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 Table of Contents  
INVITED REVIEW
Year : 2021  |  Volume : 37  |  Issue : 3  |  Page : 248-253

Behavioral addiction among children and adolescents – A review of qualitative studies


Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission20-Jul-2021
Date of Decision15-Sep-2021
Date of Acceptance17-Sep-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Harshini Manohar
Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_220_21

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  Abstract 


Background: With increasing accessibility to the virtual world, behavioral addiction is an emerging global concern among children and adolescents. Understanding attitudes and perceptions regarding behavioral addictions is critical to formulate appropriately tailored and meaningful interventions. This review aims to widen the scope of understanding behavioral addictions, by synthesizing findings from qualitative studies on perspectives, experiences, and key processes across the spectrum of behavioral addictions among children and adolescents. Methods: We conducted systematic search in PubMed and Google Scholar using keywords pertinent to qualitative research in behavioral addictions, adhering to enhancing transparency in reporting the synthesis of qualitative research guidelines. Eighteen studies were included after thorough screening of studies. We followed the analytical approach described by Petticrew and Roberts for thematic comparative synthesis. Results: There were five principal themes that articulate the experiential realities of children and adolescents in the context of behavioral addictions. They are (1) high-risk environment as a vulnerability: etiopathogenetic model for gambling, (2) attitudes toward behavioral addiction across the spectrum, (3) awareness, (4) perceived impact, and (5) perspectives and attitudes toward other's engagement in addictive behaviors. Conclusion: The findings have implications for public health policies such as promoting a supportive macrosystem while curtailing accessibility to activities and platforms of high addictive potentials. Future research in this area should include multiple stakeholder perspectives, perspectives of younger children and early adolescents, integration with quantitative findings, and studying the impact of particularly high-risk situations, such as the COVID-19 pandemic, to inform recommendations and policies, for comprehensive, multilevel, and multisystemic interventions.

Keywords: Behavioral addiction, children and adolescents, perspectives, qualitative studies, review


How to cite this article:
Manohar H, Thomas TL, Asokan K, Mukherjee N, Sharma E. Behavioral addiction among children and adolescents – A review of qualitative studies. Indian J Soc Psychiatry 2021;37:248-53

How to cite this URL:
Manohar H, Thomas TL, Asokan K, Mukherjee N, Sharma E. Behavioral addiction among children and adolescents – A review of qualitative studies. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Dec 8];37:248-53. Available from: https://www.indjsp.org/text.asp?2021/37/3/248/327284




  Introduction Top


Behavioral addictions are similar to substance addictions, in phenomenology, age of onset around adolescence/young adulthood, and a chronic relapsing course, however, they have a behavioral focus instead of ingestion of a substance.[1],[2] International classificatory systems do not yet recognize all kinds of behavioral addictions, except gambling and internet gaming, which are distinct diagnoses.[3]

The dramatic expansion and easy accessibility of digital technology have resulted in exposure/use starting at an early age, perhaps contributing to increasing prevalence of behavioral addictions.[4],[5] In adolescents, this is compounded by normative developmental vulnerabilities. Behavioral addictions negatively impact academic performance, mental health, and sleep quality.[6],[7] Comorbid psychological and physical health problems have a bidirectional relationship. During the COVID-19 pandemic, containment measures (home confinement, social distancing, and school closures) lead a large number of adolescents to spending increasing amounts of time with digital technologies that could potentially trigger behavioral addictions in vulnerable children and adolescents.[8]

Quantitative studies have examined behavioral addictions in youth, commonly to assess prevalence and predictors of development and maintenance of these disorders. Qualitative methodologies are unique in their ability to capture in-depth experiences and perspectives. This review of qualitative studies aims to widen the scope of understanding regarding behavioral addictions, by synthesizing findings of perspectives, experiences, and key processes across the spectrum of behavioral addictions among children and adolescents.


  Methods Top


This review adheres to the enhancing transparency in reporting the synthesis of qualitative research guidelines[9] that provide a comprehensive framework for conducting narrative qualitative synthesis, ensuring systematic reporting and credibility of findings.

Search strategy

The search strategy is detailed in Appendix I. Keywords were chosen based on an operational definition of “behavioral addiction.”[10] Database search was supplemented by bibliographic cross-referencing of included studies. Lead author (HM) conducted the title/abstract screening for studies retrieved by the initial searches. Any two reviewers were involved at the full text and data extraction steps, for each study. [Figure 1] depicts the search and selection processes.
Figure 1: Search outcome: Implementation of search strategies and selection of studies

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Selection criteria for studies

Original qualitative research studies, focusing on behavioral addiction, among children and adolescents (age <20 years), published in English, in peer-reviewed journals were eligible for inclusion.

