Current Addiction Reports

https://doi.org/10.1007/s40429-020-00320-0

TECHNOLOGY ADDICTION (J BILLIEUX, SECTION EDITOR)

Parental and Family Factors Associated with Problematic Gaming

and Problematic Internet Use in Adolescents: a Systematic Literature
Review
Philip Nielsen 1 & Nicolas Favez 1 & Henk Rigter 2

# Springer Nature Switzerland AG 2020

Abstract
Purpose of Review Some adolescents may develop problematic gaming (PG) or problematic Internet use (PIU). We reviewed the
literature on associations between specific parental/family (PF) characteristics and adolescents’ PG and PIU.
Recent Findings Increasingly, links are being reported between PF factors and PG and PIU. However, questions remain about the
nature of the factors involved and the strength of their link with PG and PIU. We addressed these questions in the present review.
Summary Our systematic literature search identified 27 research papers on PG and 73 on PIU and distinguished six categories of
parental/family factors. For each category, PF factors were connected with both PG and PIU. The effect size was often small.
Across categories, the protective factors (positive parenting and positive family dynamics) were associated with lower rates of PG
and PIU and the risk factors (negative parenting and negative family dynamics) with higher rates. On average, the PF factors
carried as much weight as intrapersonal characteristics of the adolescents.

Keywords Adolescents . Problematic gaming . Problematic Internet use . Parenting style . Family attachment . Systematic
literature review

Introduction
The Internet is a rich resource for adolescents in many ways; it
offers young people information and entertainment and allows
them to learn skills, to have social contacts, and to express
their feelings and opinions. Yet, some Internet-based activities
may become problematic.
One prominent example is online gaming, where people
may get so hooked playing games that they lose sleep and
real-world social contacts. They may want to play less but
are unable to. Attending school may become irregular or
This article is part of the Topical Collection on Technology Addiction
* Philip Nielsen
Philip.Nielsen@unige.ch
1 broader sense, purportedly leading to behaviour that has been
Unité de psychologie clinique des relations interpersonnelles, FPSE,
University of Geneva, Boulevard Pont-d’Arve 40,
1204 Geneva, Switzerland
2
Department of Child and Adolescent Psychiatry, Leiden University
Medical Centre (LUMC), Leiden, the Netherlands
may stop. Family relations and family life may become
disrupted.
Many researchers regard such symptoms as signs of
Internet Gaming Disorder, or IGD [1, 2•, 3]; however, this
diagnosis is still disputed. Opponents of the idea that gaming
can develop into a disorder stress, the benefits of Internet use,
and claim that labelling someone as gaming disordered would
‘medicalise’ vast numbers of young people [4]. DSM-5
(Diagnostic and Statistical Manual of Mental Disorders) lists
IGD under the heading ‘provisional’, meaning that more re-
search needs to be done before the disorder can be taken for
real or not. The World Health Organization is less hesitant and
has accepted gaming disorder as a diagnosis in their ICD-11
(International Classification of Diseases) classification sys-
tem. Nevertheless, given the ongoing debate, we prefer to
use here the term problematic gaming (PG) instead of IGD
or gaming disorder.
Beyond gaming, Internet use may become problematic in a
named ‘Internet addiction’ [5]. The problems include im-
paired control over Internet use, at the expense of other life
interests and daily activities, and by an inability to stop or
reduce Internet use even if facing negative consequences.

Rather than using the term “Addiction”, we prefer referring to
problematic Internet use or PIU.
Although differences have been noted between the two
constructs [6], PG and PIU are sensitive to similar risk and
protective factors at least to some extent. One group of factors
that has been associated with both PG and PIU are family
influences [7, 8••, 9•]. This is a wide category of factors. For
clinical and research purposes, one needs to specify which
family characteristics bear on PG and PIU.
For the sake of the systematic literature review re-
ported here, we focused on parental and family (PF)
relational-emotional factors. There is no theory
encompassing all dimensions of parenting and family
relationships that could help in identifying relevant
groups of PF factors [10, 11]. Therefore, we selected
six clusters of PF factors that have been shown to in-
fluence the development of adolescents. One cluster in-
cluded somatic or mental problems faced by the parents
[12, 13]. A second one concerned the way parents work
as a team, that is, the quality of their co-parenting rela-
tionship either collaborative or conflictive [14]. The
third group included parenting styles: uninvolved/ne-
glectful, permissive, indulgent, authoritative, and author-
itarian [15]. The fourth cluster centred around family
attachment: the degree of security felt by family mem-
bers within the family and the quality of their attach-
ment relationships [16, 17], with ‘child abuse’ split off
as a category in its own. A final category of PF factors
to consider pertained to family functioning in terms of
structure (hierarchy, borders between family subsystems,
rules) and relational organisation (cohesion, flexibility,
rituals) [10, 11, 18].
The strength of associations between PF factors and
PG and PIU is of clinical importance. A therapist
treating an adolescent presenting with PG or PIU may
target both intrapersonal issues and interpersonal, in-
cluding PF, issues [19]. However, we know little about
the relative impact of PF factors compared with intra-
personal (individual) ones. Just one review has system-
atically compared these two sets of factors; the authors
concluded that intrapersonal factors were more strongly
related to PIU than interpersonal factors [9•].
Review Questions
This systematic review targeted both PG and PIU, with the
main question being: what are the associations between pa-
rental and family factors and adolescents’ problematic gaming
and problematic Internet use? We also wanted to establish—
through an analysis of effect sizes—how strong these potential
connections are.
Curr Addict Rep
Methods
We drafted a review protocol adhering to the PRISMA Group
guidelines for systematic literature review [20].
Types of Eligible Studies
Any article, book, or book chapter was included if presenting
original research data linking parental and/or family factors to
the rate of problematic gaming (PG) and/or problematic
Internet use (PIU) in adolescents. We searched for publica-
tions issued before 1 January 2020 and written in English,
Dutch, German, or French. Case reports, meeting abstracts,
reviews, meta-analyses, and guidelines were excluded.
To be retained, a publication had to contain assessment
measures of (1) adolescent PIU or PG and (2) one or more
parental and/or family (PF) factors fitting at least one out of
the six PF categories: (1) problems faced by the parent(s)
(mental health, addiction, handicap, or somatic disease); (2)
child abuse; (3) co-parental teamwork (collaborative/support-
ive, discordant/conflictive); (4) parenting style (uninvolved/
neglectful, permissive, indulgent, authoritative, authoritarian);
(5) family attachment (the teen feels secure and protected, or
insecure and unprotected); and (6) family functioning, which
comprised rules and regulations, family organisation, commu-
nication, and rituals. We excluded publications focusing spe-
cifically on problematic smartphone, social media use, cyber
bullying, sexual harassment, and cybersex/porn. On top of
this, publications reporting solely on parental mediation prac-
tices—i.e. monitoring, supervision, and rules for screen use—
were not considered, since these were reviewed earlier [21].
As we were interested in relational-emotional dynamics rather
than sociodemographic variables, we also disregarded publi-
cations in which the information on the parents/family was
limited to education or income level of the parents, or to the
status of the family: single-parent, blended, broken up by di-
vorce or separation of the parents.
We restricted the selection to reports of cross-sectional and
prospective studies yielding quantitative data on male and/or
female adolescents between 12 and 19 years of age. If these
youths were part of a sample with a slightly wider age range,
we included the whole sample if the target group could not be
parcelled out. Clinical studies were considered if comparing a
PG/PIU group with a non-PG/non-PIU group.
Searching for Publications
We searched five databases: Web of Science, Embase,
Cochrane Central Register of Controlled Trials, Medline/
PubMed, and PsycINFO. The searches were carried out be-
tween 19 November and 6 December 2019.
We developed a three-dimensional search strategy, com-
bining a variety of terms for ‘adolescent’ (i.e. teenager, youth,
Curr Addict Rep
young adult), ‘problematic gaming/problematic Internet use’
(i.e. Internet gaming disorder, Internet addiction, compulsive
gaming, Internet dependency), and parent/family factors (i.e.
parent-child relationship, family communication/cohesion/
dysfunction). The search equations for each database are de-
tailed in Text Supplement 1.
The searches generated 1435 records (Fig. 1). Duplicates
were removed with the Rayyan QCRI Systematic Reviews
web app [22]. Later in the selection process, we screened the
lists of references of the identified publications looking for
relevant studies missed in the database searches. We also
wrote the corresponding author of each selected publication
to verify our notes and to inquire after additional publications.
Using these sources, a further 10 records were found.
Two authors (PN and HR) independently checked off all
884 identified publications against inclusion and exclusion
criteria, based on first-sweep information from the Abstract
and Methods sections. The Rayyan app allowed us to trace
discrepancies in judgement between the two assessors. Such
differences in scores occurred in 2,8% of cases, the assessors
reaching consensus in all instances. For the second round of
screening, using close full-text assessment, 121 records (all
research papers) remained, with an additional 10 sourced from
Fig. 1 Flow chart of the screening
and selection process
our own reference search. Of these papers, 100 were included
and 31 were excluded (Fig. 1). The reasons for excluding the
latter publications were no relevant PF variables examined
(N = 16), wrong population or study design (N = 10), and no
PIU/PG variables specified (N = 5).
Data Extraction
Both assessors independently extracted information from each
paper on: type of study (cross-sectional, prospective, compar-
ison sample examined or not), the size of the study samples
after correction for drop-out, the country where the study took
place, and the setting from which the samples were taken
(school, including college and university; households; clinics;
general population). We recorded the adolescents’ mean age
and the age range of the sample, the gender distribution, co-
morbidity findings, and the PF factors studied.
Further, we noted the PG or PIU screening test used and the
methods for assessing PF factors. We also registered informa-
tion on the type of statistical test or model applied and on the
outcomes of the analyses. Finally, we recorded which protec-
tive and risk factors other than PF had been examined, specif-
ically ‘individual factors’: cognitive functions, personality

