CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 17, Number 8, 2014

ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2013.0382

Internet Addictive Behavior in Adolescence:

A Cross-Sectional Study in Seven European Countries

Artemis Tsitsika, MD, PhD,1 Mari Janikian, PhD,1 Tim M. Schoenmakers, PhD,2,3
Eleni C. Tzavela, MS,1 Kjartan Ólafsson, PhD,4 Szymon Wójcik, MS,5 George Florian Macarie, PhD,6
Chara Tzavara, PhD,1 The EU NET ADB Consortium, and Clive Richardson, PhD 7

Abstract

A cross-sectional school-based survey study (N = 13,284; 53% females; mean age 15.8 – 0.7) of 14–17-year-old
adolescents was conducted in seven European countries (Greece, Spain, Poland, Germany, Romania, the
Netherlands, and Iceland). The aim of the study was to investigate the prevalence of Internet addictive behavior
(IAB) and related psychosocial characteristics among adolescents in the participating countries. In the study, we
distinguish two problematic groups: adolescents with IAB, characterized by a loss of control over their Internet
use, and adolescents ‘‘at risk for IAB,’’ showing fewer or weaker symptoms of IAB. The two groups combined
form a group of adolescents with dysfunctional Internet behavior (DIB). About 1% of adolescents exhibited
IAB and an additional 12.7% were at risk for IAB; thus, in total, 13.9% displayed DIB. The prevalence of DIB
was significantly higher among boys than among girls (15.2% vs. 12.7%, p < 0.001) and varied widely between
countries, from 7.9% in Iceland to 22.8% in Spain. Frequent use of specific online activities (e.g., gambling,
social networking, gaming) at least 6 days/week was associated with greater probability of displaying DIB.
Multiple logistic regression analysis indicated that DIB was more frequent among adolescents with a lower
educational level of the parents, earlier age at first use of the Internet, and greater use of social networking sites
and gaming sites. Multiple linear regression analysis showed that externalizing (i.e., behavioral) and inter-
nalizing (i.e., emotional) problems were associated with the presence of DIB.

Introduction isolation and neglect of social, academic, and recreational

activities, and personal health.3 IAB has received grow-

A dolescents have embraced the Internet as a tool

providing multiple options and unique opportunities for
communication, education, and entertainment. While most
adolescents use the Internet without significant problems,
some report dysfunctional ways of using the Internet.1 They
report symptoms that are akin to behavioral addictions or
substance addictions. These symptoms vary in number and
frequency. Dysfunctional Internet users have an addiction-
like pattern of Internet use, which negatively impacts their
important everyday activities, relationships, and psycholog-
ical well-being.2
In the current study, Internet addictive behavior (IAB) is
defined as a behavioral pattern characterized by loss of
control over Internet use. This behavior potentially leads to
ing research attention and various terms have been used
to describe it, such as ‘‘excessive,’’ ‘‘problematic,’’ and
‘‘pathological’’4 among others. There is no consensus
within the international scientific community, including the
American Psychiatric Association, on whether this behav-
ioral pattern constitutes a ‘‘true addiction,’’ and further
investigation is recommended.5 Currently, researchers and
clinicians have identified symptoms of IAB that share
similarities with behavioral addictions and correspond to
diagnostic criteria for impulse control disorders, mainly
pathological gambling.3,6
Two types of IAB, specific and generalized, have been
identified in the literature.7 An individual displaying gener-
alized IAB uses the Internet as a whole in a compulsive way,

1
Adolescent Health Unit, Second Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece.
2
IVO Addiction Research Institute, Rotterdam, The Netherlands.
3
Erasmus University Medical Center, Rotterdam, The Netherlands.
4
University of Akureyri, Akureyri, Iceland.
5
Nobody’s Children Foundation, Warsaw, Poland.
6
Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.
7
Panteion University of Social and Political Sciences, Athens, Greece.

