6
7 Use and Insomnia in Adolescents
8
9
10
11
Introduction
12
13 Electronic devices (e-devices); such as computers, smartphones, and tablets) use has
14
15 become a fully integrated part of people's lives. In adolescents, e-devices use has become an
16
17
18 essential part of their contemporary life and one of the adolescents' most popular leisure time
19
20 activities (The World Bank, 2016). Although reasonable use of e-devises is beneficial in
21
22
23 improving cognitive skills such as intellectual, attentional control, and problem-solving skills
24
25 (Hisam et al., 2018; Nuyens, Kuss, Lopez-Fernandez, & Griffiths, 2019; Ozcetin, Gumustas,
26
27
28
Cag, Gokbay, & Ozmel, 2019), in the recent years e-devices use has become a growing concern
29
30 for the issue of addiction and has earned increased consideration from researchers and public
31
32 health practitioners. The (World Health Organization, 2015) reported that excessive e-device use
33
34
35 is possibly a type of behavioral addiction that presents as a repetitive pattern of behavioral
36
37 action, similar to the compulsive-impulsive spectrum disorder (Block, 2008). (Block, 2008).
38
39
40 Gaming disorders, closely related to excessive e-device use, have recently been included as a
41
42 new disorder in the WHO's 11th Revision of the International Classification of Diseases (WHO,
43
44
45 2018). The increased time adolescents spend using e-devices has raised concerns about its
46
47 possible negative effect on adolescents' physical and psychological well-being health (Lemola,
48
49
Perkinson-Gloor, Brand, Dewald-Kaufmann, & Grob, 2015; Zhao, Feng, Garg, & Kelly, 2019),
50
51
52 as well as in Jordan (Atoum, Al-Rawashdeh, Atoum, Atoum, & Atoum, 2021).
53
54 Sleep disorders are among the significant outcomes of excessive e-devices use (Wang et
55
56
57 al., 2021). Systematic reviews and meta-analyses studies showed a positive relationship between
58
59 excessive e-devices use and sleep disorders, including Insomnia (Alimoradi et al., 2019; Bartel,
60
61
62
63
64
65
 1 2
2
3
4 Gradisar, & Williamson, 2015; Carter, Rees, Hale, Bhattacharjee, & Paradkar, 2016).These
5
6
7 symptoms cause severe troubles in adolescents' daily lives, including regular sleeping habits
8
9 (Herlache, Lang, & Krizan, 2018), delayed bedtimes, and late wake-up times may additionally
10
11
12 lead to rhythm desynchronization and influence school performance (Herlache et al., 2018).
13
14 Good sleep is essential for learning ability, memory processes, emotional regulation, and related
15
16
17 behaviors (Curcio, Ferrara, & De Gennaro, 2006; Kobayashi, Takahashi, Deshpande, Shimbo, &
18
19 Fukui, 2012). Furthermore, restoring sleep among adolescents is strongly correlated with better
20
21 physical, cognitive, and psychological well-being (Brand & Kirov, 2011).
22
23
24 Psychological distress also was associated with negative outcomes e-devices use
25
26 (Atwood, Beckert, & Rhodes, 2017) and with sleep problems (Bhandari et al., 2017; Elhai,
27
28
29 Dvorak, Levine, & Hall, 2017; Fang, Tu, Sheng, & Shao, 2019; Vernon, Modecki, & Barber,
30
31 2017). However, no concord on the predictive role of psychological distress in developing sleep
32
33
34 disorders, especially in adolescents, with an inadequate number of longitudinal studies (Lovato
35
36 & Gradisar, 2014). Additionally, Insomnia has shown associations with psychological distress
37
38
39
(Bhandari et al., 2017; Elhai et al., 2017; Fang et al., 2019; Vernon et al., 2017), and predicted
40
41 the onset and relapse of depression(Fang et al., 2019). Studies that highlight the relationships
42
43 between e-devices use, sleep disorders and psychological distress was limited. These
44
45
46 relationships are complex especially among adolescents' populations. Research has identified
47
48 that the onset of puberty is an indicator for the development of both psychological distress and
49
50
51 sleep problems (Jeppesen et al., 2015; Lovato & Gradisar, 2014; Maalouf & Brent, 2012). The
52
53 time-course of developing Insomnia and other psychological distress overlaps, primarily when
54
55
56
excessive e-devices are used. Therefore, psychological distress may mediate the relationship
57
58 between the duration of e-devices use and Insomnia, or the Insomnia may mediate the
59
60
61
62
63
64
65
 1 3
2
3
4 relationship between the duration of e-devices use and the development of psychological
5
6
7 distress. Many previous studies have demonstrated that Insomnia may be a potential mechanism
8
9 explaining the relationship between e-devices and psychological distress among adolescents
10
11
12 (Kim et al., 2019; Lee, Y. J., Cho, Cho, & Kim, 2012; Zhao et al., 2019). This paper aimed to
13
14 clarify these relationships by examining these possibilities in a random sample of adolescents
15
16
17 from Jordan. This will assist in achieving a better understanding and guide the development of
18
19 early intervention and prevention strategies.