traits, and mental health conditions of the adolescents. Our
definition of ‘individual factors’ excluded variables related
to online activities, such as screen use time, or social behav-
iour and relationships.
Assessing the Quality of the Selected Studies
We assessed the quality of the included studies using slightly
adapted versions of the 10-item PG and PIU checklists we
developed in the context of a previous review [21]. An exam-
ple of the Study Quality Rating Scale (PG) is annexed as Text
Supplement 2. Scores ranged from 0 to 2 per item; the max-
imum sum score was 20. The first item was about the size of
the study sample, with 2 points assigned if more than 1000
adolescents had been recruited, 1 point if the sample size was
between 100 and 1000, and 0 points for smaller samples.
Prospective studies were assigned 2 points, cross-sectional
ones 1 point (item 2). If the sampling process had been fully
(at all sampling levels, e.g. school, class, pupils) or partially
random, 2 and 1 points were given, respectively, and 0 points
if sampling had been non-random (item 3). Studies including
two independent samples of adolescents, one serving as com-
parison group for the other, got 2 points (item 4); the same
score was given if a group of parents had been recruited (item
5). Item 6 was about the proportion of sampled adolescents
who dropped out from the study before the actual data were
gathered (i.e. before baseline assessment): 2 points if the drop-
out rate was < 5%, 1 point if between 5 and 15%, and 0 points
if > 15%. We checked the information provided on the
sociodemographic characteristics of the study sample(s), fo-
cusing on age and gender, assigning 2 points if the mean age
and the proportion of males/females had been reported, 1
point for incomplete data and 0 points for missing data (items
7 and 8).
The next item addressed the psychometric quality of the
measurement tools used. PG assessment instruments were
given 2 points if awarded a sum score of 11 or higher (out
of 23) in Table 7 of the systematic review by King et al. [23],
1 point if that score ranged between 5 and 10, and 0 point
when the score was below 5 or, for tools not listed in the table,
if we failed to find reports of adequate psychometrical evalu-
ation. We used the five criteria (three aspects of validity, reli-
ability, internal consistency) from Table 1 in a review by
Lortie and Guitton [24] as frame of reference for rating the
quality of PIU assessment instruments, with 2 points assigned
if at least four criteria and 1 point if two to three criteria had
been met. In other cases, 0 points were given.
Available literature on methods to assess parent-child rela-
tions and family functions [25, 26] suggests that at least five
scales are psychometrically sound, i.e. the Family
Adaptability and Cohesion Evaluation Scale (FACES), the
McMaster Family Assessment Device (FAD), the Inventory
of Parent and Peer Attachment (IPPA), and the Parental
Curr Addict Rep
Bonding Instrument [25, 27, 28]. We assigned 2 points if a
study had measured PF with at least one of these tools (item
10). Some other regularly used instruments—the EMBU
(Egna Minnen Beträffende Uppfostran; My Memories of
Upbringing), the Family APGAR (Adaptation, Partnership,
Growth, Affection, Resolve) index, and the Family
Environment Scale (FES)—were given 1 point; these scales
have been tested for reliability and validity but incompletely
or with mixed results [25, 29, 30]. Other instruments were
scored 0 points if adequate information on reliability and va-
lidity was wanting.
Statistical Analyses
We computed the effect size of associations between dis-
tinct PF factors and PG and PIU, respectively, based on
baseline data, i.e. the only assessment in a cross-sectional
and the first one in a prospective study. All effect size
data (results of an analysis of variance or a χ2, Mann-
Whitney U or Student’s t test, odds ratios, and [Pearson]
correlations and regression analysis coefficients) were
transformed into Cohen’s d with a web-based tool [31].
If a paper reported on a series of analyses, which com-
monly was the case, we extracted the data from the model
or approach correcting for the influence of confounding
variables. Statistically significant effect sizes were classi-
fied as low when d was below 0.50, as medium when d
was between 0.50 and 0.79, and as large when d was 0.80
or higher [32].
The same procedure was followed to estimate the effect
size of Individual factors. We compared for each relevant
study the effect size class (small, medium, large) of the exam-
ined PF and the individual factors. We then noted if the effect
size of the PF factor was similar (same effect size class),
weaker, or stronger (lower or higher effect size class,
respectively).
The studies and PF effect sizes were grouped in two
ways. First, they were classified per PF category (prob-
lems of the parents; child abuse; co-parenting teamwork;
family attachment; family functioning). These categories
comprised both risk and protective factors, which we
pulled apart in the second grouping of effect sizes involv-
ing four classes: (1) positive parenting (positive parenting
style and positive co-parental teamwork); (2) negative
parenting (negative style and teamwork; child abuse;
problems of the parents); (3) positive family dynamics
(positive family attachment and family functioning); and
(4) negative family dynamics (negative family attachment
and functioning). We then analysed if these four groups
differed from each other in distribution of effect size out-
comes (non-significant, small, medium, or large effect
size) with the χ2 test for independent samples.
Table 1 Characteristics of the problematic gaming studies
Curr Addict Rep

PG publication Country Study designa Nr. of adolescents sampledb Sample from Mean age (years)c Gender (% males)c Prevalence of PG (%)c

Abedini et al. (2012) [87] Iran C 500 School 14.7 50.8 NR

Bonnaire and Phan (2017) [50] France C 434 School 13.2 53.2 8.8
Cheng (2019) [55] Taiwan C 466 school 14.0 58.8 NR
Chiu et al. (2004) [106] Taiwan C 1228 School NR 49.7 NR
Choo et al. (2015) [110] Singapore P 2 waves 2974 School 11.2 72.6 9.9
Cui et al. (2018) [39] China South Korea C 3109 school NR 56.1 (China) 51.0 (Korea) 30.4 (China) 11.4 (Korea)
Charlie Wei et al. (2011) [98] Singapore P 3 waves 1363 School 12.9 73.0 11.7
Estévez et al. (2017) [66] Spain C 472 School 15.6 48.4 NR
Gugliandolo et al. (2019) [51] Italy C 482 School NR 41.5 NR
Irmak and Erdoğan (2019) [52] Turkey C 865 School 16.5 53.5 4.3
Jeong and Kim (2011) [58] South Korea C 600 School NR 53.2 2.2
Kim and Kim (2015) [47] South Korea C 624 School NR 47.1 3.2
Kim et al. (2018) [56] South Korea C 402 School 13.0 55.5 9.0
King (2017) [57] Australia C 783 School 14.1 49.0 3.1
Kwon et al. (2011) [59] South Korea C 1136 School 14.0 60.9 NR
Lee and Kim (2017) [48] South Korea C 1556 School NR 51.0 11.4
Li, Lo et al. (2018) [42] Hong Kong P 2 waves 241 dyads School 12.1 57.0 NR
Liau et al. (2015) [107] Singapore P 3 waves 2179 School 11.2 72.7 9.9
Lyu (2017) [49] South Korea C 2215 School NR 71.4 NR
Mößle and Rehbein (2013) [78] Germany P 5 waves 739 School 11.5 wave 4 50.6 wave 4 0.8 wave 4
Muñoz-Miralles et al. (2016) [102] Spain C 4347 School NR 51.4 6.2
Rehbein and Baier (2013) [81] Germany P 2 waves 1217 School 9.7 (wave 2: 15.0) 43.5 1.3
Su et al. (2018) [60] China P 3 waves 1490 School 12.0 54.6 NR
Wang et al. (2014) [53] Hong Kong C 503 School 14.6 49.5 15.7
Wartberg et al. (2017) [33] Germany P 2 waves 1095 dyads School 13.0 50.8 23.7
Wartberg et al. (2018) [34]
Zhu et al. (2015) [61] China P 3 waves 833 School 12.5 52.2 NR

a
C, cross-sectional; P, prospective
b
Number of adolescents or dyads (adolescent–parent[s] pairs) involved in the statistical analyses of the study results
c
For prospective studies, the number given refers to the first wave assessment. NR not reported
Table 2 Characteristics of the problematic Internet use studies

PIU publication Country Study designa Nr. of Sample from Mean age (years)c Gender Prevalence
adolescents sampledb (% males) c of PIU (%)c

Ahmadi and Saghafi (2013) [112] Iran C 4177 School 16.5 50.0 1.1
Alt and Boniel-Nissim (2018) [113] Israel C 270 School NR 51.0 NR
Ballarotto et al. (2018) [63] Italy C 1105 School 15.6 43.6 NR
Bolat et al. (2018) [64] Turkey C 444 School 16.3 Cheung et al 34.0 NR
Boniel-Nissim and Sasson (2018) [114] Israel C 1000 General population 14.2 47.0 NR
Cacioppo et al. (2019) [108] Italy C 306 School 16.1 37.3 NR
Casaló and Escario (2019) [115] Spain C 37,486 School 16.2 49.0 4.4
Chen et al. (2015) [70] Taiwan P 2 waves 1153 School NR 49.7 11.4
Cheung et al. (2015) [38] China and Hong Kong C 1771 School 16.3 44.9 3.3
Chi et al. (2016) [116] China C 1173 School 19.7 62.1 15.3
Chng et al. (2015) [65] Singapore C (as part of P) 3079 School 13.0 50.4 15.9
Choi et al. (2018) [76] South Korea C 587 Households NR 52.2 NR
Chou et al. (2015) [117] Taiwan C 287 Clinic 13.1 87.5 NR
Chung et al. (2019) [99] South Korea C 1628 School 14.9 52.0 6.5
Costa et al. (2019) [118] Portugal C 548 General population 17.4 52.7 NR
Dong et al. (2019) [119] China C 10,158 School NR 46.4 10.4d
Durkee et al. (2012) [37] 10 European countries + Israel C 11,956 School 14.9 43.7 4.4
Estévez et al. (2017) [66] Spain C 472 School 15.6 48.4 NR
Gao et al. (2018) [82] China C 2259 School 16.0 46.4 NR
Gugliandolo et al. (2019) [51] Italy C 482 School NR 41.5 NR
Jang and Ji (2012) [77] South Korea C 519 School 11.5 51.3 NR
Kabasakal (2015) [83] Turkey C 663 School 20.3 33.6 17.4
Karaer and Akdemir (2019) [40] Turkey C 80 Clinic 15.4 27.5 50.0
Kilic et al. (2016) [120] Turkey C 1742 School 16.5 44.6 1.3
Kim et al. (2016) [96] South Korea C (as part of P) 1538 School 18.0 46.4 8.6
Ko et al. (2007) [71] Taiwan P 2 waves 517 School 13.6 51.6 18.2
Ko et al. (2015) [72••] Taiwan P 2 waves 1801 School 12.4 50.5 9.5
Kumğagiz (2019) [90] Turkey C 402 School 20.8 38.1 NR
Lam (2015) [43] Hong Kong C 1098 dyads School NR 44.0 24.0d
Lam and Wong (2015) [44] Hong Kong C 1098 dyads School NR 44.0 24.0d
Lau et al. (2017) [111•] Hong Kong P 2 waves 1545 School NR 59.2 16.1
Lei and Wu (2007) [67] China C 712 School 14.5 49.2 NR
Li, Li and Newman (2013) [94] China C 694 School 13.7 45.0 NR
Li, Li, Wang et al. (2013) [68] China C 2758 School 13.5 46.0 6.3
Curr Addict Rep
Table 2 (continued)

PIU publication Country Study designa Nr. of Sample from Mean age (years)c Gender Prevalence
adolescents sampledb (% males) c of PIU (%)c
Curr Addict Rep

Li et al. (2014) [92] China C 966 School 14.8 53.5 5.3

Li, Li et al. (2018) [121] China C 863 School 14.3 45.0 4.9
Li et al. (2019) [95] China C 3048 School NR 49.0 18.5
Lin and Gau (2013) [73] Taiwan C 2731 School 19.4 52.4 NR
Liu et al. (2012) [122] China C 3556 School 15.0 49.8 11.1
Liu et al. (2013) [123] China C 4559 School 15.0 48.5 10.8
Liu et al. (2019) [93] China C 2751 School 14.9 49.5 NR
Lu et al. (2018) [124] China C 1385 School 15.1 54.7 14.1 d
Muñoz-Miralles et al. (2016) [102] Spain C 4635 School NR 51.4 13.6
Oh (2003) [125] South Korea C 450 School NR 53.3 1.8
Park et al. (2008) [79] South Korea C 903 School NR 69.6 10.7
Shek and Yu (2016) [109] Hong Kong P 6 waves 3074 School 15.6 52.7 20.1 wave 4
Shek et al. (2018) [35] Hong Kong P 6 waves 3328 School 12.6 52.1 26.2
Shek et al. (2019) [36]
Shi et al. (2017) [126] China C 3289 School 15.8 41.3 20.6
Siomos et al. (2012) [91] Greece C 2017 School 15.1 51.8 15.2
Soh et al. (2018) [127] Malaysia C 1449 School 16.1 46.6 NR
Trumello et al. (2018) [128] Italy C 743 School 15.6 42.4 NR
Venkatesh et al. (2019) [45] Hong Kong C 776 dyads School 14.1 48.0 NR
Wang et al. (2011) [100] China C 14,298 School 15.6 48.7 10.6 d
Wang and Qi (2017) [46] China C 828 dyads School 13.6 57.6 NR
Wang et al. (2018) [103] China C 998 School 15.2 47.0 6.1
Wartberg et al. (2014) [129] Germany C 1744 General population 15.5 50.0 NR
Wu et al. (2013) [130] China C 1101 School 13.8 57.9 12.6d
Wu et al. (2016) [74] Hong Kong C 1163 School NR 39.6 25.3d
Xin et al. (2018) [84] China C 6468 School 13.8 69.4 1.0
Xiuqin et al. (2010) [41] China C 304 School clinic 18.0 93.8 100.0 (clinic)
Xu et al. (2014) [104] China C 5122 School 15.9 49.6 8.8
Yaffe and Seroussi (2019) [88] Israel C 180 Households 13.9 100.0 76.1 d
Yang et al. (2014) [80] China C 3798 School 15.5 51.9 NR
Yang et al. (2016) [69] China C 433 School 19.8 36.1 NR
Yen et al. (2007) [75] Taiwan C 3480 School 15.5 62.9 20.7
Yen et al. (2009) [105] Taiwan C 8941 School 14.7 48.0 18.6
Yu and Shek (2013) [131] Hong Kong C (as part of P) 4106 School 14.7 53.7 22.5
 Curr Addict Rep