528
INTERNET ADDICTIVE BEHAVIOR IN ADOLESCENCE
whereas one with specific IAB is drawn to particular online
activities such as gaming or the use of social networking sites
(SNS).8,9
It is difficult to establish prevalence rates of IAB since there
is a lack of a universal definition and diagnostic criteria. In
the scientific literature, estimates of IAB prevalence among
adolescents vary greatly between European countries. For
example, among Greek adolescents, IAB was estimated to
be 1%,10 whereas in the United Kingdom, it was estimated at
18%.3 However, most European estimates fall within the
lower part of the range, between 1% and 8%.1,8,11–15 In par-
ticular, research in similar age-groups has found an IAB
prevalence of 1.2% in Italy,1 3.7% in the Netherlands,16 4.6%
in Romania,1 5.1% in Germany,17 and 5.8% in Poland.15
IAB rates among adolescents seem to differ between
countries possibly depending on numerous factors, including
the age group sampled and the assessment instruments used.
Examples of instruments are the Young Diagnostic Ques-
tionnaire for Internet addiction12 and the Compulsive Inter-
net Use scale.8 Whereas most instruments are based on
DSM-IV criteria for pathological gambling1,3,8,10,12,16 and
some on substance use disorder,7 the operationalization of
criteria and wording of items differ between question-
naires.18 Also, the selection of criteria may differ, possibly in
relation to the number of items in the questionnaire; for
example, the Compulsive Internet Use scale, with 14
items,8,16 does not contain items on tolerance, whereas the
Young scale, with 20 items, does.1,3,10,12
IAB has been associated with multiple internalizing co-
morbid conditions, such as anxiety, depression, and suicidal
ideation,19 as well as social isolation,20 impaired social
skills,21 and social difficulties.22 IAB among adolescents has
also been related to externalizing disorders, including con-
duct problems, aggression, and hostile behavior, as well as
consequent impaired peer relations.23 The causal relationship
between IAB and emotional and behavioral problems has not
been adequately established yet. The literature to date sug-
gests both directions of causality, although evidence is
somewhat stronger for internalizing problems being an an-
tecedent of IAB.24 Internalizing problems can increase ado-
lescent vulnerability to developing IAB, as the Internet can
be remarkably reinforcing.9,25 The Internet offers ways of
avoiding difficulties encountered in the offline world; ado-
lescents can cope with life circumstances by using the In-
ternet as an escape mechanism.7 Notwithstanding, there is
some evidence that people with IAB develop mental health
problems, such as depression.2
The primary objective of the present investigation was to
explore the prevalence of IAB among adolescents in seven
European countries. There is a gap in the literature in the
assessment of emotional and behavioral characteristics of
adolescents with IAB using empirically derived self-report
instruments validated in each country. Consequently, the
secondary objective was to evaluate the association between
IAB and related emotional and behavioral problems among
the study population.
Materials and Methods
Study design and study population
A cross-sectional study was conducted by the EU NET
ADB consortium in seven European countries: Spain,
529
Poland, Germany, the Netherlands, Romania, Iceland, and
Greece. Data were collected from October 2011 to May
2012. The study protocol was approved by the appropriate
ethics committees in each participating country. Written in-
formed consent was required from the parents or legal
guardians of all eligible participants before participation in
the study.
Each country drew a clustered probability sample, with
school classes as primary sampling units. The national offi-
cial and complete school and class register was the sampling
frame for each country, and about one hundred 9th- and 10th-
grade classes were sampled per country. All students at-
tending the selected classes on the day of data collection
were included in the procedure, subject to parental permis-
sion. The detailed protocol of the EU NET ADB study has
been published elsewhere.26
Data collection
Self-report anonymous questionnaires were self-completed
by participating adolescents in class during school hours. The
questionnaire included items pertaining to personal charac-
teristics, family status, and Internet use. Participants were
asked to complete the questionnaire anonymously to help
ensure confidentiality and to minimize any potential reporting
bias. A total of 13,708 adolescents completed the survey. In
total, 85% of students who were on the class registers par-
ticipated. Further, 424 participants were excluded because of
missing data for age or gender or for age out of the permitted
range (14–17 years). This resulted in a total sample of 13,284
adolescents (F/M: 7,000/6,284; mean age 15.8 – 0.7) included
in the analyses.
Measures
A structured questionnaire was administered to adoles-
cents, which included the Internet Addiction Test (IAT3) and
the Youth Self Report (YSR27). The 20-item IAT evaluates
the degree of preoccupation with the Internet, its compulsive
use, behavioral problems and emotional changes linked with
Internet use, and the impact of Internet use on functioning.
Young3 has linked Internet addiction most closely to patho-
logical gambling, an impulse control disorder according to
the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition.28 Originally, the IAT was designed based on
symptoms for impulse control disorder and was used as a
one-factor scale. In a pilot study within this project, the
phrasing of three IAT items was modified for adolescents
and contemporary Internet use. For example, item 3, ‘‘How
often do you prefer the excitement of the Internet to intimacy
with your partner?’’ was modified to ‘‘How often do you
prefer the excitement of the Internet to being with your
boyfriend or girlfriend?’’ The test showed high reliability
(Cronbach’s a = 0.92).
Response scores to each IAT item range from 0 to 5, where
a score of 0 is defined for responses of ‘‘never/not applica-
ble,’’ 1 is defined as ‘‘rarely,’’ and a score of 5 as ‘‘always.’’
The total IAT score may range from 0 to 100 points. In order
to assess IAB, the following cutoff scores as recommended
by Young3 were applied: (a) 0–19: no signs of IAB; (b) 20–
39: mild, yet nonproblematic signs of IAB; (c) 40–69: at risk
for IAB; (d) 70–100: IAB. The first two categories are both
considered as functional Internet behavior (0–39 points),
530
while the latter two together are considered as dysfunctional