20
21
Methods
22
23
24 Design:
25
26 This study is a cross-sectional correlational study. A multiple‐ stage cluster random
27
28
29 sampling technique was employed to choose the study participants. Two secondary schools (one
30
31 for males and one for females) were randomly selected from a list of all government schools in
32
33
34 the five educational districts in Amman, Jordan's capital. Then, two classes from each ninth-,
35
36 10th-, and 11th-grade levels in each school were randomly selected. The final sample consisted
37
38
39
of 235 male and 250 female students drawn out of 1,210 males and 1,380 female students in the
40
41 selected schools. The required sample size was calculated using the G*Power 3.1.9.7 with a
42
43 small effect size of .05, statistical significance (α) of .05, a power level of 0.90, and 7 predictors.
44
45
46 The required sample size was about 373 students. We requested 120 additional participants to
47
48 overcome the expected non-response rate of about 30 % related to having the consent of both
49
50
51 students and their parents.
52
53 Procedure
54
55
56
Data were collected during the academic year of 2018/2019. Before data collection, the
57
58 Ethics Committee of the Institutional Review Board (IRB) at the university where the first author
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 1 4
2
3
4 is working (reference# 5/2/2018/2019) approved the study. In addition, the Ministry of
5
6
7 Education-Jordan approved this study. The study was briefly explained to the students and their
8
9 parents, and written consent was obtained from both parties. All participants were assured of
10
11
12 their right to participate, refuse, and draw at any time without any consequence.
13
14 Measures
15
16
17 Psychological distress. The short form of the Arabic version of the Depression Anxiety
18
19 Stress Scale-21 (DASS-21) was used to measure psychological distress. The scale measures the
20
21 depression, anxiety, and stress dimensions, with dimension score is calculated by summing the
22
23
24 responses of the seven pertinent items (Lovibond & Lovibond, 1995). The responses are rated
25
26 on a scale ranged between 0="Did not apply to me at all" to 3="Applied to me very much, or
27
28
29 most of the time. “An example of the item is "I found it difficult to relax. The dimensions scores
30
31 are summed and then multiplied by two to represent the total score of psychological distress,
32
33
34 which could range between 0 and 126. The higher scores represent severe psychological distress.
35
36 The validity and reliability of the DASS-21 questionnaire in measuring the psychological distress
37
38
39
among adolescents have been provided in several studies(Ali & Milstein, 2012; Singh,
40
41 Junnarkar, & Sharma, 2015). In the current study, Cronbach's reliability alpha was 0.71, 0.63,
42
43 0.67, and 0.83 for the stress, anxiety, depression subscales, and the total scale scores,
44
45
46 respectively.
47
48 Sleep and Insomnia. Sleep related measures assessment included the average of hours
49
50
51 slept per day (the duration of the nap, if taken during the day, is added to the hours of sleep at
52
53 night), the perception of the adequacy of the sleep (yes, no), and Insomnia. Insomnia was
54
55
56
measured using the Insomnia Severity Index (ISI). The ISI is a widely used self-report
57
58 questionnaire consisting of 7-item to measure Insomnia's nature, severity, and effect on a 5-point
59
60
61
62
63
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 1 5
2
3
4 Likert scale ranging from 0 "not at all" to 4 "very severe." The total scores were calculated by
5
6
7 summing the responses of the items and so the total scores range between 0 and 28, with a higher
8
9 score indicating severe Insomnia. The respondents were classified into no signs of Insomnia,
10
11
12 mild Insomnia, moderate Insomnia, and severe Insomnia, based on the cutoff scores of 0–7, 8–
13
14 14, 15–21, and 22–28, respectively (Morin, Belleville, Bélanger, & Ivers, 2011). The ISI has
15
16
17 shown excellent psychometric properties and was validated in adolescents (Bastien, Vallières, &
18
19 Morin, 2001; Chung, Kan, & Yeung, 2011; Morin et al., 2011). The Arabic version of the ISI has
20
21 shown excellent psychometric properties (Ahmed, 2015; Suleiman & Yates, 2011). In the current
22
23
24 study, the ISI had a Cronbach's alpha of 0.717.
