JMIR Publications

JMIR Mental Health

Internet interventions, technologies and digital innovations for mental health and behaviour change


Journal Description

JMIR Mental Health (JMH, ISSN 2368-7959) is a new spin-off journal of JMIR, the leading eHealth journal (Impact Factor 2014: 3.4). 

JMIR Mental Health focusses on digital health and Internet interventions, technologies and electronic innovations (software and hardware) for mental health, addictions, online counselling and behaviour change. This includes formative evaluation and system descriptions, theoretical papers, review papers, viewpoint/vision papers, and rigorous evaluations.

JMIR Mental Health publishes even faster and has a broader scope with including papers which are more technical or more formative/developmental than what would be published in the Journal of Medical Internet Research

JMIR Mental Health features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs.

JMIR Mental Health adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics.

Editorial Board members are currently being recruited, please contact us if you are interested ( at


Recent Articles:

  • CeHRes Roadmap.
van Gemert-Pijnen JE, Nijland N, van Limburg M, Ossebaard HC, Kelders SM, Eysenbach G, et al. A holistic framework to improve the uptake and impact of eHealth technologies. J Med Internet Res 2011;13(4):e111.

    Mixing Online and Face-to-Face Therapy: How to Benefit From Blended Care in Mental Health Care


    Blended care, a combination of online and face-to-face therapy, is increasingly being applied in mental health care to obtain optimal benefit from the advantages these two treatment modalities have. Promising results have been reported, but a variety in descriptions and ways of operationalizing blended care exists. Currently, what type of “blend” works for whom, and why, is unclear. Furthermore, a rationale for setting up blended care is often lacking. In this viewpoint paper, we describe postulates for blended care and provide an instrument (Fit for Blended Care) that aims to assist therapists and patients whether and how to set up blended care treatment. A review of the literature, two focus groups (n=5 and n=5), interviews with therapists (n=14), and interviews with clients (n=2) were conducted to develop postulates of eHealth and blended care and an instrument to assist therapists and clients in setting up optimal blended care. Important postulates for blended care are the notion that both treatment modalities should complement each other and that set up of blended treatment should be based on shared decision making between patient and therapist. The “Fit for Blended Care” instrument is presented which addresses the following relevant themes: possible barriers to receiving blended treatment such as the risk of crisis, issues in communication (at a distance), as well as possible facilitators such as social support. More research into the reasons why and for whom blended care works is needed. To benefit from blended care, face-to-face and online care should be combined in such way that the potentials of both treatment modalities are used optimally, depending on patient abilities, needs, and preferences. To facilitate the process of setting up a personalized blended treatment, the Fit for Blended Care instrument can be used. By applying this approach in research and practice, more insight into the working mechanisms and optimal (personal) “blends” of online and face-to-face therapy becomes within reach.

  • Copyright & Source:

    Efficacy of Adolescent Suicide Prevention E-Learning Modules for Gatekeepers: A Randomized Controlled Trial


    Background: Face-to-face gatekeeper training can be an effective strategy in the enhancement of gatekeepers’ knowledge and self-efficacy in adolescent suicide prevention. However, barriers related to access (eg, time, resources) may hamper participation in face-to-face training sessions. The transition to a Web-based setting could address obstacles associated with face-to-face gatekeeper training. Although Web-based suicide prevention training targeting adolescents exists, so far no randomized controlled trials (RCTs) have been conducted to investigate their efficacy. Objective: This RCT study investigated the efficacy of a Web-based adolescent suicide prevention program entitled Mental Health Online, which aimed to improve the knowledge and self-confidence of gatekeepers working with adolescents (12-20 years old). The program consisted of 8 short e-learning modules each capturing an important aspect of the process of early recognition, guidance, and referral of suicidal adolescents, alongside additional information on the topic of (adolescent) suicide prevention. Methods: A total of 190 gatekeepers (ages 21 to 62 years) participated in this study and were randomized to either the experimental group or waitlist control group. The intervention was not masked. Participants from both groups completed 3 Web-based assessments (pretest, posttest, and 3-month follow-up). The outcome measures of this study were actual knowledge, and participants’ ratings of perceived knowledge and perceived self-confidence using questionnaires developed specifically for this study. Results: The actual knowledge, perceived knowledge, and perceived self-confidence of gatekeepers in the experimental group improved significantly compared to those in the waitlist control group at posttest, and the effects remained significant at 3-month follow-up. The overall effect sizes were 0.76, 1.20, and 1.02, respectively, across assessments. Conclusions: The findings of this study indicate that Web-based suicide prevention e-learning modules can be an effective educational method to enhance knowledge and self-confidence of gatekeepers with regard to adolescent suicide prevention. Gatekeepers with limited time and resources can benefit from the accessibility, simplicity, and flexibility of Web-based training. Trial Registration: Netherlands Trial Register NTR3625; (Archived by WebCite at

  • Stress Stock Photo
Photo by tuelekza. Published on 08 February 2015
Stock photo - Image ID: 100309690

    Automated Remote Monitoring of Depression: Acceptance Among Low-Income Patients in Diabetes Disease Management