Results
of PIU (%)c
Prevalence

20.0
PG was examined in 27 studies (Table 1) and PIU in 73

NR
NR

NR
3.4
(Table 2). These numbers include three studies targeting both
PG and PIU. Two PG papers reported on the same sample and
(% males) c

the same waves of a prospective study [33, 34]; we counted

Gender

53.1
70.1
45.0
61.9

60.0
them as one publication in the analyses. The same was done
for two PIU papers [35, 36].
Mean age (years)c

Research Sites and Participants

Most PG studies were carried out in East Asia (7 South Korea,

3 China, 3 Singapore, 2 Hong Kong, and 2 Taiwan). Three PG
13.6
15.3
14.1
18.9

14.4

studies were from Germany and 2 from Spain. Australia,

France, Iran, Italy, and Turkey were represented with 1 study
each (Table 1). East Asia also dominates the sampled PIU
studies (28 China, 9 Hong Kong, 7 South Korea, 7 Taiwan,
Sample from

1 Malaysia, 1 Singapore). Five studies were conducted in

School
School
School
School

School

Turkey, 4 in Italy, and 3 in Israel as well as Spain (Table 2).

Germany, Greece, Iran, and Portugal are represented with 1
PIU study each. One study was a collaboration of ten
adolescents sampledb

European countries plus Israel.

For prospective studies, the number given refers to the first wave assessment unless stated otherwise. NR not reported
Number of adolescents or dyads (adolescent–parent[s] pairs) involved in the statistical analyses of the study results

The total numbers of adolescents surveyed were 31,853 for

the PG and 193,257 for PIU studies (Tables 1 and 2). The
participants from the PG studies were all sampled via schools.
Nr. of

A few PIU investigations sampled participants from settings

1783
1189
525
660
105

other than school: the general population (3), households (2),

and clinics (3). The mean age of PG adolescents varied be-
Study designa

tween studies from 11.2 to 16.5 (median 13.0 years) and for
PIU from 11.5 to 20.8 (median 15.2 years). Averaged across
studies, roughly half of all PG and PIU youths were male.
Across the board, the prevalence of PG ranged from 0.8 to
C
C
C
C
C

30.4%, for PIU from 1.1 to 25.3% (clinical studies excluded).

In line with the literature [21], the rates of PG and PIU were
Includes both ‘moderate’ and ‘severe’ PIU (problematic Internet use)

generally higher in males than in females.

Study Characteristics
South Korea

Most studies were cross-sectional. Nine PG and nine PIU

Country

papers reported on (waves of) prospective studies. The num-

China
China
China
China

ber of waves varied from two to six. Three studies compared

samples from different geographical areas [37–39]. In two
cases, a clinical PIU sample was compared with a matching
non-PIU sample [40, 41]. Two PG studies recruited a
C, cross-sectional; P, prospective

matching sample of parents [33, 42], so did four PIU studies

[43–46].
In all studies, assessment of PG or PIU was based on ado-
Zhang et al. (2015) [97]
Zhang et al. (2017) [85]
Zhang et al. (2019) [89]
Zhou et al. (2017) [86]
Yu et al. (2013) [101]
Table 2 (continued)

lescent self-reporting, occasionally supplemented with parent

reporting and once [42] with observation of parent-child inter-
PIU publication

actions. As for PG, Korean researchers favoured a Korean

questionnaire [47–49]. Six PG studies [33, 39, 50–53] opted
for the Gaming Addiction Scale (GAS) [54] and three other
ones for scales that, too, are based on the DSM-5 criteria for
b

d
a

c
Table 3 The strength of associations between family factors and problematic gaming in adolescents

PG paper PF factor categorya Label PF factorb PF effect sizec Individual factorsd PF vs. INDe Study quality
scoref
Curr Addict Rep

Abedini et al. (2012) [87] Parenting style Authoritarian •• Self-control PF = IND 9

Authoritative *
Neglectful •
Permissive •
Bonnaire and Phan (2017) [50] Family functioning Family conflict • – 12
Good family cohesion *
Good family relationship *
Cheng (2019) [55] Parenting style Demanding •• Temperament PF > IND 11
Chiu et al. (2004) [106] Family functioning Poor family functioning • Sensation seeking PF > IND 10
Boredom PF > IND
Choo et al. (2015) [110] Attachment Parent–child closeness * – 13
Cui et al. (2018) [39] Attachment Poor attachment to parents • (China) – 13
ns (S. Korea)
Charlie Wei et al. (2011) [98] Attachment Poor family relationship ns – 12
Negative family environment •
Estévez et al. (2017) [66] Attachment Attachment to parents * Emotion regulation PF < IND 11
Gugliandolo et al. (2019) [51] Parenting style Authoritarian (controlling) • Need satisfaction and frustration Controlling style < frustration 10
Autonomy support ns
Irmak and Erdoğan (2019) [52] Family functioning Good family functioning * (girls) Impulse control PF > both IND (girls) 14
Psychosocial problems PF < both IND (boys)
Jeong and Kim (2011) [58] Family functioning Social activities with parents ** Online and offline social self-efficacy PF < IND 12
Kim and Kim (2015) [47] Attachment Secure attachment * (especially mother) – 10
Feeling accepted *
Kim et al. (2018) [56] Family functioning Good parent–child communication ** (father) Aggression PF = IND 13
King (2017) [57] Attachment Attachment to parents ns – 15
Kwon et al. (2011) [59] Attachment Hostile parent–child relationship • Self-escape PF < IND 10
Idem, affectionate * Negative mood PF = IND
Lee and Kim (2017) [48] Attachment Attachment to parents ns – 12
Li, Lo et al. (2018) [42] Family functioning Affection * – 13
Cohesiveness *
Liau et al. (2015) [107] Attachment Family connectedness * Emotion regulation PF = IND 13
Family functioning Warm family environment *
Lyu (2017) [49] Family functioning Good family functioning * – 13
Mößle and Rehbein (2013) [78] Attachment Parental care ** Academic self-concept (SC) Dep < Abuse < Care/Hyp/SC 12
Child abuse Child abuse • Depression (Dep)
Hyperactivity (Hyp)
Muñoz-Miralles et al. (2016) [102] Attachment Poor family relationship •• – 10
Rehbein and Baier (2013) [81] Attachment Parental devotion ns – 10
 Curr Addict Rep

Study quality
Internet Gaming Disorder [55–57]. Most other PG screening

Cross-sectional data only. All effect sizes converted to Cohen’s d. One symbol (* = protective factor, • = risk factor) = small effect size; two symbols = medium and three symbols = large effect size
tools, generally weaker, were derived from questionnaires to
scoref establish PIU or gambling disorder [58–61] or were not clear-

14
11
13

12
ly based on the DSM-5 or ICD-11 IGD criteria.
In 47% of PIU studies, PIU was assessed with a 20-item,
10-item, or even briefer version of the Internet Addiction Test
(IAT), which is frequently used in its original form [24, 62].
PF(1) = both IND
Also employed were the Chen Internet Addiction Scale
PF vs. INDe

(CIAS; 14% of studies), versions of the Pathological Internet

Use Scale (PIUS; 11%), and the Internet Addiction Diagnostic
Questionnaire (IADQ; 10%). Twelve other instruments were
applied in just one or two studies.
PF factors were evaluated with a vast array of assessment
instruments. The most-used instrument was the IPPA–9 stud-
ies [47, 57, 63–69] followed by the APGAR–6 studies [70, 71,
72••, 73–75]. Many other questionnaires were not thoroughly
Externalising symptoms
Internalising symptoms

tested for reliability and validity or were adapted from tools

Individual factorsd

that cannot boast strong support in the literature.

Parent and Family Factors Overall

–
–

Table 3 lists the PF factors and effect sizes for the PG studies.
Individual factors: cognitive functions, personality traits, or mental health conditions of the adolescents concerned

There were 41 effect sizes; 33 of these were statistically sig-

PF effect sizec

nificant: 19 (46.3% of the total) as protective factor and 14

PF factor in a lower (<), the same (=), or a higher (>) effect size class than the respective individual factor

(34.1%) as risk factor. Table 4 presents the same overview for

PIU. Of the 120 effect sizes, 105 were statistically significant:
52 as protective and 53 as risk factor. Of the significant PG
ns

ns
••
*

*
•

effect sizes, most (78.8%) were small, the remainder being

Good parent–child relationship

Good parent–child relationship

medium. The numbers for PIU were 61.9% small, 30.5% me-
dium, and 7.6% large. The distribution of effect sizes did not
differ between PG and PIU (p = 0.27).
Poor family harmony
Interparent conflict
Label PF factorb

Problems of the Parents

Label given to the PF factor by the authors of the sampled publication
Depression
Anxiety

Only five studies examined the relationship between adoles-

cent PG/PIU and problems experienced by the parents.
Co-parental teamwork

However, they all showed that parents’ problems may serve

PF, parental and family (factors); IND, individual factor
PF factor categorya

as a risk factor. In the single PG study, problematic gaming of

Parent problems

the youths was linked to their parents’ level of anxiety, but not
Attachment
Attachment

Attachment

depression [33, 34]. PIU was associated with depression in

Category as assigned by the present authors

mothers [76] or both parents [43]. Addictive behaviour of

the parents (drinking, problematic Internet use) was accompa-
nied by a higher prevalence of adolescent PIU, with effect
sizes ranging from small to large [44, 75, 77].
Score on a scale from 0 to 20
Wartberg et al. (2017) [33]
Wartberg et al. (2018) [34]
Wang et al. (2014) [53]

Zhu et al. (2015) [61]

Child Abuse
Table 3 (continued)

Su et al. (2018) [60]

One PG [78] and two PIU studies [79, 80] looked at child
abuse. All three studies found child abuse to be a risk factor
PG paper

for the problem behaviour in question, though the effect size

was small.
b

d
a

f
Table 4 The strength of associations between family factors and problematic Internet use in adolescents

PIU paper PF factor categorya Label PF effect sizec Individual factorsd PF vs. INDe Study quality scoref
PF factorb
Curr Addict Rep