25
26 Data Analysis
27
28
29 Statistical Package for Social Sciences (SPSS) version 25 was used in analyzing data
30
31 with 0.05 as the significance level. Descriptive statistics such as frequency (percentage) and
32
33
34 mean (±standard deviation) as appropriate to the level of measurement, were used to summarize
35
36 the subjects' demographic and clinical characteristics. The PROCESS Macro version 3.5.3 for
37
38
39
SPSS developed by Dr. Andrew F. Hayes was used for the mediation analysis in this study
40
41 (Hayes, 2018). The PROCESS mediation analysis was done while controlling the variables of
42
43 age, gender (0=male 1=female), number of family members, income, and Body Mass Index
44
45
46 (BMI). The PROCESS mediation analysis was done using bootstrapping of 5000 samples and
47
48 95% as the level of confidence for all confidence intervals in output.
49
50
51 Results
52
53 The Subjects Sociodemographic and Clinical Characteristics
54
55
56
The subjects' mean age was 16.1 (±0.77) years (Table 1). About half of the subjects were
57
58 females and under the poverty line of JD 814 (≈ $1140). The average number of family members
59
60
61
62
63
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 1 6
2
3
4 was 4.76 (±1.26) members, with the majority having four members. The majority of subjects
5
6
7 were non-smokers and had a normal BMI.
8
9 The subjects had a high mean of daily e-devices of 5.26 (±4.0) hours. They had
10
11
12 moderately low total psychological distress scores (DASS-21, mean was 42.52 ±20.29),
13
14 indicating a mild distress level. Regarding the subjects' sleep, the subjects had a good mean (8.63
15
16
17 hours ± 2.01) of total hours of sleep /day and a mean Insomnia score of 8.76 ±4.6, indicating a
18
19 subthreshold Insomnia. Most subjects were categorized in either the "no Insomnia" group or the
20
21 "mild Insomnia" group.
22
23
24 Please insert Table 1 here.
25
26 Table 2 shows the correlation among subjects' characteristics and main study variables.
27
28
29 The hours of e-devices use had a weak but significant positive correlation with psychological
30
31 distress scores. There was no significant association between the hours of e-devices and
32
33
34 Insomnia. The psychological distress scores had a significant positive association with Insomnia,
35
36 indicating an increase in psychological distress scores is associated with increased (worse)
37
38
39
Insomnia. The other correlations are presented in Table 2.
40
41 Please insert Table 2 here.
42
43 Mediation role of psychological distress on the relationship between the hours of e-devices
44
45
46 use and Insomnia
47
48 The results of the regression analyses indicated that the hours of e-devices use were not a
49
50
51 significant predictor of the Insomnia scores (model 1, Table 3A) but, the hours of e-devices use
52
53 was a significant predictor of psychological distress (model 2, Table 3A). Insomnia was
54
55
56
significantly predicted by psychological distress only when both psychological distress and e-
57
58 devices use entered simultaneously into the regression model (model 3, Table 3A). Using
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 1 7
2
3
4 PROCESS macro for SPSS, we conducted a post-hoc mediation analysis using bootstrapping
5
6
7 (the number of bootstrap samples for percentile bootstrap confidence intervals was 5000 with a
8
9 confidence interval (CI) of 95%; Table 3B). The result showed that the relationship between the
10
11
12 hours of e-devices use, and Insomnia was mediated by psychological distress scores with an
13
14 effect of .0552 and CI for the completely standardized indirect effect(s) of X on Y were .0173
15
16
17 and .0925.
18
19 Please insert Table 3A here
20
21 Please insert Table 3B here
22
23
24 Mediation role of Insomnia on the relationship between the hours of e-devices use and
25
26 psychological distress
27
28
29 The results related to examining the role of Insomnia as a mediator of the relationship
30
31 between the hours of e-devices use and psychological distress are presented in Table 4A. The
32
33
34 number of hours of e-devices use was a significant predictor of psychological distress (model 1,
35
36 Table 4A). The Insomnia scores were not predicted by the hours of e-devices use (model 2).
37
38
39
When both Insomnia scores and hours of e-devices use entered simultaneously into the
40
41 regression model (model 3, Table 4A), both were significant predictors of psychological distress.