    Background: Remote patient monitoring is increasingly integrated into health care delivery to expand access and increase effectiveness. Automation can add efficiency to remote monitoring, but patient acceptance of automated tools is critical for success. From 2010 to 2013, the Diabetes-Depression Care-management Adoption Trial (DCAT)–a quasi-experimental comparative effectiveness research trial aimed at accelerating the adoption of collaborative depression care in a safety-net health care system–tested a fully automated telephonic assessment (ATA) depression monitoring system serving low-income patients with diabetes. Objective: The aim of this study was to determine patient acceptance of ATA calls over time, and to identify factors predicting long-term patient acceptance of ATA calls. Methods: We conducted two analyses using data from the DCAT technology-facilitated care arm, in which for 12 months the ATA system periodically assessed depression symptoms, monitored treatment adherence, prompted self-care behaviors, and inquired about patients’ needs for provider contact. Patients received assessments at 6, 12, and 18 months using Likert-scale measures of willingness to use ATA calls, preferred mode of reach, perceived ease of use, usefulness, nonintrusiveness, privacy/security, and long-term usefulness. For the first analysis (patient acceptance over time), we computed descriptive statistics of these measures. In the second analysis (predictive factors), we collapsed patients into two groups: those reporting “high” versus “low” willingness to use ATA calls. To compare them, we used independent t tests for continuous variables and Pearson chi-square tests for categorical variables. Next, we jointly entered independent factors found to be significantly associated with 18-month willingness to use ATA calls at the univariate level into a logistic regression model with backward selection to identify predictive factors. We performed a final logistic regression model with the identified significant predictive factors and reported the odds ratio estimates and 95% confidence intervals. Results: At 6 and 12 months, respectively, 89.6% (69/77) and 63.7% (49/77) of patients “agreed” or “strongly agreed” that they would be willing to use ATA calls in the future. At 18 months, 51.0% (64/125) of patients perceived ATA calls as useful and 59.7% (46/77) were willing to use the technology. Moreover, in the first 6 months, most patients reported that ATA calls felt private/secure (75.9%, 82/108) and were easy to use (86.2%, 94/109), useful (65.1%, 71/109), and nonintrusive (87.2%, 95/109). Perceived usefulness, however, decreased to 54.1% (59/109) in the second 6 months of the trial. Factors predicting willingness to use ATA calls at the 18-month follow-up were perceived privacy/security and long-term perceived usefulness of ATA calls. No patient characteristics were significant predictors of long-term acceptance. Conclusions: In the short term, patients are generally accepting of ATA calls for depression monitoring, with ATA call design and the care management intervention being primary factors influencing patient acceptance. Acceptance over the long term requires that the system be perceived as private/secure, and that it be constantly useful for patients’ needs of awareness of feelings, self-care reminders, and connectivity with health care providers. Trial Registration: NCT01781013; (Archived by WebCite at



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    Heuristic Evaluation of Ehealth Interventions: Establishing Standards That Relate to the Therapeutic Process Perspective


    In recent years, the number of available eHealth interventions aimed at treating behavioral and mental health challenges has been growing. From the perspective of health care providers, there is a need for eHealth interventions to be evaluated prior to clinical trials and for the limited resources allocated to empirical research to be invested in the most promising products. Following a literature review, a gap was found in the availability of eHealth interventions evaluation principles related to the patient experience of the therapeutic process. This paper introduces principles and concepts for the evaluation of eHealth interventions developed as a first step in a process to outline general evaluation guidelines that relate to the clinical context from health care providers’ perspective. Our approach was to conduct a review of literature that relates to the examination of eHealth interventions. We identified the literature that was most relevant to our study and used it to define guidelines that relate to the clinical context. We then compiled a list of heuristics we found to be useful for the evaluation of eHealth intervention products’ suitability for empirical examination. Four heuristics were identified with respect to the therapeutic process: (1) the product’s ease of use (ie, usability), (2) the eHealth intervention’s compatibility with the clinical setting, (3) the presence of tools that make it easier for the user to engage in therapeutic activities, and (4) the provision of a feasible therapeutic pathway to growth. We then used this set of heuristics to conduct a detailed examination of MyFitnessPal. This line of work could help to set the bar higher for product developers and to inform health care providers about preferred eHealth intervention designs.

  • Screenshot of the app.

    Usability Evaluation of a Mobile Monitoring System to Assess Symptoms After a Traumatic Injury: A Mixed-Methods Study


    Background: Victims of trauma are at high risk for mental health conditions such as posttraumatic stress disorder and depression. Regular assessment of mental health symptoms in the post-trauma period is necessary to identify those at greatest risk and provide treatment. The multiple demands of the acute post-trauma period present numerous barriers to such assessments. Mobile apps are a method by which to overcome these barriers in order to regularly assess symptoms, identify those at risk, and connect patients to needed services. Objective: The current study conducted a usability evaluation of a system to monitor mental health symptoms after a trauma. The system was developed to promote ease of use and facilitate quick transmission of data. Methods: A sample of 21 adults with a history of trauma completed a standardized usability test in a laboratory setting followed by a qualitative interview. Results: Usability testing indicated that the app was easy to use and that patients were able to answer several questions in less than 1 minute (mean [SD] 29.37 [7.53]; range 15-57). Qualitative analyses suggested that feedback should be included in such an app and recommendations for the type of feedback were offered. Conclusions: The results of the current study indicate that a mobile app to monitor post-trauma mental health symptoms would be well received by victims. Personalized feedback to the user was identified as critical to promote the usability of the software.

  • The e-couch logo is copyright of The Australian National University, 2005-2016.

    Reducing Depression Through an Online Intervention: Benefits From a User Perspective


    Background: Internet interventions are increasingly being recognized as effective in the treatment and prevention of mental health conditions; however, the usefulness of such programs from the perspective of the participants is often not reported. Objective: This study explores the experiences of participants of a 12-week randomized controlled trial of an automated self-help training program (e-couch), with and without an Internet support group, targeting depression. Methods: The study comprised a community sample of 298 participants who completed an online survey both prior to and on completion of an intervention for preventing or reducing depressive symptoms. Results: Overall, participants reported a high level of confidence in the ability of an online intervention to improve a person’s understanding of depression. However, confidence that a website could help people learn skills for preventing depression was lower. Benefits reported by participants engaged in the intervention included increased knowledge regarding depression and its treatment, reduced depressive symptoms, increased work productivity, and improved ability to cope with everyday stress. A minority of participants reported concerns or problems resulting from participation in the interventions. Conclusions: The findings provide consumer support for the effectiveness of this online intervention. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 65657330; (Archived by WebCite at

  • Image of the web-site

    Web-Based Cognitive Behavioral Relapse Prevention Program With Tailored Feedback for People With Methamphetamine and Other Drug Use Problems: Development and...