Internet behavior (DIB; 40–100 points). For the IAT scale
(20 items), two missing values per subject were permitted
and were replaced by the country-specific median.
The YSR is an empirically derived and widely used 112-
item, self-report instrument for adolescents 11–18 years of
age with excellent psychometric properties.29 The YSR is
used in both clinical and school settings in assessing ado-
lescents’ behavioral and emotional problems as well as their
competences. Adolescents rate how true each item is for
themselves (now or within the past 6 months) using a three-
point scale (0 = absent, 1 = occurs sometimes, 2 = occurs
often). The YSR generates a total of 25 scores of competences
and problem behaviors. Scale and subscale output scores are
organized into two groups: (a) competence scales (activities,
social competence, academic performance, total competence);
(b) empirically based syndrome scales (anxious/depressed,
withdrawn/depressed, somatic complaints, social problems,
thought problems, attention problems, rule-breaking [delin-
quent] behavior, aggressive behavior). The syndrome scales
cluster into broadband scales—internalizing problems and
externalizing problems—and a total problems scale. In this
report, raw scores were used. Higher scores indicated more
problems (in the syndrome scales) or greater competence (in
the competence scales).
Data were collected on Internet use. Adolescents were
asked whether they belonged to at least one SNS. If they did,
they were asked for how long they used SNS on a typical
weekday (‘‘normal school day’’) and on weekends or during
vacation (‘‘nonschool day’’) in the past 12 months. Response
options ranged from ‘‘not at all’’ to ‘‘more than 4 hours.’’
The weighted average of weekday and weekend use provided
a single estimate of daily SNS use throughout the week. The
median response ‘‘2 hours per day’’ was used to dichotomize
the frequency of SNS into moderate SNS use (< 2 hours
daily) and heavier SNS use (q2 hours daily). Adolescents
were further asked about the daily frequency of gaming
(‘‘How often do you play computer games?’’), with response
options ranging from ‘‘less than 1 hour’’ to ‘‘more than 6
hours.’’
Educational attainment of parents was used as a proxy
measure of socioeconomic status. Specifically, educational
attainment was measured by the highest qualification earned
between the two parents. Two categories were created, low/
middle (primary or secondary school) and high (postsec-
ondary or tertiary education) educational level. Missing
values for an item arose when the respondent did not tick any
of the response options or ticked ‘‘Don’t know/prefer not to
say’’ if this option was available.
Statistical analysis
Categorical variables are presented with relative fre-
quencies and 95% confidence intervals (95% CI). For the
comparison of proportions, Pearson’s chi-square tests of in-
dependence were used. Odds ratios (ORs) with 95% CIs
were computed in order to show the effect of every online
activity on having DIB. Since our measure for IAB assumes
a gradual increase in addiction-like patterns from non-
problematic, mild signs of IAB to problematic signs of IAB,
which encompasses both risky behavior and addictive be-
havior, we chose to analyze all persons with problematic
TSITSIKA ET AL.
signs in order to find factors associated with IAB: that is,
everyone showing dysfunctional Internet use (IAT scores
40–100).
To explore which participant characteristics and known
risk applications for DIB (i.e., gaming and SNS use; see
Introduction) were associated with DIB in our sample, a
multiple logistic regression analysis was used. First, we in-
cluded demographic variables into the analysis: gender, age,
and socioeconomic status as indicated by the highest edu-
cational level of the parents. Second, we included the fol-
lowing independent variables: age at first use of the Internet,6
use of SNS, and computer gaming. For the latter two, in order
to distinguish lighter from heavier users, dichotomous vari-
ables were used: namely, using those applications more or
less than 2 hours per day. Adjusted ORs are shown from the
results of the logistic regression analyses.
In order to explore the association between YSR and DIB,
linear regression analyses were conducted with dependent
variable, each YSR subscale, and independent variables, the
presence of DIB, age, gender, parental educational level, and
country. All p-values reported are two-tailed. Analyses were
conducted using the Complex Samples procedure in SPSS
statistical software (version 18.0) with countries as strata and
classes as clusters so that the computation of all statistical
tests and CIs correctly took into account the complex sample
design.
Results
Table 1 presents the demographic characteristics of the
sample by gender, age, parental educational level, and
country. Table 2 shows that the prevalence of IAB in the
sample was 1.2% (0.9% in girls vs. 1.6% in boys) and the
prevalence of at risk for IAB was 12.7% (11.8% in girls,
13.6% in boys). In total, the prevalence of DIB was 13.9%.
DIB was more frequent among boys, in those aged over
15 years and in adolescents whose parents’ highest educa-
tional level was low or middle ( p < 0.001 in each case).
Overall, the highest rate of DIB was found in Spain (22.8%)
and the lowest in Iceland (7.9%). Comparisons between pairs
of countries using a Bonferroni adjusted 5% significance
level showed that the percentages in Spain and Romania
were significantly higher than in all other countries and, in
addition, the percentage in Iceland was significantly lower
than that in Poland and Greece.
Table 3 presents the ORs for the relationships between
various online activities and DIB for all countries. Gambling
and using SNS had the strongest relation with DIB, followed
by playing games for monetary prizes, and visiting chat
rooms and Internet forums. The weakest relationships were
found for e-mail, news sites, hobbies, purchasing goods, and
single-player games (e.g., solitaire, backgammon). Watching
videos or movies was not significantly related to DIB, while
doing homework or research online was negatively associ-
ated with DIB.
Table 4 presents a multiple logistic regression analysis
with DIB as a dependent variable and country, gender, age,
parental educational level, age at first use of the Internet, use
of SNS, and gaming as the independent variables. All the
independent variables, with the exception of gender and age,
were independently associated with DIB (Table 4). The
prevalence of DIB was higher among adolescents whose
INTERNET ADDICTIVE BEHAVIOR IN ADOLESCENCE 531