42
43 The post-hoc mediation analysis using bootstrapping (Table 4B) showed that the relationship
44
45
46 between the hours of e-devices use and psychological distress was not mediated by Insomnia (the
47
48 effect was .0247 and CI for the completely standardized indirect effect(s) of X on Y were (-.0064
49
50
51 and .0578).
52
53 Please insert Table 4A here
54
55
56
Please insert Table 4B here
57
58 Discussion
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63
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 1 8
2
3
4 The present study examined the relationship among e-devices use, Insomnia, and
5
6
7 psychological distress with Insomnia and psychological as mediators. Our finding revealed that
8
9 the relationship between hours of e-devices use, and Insomnia is mediated by psychological
10
11
12 distress, but the relationship between the hours of e-devices use and psychological distress scores
13
14 was not mediated by Insomnia. The current findings support the proper use of e-devices by
15
16
17 adolescents as it has shown that the excessive e-devices use is associated with more
18
19 psychological distress and insomnia. The significant effect of the duration of hours of e-devices
20
21 use on psychological distress in our study is in line with many previous studies (Lange et al.,
22
23
24 2017; LeBourgeois et al., 2017; Schweizer et al., 2017). This study may contribute to a better
25
26 understanding of the interrelations among modifiable lifestyle factors and potentially guide the
27
28
29 development of early intervention and prevention strategies. However, having insignificant
30
31 mediation effect of Insomnia on the relationship between the hours of e-devices use and
32
33
34 psychological distress scores does not exclude the importance of maintaining good sleep during
35
36 adolescence to as having a good sleep minimizes the psychological problems and prevent the
37
38
39
onset of psychological distress.
40
41 Regarding the pathway, our results revealed that the e-devices activities were indirectly
42
43 associated with Insomnia through psychological distress. Furthermore, two meta-analyses
44
45
46 showed a significate negative effect of e-device duration on young adolescents' sleep (Bartel et
47
48 al., 2015; Carter et al., 2016). Additionally, adolescents with Insomnia are more likely to report
49
50
51 comorbid psychological distress such as depression and anxiety than those without sleep
52
53 problems (Elhai et al., 2017; Hysing, Mari, Lundervold, Posserud, & Sivertsen, 2016).The
54
55
56
adolescents in our study have duration of e-devices use (five hours) higher the recommended
57
58 duration of a maximum of two hours (Paruthi et al., 2016). This high duration is consistent with
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 1 9
2
3
4 findings of many previous studies among adolescents (Buabbas, Hasan, & Buabbas, 2021;
5
6
7 Stiglic & Viner, 2019) and the dependence of adolescents on e- devices use (Chaput et al., 2014;
8
9 Hysing, M. et al., 2015; Kappos, 2007; SUGANUMA et al., 2007). In addition, adolescents in
10
11
12 our study have moderate level of psychological distress similar to some previous research studies
13
14 (Jeong, Kim, Yum, & Hwang, 2016; Samaha & Hawi, 2016) but a higher level than those
15
16
17 reported by others (Mishra, Srivastava, Tiwary, & Kumar, 2018; Ostovar et al., 2016). For
18
19 example, subjects in our study had higher psychological distress than Indians (Mishra et al.,
20
21 2018) and Malaysian adolescents (Latiff, Tajik, Ibrahim, Abubakar, & Ali, Shirin Shameema
22
23
24 Binti Albar, 2016) but lower than those reported by Buabbas & Hasan (2021). It could be from
25
26 the influence of culture, which may interpret the differences between psychological distress
27
28
29 among the population, society, heredity, environmental factors (Putul, Kahua, Choudhury, &