    Background: Although drug abuse has been a serious public health concern, there have been problems with implementation of treatment for drug users in Japan because of poor accessibility to treatment, concerns about stigma and confidentiality, and costs. Therapeutic interventions using the Internet and computer technologies could improve this situation and provide more feasible and acceptable approaches. Objective: The objective of the study was to show how we developed a pilot version of a new Web-based cognitive behavioral relapse prevention program with tailored feedback to assist people with drug problems and assessed its acceptance and usability. Methods: We developed the pilot program based on existing face-to-face relapse prevention approaches using an open source Web application to build an e-learning website, including relapse prevention sessions with videos, exercises, a diary function, and self-monitoring. When users submitted exercise answers and their diary, researchers provided them with personalized feedback comments using motivational interviewing skills. People diagnosed with drug dependence were recruited in this pilot study from a psychiatric outpatient ward and nonprofit rehabilitation facilities and usability was evaluated using Internet questionnaires. Overall, website usability was assessed by the Web Usability Scale. The adequacy of procedures in the program, ease of use, helpfulness of content, and adverse effects, for example, drug craving, mental distress, were assessed by original structured questionnaires and descriptive form questions. Results: In total, 10 people participated in the study and completed the baseline assessment, 60% completed all relapse prevention sessions within the expected period. The time needed to complete one session was about 60 minutes and most of the participants took 2 days to complete the session. Overall website usability was good, with reasonable scores on subscales of the Web Usability Scale. The participants felt that the relapse prevention sessions were easy to use and helpful, but that the length of the videos was too long. The participant who until recently used drugs was satisfied with the self-monitoring, but others that had already maintained abstinence for more than a year felt this activity was unhelpful and were bored tracking and recording information on daily drug use. Feedback comments from researchers enhanced participants’ motivation and further insight into the disease. Serious adverse effects caused by the intervention were not observed. Some possible improvements to the program were suggested. Conclusions: The Web-based relapse prevention program was easy to use and acceptable to drug users in this study. This program will be helpful for drug users who do not receive behavioral therapy. After the pilot program is revised, further large-scale research is needed to assess its efficacy among drug users who have recently used drugs.

  • (c) Sally Kindermann.

    Using Smartphones to Monitor Bipolar Disorder Symptoms: A Pilot Study


    Background: Relapse prevention in bipolar disorder can be improved by monitoring symptoms in patients' daily life. Smartphone apps are easy-to-use, low-cost tools that can be used to assess this information. To date, few studies have examined the usefulness of smartphone data for monitoring symptoms in bipolar disorder. Objective: We present results from a pilot test of a smartphone-based monitoring system, Social Information Monitoring for Patients with Bipolar Affective Disorder (SIMBA), that tracked daily mood, physical activity, and social communication in 13 patients. The objective of this study was to investigate whether smartphone measurements predicted clinical symptoms levels and clinical symptom change. The hypotheses that smartphone measurements are (1) negatively related to clinical depressive symptoms and (2) positively related to clinical manic symptoms were tested. Methods: Clinical rating scales were administered to assess clinical depressive and manic symptoms. Patients used a smartphone with the monitoring app for up to 12 months. Random-coefficient multilevel models were computed to analyze the relationship between smartphone data and externally rated manic and depressive symptoms. Overall clinical symptom levels and clinical symptom changes were predicted by separating between-patient and within-patient effects. Using established clinical thresholds from the literature, marginal effect plots displayed clinical relevance of smartphone data. Results: Overall symptom levels and change in clinical symptoms were related to smartphone measures. Higher overall levels of clinical depressive symptoms were predicted by lower self-reported mood measured by the smartphone (beta=-.56, P<.001). An increase in clinical depressive symptoms was predicted by a decline in social communication (ie, outgoing text messages: beta=-.28, P<.001) and a decline in physical activity as measured by the smartphone (ie, cell tower movements: beta=-.11, P=.03). Higher overall levels of clinical manic symptoms were predicted by lower physical activity on the smartphone (ie, distance travelled: beta=-.37, P<.001), and higher social communication (beta=.48, P=.03). An increase in clinical manic symptoms was predicted by a decrease in physical activity on the smartphone (beta=-.17, P<.001). Conclusions: Clinical symptoms were related to some objective and subjective smartphone measurements, but not all smartphone measures predicted the occurrence of bipolar symptoms above clinical thresholds. Thus, smartphones have the potential to monitor bipolar disorder symptoms in patients’ daily life. Further validation of monitoring tools in a larger sample is needed. Conclusions are limited by the low prevalence of manic and depressive symptoms in the study sample. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 05663421; (Archived by WebCite at

  • CopeSmart app screenshots.

    Feasibility of "CopeSmart": A Telemental Health App for Adolescents


    Background: Early intervention is important in order to improve mental health outcomes for young people. Given the recent rise in mobile phone ownership among adolescents, an innovative means of delivering such intervention is through the use of mobile phone applications (apps). Objective: The aim of this study was to evaluate the feasibility of “CopeSmart”, a telemental health app developed to foster positive mental health in adolescents through emotional self-monitoring and the promotion of positive coping strategies. Methods: Forty-three adolescents (88% female) aged 15-17 years downloaded the app and used it over a one-week period. They then completed self-report questionnaires containing both open-ended and closed-ended questions about their experiences of using the app. The app itself captured data related to user engagement. Results: On average participants engaged with the app on 4 of the 7 days within the intervention period. Feedback from users was reasonably positive, with 70% of participants reporting that they would use the app again and 70% reporting that they would recommend it to a friend. Thematic analysis of qualitative data identified themes pertaining to users’ experiences of the app, which were both positive (eg, easy to use, attractive layout, emotional self-monitoring, helpful information, notifications, unique) and negative (eg, content issues, did not make user feel better, mood rating issues, password entry, interface issues, engagement issues, technical fixes). Conclusions: Overall findings suggest that telemental health apps have potential as a feasible medium for promoting positive mental health, with the majority of young people identifying such technologies as at least somewhat useful and displaying a moderate level of engagement with them. Future research should aim to evaluate the efficacy of such technologies as tools for improving mental health outcomes in young people.

  • Screenshot from “Beating Bipolar” Internet-based psychoeducation program, Cardiff University.