Table 1. Demographic Characteristics of the Sample by Gender, Age, Parental

Educational Level, and Country
Gender Age Parental education
Female, Male, 14–15 years, 16–17 years, Low/middle, High,
N (%) N (%) N (%) N (%) N (%) N (%)
All adolescents 7,000 (52.7) 6,284 (47.3) 8,156 (61.4) 5,128 (38.6) 4,165 (37.3) 7,007 (62.7)
Greece 1,010 (51.3) 957 (48.7) 1,375 (69.9) 592 (30.1) 819 (44.4) 1,024 (55.6)
Spain 1,024 (51.7) 956 (48.3) 1,296 (65.5) 684 (34.5) 713 (40.5) 1,046 (59.5)
Romania 1,021 (55.8) 809 (44.2) 486 (26.6) 1,344 (73.4) 775 (48.6) 820 (51.4)
Poland 1,030 (52.1) 948 (47.9) 1,468 (74.2) 510 (25.8) 767 (50.0) 766 (50.0)
Germany 1,281 (54.4) 1,073 (45.6) 1,351 (57.4) 1,003 (42.6) 575 (30.4) 1,319 (69.6)
The Netherlands 625 (50.0) 624 (50.0) 480 (38.4) 769 (61.6) 188 (19.8) 763 (80.2)
Iceland 1,009 (52.4) 917 (47.6) 1,700 (88.3) 226 (11.7) 328 (20.5) 1,269 (79.5)