Ahmadi and Saghafi (2013) [112] Attachment Good family relationship * – 13

Alt and Boniel-Nissim (2018) [113] Family functioning Good parent–child communication * Fear of missing out PF < IND 11
Ballarotto et al. (2018) [63] Attachment Attachment to parents * – 12
Bolat et al. (2018) [64] Attachment Attachment to parents * Alexithymia PF < IND 11
Boniel-Nissim and Sasson (2018) [114] Family functioning Poor parent–child communication •• – 11
Cacioppo et al. (2019) [108] Family functioning Affective involvement ** – 11
Good family functioning *
Good communication ns
Casaló and Escario (2019) [115] Attachment Affective parenting * – 12
Chen et al. (2015) [70] Attachment High family support * ADHD PF = IND 16
Parenting style Protective * Autism PF > IND
Cheung et al. (2015) [38] Parenting style Authoritarian ns – 14
Flexible ns
Inconsistent ••
Permissive •• (Hong Kong site)
Chi et al. (2016) [116] Attachment Good parent–child relationship * Depression PF = IND 11
Psychosocial competence PF = IND
Chng et al. (2015) [65] Attachment Attachment to parents ** – 13
Good communication *
Choi et al. (2018) [76] Parent problems Depression mother • Aggression PF = IND 13
Attention problems PF = IND
Depression and anxiety PF > IND
Chou et al. (2015) [117] Attachment Satisfaction with family relationship * ADHD PF > IND 13
Chung et al. (2019) [99] Attachment Good family cohesion ns Depression PF < IND 15
Aggression PF < IND
Impulsivity PF < IND
Costa et al. (2019) [118] Family functioning Poor family functioning • Loneliness PF = IND 11
Dong et al. (2019) [119] Attachment Good parent−child relationship * (father) Self-esteem PF = IND 12
Social anxiety PF = IND
Durkee et al. (2012) [37] Family functioning Low parental involvement • – 12
Estévez et al. (2017) [66] Attachment Attachment to parents * Emotion regulation PF < IND 12
Gao et al. (2018) [82] Co-parental teamwork Interparent conflict •• Depression and anxiety PF = IND 12
Gugliandolo et al. (2019) [51] Parenting style Authoritarian (controlling) •• Need satisfaction PF = IND 10
Autonomy support ns
Jang and Ji (2012) [77] Parent problems Problem drinking parent (PP) ••• Aggression PP = IND 10
Family functioning Good family functioning * (girls) Depression and anxiety PP > IND
Self-esteem PF < IND
Kabasakal (2015) [83] Co-parental teamwork Poor interparental relationship • Life satisfaction PF = IND 10
Family functioning Poor family functioning •
Karaer and Akdemir (2019) [40] Attachment (1) Low parents’ emotional availability • Alexithymia PF(1) = IND 13
Parenting style (2) Authoritarian ns Emotion regulation
Democratic ns
Neglectful ns
Permissive ns
Kilic et al. (2016) [120] Attachment Social support * Communication skills PF = IND 14
Table 4 (continued)

PIU paper PF factor categorya Label PF effect sizec Individual factorsd PF vs. INDe Study quality scoref
PF factorb

Kim et al. (2016) [96] Attachment Parents’ support and affection ns Self-efficacy PF(2) = IND 12
Parenting style Harsh, controlling • (mother)
Ko et al. (2007) [71] Family functioning Good family functioning * Mental health PF > IND 14
Self-esteem PF < IND
Ko et al. (2015) [72••] Attachment Parent–child conflict • – 13
Co-parental teamwork Interparent conflict •
Family functioning Good family functioning *
Kumğagiz (2019) [90] Parenting style Parental bonding ** (care) – 12
•• (overprotection)
Lam (2015) [43] Parent problems Depression parent •• Adolescent: PF > IND 16
Anxiety PF = IND
Depression PF > IND
Stress
Lam and Wong (2015) [44] Parent problems Parent PIU •• Life satisfaction PF > IND 17
Stress PF < IND
Lau et al. (2017) [111•] Family functioning Family support * Depression PF < IND 12
Loneliness PF = IND
Positive affect PF = IND
Self-esteem PF = IND
Social anxiety PF = IND
Lei and Wu (2007) [67] Attachment (father) Alienation • – 10
Trust *
Li, Li and Newman (2013) [94] Parenting style Love withdrawal • Self-control PF < IND 14
Authority support ns
Li, Li, Wang et al. (2013) [68] Attachment Attachment to parents ** Self-control PF < IND 15
Li et al. (2014) [92] Parenting style Positive support * Self-control PF < IND 11
Negative control •
Li, Li et al. (2018) [121] Family functioning Good family functioning ** Social sensitivity PF = IND 11
Li et al. (2019) [95] Parenting style Punishment ••• Cognitive function PF > IND 12
Rejection •••
Overinvolvement •••
Lin and Gau (2013) [73] Attachment Affectionate parenting * (mother) Diurnal rhythm PF(2) = IND 9
Family functioning Family support * Anxiety PF(2) = IND
Liu et al. (2012) [122] Family functioning Good communication * – 13
Liu et al. (2013) [123] Attachment Good parent–child relationship * (father) – 12
Liu et al. (2019) [93] Parenting style Responsiveness ** Need satisfaction PF > IND 11
Family functioning Good communication **
Lu et al. (2018) [124] Attachment Good family relationship ** Depression PF > IND 12
Religious beliefs PF > IND
Muñoz-Miralles et al. (2016) [102] Attachment Poor family relationship • – 10
Oh (2003) [125] Family functioning Family support * Depression PF < IND 10
Self-control PF < IND
Park et al. (2008) [79] Attachment Family cohesion ** – 10
Co-parental teamwork Interparent conflict •
Parenting style Positive parenting attitude **
Curr Addict Rep
Table 4 (continued)

PIU paper PF factor categorya Label PF effect sizec Individual factorsd PF vs. INDe Study quality scoref
PF factorb
Curr Addict Rep

Family functioning Good communication **

Child abuse Child abuse •
Shek and Yu (2016) [109] Family functioning Poor family functioning ns Positive youth development PF < IND 15
Shek et al. (2018) [35] Attachment Good mother−child relationship * – 15
Shek et al. (2019) [36] Parenting style Psychological control by parents •
Shi et al. (2017) [126] Family functioning Good family functioning * Loneliness PF < IND 11
Self-esteem PF < IND
Siomos et al. (2012) [91] Parenting style Care ** – 15
Overprotection ••
Soh et al. (2018) [127] Attachment Attachment ** – 11
Trumello et al. (2018) [128] Attachment Availability parents * (mother) Callous-unemotional traits PF < IND 9
Emotion regulation PF = IND
Venkatesh et al. (2019) [45] Attachment Attachment to parents * Depression and anxiety PF > IND 12
Loneliness PF > IND
Wang et al. (2011) [100] Attachment Poor family relationship •• Stress PF > IND 11
Poor communication ns
Wang and Qi (2017) [46] Parenting style Harsh • Emotion regulation PF < IND 13
Wang et al. (2018) [103] Attachment Good parent−child relationship * Emotion regulation PF = IND 10
Wartberg et al. (2014) [129] Family functioning Good family functioning *** – 16
Wu et al. (2013) [130] Attachment Good parent−child relationship * Hyperactivity-impulsivity PF = IND 13
Wu et al. (2016) [74] Attachment Poor parent−child relationship •• – 10
Co-parental teamwork Poor interparental relationship •
Family functioning Poor family functioning •
Xin et al. (2018) [84] Co-parental teamwork Poor interparental relationship • – 15
Parenting style Inconsistent parenting •
Positive parenting *
Xiuqin et al. (2010) [41] Parenting style Emotional warmth ** Personality type PF = IND 11
Overinvolvement ••
Rejection ••
Xu et al. (2014) [104] Attachment Poor parent−child relationship ••• – 14
Yaffe and Seroussi (2019) [88] Parenting style Authoritarian ••• – 11
Authoritative *
Yang et al. (2014) [80] Child abuse Child abuse • Depression PF = IND 15
Yang et al. (2016) [69] Attachment Attachment to parents * – 13
Co-parental teamwork Interparent conflict •
Yen et al. (2007) [75] Attachment Parent−child conflict •• – 14
Co-parental teamwork Interparent conflict •
Family functioning Poor family functioning •
Parent problems Alcohol abuse •
Yen et al. (2009) [105] Attachment Family conflict • (young girls) Depression PF < IND 13
Yu and Shek (2013) [131] Family functioning Good family functioning * Positive youth development PF > IND 15
Yu et al. (2013) [101] Attachment Acceptance by parent ns Emotion regulation PF = IND 12
Rejection ns
Zhang et al. (2015) [97] Parenting style Authoritarian •• Maladaptive cognition PF < IND 9
Authoritative * Temperament PF = IND
 Curr Addict Rep

Only cross-sectional data considered here. All effect sizes have been converted to Cohen’s d. One symbol (* = protective factor, • = risk factor) = small effect size; two symbols = medium and three
Study quality scoref
Co-Parental Teamwork

The only factor under this heading featuring in the sampled

papers was conflict between the parents. The effect size was
not significant in the single PG study [81] but was so in the ten
12

10
10
PIU studies concerned [69, 72••, 74, 75, 79, 82–86]. A discor-
dant relationship between the parents was associated with a
PF vs. INDe

higher rate of PIU, the effect size generally being small.

PF < IND

PF = IND
PF = IND
PF > IND

Parenting Style

Parenting style was assessed in three PG studies. An authori-

Emotional regulation

Emotional insecurity
Individual factorsd

tarian or demanding style correlated with a higher prevalence

Conscientiousness

Personality type

of PG [51, 55, 87], which was also true of neglectful and

permissive styles in the one study distinguishing these atti-
tudes [87].
Parenting style featured in 19 PIU studies, labelled as ‘au-
thoritative’ [88, 89], ‘caring’ [90, 91], ‘emotionally warm’
[41, 89], ‘positive’ [79, 84, 92], ‘protective’ [70], ‘responsive’
[93], or ‘supportive’ [92]. Or, in risk factor terms, as ‘author-
PF effect sizec

itarian’ [38]; ‘controlling’ [35, 36, 92], ‘dismissive’ (rejection;

love withdrawal) [41, 94, 95]; ‘harsh’ or ‘punitive’ [95, 96],
Individual factors: cognitive functions, personality traits, or mental health conditions of the adolescents concerned

‘inconsistent’ [38, 46, 84], ‘overinvolved’ [41, 95], ‘overpro-

•••

**
••

••

tective’ [89–91], or ‘permissive’ [38, 97]. Except for one

•

PF factor in a lower (<), the same (=), or a higher (>) effect size class than the respective individual factor

study [40], the protective and risk factor associations with

PIU were significant, with the effect size being medium to
large in 62.5% of cases.
Interparent conflict

Interparent conflict

Attachment
Overprotection
Permissive
PF factorb

The influence of family attachment was evaluated in 14 PG

Warmth
Refusal
Label

studies, yielding 17 effect sizes (Table 3). Attachment mea-

Label given to the PF factor by the authors of the sampled publication

sures did not significantly correlate with PG in four studies

[48, 57, 81, 98]. The same was true of the sample of South
Co-parental teamwork

Co-parental teamwork

Korean adolescents in a study comparing Chinese and Korean

PF factor categorya

school pupils [39]. In the other PG investigations, positive

Parenting style

PF, parental and family (factors); IND, individual factor

attachment of adolescents to their parents was associated with

a lower rate of PG, and negative attachment with a higher rate.
With few exceptions, the effect size was small.
Category as assigned by the present authors

Family attachment featured in 35 PIU studies, with 39

effect sizes (Table 4). Correlations were statistically sig-
nificant in all studies but three [99–101]. ‘Secure attach-
ment between parents and child’ was associated with low-
Score on a scale from 0 to 20

er rates of PIU in 25 studies, with the effect size mostly

symbols = large effect size

being small (20 studies). Poor family attachment—

Zhang et al. (2017) [85]
Zhang et al. (2019) [89]

including ‘poor family relationship’ [74, 102–104], ‘con-

Zhou et al. (2017) [86]
Table 4 (continued)

flicts between parents and child’ [72••, 75, 105], ‘alien-

ation’ [67], and ‘low emotional availability’ of the par-
PIU paper

ents [40]—was connected with higher rates of PIU in 10

studies; the effect size was small or medium and in one
study large.
b

d
a

f
Curr Addict Rep

Family Functioning negative family dynamics (χ2[4, N = 161] = 9.17, p = 0.03).