    How Patients Contribute to an Online Psychoeducation Forum for Bipolar Disorder: A Virtual Participant Observation Study


    Background: In a recent exploratory randomized controlled trial, an online psychoeducation intervention for bipolar disorder has been found to be feasible and acceptable to patients and may positively impact on their self-management behaviors and quality of life. Objective: The objective of the study was to investigate how these patients contribute to an online forum for bipolar disorder and the issues relevant for them. Methods: Participants in the intervention arm of the Bipolar Interactive PsychoEDucation (“BIPED”) trial were invited to contribute to the Beating Bipolar forum alongside receiving interactive online psychoeducation modules. Within this virtual participant observation study, forum posts were analyzed using thematic analysis, incorporating aspects of discourse analysis. Results: The key themes which arose from the forum posts included: medication, employment, stigma, social support, coping strategies, insight and acceptance, the life chart, and negative experiences of health care. Participants frequently provided personal narratives relating to their history of bipolar disorder, life experiences, and backgrounds, which often contained emotive language and humor. They regularly sought and offered advice, and expressed encouragement and empathy. The forum would have benefitted from more users to offer a greater support network with more diverse views and experiences. Conclusions: Online forums are inexpensive to provide and may offer peer support and the opportunity for patients to share their experiences and explore issues related to their illness anonymously. Future research should focus on how to enhance patient engagement with online health care forums. Trial Registration: ISRCTN81375447; (Archived by WebCite at


    Word Recall: Cognitive Performance Within Internet Surveys


    Background: The use of online surveys for data collection has increased exponentially, yet it is often unclear whether interview-based cognitive assessments (such as face-to-face or telephonic word recall tasks) can be adapted for use in application-based research settings. Objective: The objective of the current study was to compare and characterize the results of online word recall tasks to those of the Health and Retirement Study (HRS) and determine the feasibility and reliability of incorporating word recall tasks into application-based cognitive assessments. Methods: The results of the online immediate and delayed word recall assessment, included within the Women’s Health and Valuation (WHV) study, were compared to the results of the immediate and delayed recall tasks of Waves 5-11 (2000-2012) of the HRS. Results: Performance on the WHV immediate and delayed tasks demonstrated strong concordance with performance on the HRS tasks (ρc=.79, 95% CI 0.67-0.91), despite significant differences between study populations (P<.001) and study design. Sociodemographic characteristics and self-reported memory demonstrated similar relationships with performance on both the HRS and WHV tasks. Conclusions: The key finding of this study is that the HRS word recall tasks performed similarly when used as an online cognitive assessment in the WHV. Online administration of cognitive tests, which has the potential to significantly reduce participant and administrative burden, should be considered in future research studies and health assessments.

  • Screenshot from information video about the study.

    Preferences of Young Adults With First-Episode Psychosis for Receiving Specialized Mental Health Services Using Technology: A Survey Study


    Background: Despite the potential and interest of using technology for delivering specialized psychiatric services to young adults, surprisingly limited attention has been paid to systematically assess their perspectives in this regard. For example, limited knowledge exists on the extent to which young people receiving specialized services for a first-episode psychosis (FEP) are receptive to using new technologies as part of mental health care, and to which types of technology-enabled mental health interventions they are amenable to. Objective: The purpose of this study is to assess the interest of young adults with FEP in using technology to receive mental health information, services, and supports. Methods: This study uses a cross-sectional, descriptive survey design. A convenience sample of 67 participants between the ages of 18 and 35 were recruited from two specialized early intervention programs for psychosis. Interviewer-administered surveys were conducted between December 2013 and October 2014. Descriptive statistics are reported. Results: Among the 67 respondents who completed the survey, the majority (85%, 57/67) agreed or strongly agreed with YouTube as a platform for mental health-related services and supports. The top five technology-enabled services that participants were amenable to were (1) information on medication (96%, 64/67); (2) information on education, career, and employment (93%, 62/67); (3) decision-making tools pertaining to treatment and recovery (93%, 62/67); (4) reminders for appointments via text messaging (93%, 62/67); and (5) information about mental health, psychosis, and recovery in general (91%, 61/67). The top self-reported barriers to seeking mental health information online were lack of knowledge on how to perform an Internet search (31%, 21/67) and the way information is presented online (27%, 18/67). Two thirds (67%; 45/67) reported being comfortable in online settings, and almost half (48%; 32/67) reported a preference for mixed formats when viewing mental health information online (eg, text, video, visual graphics). Conclusions: Young people diagnosed with FEP express interest in using the Internet, social media, and mobile technologies for receiving mental health-related services. Increasing the awareness of young people in relation to various forms of technology-enabled mental health care warrants further attention. A consideration for future research is to obtain more in-depth knowledge on young people’s perspectives, which can help improve the design, development, and implementation of integrated technological health innovations within the delivery of specialized mental health care.

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  • A thematic analysis of stigma and disclosure for perinatal depression on an online forum

    Date Submitted: Feb 6, 2016

    Open Peer Review Period: Feb 8, 2016 - Apr 4, 2016

    Background: Perinatal mental illness is a global health concern, however, many women do not get the treatment they need to recover. Some women choose not to seek professional help and get no treatment...

    Background: Perinatal mental illness is a global health concern, however, many women do not get the treatment they need to recover. Some women choose not to seek professional help and get no treatment because they feel stigmatised. Online forums for various health conditions, including perinatal mental health, can be beneficial for members. Little is known about the role that online forums for perinatal illness play in reducing stigma and subsequent disclosure of symptoms to healthcare professionals and treatment uptake. Objective: This study aimed to examine stigma and disclosure in forums and describe any potential disadvantages of forum use. Methods: An online forum for mothers was examined and 1546 messages extracted from 102 threads from the antenatal/postnatal depression section. These messages were subject to deductive systematic thematic analysis to identify common themes regarding stigma and disclosure of symptoms and potential disadvantages of forum use. Results: Two major themes were identified stigma and negative experiences of disclosure. Stigma had three subthemes; internal stigma, external stigma and treatment stigma. Many women were concerned with feeling like a “bad” or “failed” mother and worried that if they disclosed their symptoms to a healthcare professional they would be stigmatised. Posts in response to this frequently encouraged women to disclose their symptoms to healthcare professionals and accept professional treatment. Forum discourse reconstructed the ideology of motherhood as compatible with perinatal mental illness, especially if the woman sought help and adhered to treatment. Many women overcame stigma and replied that they had taken advice and disclosed to a healthcare professional and/or taken treatment. Conclusions: Forum use may increase women's disclosure to healthcare providers by challenging their internal and external stigma and this may strengthen professional treatment uptake and adherence. However, a few posts described negative experiences when disclosing to healthcare professionals.

  • A systematic review of web-based technology to assist emotional adjustment and self-management of symptoms related to post-traumatic stress

    Date Submitted: Jan 24, 2016

    Open Peer Review Period: Jan 25, 2016 - Mar 21, 2016

    Background: Post-traumatic stress disorder (PTSD) is an anxiety disorder characterised by symptoms of hyper-arousal, intrusive memories or thoughts about a traumatic life event and the urge to avoid r...