parents have lower educational attainment, among those who
started using the Internet at an earlier age, and, importantly,
among adolescents who spent more than 2 hours per day on
gaming or SNS as compared with adolescents who spent less
time on these applications.
Table 5 presents the results of multiple linear regression
analyses with dependent variable, each YSR subscale in turn,
and independent variables, the presence of DIB, age, gender,
parental educational level and country. The regression was
fitted first without and then with DIB, so that the contribution
of DIB to the explained variation could be seen. We found
that the presence of DIB, controlling for the other indepen-
dent variables, significantly predicted higher scores (greater
problems) on all scales of emotional and behavioral prob-
lems (regression coefficients range from 1.6 to 7.9; all
p’s < 0.001). On the contrary, DIB significantly but very
weakly predicted lower scores (lower competence) on ac-
tivities, social competence, academic performance, and total
competence score (regression coefficients range between 0.2
and 1.1; all p’s < 0.001 except for social competence,
p = 0.028). With the exception of social competence, the
regression coefficients all remain statistically significant at
p < 0.01 after carrying out a simple Bonferroni correction to
allow for the multiple testing of the 12 scale scores.
Discussion
The present study assessed the prevalence of IAB and its
association with psychosocial characteristics among adoles-
cents in seven European countries. The findings indicated that
approximately 1% of the adolescents examined exhibited
IAB. This prevalence is consistent with that reported in other

Table 2. Percentage of Adolescents with Functional and Dysfunctional Internet Behavior

by Gender, Age, Parental Educational Level, and Country
Functional Internet Dysfunctional Internet
behavior (N = 11,029) behaviora (N = 1,778) % Total
dysfunctional
% No signs of % Mild signs of % At risk for % IAB Internet behavior
IAB (95% CI) IAB (95% CI) IAB (95% CI) (95% CI) (95% CI)
All adolescents 47.2 (46.1–48.3) 38.9 (37.9–39.9) 12.7 (12.0–13.4) 1.2 (1.0–1.5) 13.9 (13.1–14.7)
Gender
Female 48.5 (47.1–50.0) 38.8 (37.4–40.1) 11.8 (11.0–12.7) 0.9 (0.7–1.2) 12.7 (11.8–13.6)
Male 45.7 (44.3–47.2) 39.0 (37.7–40.3) 13.6 (12.7–14.6) 1.6 (1.3–2.0) 15.2 (14.2–16.3)
Age
14–15 years 48.0 (46.7–49.4) 39 (37.7–40.2) 12 (11.2–12.8) 1.1 (0.8–1.4) 13.0 (12.2–14.0)
16–17 years 46.0 (44.3–47.6) 38.8 (37.3–40.3) 13.8 (12.7–14.9) 1.5 (1.2–1.9) 15.2 (14.2–16.4)
Parental education
Low/middle 45.3 (43.4–47.1) 38.4 (36.7–40.1) 14.9 (13.6–16.3) 1.4 (1.1–1.9) 16.3 (14.9–17.8)
High 47.4 (46.0–48.9) 39.9 (38.6–41.3) 11.6 (10.8–12.5) 1.0 (0.8–1.4) 12.6 (11.8–13.5)
Spain 19.3 (17.2–21.6) 57.9 (55.4–60.5) 21.3 (19.2–23.5) 1.5 (0.9–2.3) 22.8 (20.6–25.1)
Romania 45.5 (42.6–48.5) 36.8 (34.3–39.3) 16.0 (13.9–18.4) 1.7 (1.1–2.4) 17.7 (15.5–20.1)
Poland 50.3 (47.9–52.8) 36.4 (34.3–38.7) 12.0 (10.5–13.7) 1.3 (0.8–1.9) 13.2 (11.6–15.0)
Greece 59.0 (56.2–61.7) 28.3 (26.0–30.8) 11.0 (9.4–12.9) 1.7 (1.1–2.5) 12.7 (10.9–14.8)
The Netherlands 45.3 (42.1–48.5) 42.5 (39.5–45.6) 11.4 (9.3–13.9) 0.8 (0.4–1.5) 12.2 (10.0–14.7)
Germany 53.9 (51.1–56.7) 35.4 (33.0–38.0) 9.7 (8.2–11.5) 0.9 (0.6–1.4) 10.6 (9.0–12.5)
Iceland 56.2 (53.5–58.9) 35.9 (33.3–38.5) 7.2 (5.9–8.7) 0.8 (0.4–1.6) 7.9 (6.4–9.7)
a
Differences in % of DIB by gender, age, parental education, and country are all statistically significant at p < 0.001.
CI, confidence interval; DIB, dysfunctional Internet behavior; IAB, Internet addictive behavior.
532 TSITSIKA ET AL.