30
31 Shobhana, 2018).
32
33
34 In our study, hours of e-devices predicted adolescent psychological distress, similar to
35
36 findings reported by many previous studies (Al Salman, Al Debel, Al Zakaria, Shafey, &
37
38
39
Darwish, 2020; Ramón-Arbués et al., 2020). Excessive use of e-devices provokes adverse
40
41 psychological problems (Elhai et al., 2017; Madigan, Browne, Racine, Mori, & Tough, 2019;
42
43 Neophytou, Manwell, & Eikelboom, 2021; Stiglic & Viner, 2019). E-devices can be solitary
44
45
46 activities, reducing adolescents' opportunities to engage in face-to-face social contact. Moreover,
47
48 these relieving of social deprivation and isolation have unique effects on the brain and behavioral
49
50
51 development, which sequentially are implicated in psychological problems (Orben, Tomova, &
52
53 Blakemore, 2020). Excessive e-devices use can cause an imbalance in the gamma-aminobutyric
54
55
56
acid (GABA) brain chemistry, which correlates with developing depression and anxiety (Seo
57
58 HS, Jeong EK, Choi SW, Kwon YA, Park HJ, Kim IS, 2017). This cycle could further initiate or
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 1 10
2
3
4 worsen psychological well-being and trigger further e-devices addiction (Yen, Lin, Chou, Liu,
5
6
7 & Ko, 2019), as it could be used as a coping mechanism (Avci & Kelleci, 2016; Domingues‐
8
9 Montanari, 2017; Vidal, Lhaksampa, Miller, & Platt, 2020). Further, it was suggested that family
10
11
12 relationships, economic conditions, and academic school pressure were related to real
13
14 psychological distress. The reason may be that the use of e-device was not linked to the
15
16
17 biological clock of the sample and its effect was not evident in this regard, although those
18
19 adolescents sleep less than recommended (Paruthi et al., 2016).
20
21 Subjects who use e-devices for approximately 5 hours per day can cause severe trouble in
22
23
24 psychological wellbeing and sleeping habits (Herlache et al., 2018), while others indicate that
25
26 those problems are common among those who use e-devices for more than 6 hours (Lee, J. J. et
27
28
29 al., 2020). In conclude to support healthy e-devices usage, strategies aimed at relieving the
30
31 harmful psychological effect of e-devices use on psychological distress might benefit from those
32
33
34 aimed at enhancing sleep quality.
35
36 The literature suggests a complex bidirectional relationship between sleep problems
37
38
39
including Insomnia and psychological disorders (Cousins et al., 2011; Fang et al., 2019).
40
41 Adolescents with psychological problems may have difficulty initiating or maintaining sleep and
42
43 have difficulty awakening in the morning (Demirci, Akgönül, & Akpinar, 2015; Gottschalk,
44
45
46 2019; Mei et al., 2018). Consequently, spending a lot of the total time in bed awake (Hysing et
47
48 al., 2015; King, Delfabbro, Zwaans, & Kaptsis, 2014a; King, Delfabbro, Zwaans, & Kaptsis,
49
50
51 2014b; Lemola et al., 2015), and improved sleep was related to a better psychological well-being
52
53 status in adolescents (Cairns, Yap, Pilkington, & Jorm, 2014; Lovato & Gradisar, 2014). Several
54
55
56
possible mechanisms could explain the relationship between Insomnia and psychological distress
57
58 among adolescents. First, screen light emitted from e-devices can affect sleeping patterns by
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 1 11
2
3
4 altering adolescents' circadian rhythm and hormone levels of melatonin-suppressing effect,
5
6
7 especially during bedtime (Lemola et al., 2015; Lewy, 2015). Using e-devices in the last hour
8
9 before sleeping for a long time at the onset of latency and increasing the lack of sleep cause a
10
11
12 positive correlation between e-device use in bed and Insomnia as a study by (Driller & Uiga,
13
14 2019; Fossum, Nordnes, Storemark, Bjorvatn, & Pallesen, 2014).
15
16
17 (Driller & Uiga, 2019; Fossum et al., 2014). Second, a short duration of sleep adversely affects
18
19 levels of neurotransmitters that regulate and express emotions of brain function (Goldstein &
20
21 Walker, 2014). It is also resulting differences in brain functions (Dutil et al., 2018), including
22
23
24 working memory, inhibitory control, anger, aggression behavior, and development of psychiatric
25
26 disorders (Ranum et al., 2019; Rohlf, Holl, Kirsch, Krahé, & Elsner, 2018).Third, sleep
27
28
29 deprivation could be related to increased cortisol response, and dysregulation of cortisol and
30
31 pubertal hormone levels among adolescents can cause Insomnia and psychological disorders
32
33
34 (Blake, Trinder, & Allen, 2018; Dolsen, Wyatt, & Harvey, 2019; Minkel et al., 2014). Finally,
35
36 Insufficient Sleep can make the preservation of healthy active living more difficult due to
37
38
39
subsequent sleepiness, and daytime impairments pose severe health threats (Owens, Adolescent
40
41 Sleep Working Group, & Committee on Adolescence, 2014). The potential pathways linking e-
42
43 devices to psychological distress and Insomnia have not been fully realized. Therefore, timely
44
45
46 diagnosis and management of sleep disorders appear critical for growth and development in
47
48 adolescents. There is a need to confirm this relationship in a longitudinal study with a larger
49
50
51 sample size in future studies.