Family functioning was assessed in 8 PG studies. All 11 effect
sizes were statistically significant; two of them were of medi-
um magnitude [56, 58] and the other ones small [42, 49, 50,
52, 106, 107]. Good family functioning—family cohesion,
communication, relationship; doing social activities with the
family—was a protective factor, and poor family functioning
was a risk factor.
Family functioning was addressed in 22 PIU studies, with a
total of 23 effect sizes. With two exceptions [108, 109], all
effect sizes were statistically significant, though mostly small.
Protective Factors Versus Risk Factors
Figure 2 shows, for PG and PIU combined, the distribution of
effect size outcomes for two categories of protective (positive
parenting and positive family dynamics) and risk factors (neg-
ative parenting and negative family dynamics), respectively.
The distribution of effect size outcomes differed between col-
lapsed protective factors (positive parenting and positive fam-
ily dynamics) and risk factors (negative parenting and
Medium and large effect sizes were more common among
the risk than the protective factors.
Parent and Family Factors Compared with Individual
Factors
Thirteen PG (50%) and 41 PIU (56.9%) investigations not
only evaluated PF factors but also individual factors, i.e. char-
acteristics of the adolescents. A wide variety of individual
f ac t o r s h a ve b e e n co n s i de r e d ( T ab l e s 3 a nd 4) .
ADHD/hyperactivity/attention problems, anxiety, depression,
emotion regulation, self-control, and self-esteem featured in
five or more studies. The latter factors’ effect sizes did not
notably differ from those of PF factors. For instance, the effect
size of the correlation of depression with PG or PIU was
similar to that of PF in five comparisons, lower in four, and
higher in five. Across all PG and PIU studies, PF and individ-
ual factors had a similar effect size in 40.2% of the compari-
sons. PF ranked higher in effect size than individual factors in
28.9% of cases and lower in 30.9%.

Fig. 2 Distribution of effect sizes

(Cohen’s d) per group of parental
and family factors for PG and PIU
combined. Parental factors (panel
a) include problems faced by the
parents, child abuse, and
parenting styles. Family factors
(panel b) comprise family
attachment and family
functioning. Shown is the
percentage of effect sizes being
classified as ns (not statistically
significant), small (d ranging
from 0.20 to 0.49), and
(combined) medium (0.50 to
0.79) and large (0.80 and higher),
respectively

Effect of Study Quality on Outcomes
The PG study quality score ranged from 9 to 15 (median 12.0;
Table 3), and the PIU score from 9 to 17 (median 12.0;
Table 4). Main reasons for low quality scores were the survey
being cross-sectional rather than prospective, non-random
sampling, failure to include an independent comparison sam-
ple or a sample of parents, and inadequate measurement of
PG/PIU or PF factors. Study quality (scores 9–11 vs. 12 and
higher) was not related to effect size class (χ2 = 0.07).
Prospective Studies
If a PF correlated with PG or PIU in the first wave assessment,
the same factor generally also correlated with PG or PIU at the
next wave [42, 70, 78, 107, 110]. One prospective study
charted bidirectional associations between PF and PIU. Low
family functioning at the first wave predicted an elevated rate
of PIU 1 year later, whereas PIU at the first wave predicted
poor family functioning at the second assessment [72••].
One PG paper and three PIU papers present data from
which the incidence (emergence of new PG/PIU cases)
and remission rates can be derived. In the PG study, the
incidence rate was 15.5%, i.e. about one in seven adoles-
cents who were not classified as PG case at the first as-
sessment developed PG later on [34]. The incidence rates
in the two PIU studies reporting this figure were 7.5%
[71] and 9.1% [72••]. A sizable proportion of PG/PIU
cases at the first assessment did not qualify as such any-
more in the next assessment round; remission rates were
41.3% [34], 45.9% [111•], 49.4% [72••], and 51.5%
[72••]. Three studies related PF factors to incidence and/
or remission of PIU, with mixed results. Poor family func-
tioning was associated with a higher incidence rate in one
study [71] but not in another one [72••]. PF factors were
not connected with remission in these two investigations,
but feeling supported by one’s family was associated with
a higher remission rate in a third study [111•].
Discussion and Conclusions
The present study systematically reviewed parental and
family (PF) factors connected to problematic gaming
(PG) and problematic Internet use (PIU) in adolescents.
We sampled 100 research papers, 27 on PG and 73 on
PIU, reporting on 41 and 120 effect sizes, respectively.
Our findings confirm the conclusions of previous reviews
and a meta-analysis [7, 8••, 9•] that parental and family
factors are associated with PG and PIU. The majority of
significant effect sizes were small, for both PG and PIU.
The same pattern of results—relatively few effect sizes
being non-significant, many being small, no difference
Curr Addict Rep
noted between PG and PIU—was seen for each of the six
categories of PF factors distinguished: problems faced by
the parents, child abuse, co-parental teamwork, parenting
style, family attachment, and family functioning. The ef-
fect size of negative parenting styles tended to be medium/
large.
We rearranged the categories to form two groups of pro-
tective factors (positive parenting and positive family dynam-
ics) and two groups of risk factors (negative parenting and
negative family dynamics). The protective factors were con-
sistently associated with lower rates of PG and PIU, the risk
factors with higher rates.
To place the importance of parental and family factors in
context, we compared the effect sizes of PF variables with
those of the intrapersonal characteristics of the adolescent (in-
dividual factors) that were examined in the same study. The
PF factors had comparable effect sizes as the individual fac-
tors, inconsistent with an earlier review [9•]. However, that
publication was limited to studies among Chinese youth and it
classified PF as part of a category of variables termed ‘inter-
personal’. The latter referred to any social contact, also with
friends for instance, and even to social anxiety, which we
listed as an individual factor. In other words, the terms ‘PF’
and ‘interpersonal’ do not cover one and the same set of
variables.
Prospective Studies
Most studies sampled were cross-sectional, which may show
associations between PF factors and PG and PIU, but are
inconclusive as to the nature of the link. What was first, the
PF factor or PG/PIU? Or were PF and PG/PIU interrelated via
a third set of variables, such as individual factors? Even with
advanced model analysis of mediating and moderating vari-
ables, this is hard to tell from cross-sectional data. Prospective
studies may provide more insight here, though the few pro-
spective studies in our sample linking PF to the incidence of
PG or PIU yielded mixed results. Only one study explicitly
addressed the possibility of a bidirectional connection be-
tween PF and PIU. Low family function preceded incident
PIU, and PIU preceded a lowering of family functioning
[72••].
Prospective data on the remission of PG and PIU was re-
ported in four papers, which showed a remarkably high remis-
sion rate (40–50%). Owing to the sparsity of relevant studies,
we could not identify a relation between PF and remission.
More studies on determinants of remission are needed.
Study Quality
Study quality scores ranged from 9 to 17 out of a maximum of
20 points and were not linked to the nature or magnitude of
effect sizes.
Curr Addict Rep
Study quality can be increased by opting for randomised
sampling of study participants, a prospective study design,
and using validated instruments to measure PG, PIU, and
clearly defined parental and family factors. The striking vari-
ation in both PG and PIU rates we observed probably results
in part from the widely varying assessment tools used, as well
as variation in the cut-off points applied by researchers.
Occasionally, youths with ‘moderate’ Internet use problems
were lumped together with youths having severe problems.
Even more unsettling was the huge variability of measures
of PF factors (and individual factors). Self-made question-
naires with just a few items, and questionnaires pieced togeth-
er from existing tools (with items deleted and added) were too
often a matter of course. This variation in study design
highlighted the need for standardisation of PG, PIU, and PF
assessments.
Limitations of this Review
China and South Korea have markedly contributed to the field
of PG and PIU research, with research regularly reported in
English. However, a number of studies we were interested in
reviewing were published in Chinese and Korean, leading to
underrepresentation in our selection of papers. This may have
affected the generalisability of our findings. Fortunately, both
the Chinese and the Korean PIU literature have been
reviewed. These reviews arrived at the same conclusion as
we did: PF factors are associated with PIU in adolescents
[8••, 9•].
Another limitation to consider is how we categorised the
effect sizes, turning them into nominal data. One might argue
that the effect sizes should have been treated as interval data,
as Koo and Kwon [8••] did in their meta-analysis of intraper-
sonal and interpersonal factors connected with PIU. These
authors found the effect sizes of interpersonal factors to be
generally small, as we did. The effect sizes of intrapersonal
factors were small as well. However, when entering the exact
values of Cohen’s d in the analyses, the effect size of intraper-
sonal factors was significantly larger than that of interpersonal
factors. Perhaps, we might have confirmed this result if we
had followed the same statistical approach. Given that the
individual factors were so numerous and the outcome mea-
sures so variable, opting for a meta-analysis would have
forced us to make many debatable assumptions to bring ana-
lytical order in this chaos. We therefore settled for a systematic
review.
Conclusions
Positive parenting and positive family dynamics proved pro-
tective and are associated with lower rates of both PG and PIU
in adolescents. The reverse is true of negative parenting and
negative family dynamics, with these classes of risk factors
correlated to enhanced levels of PG and PIU. The effect sizes,
although often small, were statistically significant in the ex-
pected direction in the overwhelming majority of the 100
studies we reviewed.
The high remission rates reported suggest that many
PG/PIU teens grow out of their screen frenzy. This is
hopeful news and should encourage clinicians to remain
cautious about over-diagnosis of cases. However, the
modest link between PF factors and PG and PIU left us
with the impression of a disconnect between the present
findings and our clinical practice. We have treated hun-
dreds of cases of youths caught up in a tangle of risk
factors of intrapersonal, parental, family, and socio-
academic nature, pulling them and their families down
in a destructive spiral [20]. Not only do the adolescents
have problems requiring treatment, but the dysfunctional
family relationships which have fueled PG and PIU also
need tending. These family dynamics may make PG teens
more challenging to treat than teens with substance use
disorder.
All things considered, it is a giant leap from survey to
clinic. We offer this as a hypothesis for further research: prob-
lems begin requiring therapy in cases where intrapersonal and
interpersonal factors are intertwined rather than weakly
linked. We believe it would help the international debate on
the PG (or IGD) and PIU constructs to pay more attention to
the potential “multidimensional syndrome” of behavioural
problems (PG and PIU) related to problematic parenting and
family dynamics.
Acknowledgements We thank Mafalda Burri and Muriel Leclerc,
Service de référence, University of Geneva Library, for assisting us in
identifying search terms, developing the search strategies and equations,
and for carrying out the database searches.
Authors’ Contributions The authors jointly developed the study concept.
The review was designed and carried out by PN and HR and supervised
by NF. PN and HR wrote the paper, with critical input and assistance with
data interpretation from NF. All authors had full access to all study data
and take responsibility for the integrity of the data and the accuracy of the
data analysis.
Compliance with Ethical Standards
Conflict of Interest The authors declare they have no conflicts of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
Abbreviations DSM, Diagnostic and Statistical Manual for Mental
Disorders; ICD, International Classification of Diseases; IGD, Internet
Gaming Disorder; PF, parental and family (factor); PG, problematic gam-
ing; PIU, problematic Internet use