Table 3. Odds Ratios and 95% Confidence Intervals Table 4. Factors Independently Associated
for Relationships Between Online Activities with Dysfunctional Internet Behavior
and Dysfunctional Internet Behavior in Multiple Logistic Regression: Adjusted
Odds Ratio and 95% Confidence Interval
%a ORb 95% CI
OR (95% CI) p
Gambling 8.4 2.97 2.52–3.49
Social networking sites 92.5 2.62 1.95–3.51 Country
(e.g., Facebook) Spain 4.94 (3.71–6.58) < 0.001
Monetary prize games 15.5 2.58 2.26–2.95 Romania 2.68 (1.94–3.70) < 0.001
Chat rooms 60.0 2.45 2.16–2.79 Poland 1.94 (1.43–2.61) < 0.001
Internet forums 50.4 2.44 2.18–2.74 The Netherlands 1.80 (1.25–2.59) 0.002
Searching for sexual information 35.4 2.40 2.16–2.67 Greece 1.54 (1.12–2.11) 0.008
Making personal 28.6 2.31 2.07–2.59 Germany 1.44 (1.04–1.99) 0.030
Web sites or blogging Iceland 1.00a
Instant messaging (e.g., MSN) 85.6 2.29 1.86–2.81 Gender
Downloading movies 66.9 2.16 1.87–2.50 Female 1.00
Downloading music 87.8 2.15 1.72–2.70 Male 0.95 (0.82–1.10) 0.49
Real-time strategy games 33.8 2.11 1.89–2.36
Downloading games 51.3 2.00 1.79–2.24 Age
Downloading software 61.2 2.00 1.78–2.25 14–15 years 1.00
Multiplayer role-playing games 44.8 1.82 1.63–2.04 16–17 years 1.01 (0.88–1.16) 0.89
Searching for medical information 43.2 1.80 1.62–2.00 Parental education
Shooter games 48.0 1.66 1.49–1.86 Low/middle 1.00
E-mail 84.3 1.57 1.31–1.87 High 0.85 (0.74–0.98) 0.028
News sites 74.5 1.48 1.31–1.69 Age at first use of 0.94 (0.91–0.98)b 0.001
Hobbies 82.7 1.42 1.22–1.66 the Internet (years)
Purchasing goods 53.1 1.31 1.17–1.47 Daily use of SNSs
Single-player games 64.2 1.26 1.13–1.41 No use/< 2 hours 1.00
(e.g., solitaire, backgammon) q2 hours/day 3.47 (3.05–3.94) < 0.001
Watching videos or movies 97.5 1.01 0.68–1.48
Average hours of playing
Doing homework or research 93.3 0.68 0.57–0.83
games per weekday
a
Proportion of adolescents reporting the specific activity at least No gaming/< 2 hours 1.00
weekly. q2 hours/day 2.34 (1.99–2.75) < 0.001
b
All ORs are statistically highly significant ( p < 0.001) except for a
‘‘watching videos or movies’’ ( p = 0.98). Indicates reference category.
b
ORs, odds ratios. For 1-year increase.
SNSs, social networking sites.