52
53 Limitations and Implications
54
55
56
Although our study has many strengths such as using reliable and valid tools, fairly large
57
58 sample, and use of randomized sampling that may help in generalization of the findings.
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 1 12
2
3
4 Nevertheless, the study's cross-sectional design limits inferring of the cause-effect relationship.
5
6
7 All variables were evaluated through a self-report questionnaire, which may lead to social
8
9 desirability bias. It is highly recommended to add objective measures of the variables. Future
10
11
12 studies may benefit from comparing findings from subjective and objective measures. Although
13
14 this study was conducted in two randomly selected secondary schools, it could not represent all
15
16
17 adolescent students from both genders in Jordan. Future research should increase the
18
19 representativeness of the sample. Further, longitudinal and experimental studies are needed to
20
21 allow attribution of causation. Despite these limitations, our study extends the previous results
22
23
24 regarding the relationship between e-devices, sleep problems, and psychological distress by
25
26 estimating the mediating effects of sleep on the relationship between e-devices and psychological
27
28
29 distress among adolescents' students. In our study, we do not specify the used e-devices. At the
30
31 same time, many authors reported that the positive and negative consequences of e-devices use
32
33
34 are contingent on what kind of digital activity is engaged (Pandya & Lodha, 2021).
35
36 The study highlights the need for increasing awareness about the effects of e-devices on
37
38
39
psychological wellbeing and sleep in adolescents, which should regularly assessed and
40
41 monitored especially in the Coronavirus era and thereafter where most adolescents become using
42
43 e-devices more often and owning at least one e-device. It also highlights the need for further
44
45
46 research on identifying the effective interventions regarding these issues among adolescents and
47
48 involving clinicians, teachers, parents, and adolescents to foster proper e-device use and promote
49
50
51 the psychological wellbeing and healthy sleep habits. Students' curriculum should provide the
52
53 adolescent students with knowledge about the proper use of e-devices and should improve
54
55
56
students' self-ability to control or monitor the time they use e-devices. Psychoeducation training
57
58 programs and crisis interventions for the high-risk target of psychological problems and the
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 1 13
2
3
4 general population, such as time management, problem-solving skills, and finding alternate
5
6
7 events to fill the adolescents' free time.
8
9 The finding also emphasized the importance of restricting and limiting the total time
10
11
12 spent on e-devices using software applications to monitor and prevent e-devices addiction
13
14 (Sediyono & Ariwibowo, 2017). Although specific software applications were constructed to
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17 help users control their excessive e-devices use, these applications seem to have failed to reduce
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19 actual usage (Zimmermann, 2021). But a real way may be by using parental restricting styles
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21 intervention (Nikken, 2018) and self-regulation as a protective influence on adolescents'
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24 excessive e-devices uses (Chang et al., 2019; Meeus, Eggermont, & Beullens, 2019). In a
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26 systematic review meeting, the recommendations ensure the combination of physical activity,
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29 sedentary time, and sleep duration to improve psychological well-being among adolescents
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31 (Sampasa-Kanyinga et al., 2020). Additionally, based on the current findings, future research
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34 should focus on the interventions related to excessive e-devices use and concentrate on sleeping
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36 problems and psychological distress. Overall, it is crucial to provide strategies at the community
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and school levels to avoid excessive e-devices.
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41 Conclusion
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43 This study found that the relationship between the hours of e-devices use, and
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45 psychological distress was not mediated by Insomnia and that the relationship between e-devices
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48 use and Insomnia was mediated by psychological distress. The hours of e-devices use,
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50 psychological distress, and Insomnia was mediated. Throughout the consequences of prolonged
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e-devices, use a strict need for teaching healthy habits to limit the total time spent on e-devices,
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55 especially knowing that e-devices technology is here to stay and grow up with time.
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57 A collaborative team from parents, educators, policymakers, and health professionals to
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60 prevent harmful effects of excessive e-devices. Based on the findings of this study, the following
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4 recommendations are suggested to avoid the detrimental impacts of hours of e-devices use and
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7 psychological distress. First, parents should limit the hours of e-devices use; second, schools
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9 should educate students about the effects of e-devices use. Third, conducted further research on
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12 e-device effects, especially psychological effects.
