Problematic Internet use (PIU) by adolescents is of growing concern among both parents and pediatricians. Early controversies may have contributed to challenges in defining and measuring PIU. A variety of screening tools have evolved, aligned with different constructs of PIU, although a validated screening tool does exist. Current data and American Academy of Pediatrics policy reflect evidence-driven screening for PIU for all youth.

Internet use is nearly ubiquitous among adolescents and young adults. Current US data suggest that 93% of adolescents and adults between 12 and 29 years of age go online, and up to 25% of teens describe themselves as “constantly connected.”1  Given these high rates of Internet use, problematic Internet use (PIU) is a growing concern.2,3  Researchers have identified a rising number of consequences associated with increased Internet use among adolescents, including, but not limited to, psychological issues, behavior problems, attention problems, and physical problems.4  Given that Internet use begins increasingly earlier in adolescence and even during the childhood years, pediatricians are uniquely positioned to conduct early screening for PIU.5 

An initial principle important to understanding this topic is the notion that Internet addiction and PIU represent different concepts. Although these terms have been used interchangeably in the past, they represent 2 separate frameworks for identifying Internet overuse. Internet addiction may be considered more analogous to a classic substance addiction, with loss of control and feelings of withdrawal. PIU represents a broader array of problems related to Internet use, including social, behavioral, and emotional issues.6  An extreme case of PIU may involve Internet addiction, but PIU is a broader, more multifaceted concept.

Efforts toward developing diagnostic criteria for PIU began 2 decades ago. Reviewing the evolution of the concept of PIU illustrates the dilemma around whether PIU represents a behavioral addiction, impulsivity, or a broader range of behaviors. The focus on aspects of addictive behaviors likely stems from 2 initial approaches to defining PIU, grounded in existing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, disorders: substance abuse and/or dependency and pathologic gambling.7,8  After this early work came the introduction of 3 conceptual approaches. First, PIU was more broadly described as a general behavioral addiction.9,10  Second, a cognitive-behavioral model of PIU drew attention to the impact of an individual’s thoughts on his or her development of problematic behaviors and separated PIU into “generalized” PIU (or multidimensional overuse of the Internet) and “specific” PIU.11  Specific PIU was defined as dependence on a specific function of the Internet, such as online shopping. Third, a model proposed that PIU should be more widely classified as an impulse control disorder with criteria, including maladaptive preoccupation with Internet use characterized by either irresistible use or use that is excessive and longer than planned, clinically significant distress or impairment, and the absence of other Axis I disorders.12 

At present, the current definition of PIU arose from a previous study that was focused on developing stakeholder-driven consensus-based criteria. In this study, the authors used a concept mapping approach, which integrates qualitative and quantitative data from key stakeholders with expertise or investment in the topic. For this study, investigators incorporated data from researchers in the fields of adolescent health, addiction science, and technology, as well as from adolescents and young adults themselves. The authors identified 7 specific constructs within PIU: (1) psychosocial risk factors (ie, anxiety) that increase because of PIU behavior, (2) physical impairment, (3) emotional impairment, (4) social and/or functional impairment, (5) risky Internet use, (6) impulsive Internet use, and (7) dependent Internet use.13  The strength of this definition is supported by its thorough review of the phenomenon as it may present among adolescents. From this study’s findings, PIU was defined as “Internet use that is risky, excessive, or impulsive in nature, leading to adverse life consequences, specifically physical, emotional, social, or functional impairment.”

It is important to note that PIU among adolescents goes beyond just spending too much time online. The definitions and constructs above represent both how much time is spent online (ie, the quantity of use) as well as the relationship with the online world, which represents quality of use.

It is estimated that 7% to 11% of adolescents in the United States suffer from PIU.1316  Hence, it is possible that it affects 1 in every 10 adolescent patients. This is a consequential statistic because PIU is associated with conduct problems (fighting), hyperactivity, symptoms of depression, a negative impact on daily functions and physical health,17  trouble concentrating, suicidal ideation among women in college,18  and poor interpersonal relationships.19 

One of the more problematic aspects of PIU is the challenge of screening for it. In comparison to a dependence on a substance, PIU is a maladaptive relationship with tools that one needs to function in society. Hence, there are 3 strategies that can potentially serve to help identify patients with PIU: know the risk factors, use an established screening tool, and identify opportunities to screen.