References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Saunders JB, Hao W, Long J, King DL, Mann K, Fauth-Buhler M,
et al. Gaming disorder: its delineation as an important condition
for diagnosis, management, and prevention. J Behav Addict.
2017;6(3):271–9. https://doi.org/10.1556/2006.6.2017.039.
2.• Kuss DJ, Griffiths MD, Pontes HM. Chaos and confusion in
DSM-5 diagnosis of Internet gaming disorder: issues, concerns,
and recommendations for clarity in the field. J Behav Addict.
2017;6(2):103–9. https://doi.org/10.1556/2006.5.2016.062 An
informative overview of terminological and conceptual issues
in the research literature on problematic gaming.
3. King DL, Delfabbro PH. The concept of “harm” in Internet gam-
ing disorder. J Behav Addict. 2018;7(3):562–4. https://doi.org/10.
1556/2006.7.2018.24.
4. van Rooij AJ, Ferguson CJ, Colder Carras M, Kardefelt-Winther
D, Shi J, Aarseth E, et al. A weak scientific basis for gaming
disorder: let us err on the side of caution. J Behav Addict.
2018;7(1):1–9. https://doi.org/10.1556/2006.7.2018.19.
5. Young KS. Internet addiction: the emergence of a new clinical
disorder. CyberPsychol Behav. 1998;1(3):237–44. https://doi.
org/10.1089/cpb.1998.1.237.
6. Pontes HM, Griffiths MD. Internet addiction disorder and Internet
gaming disorder are not the same. J Addict Res Ther. 2014;5(4).
https://doi.org/10.4172/2155-6105.1000e124.
7. Schneider LA, King DL, Delfabbro PH. Family factors in adoles-
cent problematic internet gaming: a systematic review. J Behav
Addict. 2017;6(3):321–33. https://doi.org/10.1556/2006.6.2017.
035.
8.•• Koo HJ, Kwon JH. Risk and protective factors of internet addic-
tion: a meta-analysis of empirical studies in Korea. Yonsei Med J.
2014;55(6):1691–711. https://doi.org/10.3349/ymj.2014.55.6.
1691 Discloses papers published in Korean and provides a
classification of risk and protective factors.
9.• Li W, Garland EL, Howard MO. Family factors in Internet addic-
tion among Chinese youth: a review of English- and Chinese-
language studies. Comput Hum Behav. 2014;31:393–411.
https://doi.org/10.1016/j.chb.2013.11.004 Discloses papers
published in Chinese.
10. Sperry L. Couple and family assessment: contemporary and
cutting-edge strategies: Routledge; 2019.
11. Walsh F. Normal family processes: growing diversity and com-
plexity: Guilford Press; 2012.
12. Reupert A, Maybery D. What do we know about families where
parents have a mental illness? A systematic review. Child Youth
Serv. 2016;37(2):98–111. https://doi.org/10.1080/0145935X.
2016.1104037.
13. Rolland JS. Helping couples and families navigate illness and
disability: an integrated approach: Guilford Publications; 2018.
14. McHale JP, Lindahl KM. Coparenting: a conceptual and clinical
examination of family systems. American Psychological
Association; 2011.
15. Baumrind D. The influence of parenting style on adolescent com-
petence and substance use. J Early Adolesc. 1991;11(1):56–95.
https://doi.org/10.1177/0272431691111004.
16. Cummings EM, Davies PT. Marital conflict and children: an emo-
tional security perspective: Guilford Press; 2010.
17. Erdman P, Caffery T. Attachment and family systems: conceptual,
empirical and therapeutic relatedness: Routledge; 2013.
Curr Addict Rep
18. Lebow J, Stroud CB. Assessment of effective couple and family
functioning: prevailing models and instruments. 2012.
19. Bonnaire C, Liddle HA, Har A, Nielsen P, Phan O. Why and how
to include parents in the treatment of adolescents presenting
Internet gaming disorder? J Behav Addict. 2019;8(2):201–12.
https://doi.org/10.1556/2006.8.2019.27.
20. Moher D, Liberati A, Tetzlaff J, Altman DG. Group atP. Preferred
reporting items for systematic reviews and meta-analyses: the
PRISMA statement. Ann Intern Med. 2009;151(4):264–9.
https://doi.org/10.7326/0003-4819-151-4-200908180-00135.
21. Nielsen P, Favez N, Liddle HA, Rigter H. Linking parental medi-
ation practices to adolescents’ problematic online screen use: a
systematic literature review. J Behav Addict. 2019;8:1–15.
https://doi.org/10.1556/2006.8.2019.61.
22. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A.
Rayyan—a web and mobile app for systematic reviews. Syst
Rev. 2016;5(210). https://doi.org/10.1186/s13643-016-0384-4.
23. King DL, Chamberlain SR, Carragher N, Billieux J, Stein D,
Mueller K, et al. Screening and assessment tools for gaming dis-
order: a comprehensive systematic review. Clin Psychol Rev.
2020;77:101831. https://doi.org/10.1016/j.cpr.2020.101831.
24. Lortie CL, Guitton MJ. Internet addiction assessment tools: di-
mensional structure and methodological status. Addiction.
2013;108(7):1207–16. https://doi.org/10.1111/add.12202.
25. Hamilton E, Carr A. Systematic review of self-report family as-
sessment measures. Fam Process. 2016;55(1):16–30. https://doi.
org/10.1111/famp.12200.
26. Favez N. L’examen clinique de la famille: modèles et instruments
d’évaluation. Editions Mardaga; 2011.
27. Jewell T, Gardner T, Susi K, Watchorn K, Coopey E, Simic M,
et al. Attachment measures in middle childhood and adolescence:
a systematic review of measurement properties. Clin Psychol Rev.
2019;68:71–82. https://doi.org/10.1016/j.cpr.2018.12.004.
28. Ngai SSY, Cheung CK, Xie LL, Ng YH, Ngai HL, Liu Y, et al.
Psychometric properties of the parental bonding instrument: data
from a Chinese adolescent sample in Hong Kong. J Child Fam
Stud. 2018;27(7):2112–24. https://doi.org/10.1007/s10826-018-
1058-8.
29. Gerlsma C, Arrindell WA, Vanderveen N, Emmelkamp PMG. A
parental rearing style questionnaire for use with adolescents - psy-
chometric evaluation of the Embu-A. Personal Individ Differ.
1991;12(12):1245–53. https://doi.org/10.1016/0191-8869(91)
90196-I.
30. Gardner W, Nutting PA, Kelleher KJ, Werner JJ, Farley T,
Stewart L. Does the family APGAR effectively measure family
functioning? J Fam Pract. 2001;50.
31. Lenhard W, Lenhard A. Calculation of effect sizes. 2015.
Psychometrica, Bibergau (Germany) Available: http://www.
psychometrica.de/effect_size.html.
32. Cohen J. Statistical power analysis for the behavioral sciences:
Jacob Cohen. J Am Stat Assoc. 1988;84(363):19–74.
33. Wartberg L, Kriston L, Kramer M, Schwedler A, Lincoln TM,
Kammerl R. Internet gaming disorder in early adolescence: asso-
ciations with parental and adolescent mental health. Eur
Psychiatry. 2017;43:14–8. https://doi.org/10.1016/j.eurpsy.2016.
12.013.
34. Wartberg L, Kriston L, Zieglmeier M, Lincoln T, Kammerl R. A
longitudinal study on psychosocial causes and consequences of
Internet gaming disorder in adolescence. Psychol Med.
2018;49(2):287–94. https://doi.org/10.1017/
S003329171800082X.
35. Shek DTL, Zhu X, Ma CMS. The influence of parental control
and parent-child relational qualities on adolescent internet addic-
tion: a 3-year longitudinal study in Hong Kong. Front Psychol.
2018;9:642. https://doi.org/10.3389/fpsyg.2018.00642.
Curr Addict Rep
36. Shek DTL, Zhu X, Dou D. Influence of family processes on
Internet addiction among late adolescents in Hong Kong. Front
Psychiatry. 2019;10:113. https://doi.org/10.3389/fpsyt.2019.
00113.
37. Durkee T, Kaess M, Carli V, Parzer P, Wasserman C, Floderus B,
et al. Prevalence of pathological Internet use among adolescents in
Europe: demographic and social factors. Addiction. 2012;107(12):
2210–22. https://doi.org/10.1111/j.1360-0443.2012.03946.x.
38. Cheung CK, Yue XD, Wong DSW. Addictive internet use and
parenting patterns among secondary school students in
Guangzhou and Hong Kong. J Child Fam Stud. 2015;24(8):
2301–9. https://doi.org/10.1007/s10826-014-0033-2.
39. Cui JH, Lee C, Bax T. A comparison of `psychosocially problem-
atic gaming' among middle and high school students in China and
South Korea. Comput Hum Behav. 2018;85:86–94. https://doi.
org/10.1016/j.chb.2018.03.040.
40. Karaer Y, Akdemir D. Parenting styles, perceived social support
and emotion regulation in adolescents with Internet addiction.
Compr Psychiatry. 2019;92:22–7. https://doi.org/10.1016/j.
comppsych.2019.03.003.
41. Xiuqin H, Huimin Z, Mengchen L, Jinan W, Ying Z, Ran T.
Mental health, personality, and parental rearing styles of adoles-
cents with Internet addiction disorder. Cyberpsychol Behav Soc
Netw. 2010;13(4):401–6. https://doi.org/10.1089/cyber.2009.
0222.
42. Li AY, Lo BC, Cheng C. It is the family context that matters:
concurrent and predictive effects of aspects of parent-child inter-
action on video gaming-related problems. Cyberpsychol Behav
Soc Netw. 2018;21(6):374–80. https://doi.org/10.1089/cyber.
2017.0566.
43. Lam LT. Parental mental health and Internet addiction in adoles-
cents. Addict Behav. 2015;42:20–3. https://doi.org/10.1016/j.
addbeh.2014.10.033.
44. Lam LT, Wong EM. Stress moderates the relationship between
problematic Internet use by parents and problematic internet use
by adolescents. J Adolesc Health. 2015;56(3):300–6. https://doi.
org/10.1016/j.jadohealth.2014.10.263.
45. Venkatesh V, Sykes TA, Chan FKY, Thong JYL, Hu PJ-H.
Children’s Internet addiction, family-to-work conflict, and job
outcomes: a study of parent–child dyads. MIS Q. 2019;43(3):
903–27. https://doi.org/10.25300/misq/2019/12338.
46. Wang M, Qi W. Harsh parenting and problematic Internet use in
Chinese adolescents: child emotional dysregulation as mediator
and child forgiveness as moderator. Comput Hum Behav.
2017;77:211–9. https://doi.org/10.1016/j.chb.2017.09.005.
47. Kim K, Kim K. Internet game addiction, parental attachment, and
parenting of adolescents in South Korea. J Child Adolesc Subst
Abuse. 2015;24(6):366–71.
48. Lee CH, Kim O. Predictors of online game addiction among
Korean adolescents. Addict Res Theory. 2017;25(1):58–66.
https://doi.org/10.1080/16066359.2016.1198474.
49. Lyu SO. Developmental process of internet gaming disorder
among south Korean adolescents: effects of family environment
and recreation experience. J Child Fam Stud. 2017;26(6):1527–
35.
50. Bonnaire C, Phan O. Relationships between parental attitudes,
family functioning and Internet gaming disorder in adolescents
attending school. Psychiatry Res. 2017;255:104–10. https://doi.
org/10.1016/j.psychres.2017.05.030.
51. Gugliandolo MC, Costa S, Kuss DJ, Cuzzocrea F, Verrastro V.
Technological addiction in adolescents: the interplay between par-
enting and psychological basic needs. Int J Ment Heal Addict.
2019. https://doi.org/10.1007/s11469-019-00156-4.
52. Irmak AY, Erdogan S. Predictors for digital game addiction
among Turkish adolescents: a Cox’s interaction model-based
study. J Addict Nurs. 2019;30(1):49–56. https://doi.org/10.1097/
JAN.0000000000000265.
53. Wang CW, Chan CLW, Mak KK, Ho SY, Wong PWC, Ho RTH.
Prevalence and correlates of video and Internet gaming addiction
among Hong Kong adolescents: a pilot study. Sci World J.
2014;2014: Artn 874648. https://doi.org/10.1155/2014/874648
54. Lemmens JS, Valkenburg PM, Peter J. Development and valida-
tion of a game addiction scale for adolescents. Media Psychol.
2009;12(1):77–95. https://doi.org/10.1080/15213260802669458.
55. Cheng Y. The mediating effects of motivation for playing
Pokemon go on Internet gaming disorder and well-being. Am J
Fam Ther. 2019;47(1):19–36. https://doi.org/10.1080/01926187.
2019.1583614.
56. Kim E, Yim HW, Jeong H, Jo SJ, Lee HK, Son HJ, et al. The
association between aggression and risk of Internet gaming disor-
der in Korean adolescents: the mediation effect of father-
adolescent communication style. Epidemiol Health. 2018;40:
e2018039. https://doi.org/10.4178/epih.e2018039.
57. King DL, Delfabbro PH. Features of parent-child relationships in
adolescents with Internet gaming disorder. Int J Ment Heal Addict.
2017;15(6):1270–83. https://doi.org/10.1007/s11469-016-9699-
6.
58. Jeong EJ, Kim DH. Social activities, self-efficacy, game attitudes,
and game addiction. Cyberpsychol Behav Soc Netw. 2011;14(4):
213–21. https://doi.org/10.1089/cyber.2009.0289.
59. Kwon JH, Chung CS, Lee J. The effects of escape from self and
interpersonal relationship on the pathological use of Internet
games. Community Ment Hlt J. 2011;47(1):113–21. https://doi.
org/10.1007/s10597-009-9236-1.
60. Su B, Yu C, Zhang W, Su Q, Zhu J, Jiang Y. Father-child longi-
tudinal relationship: parental monitoring and internet gaming dis-
order in Chinese adolescents. Front Psychol. 2018;9:95. https://
doi.org/10.3389/fpsyg.2018.00095.
61. Zhu JJ, Zhang W, Yu CF, Bao ZZ. Early adolescent Internet game
addiction in context: how parents, school, and peers impact youth.
Comput Hum Behav. 2015;50:159–68. https://doi.org/10.1016/j.
chb.2015.03.079.
62. Moon SJ, Hwang JS, Kim JY, Shin AL, Bae SM, Kim JW.
Psychometric properties of the internet addiction test: a systematic
review and meta-analysis. Cyberpsychol Behav Soc Netw.
2018;21(8):473–84. https://doi.org/10.1089/cyber.2018.0154.
63. Ballarotto G, Volpi B, Marzilli E, Tambelli R. Adolescent internet
abuse: a study on the role of attachment to parents and peers in a
large community sample. Biomed Res Int. 2018;2018:1–10.
https://doi.org/10.1155/2018/5769250.
64. Bolat N, Yavuz M, Eliacik K, Zorlu A. The relationships between
problematic Internet use, alexithymia levels and attachment char-
acteristics in a sample of adolescents in a high school. Turkey
Psychol Health Med. 2018;23(5):604–11. https://doi.org/10.
1080/13548506.2017.1394474.
65. Chng GS, Li DD, Liau AK, Khoo A. Moderating effects of the
family environment for parental mediation and pathological
Internet use in youths. Cyberpsych Beh Soc N. 2015;18(1):30–6.
https://doi.org/10.1089/cyber.2014.0368.
66. Estevez A, Jauregui P, Sanchez-Marcos I, Lopez-Gonzalez H,
Griffiths MD. Attachment and emotion regulation in substance
addictions and behavioral addictions. J Behav Addict. 2017;6(4):
534–44. https://doi.org/10.1556/2006.6.2017.086.
67. Lei L, Wu Y. Adolescents’ paternal attachment and Internet use.
CyberPsychol Behav. 2007;10(5):633–9. https://doi.org/10.1089/
cpb.2007.9976.
68. Li D, Li X, Wang Y, Zhao L, Bao Z, Wen F. School connected-
ness and problematic internet use in adolescents: a moderated
mediation model of deviant peer affiliation and self-control. J
Abnorm Child Psychol. 2013;41(8):1231–42. https://doi.org/10.
1007/s10802-013-9761-9.