adolescent populations using the same instrument.10,12 Boys

had a higher prevalence of IAB (1.6%) than girls (0.9%).
Similar gender differences concerning the nature of Internet
use have been reported elsewhere.30,31 The observed gender
differences may be attributed to the effect of the differential
frequency of Internet utilization between genders. Specifi-
cally, since boys spend more time on the Internet than girls,10
the average weekly hours of Internet use may serve as a po-
tential confounder for the development of IAB.
Overall, the prevalence rates of IAB were higher in the
Southern and Eastern/Middle European countries from the
sample, and lower in the Northern European countries. The
same trend held for the prevalence of DIB, which includes
IAB as well as adolescents ‘‘at risk for IAB.’’ The country
with the highest rate of DIB was Spain, which had a rate
(23%) almost three times higher than Iceland’s (8%). Future
studies are needed to elucidate the cross-cultural variations
in the phenomenon’s prevalence. In addition, using the
current dataset, differences between countries in scores on
predicting variables for DIB could be studied.
Since the number of adolescents with IAB in the sample
was rather low for subgroup analyses, further analyses were
restricted to DIB. Adolescents with this behavior scored
relatively high on symptoms for IAB and thus experienced a
significant number of problems related to their Internet use.
Corroborating previous research,8,32–34 the present results
showed that adolescents who gambled at least a few times a
week had increased likelihood of exhibiting DIB compared
with those who never engaged in online gambling. It is
maintained that the Internet may provide a readily accessible
medium for adopting gambling patterns,35 and the sustain-
ment of such behaviors through this medium may in turn lead
to the development of IAB.32,33 Thus, adolescents who
participated even infrequently in Internet gambling had an
increased likelihood of presenting with DIB. On the other
hand, those who used the Internet to carry out homework or
research activities were less likely to present with DIB.
Earlier studies have shown that SNS and gaming are the
strongest predictors of IAB.8,36 Therefore, these were in-
cluded in a multivariate analysis of DIB. Results showed
that DIB was correlated somewhat stronger with SNS than
with online gaming. The maintenance of online networks
and the need to stay connected are the key factors explaining
increased attraction to SNS.37 In a Greek sample, Kormas
et al.36 found a similar pattern, whereas in a Dutch sample,
Van Rooij et al.8 found that social online games were actually
more predictive of compulsive Internet use than social activ-
ities such as SNS, and also more than other types of online
games. In the present analysis, however, social games and
other online games were not distinguished, thereby possibly
masking a stronger effect of social online games.
INTERNET ADDICTIVE BEHAVIOR IN ADOLESCENCE 533