Risk Factors for PIU

There are some categories of individuals who might be at higher risk for PIU. First, any of the associated consequences noted above may serve as indicators. This is because causal connections between PIU and Internet addiction and the various outcomes have yet to be strongly established in the literature.20  Previous research supports that there are particular groups at increased risk, including males,2123  those who experience depressive symptoms and use the Internet for relationships and mood regulation,24  adolescents with high levels of narcissism and the feeling of a need to belong,25  and those who experience fear of missing out.26  Family risk factors can also play a role, including adolescents who experience family dissatisfaction22  and adolescents who have parents with mental health issues.27 

Screening Tools for PIU

Given the number of different definitions proposed for PIU, it may not be surprising that a number of different tools have been developed to assess for PIU and Internet addiction.17,2830  However, a systematic review that was focused on PIU screening instruments illustrated that many tools were not supported by evidence. For example, most tools had one or more of the following flaws: they were designed for adults, used different conceptual foci than PIU, had varied or seemingly random cutoff points for indicating an at-risk individual, and had a lack of scientific validation for the tool.31  One pediatric-focused validated screening tool for PIU is the Problematic and Risky Internet Use Screening Scale (PRIUSS),15  an 18-item scale that has 3 distinct subscales: social impairment, emotional impairment, and risky and/or impulsive Internet use (see Supplemental Information). At present, this remains the only validated screening tool for pediatric populations.

Nonrecommended Screening Approaches for PIU

It is also important to point out a nonrecommended approach, which is to focus on time spent online. Whereas early screening approaches asked patients and families to report the number of hours of “screen time,” the 2016 American Academy of Pediatrics (AAP) policy statement on media use in school-aged children and adolescents no longer recommends that strategy for this population.32  This shift in screening focus represents newer evidence that illustrates time spent online is not the only factor involved in PIU as well as a lack of evidence to support strict hour-based recommendations that can apply across various developmental stages.

When To Screen for PIU

An opportune time to screen is during routine health supervision visits because many pediatricians use paper or digital screening tools to assess multiple behavioral concerns at these visits. The 18-item PRIUSS typically takes 5 minutes or less to complete; however, a shorter, validated screening tool is the 3-item PRIUSS, which has 3 questions regarding anxiety when away from the Internet, loss of motivation when on the Internet, and feelings of withdrawal when away from the Internet.33  These 3 questions can be incorporated with other commonly used behavioral screening tools. Positive screens on the 3-item PRIUSS can be followed-up with the full scale, similar to the use of the Patient Health Questionnaire-2, which is commonly used to identify those who would benefit from screening with the Patient Health Questionnaire 9.

Other opportunities to screen children and adolescents may be in cases when parents are concerned about sleep patterns or have challenges in limiting screen time around bedtime. Children and adolescents who experience a dramatic change in grades may also benefit from screening.

Unfortunately, there are currently no evidence-based prevention strategies or interventions to rely on if a pediatric patient screens at risk for PIU. In absence of this evidence, one tool to consider is the Family Media Use Plan (https://www.healthychildren.org/english/media/pages/default.aspx), developed by the AAP. This tool allows families to view suggested structure and ideas for Internet and media use and select (or create) items that fit their families’ needs and values. It also includes a “media time calculator” that allows individuals to consider a typical day’s activities and how much media or Internet time fits in alongside critical health activities such as sleep and physical activities, social activities (ie, family or friend time), and academic activities (ie, school and homework). This tool can be used at any age, and it is recommended that the plan be reviewed and updated at least yearly or with changes in schedule (eg, school schedule to summer schedule). The Family Media Use Plan was developed alongside the 2016 AAP policy statement on media use among school-aged children and adolescents32  in an effort to translate those evidence-based recommendations into a parent-facing tool.

Given that PIU remains a newer pediatric concern, there are a number of important areas for future research. Much of the past research has been focused on developing different conceptual approaches and screening tools. More recently, there have been a number of new screening tools that are focused on different aspects of PIU. This includes screening tools specifically for social media addiction and smartphone addiction.34,35  At this point, research has become semisaturated with new screening tools with little scientific validation or clinical usefulness. However, there is a dearth of research in the areas of prevention and intervention. Teenagers may tell pediatricians anecdotal reports of teachers who institute “screen-free weeks” or about their experiences with losing Internet access on summer vacation and how different they feel. These unpublished stories support the need for research to understand pediatric patients’ experiences and leverage them for effective prevention and intervention approaches.