    Background: Post-traumatic stress disorder (PTSD) is an anxiety disorder characterised by symptoms of hyper-arousal, intrusive memories or thoughts about a traumatic life event and the urge to avoid reminders. Evidence-based psychological interventions have been developed to treat these symptoms and reduce distress, the majority of which were designed to be delivered face-to-face with trained therapists. However, new developments in the use of technology to supplement and extend healthcare have led to the creation of web-based self-help tools to treat symptoms of mental health disorders and these approaches have been applied to PTSD. Objective: To assess the scope and efficacy of web-based therapeutic technology to aid self-management of symptoms associated with PTSD. Methods: For this review, the following databases were searched: the Cochrane Library (all years), MEDLINE (1946 to March 2015 week 2), EMBASE (1980 to 2015 week 11), and PsycINFO (1806 to March 2015 week 2) with a search algorithm to identify self-help based interventions for treatments of symptoms of PTSD. In addition to these searches, hand searches were performed of citations reported in the included studies and recent meta-analyses or systematic reviews on self-help technology and web-based treatments for anxiety disorder that might contain treatment of post-traumatic stress. From the resulting studies only those that used randomised controlled trial design were considered. The primary outcome measure was the severity of PTSD-related symptoms. Authors were contacted to try to obtain missing data where possible. The quality of each paper was rated using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Results: A total of 31 studies were reviewed. These studies spanned clinical and sub-clinical populations, including people with a diagnosis of PTSD as well as ‘at risk’ groups such as survivors of natural disasters, veterans of war and life-threating illnesses. The majority of previous research has trialled web-based interventions drawing on psychological models of Trauma-Focussed Cognitive Behavioural Therapy (TF-CBT), non-trauma focussed CBT and behavioural exposure, but also has included attention bias modification paradigms, third-wave CBT approaches and social networking concepts. Approach and quality of design varied depending on the settings in which research studies were carried out, limiting conclusions. However, of all the studies included in the review, 77.8% (21/27) reported a significant reduction in symptoms associated with PTSD. Conclusions: There is some support for web-based resources to treat symptoms of PTSD. This may be particularly helpful for people who may not have ready access to therapy, e.g. people on waiting lists or amongst sub-clinical or ‘at risk’ groups. There is scope for further research in this area to better understand the added benefits of technology in supporting emotional adjustment to trauma and self-management of stress-related symptoms. Future studies need to focus on maintaining high quality assessment when evaluating the efficacy and acceptability of these technologies in the face of a rapidly developing industry.

  • Internet Addiction through the Phase of Adolescence

    Date Submitted: Jan 19, 2016

    Open Peer Review Period: Jan 19, 2016 - Mar 15, 2016

    Background: Adolescence can be defined as the period between puberty and adulthood, usually between the ages of 11 and 18 years. Events during this period have a great influence on a person's developm...