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14 Table 1. Demographic and clinical characteristics of the subjects (N=485).
15 Characteristic Mean ±SD or n (%)
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17 Age, Years 16.1 ±0.77
18 15 years 111 (22.9)
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20 16 years 230 (47.4)
21 17 years 132 (27.2)
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18 years 12 (2.5)
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24 Gender, Female 250 (51.5)
25 Number of Family Members, 4.76±1.26
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27 3 Members 79 (16.3)
28 4 Members 154 (31.8)
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5 Members 117 (24.1)
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31 ≥ 6 Members 135 (27.8)
32 Family Income, JD 745.98±214
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34 ≤ 814 (below the poverty line) 243 (50.1)
35 >814 242 (49.9)
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BMI 21.38±3.94
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38 Underweight (<19) 122 (25.2)
39 Normal (19-25) 297 (61.2)
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41 Overweight (>25) 66 (13.6)
42 Smoking status,
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Non-smokers 437 (90.1)
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45 Smokers 48 (9.9)
46 Hours of e-devices use/day 5.26±4.0
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48 Total Psychological distress scores (DASS-21) 42.52±20.29
49 Total Insomnia Severity Index scores 8.76±4.6
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No Insomnia (0–7) 222 (45.8)
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52 Subthreshold/mild (8–14) 212 (43.7)
53 Moderate Insomnia (15-21) 48 (9.9)
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55 Severe Insomnia (>22) 3 (0.6)
56 Total hours of sleep time (including naps)/day 8.63± 2.01
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58
SD = standard deviation; DASS 21= Depression Anxiety Stress Scale-21; MSPSS=
59 Multidimensional Scale of Perceived Social Support
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20 Table 2: correlation among subjects' characteristics and main study variables (N=485).
21
22
23 1 2 3 4 5 6 7
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25 1 Age --
26 2 Gender .176** --
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3 Number of family members .125** .048 --
29 4 Income -.143** .012 -.038 --
30 5 BMI .090* -.021 .086 .057 --
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32 6 Hours of e-devices use .099* .074 -.029 .008 .009 --
33 7 Total DASI-21 .202** .144** .149** -.041 .107* .160** --
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8 Insomnia scores .090* .026 -.016 -.073 .060 .077 .386**
36 * Correlation is significant at the 0.05 level (2-tailed); ** Correlation is significant at the 0.01 level (2-tailed)
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20 Table 3A. Standard multiple linear regression analyses with the psychological distress scores as a mediator of the relationship
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between the Hours of e-devices use (independent variable) and Insomnia scores as dependent variable (N=485).
23
24
Model/ Predictors B S. Error β t p LLCI ULCI
25 1. Outcome: Insomnia (dependent variable)
26
27
Hours of e-devices use .0786 .0524 .0684 1.4994 .1344 -.0244 .1816
28 Age .4160 .2821 .0696 1.4744 .1410 -.1384 .9703
29 Gender (ref=female) .1112 .4244 .0121 .2621 .7934 -.7227 .9452
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31
Number of family members -.1140 .1675 -.0312 -.6807 .4964 -.4431 .2151
32 Income -.0015 .0010 -.0685 -1.4914 .1365 -.0034 .0005
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34
Body Mass Index .0696 .0534 .0596 1.3026 .1933 -.0354 .1745
2
F(6, 478) =1.699 R=.1445 R =.0209 P= .1192
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36
37
2. Outcome: Psychological distress (the mediator)
38 Hours of e-devices use .7140 .2223 .1409 3.2124 .0014 .2773 1.1508
39 Age 3.7958 1.1966 .1440 3.1721 .0016 1.4445 6.1471
40 Gender (ref=female) 4.2172 1.8001 .1039 2.3428 .0195 .6802 7.7543
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42
Number of family members 1.9645 .7104 .1219 2.7655 .0059 .5687 3.3603
43 Income -.0022 .0042 -.0235 -.5325 .5946 -.0104 .0060
44 Body Mass Index .4434 .2265 .0861 1.9571 .0509 -.0018 .8885
45 F(6, 478) =8.3591 R=.3082 R2=.0950 P= .0000
46 3. Outcome: Insomnia (dependent variable)
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48 Hours of e-devices use .0152 .0491 .0132 .3096 .7570 -.0813 .1117
49 DASS-21 .0887 .0100 .3915 8.8738 .0000 .0691 .1084
50 Age .0791 .26544 .0132 .2992 .7649 -.4404 .5986
51 Gender (ref=female) -.2630 .3959 -.0286 -.6645 .5067 -1.0409 .5148
52
53
Number of family members -.2883 .1566 -.0789 -1.8417 .0661 -.5960 .0193
54 Income -.0013 .0009 -.0593 -1.3961 .1647 -.0031 .0005
55 Body Mass Index .0302 .0497 .0259 .6077 .5437 -.0675 .1279
56 F(7, 477) = 12.943 R= .3995 R2=.1596 P= .0000
57
B= Unstandardized & β=Standardized coefficients; LLCI & ULCI = Lower limit & upper limit confidence interval (CI); CI =95%
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20 Table 3B. The PROCESS macro post-hoc mediation analysis using bootstrapping of the effect of psychological distress scores
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as a mediator on the relationship between hours of e-devices use and Insomnia scores.