Although PIU is still a relatively new phenomenon, there is general agreement that it is a serious issue that adolescents face and can present patients with an array of negative consequences. It is important for pediatricians to understand this emerging literature, the risk factors, and how to screen and counsel to best support their patients.

Both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

AAP

American Academy of Pediatrics

PIU

problematic Internet use

PRIUSS

Problematic and Risky Internet Screening Scale

1
Lenhart
APK
,
Smith
A
,
Zickhur
K
.
Social Media and Young Adults
.
Washington, DC
:
Pew Internet and American Life Project
;
2010
2
Christakis
DA
,
Moreno
MA
.
Trapped in the net: will internet addiction become a 21st-century epidemic?
Arch Pediatr Adolesc Med
.
2009
;
163
(
10
):
959
960
3
Dell’Osso
B
,
Altamura
AC
,
Allen
A
,
Marazziti
D
,
Hollander
E
.
Epidemiologic and clinical updates on impulse control disorders: a critical review
.
Eur Arch Psychiatry Clin Neurosci
.
2006
;
256
(
8
):
464
475
4
Rosen
LD
,
Lim
AF
,
Felt
J
, et al
.
Media and technology use predicts ill-being among children, preteens and teenagers independent of the negative health impacts of exercise and eating habits
.
Comput Human Behav
.
2014
;
35
:
364
375
5
Jelenchick
LA
,
Christakis
DA
. Problematic internet use during adolescence and young adulthood. In:
Strasburger
VC
,
Moreno
MA
, eds.
AM: STARs Social Networking & New Technologies: Adolescent Medicine State of the Art Review
.
Itasca, IL
:
American Academy of Pediatrics
;
2014
:
605
620
6
Cheever
NA
,
Moreno
MA
,
Rosen
LD
. When does internet and smartphone use become a problem? In:
Moreno
MA
,
Radovic
A
, eds.
Technology and Adolescent Mental Health
.
New York, NY
:
Springer
;
2018
:
121
131
7
Young
KS
.
Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype
.
Psychol Rep
.
1996
;
79
(
3 pt 1
):
899
902
8
Young
KS
.
Internet addiction: the emergence of a new clinical disorder
.
Cyberpsychol Behav
.
1998
;
1
(
3
):
237
244
9
Griffiths
M
.
Internet addiction: fact or fiction?
Psychologist
.
1999
;
12
(
5
):
246
250
10
Grant
JE
,
Potenza
MN
,
Weinstein
A
,
Gorelick
DA
.
Introduction to behavioral addictions
.
Am J Drug Alcohol Abuse
.
2010
;
36
(
5
):
233
241
11
Davis
RA
.
A cognitive-behavioral model of pathological Internet use
.
Comput Human Behav
.
2001
;
17
(
2
):
187
195
12
Shapira
NA
,
Lessig
MC
,
Goldsmith
TD
, et al
.
Problematic internet use: proposed classification and diagnostic criteria
.
Depress Anxiety
.
2003
;
17
(
4
):
207
216
13
Moreno
MA
,
Jelenchick
LA
,
Christakis
DA
.
Problematic internet use among older adolescents: a conceptual framework
.
Comput Human Behav
.
2013
;
29
(
4
):
1879
1887
14
Jelenchick
LA
,
Hawk
ST
,
Moreno
MA
.
Problematic Internet use and social networking site use among Dutch adolescents
.
Int J Adolesc Med Health
.
2016
;
28
(
1
):
119
121
15
Jelenchick
LA
,
Eickhoff
J
,
Christakis
DA
, et al
.
The Problematic and Risky Internet Use Screening Scale (PRIUSS) for adolescents and young adults: scale development and refinement
.
Comput Human Behav
.
2014
;
35
:
171
178
16
Jelenchick
LA
,
Christakis
DA
,
Moreno
MA
.
A longitudinal evaluation of problematic Internet use (PIU) symptoms in older adolescents. In: Proceedings from the 2014 Pediatric Academic Society; May 3–7, 2014; Vancouver, British Columbia, Canada