    Background: Adolescence can be defined as the period between puberty and adulthood, usually between the ages of 11 and 18 years. Events during this period have a great influence on a person's development and can determine their attitudes and behavior in later life [1]. We live in a digitalized world and information society in which access to and use of the Internet has become an essential part of everyday life of the modern man. Designed to make life easier, facilitate communication and make available information from countless sources, the Internet has opened many possibilities, new ways of expression, business, socializing, entertaining and informing; however, it has also given new concerns and ethical dilemmas [2]. Misuse of the Internet is a phenomenon which has followed the Internet from its very beginning. Today, it is mostly geared towards children and adolescents who still lack an established system of ethical discernment of morally unacceptable content provided on Web resources. Most often through music, movies and video games, undesirable behaviors are inflicted upon children and adolescents. As a result of children's curious nature, they are often attracted by harmful websites that promote pornography, encourage hatred, rumors and slander under the pretense of being news, as well as suggest certain forms of self-destructive behaviour. Hence, through these types of websites, children are exposed to inadequate and inappropriate material. Consequently, such exposure may result in the development of addictive behaviors, which adolescents, in particular, are highly susceptible to. For the purposes of this study, we want to define adolescence as a period of growth, development and maturation of an individual after which enters adulthood and becomes able to accept the responsibilities and obligations of everyday life [2]. However, due to the individuality of this maturation process and assuming obligations, recent behavioral research divided adolescence into several phases: pre-adolescence, early, middle and late adolescence, and postadolescence [3]. One of the most important functions of adolescence is to develop one’s own perceptions of sexuality, without conflict with oneself and always acting within acceptable moral standards. The easing of parental authority helps to guide the individual through new and independent relationships, reducing dependence on peer groups thus helping to find one's own identity. [4] Teenagers are often in conflict with authority and the cultural and moral norms of society, so certain developmental effects can trigger a series of defense mechanisms [3]. For all age groups, from school age to adulthood, the most dominating and uncontrollable emotion is sorrow, which can lead to depression, discouragement and loneliness. These emotions are central to most experiences of depression. These symptoms usually increase with age for females who generally demonstrate a higher degree than males. During the developmental stages of adolescence, there is an increased danger of crises, often accompanied by mood changes, periods of anxiety and depressive behavior which adolescents attempt to fight through withdrawal, avoidance of overly emphasized social contact, aggressive reactions and addictive behavior [5], [6] . Adolescents are exceptionally vulnerable during this period and, because of their receptive age, can become drawn to the Internet as a release. This can, in time, lead to a type of addiction. Adolescents are especially attracted to new and technological methods of communication which offer interaction with others and, at the same time, give them anonymity and an impression of belonging to a community as well as social acceptability. The Internet is a global network which connects millions of people throughout the world, enabling users to exchange information and, importantly, this information is available at any time and any place [7]. In a very short time, the Internet has become the most popular and sophisticated medium for influencing the needs of children and young persons [8]. Access to information is unlimited and it can be a source of amusement as well as a generator of new interests [9]. However, the Internet can also represent new and unknown threats. Simple and uncontrolled information access and the anonymity that goes with it can endanger the moral development of the young [9]. The Internet can generate negative attitudes, aggressive feelings and insensitivity to unethical behavior due to the fact that there is no direct contact between individuals. Factors which can lead to addictive attitudes towards the Internet are depression, loneliness, intimacy, simplicity, availability of approach, anonymity, and high level of curiosity paired with strong pressures from ones surroundings. Addiction is often the result of social crises, lack of self-confidence, a need to conform, boredom and the availability of interesting and amusing pastimes [9]. The concept of addictions to particular behaviors or substances has been known for centuries, as have the psychological effects these have. Regardless of the extensive knowledge about such tendencies, they do not appear to diminish; on the contrary, these traits seem to be increasingly attractive to some and often become compulsive [10]. Persons addicted to Internet use have been noticed to have three to five psychiatric disturbances. The most common of these are social phobias, ADD/ADHD, insomnia, behavioral disorders, anxiety, and compulsive attitudes to gambling and other social pastimes [11]. Anxiety issues often affect problem children and adolescents and, during this period, there is a distinct tendency towards symptoms of depression [11]. In addition to these conclusions, we can cite a number of drawbacks/benefits that Internet access allows. They are confirmed by specific research upon which we added our own findings. Recent research by Nalwa & Anand points to the fact that the Internet gives students numerous advantages for learning due to the wide access to literature, e-learning, courses, etc. However, frequent access to the many unimportant web sites such as those for chat, games, etc. can easily cause addiction which could have negative results on their health and standards of learning. Children often abandon traditional pastimes and replace them with time spent surfing the Internet. This can lead to late bed time with the subsequent loss of peaceful sleep. Often, life is considered boring without the Internet which can lead to a strong feeling of loneliness [12]. The purpose of this paper is to observe the psychosocial effects of Internet addiction during adolescence. Since the early and middle stages of adolescence are crucial for emotional Objective: Due to the lack of scientific proof, it is difficult to ascertain in which stages adolescents use the Internet and to what purposes. It is also hard to establish how the virtual model of life preferred by the Internet addicts influences psychosocial functioning and the quality of life. Since Internet addicts spend most of their time surfing in front of the computer, the goal was to establish for which purposes they most often use the Internet. The goal was also to note whether there are differences among the Croatian, Polish and Finnish adolescents with regards to the purpose of Internet use as well as any possible differences with respect to gender. Hypothesis There is an influence, a correlation between the purpose of Internet use and the age, and the interaction of the two, on the level of addiction to the Internet. Methods: The sample surveys Participants are defined as students who attend regular, public school, aged 11- 18 years old. From a table of random samples from Croatia, the city of Split was chosen. Additionally, Pakość in Poland and Turku in Finland were the cities chosen from the European Union. The respondents comprised a simple random representative sample. When choosing a school, the method of random numbers was used, always respecting the structure of education. In Split, four schools per 100 respondents were randomly selected, while two schools per 100 respondents were randomly selected for the town of Turku and Pakosc, respectively. Hence, all schools that participated in the study were randomly chosen and covered by the Internet network.The schools that participated in this research are Poljišani Elementary School (Viska 12, Split) and Blatine-Skrape Elementary School (Kržice 2, Split), as well as First Gymnasium School (Teslina 10, Split) and Third Gymnasium School (Matice Hrvatske 11, Split). From Finland the following schools were chosen: Raunistulan koulu, Teräsrautelan koulu / Suikkilan yksikkö, Talinkorventie 16, 20320 Turkish, Finland, Turun suomalaisen yhteiskoulun lukio, Kauppiaskatu 17, FINE-20100 Turkish. From Poland the following schools participated: Szkoła Podstawowa them. Powstancow Wielkopolskich to the ul. More painfully 2 88-170 Pakość ; Gimnazjum them. Ewerysta Estkowskiego to the ul. Szkolna 44 88-170 Pakość. Research was carried out with permissions of the ministries in charge of education in Croatia, Poland and Finland, ethical commissions of the schools and with consent of the participants themselves. The schools were issued an invitation to participate with assurances of the complete respect of the privacy of individual students with the informed consent of the students and their parents or guardians. The questionnaire was developed in Google documents format and sent to schools in an electronic form along with instructions and contact information of the researchers. The title page instructed the participants to fill the questionnaires out fully and truthfully. They were informed that participation is anonymous and voluntary, that the data will be used for research purposes only and general and particular importance of the research was pointed