Table 5. Regression Coefficients for the Presence However, DIB has been observed to lead to unsuccessful
of Dysfunctional Internet Behavior in Multiple life-coping mechanisms,45,46 thus creating a vicious circle
Linear Regressions with the Dependent Variable centered upon Internet usage and psychosocial maladjust-
the YSR Scores, Adjusting for Age, Gender, ment. It is possible that DIB may exacerbate preexisting
Parental Educational Level, and Country psychosocial symptomatology present among adolescents,
R2 for thus adversely affecting their functioning and performance
control R2 when Regression within both their academic and social environments.
Dependent variables DIB coefficient Results of the study should be interpreted in the light of a
variable only added for DIBa number of research limitations. First, as is typical of school-
based surveys of adolescents, adolescents who do not attend
Activities 0.189 0.193 - 0.79 – 0.12b school or were absent on the day of data collection were not
Social competence 0.256 0.263 - 0.17 – 0.08 represented. Second, the data are cross sectional, and so do
Academic performance 0.102 0.111 - 0.18 – 0.02 not indicate the direction of relationships or provide infor-
Total competence score 0.272 0.278 - 1.10 – 0.18
Anxious/depressed 0.081 0.136 2.90 – 0.16 mation about preceding influences or long-term outcomes of
Withdrawn/depressed 0.109 0.148 1.55 – 0.10 IAB. Third, surveys of this magnitude must rely on self-
Somatic complaints 0.087 0.128 1.79 – 0.12 report data, limiting the measurement of Internet behavior to
Social problems 0.021 0.088 2.07 – 0.12 individual perceptions possibly tainted by recall bias. Fi-
Thought problems 0.040 0.113 2.52 – 0.14 nally, seven European countries participated in the study;
Attention problems 0.039 0.115 2.64 – 0.12 findings from this study may not be generalizable to Europe
Rule-breaking 0.043 0.122 3.30 – 0.16 as a whole or to other parts of the world.
(delinquent) behavior A major strength of this study is the large sample of ado-
Aggressive behavior 0.053 0.142 4.54 – 0.20 lescents sampled from randomly selected schools, across
Internalizing 0.084 0.149 6.20 – 0.33 seven European countries. The students were surveyed using
problems score
Externalizing 0.034 0.138 7.89 – 0.33 consistent procedures in each country. The present study is
problems score the first of its kind to assess the emotional and behavioral
Total problem score 0.063 0.177 22.3 – 0.96 characteristics of adolescents using the YSR, an empirically
derived and widely applied self-report instrument validated
a
Adjusted for age, gender, parental educational level, and country. in each country.
All coefficients are statistically highly significant ( p < 0.001) except To sum up, our main findings indicated that DIB is asso-
for social competence ( p = 0.028).
b
Standard error. ciated with internalizing and externalizing problems among
YSR, Youth Self Report. adolescents. On the basis of the results of the current cross-
sectional study, we cannot draw conclusions about the
Adolescents whose parents had higher educational level direction of any causal relations between DIB and psycho-
had a lower probability of showing dysfunctional Internet logical or behavioral problems. Further research using lon-
use. This finding agrees with earlier studies that showed a gitudinal designs is needed to address issues of causality.
significant association between dysfunctional Internet use Knowledge of comorbidity with DIB is, however, interesting
and lower parental educational attainment.38 A possible from a preventative and therapeutic perspective; it shows
pathway that may partly account for these differences be- that the problem addressed often does not stand by itself but
tween low and high parental educational attainment in DIB is is accompanied and possibly exacerbated by other problems.
parental involvement.39 Lower levels of parental engage-
ment have been correlated with IAB9 as well as with various Acknowledgments
negative behavioral outcomes in adolescents, such as poorer
This project was funded under the Safer Internet plus
academic performance and delinquency.40
program (SIP-KEP-4101007), a European multiannual com-
The study findings indicated that DIB was significantly
munity program on promoting safer use of the Internet and
associated with marked psychosocial and emotional mal-
new online technologies.
adjustment. This evidence for the concomitant occurrence of
The authors would like to thank Elena Critselis for her
DIB with both internalizing and externalizing problems is
contributions in conceptualizing the study and George An-
consistent with previous research, indicating that adolescents
tonogeorgos for statistical support; the project’s International
with DIB engage in more aggressive actions41 and display
Advisory Board members, especially Dr. Ellen Helsper, for
increased social isolation and impaired communication
their continuous support and contribution; and the external
skills21 as well as depressive and anxiety symptoms, among
advisors Dr. Donald Greydanus, Dr. Elisabeth Staksrud, and
others.42,43 DIB was further found to be weakly related to
Dr. Hatim Omar for their valuable feedback and evaluation.
decreased scores on the competence scales. Adolescents
engaging in such online behavioral patterns are potentially
Author Contributions
neglecting alternative leisure activities, hobbies, and social
contacts, spending more time online. As the amount of online A.T. participated in the study design, supervision, and
time increases, possible offline events that could serve as coordination. M.J. participated in the study design, article
sources of reward are experienced less often. In conse- composition, and interpretation of the data. T.M.S. partici-
quence, adolescents may retreat into their familiar and pated in the article composition and interpretation of the
comfortable world of the Internet.8 data. E.C.T. coordinated the data acquisition and data entry
It has been proposed that poorly adjusted adolescents may and participated in the editing of the article. K.O. helped
engage in DIBs in order to cope with emotional turmoil.44 critically revise the article for intellectual content. S.W.
534
participated in the editing and revision of the article. G.F.M.
participated in the editing of the article and revision. C.T.
performed the statistical analysis and interpretation of the
data. C.R. participated in supervision of the statistical anal-
ysis and in the editing of the final article. The EU NET ADB
consortium (member list: www.eunetadb.eu) was responsi-
ble for the design, data collection, and data interpretation.
Each author listed on the article has seen and approved the
submission of this version of the article and takes full re-
sponsibility for the article. The corresponding author affirms
that she has listed everyone who contributed significantly to
the work in the Author Contribution section. Previous oral or
poster presentations at local, regional, national, or interna-
tional meetings where part of the data was presented include
the following: International conference of the Safer Internet
Day: The Effects of Internet on Children and Young People,
Budapest, Hungary, 2012; 6th International Conference:
Keeping Children and Young People Safe Online, Warsaw,
Poland, 2012; 17th European Annual Meeting of the Inter-
national Association of Adolescent Health, Antalya, Turkey,
2012; Insafe Conference, Larnaca, Cyprus, 2012.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Dr. Artemis Tsitsika
Adolescent Health Unit
Second Department of Pediatrics
National and Kapodistrian University of Athens
Leoforos Mesogeion 24
Goudi 11527, Athens
Greece
E-mail: info@youth-health.gr