17
Aboujaoude
E
.
Problematic Internet use: an overview
.
World Psychiatry
.
2010
;
9
(
2
):
85
90
18
Moreno
MA
,
Jelenchick
LA
,
Breland
DJ
.
Exploring depression and problematic internet use among college females: a multisite study
.
Comput Human Behav
.
2015
;
49
:
601
607
19
Milani
L
,
Osualdella
D
,
Di Blasio
P
.
Quality of interpersonal relationships and problematic Internet use in adolescence
.
Cyberpsychol Behav
.
2009
;
12
(
6
):
681
684
20
Cerniglia
L
,
Zoratto
F
,
Cimino
S
,
Laviola
G
,
Ammaniti
M
,
Adriani
W
.
Internet addiction in adolescence: neurobiological, psychosocial and clinical issues
.
Neurosci Biobehav Rev
.
2017
;
76
(
pt A
):
174
184
21
Stavropoulos
V
,
Alexandraki
K
,
Motti-Stefanidi
F
.
Recognizing internet addiction: prevalence and relationship to academic achievement in adolescents enrolled in urban and rural Greek high schools
.
J Adolesc
.
2013
;
36
(
3
):
565
576
22
Lam
LT
,
Peng
Z-W
,
Mai
J-C
,
Jing
J
.
Factors associated with Internet addiction among adolescents
.
Cyberpsychol Behav
.
2009
;
12
(
5
):
551
555
23
Widyanto
L
,
Griffiths
M
.
‘Internet addiction’: a critical review
.
Int J Ment Health Addict
.
2006
;
4
(
1
):
31
51
24
Gámez-Guadix
M
.
Depressive symptoms and problematic Internet use among adolescents: analysis of the longitudinal relationships from the cognitive-behavioral model
.
Cyberpsychol Behav Soc Netw
.
2014
;
17
(
11
):
714
719
25
Casale
S
,
Fioravanti
G
.
Why narcissists are at risk for developing Facebook addiction: the need to be admired and the need to belong
.
Addict Behav
.
2018
;
76
:
312
318
26
Oberst
U
,
Wegmann
E
,
Stodt
B
,
Brand
M
,
Chamarro
A
.
Negative consequences from heavy social networking in adolescents: the mediating role of fear of missing out
.
J Adolesc
.
2017
;
55
:
51
60
27
Lam
LT
.
Parental mental health and Internet addiction in adolescents
.
Addict Behav
.
2015
;
42
:
20
23
28
Chen
SH
,
Weng
LJ
,
Su
YJ
,
Wu
HM
,
Yang
PF
.
Development of a Chinese Internet addiction scale and its psychometric study
.
Chin J Psychol
.
2003
;
45
(
3
):
279
294
29
Ko
C-H
,
Yen
J-Y
,
Yen
C-F
,
Chen
C-C
,
Yen
C-N
,
Chen
S-H
.
Screening for Internet addiction: an empirical study on cut-off points for the Chen Internet Addiction Scale
.
Kaohsiung J Med Sci
.
2005
;
21
(
12
):
545
551
30
Young
KS
.
Caught in the Net: How to Recognize the Signs of Internet Addiction–and a Winning Strategy for Recovery
.
New York, NY
:
John Wiley & Sons
;
1998
31
Kuss
DJ
,
Griffiths
MD
,
Karila
L
,
Billieux
J
.
Internet addiction: a systematic review of epidemiological research for the last decade
.
Curr Pharm Des
.
2014
;
20
(
25
):
4026
4052
32
Council on Communications and Media
.
Media use in school-aged children and adolescents
.
Pediatrics
.
2016
;
138
(
5
):
e20162592
33
Moreno
MA
,
Arseniev-Koehler
A
,
Selkie
E
.
Development and testing of a 3-item screening tool for problematic Internet use
.
J Pediatr
.
2016
;
176
:
167
172.e1
34
Csibi
S
,
Demetrovics
Z
,
Szabó
A
.
[Development and psychometric validation of the Brief Smartphone Addiction Scale (BSAS) with schoolchidren]
.
Psychiatr Hung
.
2016
;
31
(
1
):
71
77
35
Bányai
F
,
Zsila
Á
,
Király
O
, et al
.
Problematic social media use: results from a large-scale nationally representative adolescent sample
.
PLoS One
.
2017
;
12
(
1
):
e0169839

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data