out to them. Furthermore, they were notified as to the type and duration of the procedures used and they were informed of the confidentiality of the data gathered and the protection of privacy of the participants. The participants were free to refuse participation or to quit at any time without explanation. Having been notified of all the particulars, they proceeded to fill out the questionnaires. Method of Research Our research systematically analyzed all significant variables necessary for scientific research. The survey consists of three parts. A standardized procedure of double translation was applied to each part for each country/language. The initial step was defined by taking the general data and demographic measures. General Information Demographic parameters used in the research include: • Age • Gender (1-female; 2-male) • Country of residence • Purpose of Internet use Participants were asked to appraise whether they use the Internet more often for amusement or educational purposes. Internet Addiction Questionnaire Specific aspects that have been included in a more detailed analysis of research on Internet addiction have been assessed in previous studies. These include assessing Internet addiction using Young’s (1996) IAT (Internet Addiction Test), also known as YIAS (Young’s Internet Addiction Scale). IAT contains 20 questions based on the criteria for pathological gambling. These questions reflect typical addictive behavior. Widiyanto and McMurran report that the scale reflects six dimensions of Internet addiction: salient preoccupation, overuse of the Internet, neglecting work responsibilities, expectation, lack of self-control and neglecting social life. The authors have found that the factors of saliency and overuse are in connection with a more intensive use, while neglecting work is only correlated with age and that in a negative way. The conclusion drawn by the authors is that IAT “does measure some of the key aspects of Internet addiction”. [13]. In this research, the level of addiction was graded on a scale, ranging from 20 to 100. 20-49 – Normal 50-79 – Moderate addiction 80-100 – Serious addiction Among the factors that will be explained, the Likert scale was used. Each question can score up to 5 points (1 very rarely, 2 rarely, 3 often, 4 very often, 5 always). The scale demonstrates excellent internal consistency with the alpha coefficient of 0.93 in the current studies. Statistacl Methods For statistical analysis, SPSS will be used, a software package for Social Research. For data analysis, we will use three groups of methods: descriptive statistical analysis (relative numbers, the median, measures of dispersion), inferential statistical analysis (chi-square test, t-test, analysis of variance) and multivariate analysis (reliability factor analysis). Results: A total of 1078 adolescents from Croatia, Poland and Finland participated in the research. The representative sample of n = 1078 comprised of roughly an equal number of participants of both genders: 534 males and 525 females (for 19 of them, the gender was unknown). The age varied between 11 and 18; the average age being 14.9 with the average discrepancy of 1.92 years which is a small dispersion (with the variance coefficient of only 13%). Participants were predominantly 15-year-olds, so both the median and mode values are 15 years. The structure of the participant sample is shown in Graph 1 with regard to their gender, age, country and the purpose of Internet use. Variables studies considering the age of the respondents Graph 1: Structure of polled adolescents with regard to gender, age, origin and purpose of Internet use (in percentages) The predominant purpose of Internet use with the 1078 participants is for entertainment (84%), with school/work far behind at 16%. Using the chi-square test, a correlation was established between the purpose of Internet use and gender and the purpose of Internet use and nationality (country of residence), as can be observed in the following contingency tables (Table 1 and Table 2) used in these tests. Table 1: Number of interviewed adolescents according to gender and purpose of Internet use (n=1078) The values of the chi-square test, computed using Table 1 (χ2 = 11.285; df = 1; N = 1042; p = 0.001), point to the conclusion that there is a statistically significant link (p = 0.001) between gender and the purpose of Internet use. What is this link? Female participants use the Internet for school or work related purposes (20%) much more than their male counterparts (12%). Variables studies due to the state origin of the respondents However, if the analyses of this correlation between gender and the purpose of Internet use are carried out separately for each country, the results are different: Table 2: Correlation between gender and purpose of Internet use for each country This statistically significant link is present with Croatian participants (χ2 = 26.811; df = 1; N = 476; p < 0.001), however it is not present with the Finnish and Polish ones (p > 0.05). Therefore, the Croatian participants have importantly contributed to the conclusion that there is a statistically significant correlation between gender and the purpose of Internet use (in all three countries). Table 3: Number of interviewed adolescents according to country and purpose of Internet use (N=534) The values of the chi-square test, computed using Table 3 (χ2= 27.274; df = 2; N = 1058; p < 0.001) point to the conclusion that there is a statistically highly significant correlation between the country and the purpose of Internet use (p < 0.001). For example, the use of Internet for school/work is less in Croatia (16%) than in Poland (24%) with Finland in last place at only 8%. Correlation between the tested variables There is a statistically significant correlation (χ2 = 19.742; df = 6; N = 919; p = 0.003) between age and the level of Internet addiction. Using the contingency table (Table 3), it is possible to calculate that the percentage of moderate and serious addicts grows simultaneously with the participants’ age: youngest (11-12) – 6% slightly older (13-14) – 12% older (15-16) – 19% the oldest (17-18) – drops down to 13% The results show a correlation between age and Internet addiction (χ2= 13.512; df = 3; N = 919; p = 0.004). This correlation can be further broken down by gender, country and the purpose of Internet use. According to gender, the adolescents can be categorized as male or female and we can calculate a separate chi-square test for each of these sub-sections in order to ascertain the correlation between the age of adolescents and Internet addiction. This result will show us whether it is the male or the female demographic which contributes to the correlation between age and Internet addiction. The same can be done with the remaining two independent variables – country and the purpose of Internet use. Due to the preciseness of tests, Internet addiction is expressed on only two levels: normal addiction and moderate and serious addiction. Correlation between age and Internet addiction Table 4: Correlation between age and Internet addiction Thus, the males (p = 0.001) and those adolescents who have used the Internet mostly for entertainment purposes (p = 0.038) have mostly contributed to the correlation between the age of adolescents and Internet addiction. Using correlation analysis, age was considered as being a continuous independent variable and Internet addiction as a dependent ordinal variable. Non-parametric method was used to calculate the Spearman’s coefficient of correlation of 0.08 for N = 1033 and with p = 0.011. It can be concluded that the correlation between the age of adolescents and Internet addiction is weak, positive and statistically significant. A two-factor variance analysis was carried out using the following variables: Dependent quantitative variable = Internet addiction (expressed in points). This variable was formed as a sum of answers to the 20 questions on Internet use. First independent categorical variable = purpose of Internet use (factor 1) with two modalities: school/work and entertainment. Second independent categorical variable = age group (factor 2) with four modalities: 11-12, 13-14, 15-16, and 17-18. Influence of the purpose of Internet use on the level of Internet addiction In describing the analysis data obtained through the described model, the Levene test of variance equality has to be mentioned first, as it has established that variances are not homogenous (p < 0.001) for the analyzed sample of participants . Table 5: The analysis data obtained through the described model We conclude the following: The p values obtained in the table 5, enable us to answer the three questions: • There is no statistically significant influence of the purpose of Internet use on the level of Internet addiction (disregarding the age of participants), as p = 0.215, that is p > 0.05. • There is a statistically important influence of the age of participants on the level of Internet addiction (disregarding the purpose of Internet use), as p < 0.001. • There is a statistically significant interaction between the purpose of Internet use and age regarding the level of Internet addiction (p = 0.001). Comparing the eight mean values among themselves Table 6, we are able to conclude where this level of Internet addiction is at its lowest and where at its highest: Table 6: Summary results of descriptive statistical analysis with analysis of variance The lowest level of Internet addiction is noted with the youngest group who use the Internet for school (32.5). Adolescents between the ages of 15 and 16 who also use the Internet for school have the highest level. Single factor variance analysis (F test) was used to compare the average values of Internet addiction in adolescents of different ages Table 7. These average values (points