69. Yang X, Zhu L, Chen Q, Song P, Wang Z. Parent marital conflict
and Internet addiction among Chinese college students: the medi-
ating role of father-child, mother-child, and peer attachment.
Comput Hum Behav. 2016;59:221–9. https://doi.org/10.1016/j.
chb.2016.01.041.
70. Chen YL, Chen SH, Gau SS. ADHD and autistic traits, family
function, parenting style, and social adjustment for Internet addic-
tion among children and adolescents in Taiwan: a longitudinal
study. Res Dev Disabil. 2015;39:20–31. https://doi.org/10.1016/
j.ridd.2014.12.025.
71. Ko CH, Yen JY, Yen CF, Lin HC, Yang MJ. Factors predictive
for incidence and remission of internet addiction in young adoles-
cents: a prospective study. CyberPsychol Behav. 2007;10(4):545–
51. https://doi.org/10.1089/cpb.2007.9992.
72.•• Ko CH, Wang PW, Liu TL, Yen CF, Chen CS, Yen JY.
Bidirectional associations between family factors and Internet ad-
diction among adolescents in a prospective investigation.
Psychiatry Clin Neurosci. 2015;69(4):192–200. https://doi.org/
10.1111/pcn.12204 This was the only study that explicitly
examined the bidirectional relationships between family
factors and problematic Internet use.
73. Lin YH, Gau SS. Association between morningness-eveningness
and the severity of compulsive Internet use: the moderating role of
gender and parenting style. Sleep Med. 2013;14(12):1398–404.
https://doi.org/10.1016/j.sleep.2013.06.015.
74. Wu CST, Wong HT, Yu KF, Fok KW, Yeung SM, Lam CH, et al.
Parenting approaches, family functionality, and internet addiction
among Hong Kong adolescents. BMC Pediatr. 2016;16:130.
https://doi.org/10.1186/s12887-016-0666-y.
75. Yen JY, Yen CF, Chen CC, Chen SH, Ko CH. Family factors of
Internet addiction and substance use experience in Taiwanese ad-
olescents. CyberPsychol Behav. 2007;10(3):323–9. https://doi.
org/10.1089/cpb.2006.9948.
76. Choi DW, Chun SY, Lee SA, Han KT, Park EC. The association
between parental depression and adolescent’s Internet addiction in
South Korea. Ann General Psychiatry. 2018;17(1):15. https://doi.
org/10.1186/s12991-018-0187-1.
77. Jang MH, Kim MJ, Choi H. Influences of parental problem drink-
ing on internet addiction among early adolescents: a multiple-
mediation analysis. J Addict Nurs. 2012;23(4):258–70. https://
doi.org/10.1097/JAN.0b013e31826f69ac.
78. Mößle T, Rehbein F. Predictors of problematic video game usage
in childhood and adolescence. Sucht. 2013;59(3):153–64. https://
doi.org/10.1024/0939-5911.a000247.
79. Park SK, Kim JY, Cho CB. Prevalence of Internet addiction and
correlations with family factors among south Korean adolescents.
Adolescence. 2008;43(172):895–909.
80. Yang L, Sun L, Zhang Z, Sun Y, Wu H, Ye D. Internet addiction,
adolescent depression, and the mediating role of life events: find-
ing from a sample of Chinese adolescents. Int J Psychol.
2014;49(5):342–7. https://doi.org/10.1002/ijop.12063.
81. Rehbein F, Baier D. Family-, media-, and school-related risk fac-
tors of video game addiction. J Media Psychol-Ger. 2013;25(3):
118–28. https://doi.org/10.1027/1864-1105/a000093.
82. Gao T, Meng X, Qin Z, Zhang H, Gao J, Kong Y, et al.
Association between parental marital conflict and Internet addic-
tion: a moderated mediation analysis. J Affect Disord. 2018;240:
27–32. https://doi.org/10.1016/j.jad.2018.07.005.
83. Kabasakal Z. Life satisfaction and family functions as-predictors
of problematic Internet use in university students. Comput Hum
Behav. 2015;53:294–304. https://doi.org/10.1016/j.chb.2015.07.
019.
84. Xin M, Xing J, Pengfei W, Houru L, Mengcheng W, Hong Z.
Online activities, prevalence of Internet addiction and risk factors
related to family and school among adolescents in China. Addict
Curr Addict Rep
Behav Rep. 2018;7:14–8. https://doi.org/10.1016/j.abrep.2017.
10.003.
85. Zhang H, Spinrad TL, Eisenberg N, Luo Y, Wang Z. Young
adults’ Internet addiction: prediction by the interaction of parental
marital conflict and respiratory sinus arrhythmia. Int J
Psychophysiol. 2017;120:148–56. https://doi.org/10.1016/j.
ijpsycho.2017.08.002.
86. Zhou Y, Li D, Jia J, Li X, Zhao L, Sun W, et al. Interparental
conflict and adolescent Internet addiction: the mediating role of
emotional insecurity and the moderating role of big five personal-
ity traits. Comput Hum Behav. 2017;73:470–8. https://doi.org/10.
1016/j.chb.2017.04.012.
87. Abedini Y, Zamani BE, Kheradm A, Rajabizadeh G. Impacts of
mothers’ occupation status and parenting styles on levels of self-
control, addiction to computer games, and educational progress of
adolescents. Addiction & health. 2012;4(3):102–10.
88. Yaffe Y, Seroussi D-E. Problematic Internet use in Israeli-Arab
adolescent males: do parenting styles matter? Cyberpsychology.
2019;13(4). https://doi.org/10.5817/cp2019-4-5.
89. Zhang R-p, Bai B-y, Jiang S, Yang S, Zhou Q. Parenting styles
and Internet addiction in Chinese adolescents: conscientiousness
as a mediator and teacher support as a moderator. Comput Hum
Behav. 2019;101:144–50. https://doi.org/10.1016/j.chb.2019.07.
019.
90. Kumcağız H. Examination of Turkish university students’ Internet
addiction in relation to their parental attachment styles and
sociodemographics. SAGE Open. 2019;9(2). https://doi.org/10.
1177/2158244019845946.
91. Siomos K, Floros G, Fisoun V, Evaggelia D, Farkonas N,
Sergentani E, et al. Evolution of Internet addiction in Greek ado-
lescent students over a two-year period: the impact of parental
bonding. Eur Child Adolesc Psychiatry. 2012;21(4):211–9.
https://doi.org/10.1007/s00787-012-0254-0.
92. Li C, Dang J, Zhang X, Zhang Q, Guo J. Internet addiction among
Chinese adolescents: the effect of parental behavior and self-con-
trol. Comput Hum Behav. 2014;41:1–7. https://doi.org/10.1016/j.
chb.2014.09.001.
93. Liu Q, Lin Y, Zhou Z, Zhang W. Perceived parent–adolescent
communication and pathological Internet use among Chinese ad-
olescents: a moderated mediation model. J Child Fam Stud.
2019;28(6):1571–80. https://doi.org/10.1007/s10826-019-01376-
x.
94. Li X, Li D, Newman J. Parental behavioral and psychological
control and problematic internet use among Chinese adolescents:
the mediating role of self-control. Cyberpsychol Behav Soc Netw.
2013;16(6):442–7. https://doi.org/10.1089/cyber.2012.0293.
95. Li Y, Wang Y, Ren Z, Gao M, Liu Q, Qiu C, et al. The influence
of environmental pressure on internet use disorder in adolescents:
the potential mediating role of cognitive function. Addict Behav.
2020;101:105976. https://doi.org/10.1016/j.addbeh.2019.04.034.
96. Kim JE, Epstein NB, Moon UJ. Self-efficacy and perceived pa-
rental support/affection as mediators of stressor risk factors for
adolescent Internet addiction in South Korea. Family and Family
Therapy. 2016;24(4):483–504.
97. Zhang H, Li D, Li X. Temperament and problematic internet use
in adolescents: a moderated mediation model of maladaptive cog-
nition and parenting styles. J Child Fam Stud. 2014;24(7):1886–
97. https://doi.org/10.1007/s10826-014-9990-8.
98. Charlie CWD, HyeKyung C, Khoo A. Role of parental relation-
ships in pathological gaming. Procedia Soc Behav Sci. 2011;30:
1230–6. https://doi.org/10.1016/j.sbspro.2011.10.238.
99. Chung S, Lee J, Lee HK. Personal factors, internet characteristics,
and environmental factors contributing to adolescent internet ad-
diction: a public health perspective. Int J Environ Res Public
H e a l t h . 2 01 9 ; 1 6( 2 3 ) : 4 6 35 . h t t p s : / / do i . org / 1 0 . 3 39 0/
ijerph16234635.
Curr Addict Rep
100. Wang H, Zhou XL, Lu CY, Wu J, Deng XQ, Hong LY.
Problematic Internet use in high school students in Guangdong