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24
Effect Effect S. Error t p LLCI ULCI c_ps c_cs
25 Total effect of X on Y .0786 .0524 1.4994 .1344 -.0244 .1816 .0171 .0684
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27
Effect S. Error t p LLCI ULCI c'_ps c'_cs
28 Direct effect of X on Y .0152 .0491 .3096 .7570 -.0813 .1117 .0033 .0132
29
30 Effect Bootstrap Bootstrap Bootstrap
31 SE LLCI ULCI
32 Indirect effect(s) of X on Y .0634 .0222 .0204 .1081
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34 Partially standardized .0138 .0048 .0044 .0233
35 indirect effect(s) of X on Y
36 Completely standardized .0552 .0190 .0173 .0925
37 indirect effect(s) of X on Y
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39
The number of bootstrap samples was 5000; CI=confidence interval; CI was 95%; LLCI= Lower limit CI; ULCI= Upper limit
40 CI; c_ps; c_cs; c'_ps; c'_cs
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17 19
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20 Table 4A. Standard multiple linear regression with Insomnia as a mediator of the relationship between the Hours of e-devices
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use (independent variable) and psychological distress as dependent variable (N=485).
23 Model/ Predictors B S. Error β t p LLCI ULCI
24 1. Outcome: Psychological distress (dependent variable): see model 2 Table 3A
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26 2. Outcome: Insomnia (the mediator): see model 1 Table 3A
27 3. Outcome: Psychological distress (dependent variable)
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29 Hours of e-devices use .5886 .2066 .1161 2.8486 .0046 .1826 .9946
30 Insomnia 1.5965 .1799 .3619 8.8738 .0000 1.2430 1.9501
31 Age 3.1316 1.1123 .1188 2.8155 .0051 .9460 5.3173
32 Gender (ref=female) 4.0397 1.6695 .0996 2.4196 .0159 .7591 7.3202
33
34 Number of family members 2.1465 .6591 .1331 3.2567 .0012 .8514 3.4416
35 Income .0001 .0039 .0013 .0311 .9752 -.0075 .0078
36 Body Mass Index .3323 .2105 .0645 1.5788 .1150 -.0813 .7459
37 F(7, 477) =19.5796 R= .4724 R2=.2232 P= .0000
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39
B= Unstandardized & β=Standardized coefficients; LLCI & ULCI = Lower limit & upper limit confidence interval (CI); CI =95%
40
41
42 Table 4B. The PROCESS macro post-hoc mediation analysis using bootstrapping of the Insomnia as a mediator on the
43 relationship between hours of e-devices use and psychological distress scores.
44 Effect Effect S. Error t p LLCI ULCI c_ps c_cs
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46 Total effect of X on Y .7140 .2223 3.2124 .0014 .2773 1.1508 .0352 .1409
47 Effect S. Error t p LLCI ULCI c'_ps c'_cs
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49 Direct effect of X on Y .5886 .2066 2.8486 .0046 .1826 .9946 .0290 .1161
50 Effect Bootstrap SE Bootstrap LLCI Bootstrap ULCI
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52 Indirect effect(s) of X on Y .1255 .0847 -.0311 .2981
53 Partially standardized indirect 0062 .0042 -.0015 .0148
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55
effect(s) of X on Y
56 Completely standardized indirect .0247 .0164 -.0064 .0578
57 effect(s) of X on Y
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17 20
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20 The number of bootstrap samples was 5000; CI=confidence interval; CI was 95%; LLCI= Lower limit CI; ULCI= Upper
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