calculated on the basis of the answers to the 20 questions in the questionnaire), according to age groups, are: Table 7: Results T-test comparing the arithmetic means Note: * statistical significance of 5%; ** Statistical significance of 1%; *** Statistical significance to 0.1% The average score overall was 37.8 ± 12.34.. There is a statistically significant difference between the four averages (F = 14.461 with df = 3 and N = 919), as p < 0.001). Post-hoc test according to Bonferroni gave five statistically significant p values of these possible six (p <0.05) as shown in Table 8. Table 8: Results post-hoc test at Bonferroni (p values) Note: * statistical significance of 5%; ** Statistical significance of 1%; *** Statistical significance to 0.1% Graphically, these are represented as follows: Graph 2: Comparison of the average values of Internet addiction in adolescents of different ages Hereinafter, we will try to give a summary analysis of the considered data. Discussion The goal of this research was to investigate the existence of differences between the adolescents in Croatia, Poland and Finland with regard to the purpose of Internet use and also to establish whether there are differences between the genders regarding the purpose of Internet use. Our findings show that the basic purpose of Internet use among the 1078 participants is predominantly for entertainment (84%), with only 16% using the Internet for school/work. Female participants use the Internet for school/work significantly more (20%) than their male counterparts (12%). Croatian participants (16%) use the Internet for school much less than the Polish ones (24%), while the Finnish participants use it the least (just 8%). Similar studies have shown consistent results regarding the observed issues. Lenhart & Madden got similar results in their research; male adolescents in America use functional and entertainment activities on the Internet much more than the girls who use it for educational and social activities to a much higher degree [14]. Furthermore, similar data was also obtained by Lin & Tsai. They concluded that Taiwanese boys use the Internet to elevate their mood levels, while Taiwanese girls possess a more practical view of the Internet [15]. Programs and activities on the Internet offer the younger generations new dimensions of social activities, so the use of the Internet can expand and reinforce the connection with friends and colleagues [16]. Tsai and Lin noticed that some adolescents were so preoccupied with activities on the Internet that they were displaying signs of addiction [15]. In accordance with the correlations of risky forms of behavior and the developmental stages of adolescence, the following hypothesis was accepted: different stages of adolescence show a different percentage of Internet addicts. This means that there is a correlation between the age of adolescents and Internet addiction and it is weak, positive and statistically significant (χ2= 13.512; df = 3; N = 919; p = 0.004). The percentage of moderate and serious addicts grows with age: - Youngest (11-12) – 6% - Slightly older (13-14) – 12% - Older (15-16) – 19% - Oldest (17-18) – drops down to 13% The greatest contributors to this correlation are males (p = 0.001) and those adolescents who use the Internet predominately for entertainment (p = 0.038). Adolescents aged 15 – 16 demonstrate the highest degree of addiction, possibly because at this age they achieve a greater level of independence. Their free time and social activities are less controlled by their parents. Online communication has a strong influence on the developmental stages of adolescence. Adolescents share their experience through new forms of communication; they seek their own position within a group and report their friends as being a great source of social support, even greater than their parents [18]. A two-factor variance analysis was carried out utilizing the following variables: Dependent quantitative variable “Internet addiction” and factor 1, “the purpose of Internet use” with two modalities: school/work and entertainment. The second, independent categorical variable, “age group” had four modalities: 11-12, 13-14, 15-16 and 17-18. Regarding the analyzed sample of participants: There is no statistically significant influence of the purpose of Internet use on the level of Internet addiction, while there is a statistically significant influence of the age of participants on the level of Internet addiction. There is a statistically significant interaction between the purpose of Internet use and age with regard to the level of Internet addiction (p = 0.001). Comparing the eight mean values between themselves, we established that the lowest level of addiction occurs with the youngest group (11-12) who use the Internet for school (32.5). They are also the ones who use the Internet for entertainment the least (32.8). The highest level of Internet addiction occurs with the adolescents aged 15-16. Their purpose of use of the Internet for school is the highest (46.5) of the age groups, as is their use for the purposes of entertainment (39.3). Those aged 13-14 use the Internet more for entertainment (38.2) and less for school (34.2). The 17-18-year-old group uses the Internet at the percentage of 38.2 for school/work and 35.9 for entertainment. Single factor variance analysis (F test) was used to compare average values of Internet addiction in adolescents of different ages. These averages were calculated on the basis of answers given to the 20 questions in the questionnaire. They are the following: Ages 11 – 12 – 32.4 Ages 13 – 14 – 37.6 Ages 15 – 16 – 40.6 Ages 17 – 18 – 36.4 The average overall score was 37.8 and there is a statistically significant difference between the four averages (F = 14.461 with df = 3 and N = 919), as p < 0.001. Conclusions: Through the stages of adolescence, there is psychosocial adaptation to Internet addiction, whereby the degree of addiction is affected by the purpose of using the Internet, age, sex, and the country of origin of the respondents. As the use of the Internet rises for the purpose of school, so does the use for pleasure, in favor of entertainment; thus together, they are conducive to the development of Internet addiction. The development of addiction is more inclined to occur in the specific phases of adolescence of which our sample is comprised. We conclude the following: • There is no statistically significant influence of the purpose of Internet use on the level of Internet addiction (p > 0.05). • There is a statistically important influence of the age of participants on the level of Internet addiction (p < 0.001). • There is a statistically significant interaction between the purpose of Internet use and age regarding the level of Internet addiction (p = 0.001). In fact, it is during this period that adolescents’ curiosity is heightened and the need to be accepted in society, to be a part of the community is emphasized. The Internet is precisely the means which provides unlimited opportunities to access information anywhere and at any time as a global network connecting millions of people all over the world. Furthermore, it enables interaction with others in anonymity, providing opportunities for the exchange information as well as the experience and feeling of acceptance. Adolescents need time to resolve their identity crisis, to strengthen their positions in society, to find their career path and to create healthy relationships. Emotional control is an important mechanism by which the personal characteristics of the child and the child's environment, particularly the family, have an influence on the child's ability to adjust. It is during this period of adjustment that adolescents are at certain stages more sensitive and vulnerable to various addictive behaviours, including Internet addiction. Gross (1998) defines emotional control as the process by which individuals influence the emotions they will experience, when they will experience them and how they will express them [17]. In general, it can be concluded that emotional regulation helps individuals to comply their emotional expressions with the demands of their environment (behaviour control) and to protect themselves from negative, unpleasant emotions. It also helps individuals restrain themselves so that emotions do not interfere with their normal functioning (regulation of emotional experience) [18]. Adolescents often engage in risky behaviour (including addiction) in order to take control of their lives and deal with anxiety, frustration and failure easier [18]. For further analysis of the data obtained in this research, it will be necessary to focus on the analysis of the studied web content. Since it can encourage different forms of im/moral or un/ethical materials that can significantly affect the formation of adolescent groups at risk, it will be necessary to introduce supervision and prevention as well as limitation of certain undesirable sources. It is also an incentive for new analyses and interpretations that may be the key to suppressing Internet addiction in addition to the potential manipulation of available web material. Internet content can provide enormous opportunities if it is used sensibly and with the awareness of its positive educational and communication power, but with caution related to the moral and ethical. Limitations This research did not manage to clarify the relationship between the different development phases of adolescence and the growing number of Internet addicts. Another limitation of this study is that we have no specific clinical criteria for which children aged 15 - 16 are the most sensitive and most vulnerable to Internet addiction. So, the current findings increase our understanding of the relationships between internet addiction and different development phasesof adolescence.