Province, China. PLoS One. 2011;6(5):e19660. https://doi.org/
10.1371/journal.pone.0019660.
101. Yu JJ, Kim H, Hay I. Understanding adolescents’ problematic
internet use from a social/cognitive and addiction research frame-
work. Comput Hum Behav. 2013;29(6):2682–9. https://doi.org/
10.1016/j.chb.2013.06.045.
102. Muñoz-Miralles R, Ortega-González R, López-Morón MR,
Batalla-Martínez C, Manresa JM, Montellà-Jordana N et al. The
problematic use of information and communication technologies
(ICT) in adolescents by the cross sectional JOITIC study. BMC
Pediatr. 2016;16(1).
103. Wang W, Li D, Li X, Wang Y, Sun W, Zhao L, et al. Parent-
adolescent relationship and adolescent internet addiction: a mod-
erated mediation model. Addict Behav. 2018;84:171–7. https://
doi.org/10.1016/j.addbeh.2018.04.015.
104. Xu J, Shen LX, Yan CH, Hu H, Yang F, Wang L, et al. Parent-
adolescent interaction and risk of adolescent Internet addiction: a
population-based study in Shanghai. BMC Psychiatry. 2014;14:
112. https://doi.org/10.1186/1471-244X-14-112.
105. Yen CF, Ko CH, Yen JY, Chang YP, Cheng CP. Multi-
dimensional discriminative factors for Internet addiction among
adolescents regarding gender and age. Psychiatry Clin Neurosci.
2009;63(3):357–64. https://doi.org/10.1111/j.1440-1819.2009.
01969.x.
106. Chiu SI, Lee JZ, Huang DH. Video game addiction in children and
teenagers in Taiwan. CyberPsychol Behav. 2004;7(5):571–81.
https://doi.org/10.1089/cpb.2004.7.571.
107. Liau AK, Choo H, Li DD, Gentile DA, Sim T, Khoo A.
Pathological video-gaming among youth: a prospective study ex-
amining dynamic protective factors. Addict Res Theory.
2015;23(4):301–8. https://doi.org/10.3109/16066359.2014.
987759.
108. Cacioppo M, Barni D, Correale C, Mangialavori S, Danioni F,
Gori A. Do attachment styles and family functioning predict ado-
lescents’ problematic Internet use? A relative weight analysis. J
Child Fam Stud. 2019;28(5):1263–71. https://doi.org/10.1007/
s10826-019-01357-0.
109. Shek DT, Yu L. Adolescent internet addiction in Hong Kong:
prevalence, change, and correlates. J Pediatr Adolesc Gynecol.
2016;29(1 Suppl):S22–30. https://doi.org/10.1016/j.jpag.2015.
10.005.
110. Choo H, Sim T, Liau AKF, Gentile DA, Khoo A. Parental influ-
ences on pathological symptoms of video-gaming among children
and adolescents: a prospective study. J Child Fam Stud.
2015;24(5):1429–41. https://doi.org/10.1007/s10826-014-9949-
9.
111.• Lau JTF, AMS W, Gross DL, Cheng KM, Lau MMC. Is Internet
addiction transitory or persistent? Incidence and prospective pre-
dictors of remission of Internet addiction among Chinese second-
ary school students. Addict Behav. 2017;74:55–62. https://doi.
org/10.1016/j.addbeh.2017.05.034 Provides data on the
incidence and remission of problematic Internet use.
112. Ahmadi K, Saghafi A. Psychosocial profile of Iranian adolescents’
Internet addiction. Cyberpsychol Behav Soc Netw. 2013;16(7):
543–8. https://doi.org/10.1089/cyber.2012.0237.
113. Alt D, Boniel-Nissim M. Parent–adolescent communication and
problematic Internet use: the mediating role of fear of missing out
(FoMO). J Fam Issues. 2018;39(13):3391–409. https://doi.org/10.
1177/0192513X18783493.
114. Boniel-Nissim M, Sasson H. Bullying victimization and poor re-
lationships with parents as risk factors of problematic internet use
in adolescence. Comput Hum Behav. 2018;88:176–83. https://doi.
org/10.1016/j.chb.2018.05.041.
115. Casaló LV, Escario J-J. Predictors of excessive Internet use among
adolescents in Spain: the relevance of the relationship between
parents and their children. Comput Hum Behav. 2019;92:344–
51. https://doi.org/10.1016/j.chb.2018.11.042.
116. Chi XL, Lin L, Zhang PC. Internet addiction among college stu-
dents in China: prevalence and psychosocial correlates.
Cyberpsych Beh Soc N. 2016;19(9):567–73. https://doi.org/10.
1089/cyber.2016.0234.
117. Chou WJ, Liu TL, Yang P, Yen CF, Hu HF. Multi-dimensional
correlates of internet addiction symptoms in adolescents with at-
tention-deficit/hyperactivity disorder. Psychiatry Res.
2015;225(1–2):122–8. https://doi.org/10.1016/j.psychres.2014.
11.003.
118. Costa RM, Patrao I, Machado M. Problematic Internet use and
feelings of loneliness. Int J Psychiatry Clin Pract. 2019;23(2):
160–2. https://doi.org/10.1080/13651501.2018.1539180.
119. Dong B, Zhao F, Wu XS, Wang WJ, Li YF, Zhang ZH, et al.
Social anxiety may modify the relationship between Internet ad-
diction and its determining factors in Chinese adolescents. Int J
Ment Heal Addict. 2019;17(6):1508–20. https://doi.org/10.1007/
s11469-018-9912-x.
120. Kilic M, Avci D, Uzuncakmak T. Internet addiction in high school
students in Turkey and multivariate analyses of the underlying
factors. J Addict Nurs. 2016;27(1):39–46. https://doi.org/10.
1097/JAN.0000000000000110.
121. Li J, Li D, Jia J, Li X, Wang Y, Li Y. Family functioning and
Internet addiction among adolescent males and females: a moder-
ated mediation analysis. Child Youth Serv Rev. 2018;91:289–97.
https://doi.org/10.1016/j.childyouth.2018.06.032.
122. Liu Q-X, Fang X-Y, Deng L-Y, Zhang J-T. Parent–adolescent
communication, parental Internet use and Internet-specific norms
and pathological Internet use among Chinese adolescents. Comput
Hum Behav. 2012;28(4):1269–75. https://doi.org/10.1016/j.chb.
2012.02.010.
123. Liu QX, Fang XY, Zhou ZK, Zhang JT, Deng LY. Perceived
Parent-Adolescent Relationship, Perceived Parental Online
Behaviors and Pathological Internet Use among Adolescents:
Gender-Specific Differences. PLoS One. 2013;8(9).
124. Lu L, Xu DD, Liu HZ, Zhang L, Ng CH, Ungvari GS, et al.
Internet addiction in Tibetan and Han Chinese middle school stu-
dents: prevalence, demographics and quality of life. Psychiatry
Res. 2018;268:131–6. https://doi.org/10.1016/j.psychres.2018.
07.005.
125. Oh WO. Factors influencing Internet addiction tendency among
middle school students in Gyeong-Buk area. Taehan Kanho
Hakhoe Chi. 2003;33(8):1135–44. https://doi.org/10.4040/jkan.
2003.33.8.1135.
126. Shi X, Wang J, Zou H. Family functioning and internet addiction
among Chinese adolescents: the mediating roles of self-esteem
and loneliness. Comput Hum Behav. 2017;76:201–10. https://
doi.org/10.1016/j.chb.2017.07.028.
127. Soh PC-H, Chew KW, Koay KY, Ang PH. Parents vs peers’
influence on teenagers’ internet addiction and risky online activi-
ties. Telematics Inform. 2018;35(1):225–36. https://doi.org/10.
1016/j.tele.2017.11.003.
128. Trumello C, Babore A, Candelori C, Morelli M, Bianchi D.
Relationship with parents, emotion regulation, and callous-
unemotional traits in Adolescents' internet addiction. Biomed
Res Int. 2018;2018:7914261–10. https://doi.org/10.1155/2018/
7914261.

129. Wartberg L, Kammerl R, Rosenkranz M, Hirschhauser L, Hein S,
Schwinge C, et al. The interdependence of family functioning and
problematic internet use in a representative quota sample of ado-
lescents. Cyberpsychol Behav Soc Netw. 2014;17(1):14–8.
https://doi.org/10.1089/cyber.2012.0494.
130. Wu XH, Chen XG, Han J, Meng H, Luo JH, Nydegger L, et al.
Prevalence and factors of addictive Internet use among adoles-
cents in Wuhan, China: interactions of parental relationship with
age and hyperactivity-impulsivity. PLoS One. 2013;8(4):e61782.
https://doi.org/10.1371/journal.pone.0061782.
Curr Addict Rep
131. Yu L, Shek DT. Internet addiction in Hong Kong adolescents: a
three-year longitudinal study. J Pediatr Adolesc Gynecol.
2013;26(3 Suppl):S10–7. https://doi.org/10.1016/j.jpag.2013.03.
010.
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.