Data extraction

Data extraction was done using a semi-structured pro forma and tabulated. Extracted data included study objectives, sampling methods, sample characteristics, qualitative method used, analytic approach, key themes and constructs identified, and quotes relevant to the themes and constructs. A pilot phase of data extraction for at least two studies by each author was done to ascertain inter-rater reliability. Data extraction was done by two independent authors, and conflicts arising at any stage were resolved in discussion with a third reviewer. The critical appraisal Skills program checklist was used for quality assessment of included studies.[11]

Analytical approach

We used the analytical approach described by Petticrew and Roberts for thematic synthesis with constant comparison.[12] Thematic synthesis has been applied in several systematic reviews that address research questions related to people's perspectives and experiences.[13] In the first stage, studies that were included were organized into broad categories based upon specific behavioral addiction examined or area of inquiry (patterns of use, consequences of use, etc.) In the second stage, findings of studies within each category were analyzed, and themes and subthemes were created inductively. Themes/subthemes in consecutive studies were compared with those already arrived at, and either incorporated or new themes/subthemes created as appropriate. Synthesized themes and subthemes were concurred upon during team discussions. The last stage involved synthesizing findings across all the studies included for analysis.


  Results Top


Eighteen studies were included in the final review [Supplementary Table 1]. These studies present data from 989 participants, age range 6–20 years, with a focus on internet and technology use (n = 4),[14],[15],[16],[17] gambling (n = 3),[18],[19],[20] gaming (n = 2),[21],[22] and social media addiction (n = 9),[23],[24],[25],[26],[27],[28],[29],[30],[31] respectively. Only one study included adolescents with mental health morbidity.[25] Results of the critical appraisal of studies are presented in [Supplementary Table 2]. Most studies reported details on quality criteria such as aims, qualitative methodology, recruitment source, data collection, analytic approach, and findings. However, only a minority adequately addressed justification of research design and analytical approach, how the relationship between the researcher and participants may have influenced findings, and analytical triangulation, member checking, or respondent validation.



[Figure 2] depicts the derivation and organization of themes and subthemes. Initial coding was to identify the area of inquiry (patterns of use, perspectives, experiences). The next level codes depicted reasons and the functions of behavioral addiction patterns (social, relational, pleasure, physical health, mental health). First-order constructs reflect study participants' views as presented in the excerpts and second-order constructs reflect authors' interpretations. The initial framework of coding was agreed upon by consensus and refined in accordance with the objectives of the review. Codes were organized into five principal themes that articulate the experiential realities of behavioral addictions in children and adolescents. These psychological constructs are clearly delineated in their implications and influences on motivation and behavior.
Figure 2: Conceptual map of thematic synthesis

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Theme 1. High-risk environment as a vulnerability: Etiopathogenetic model for gambling

Studies on pathological gambling highlight the crucial role of high-risk sociocultural environments as a vulnerability for behavioral addictions. Youth attitudes toward gambling, influenced by societal perceptions, ranged from positive, for friendly gambling and low stakes, to negative, for addiction and legalized forms of gambling.[18] Association of the community gambling venues with family-friendly and school activities influenced children's overall positive perception and a reduced risk/harm perception.[20] Further, modeling by adult gambling behavior triggered the use of electronic gambling machines among children.[19] Despite negative perceptions toward pathological gambling, children were unaware of the pathways toward addiction and did not feel the need for information related to problems associated with gambling.[18]

Theme 2. Attitudes toward behavioral addiction across the spectrum

Attitude refers to a relatively enduring and general evaluation of object, person, group, issue, or concept, on a dimension ranging from negative to positive.[32] Diverse attitudes related to the internet and social media, ranging from positive and favorable, to negative attitudes of social media being a problematic space have been reported.[24],[26] Parents are often concerned that children spend excessive time on phones and worry about the negative consequences on their daily lives, whereas adolescents' perspectives differ.[25],[30] The subthemes on attitudes are described below.

Reasons for usage

Time spent on the internet is divided across social media, school work, and other activities.[23] Emotional (mood and feelings,[22] boredom or stress), social (lack of friends or as a social activity requirement to ensure that current events are not missed),[15],[31] and functional (feeling of fulfilling a task or escapism) factors trigger internet use. Social media is often intermingled with social life,[15],[31] becoming almost irreplaceable.[14] Being an introvert[14] and belonging to complex and dysfunctional family environments[22] are prominent vulnerabilities.

Positive experiences

Adolescents reported positive experiences include making social connections and establishing friendships,[25],[26] searching for positive content,[25] and peer validation.[22],[23],[25],[27],[28] Subthemes include connectedness, validation, and engagement.

Connectedness

Social media is a way out when physical distance is an obstacle in maintaining friendships, a central aspect of adolescent life. Adolescents cited an utility of social media in improving social skills.[26]

Validation

The portrayal of relationships in social media, like Instagram, is a positive experience appreciated through followers and “likes.”[24] Peer validation on social media is almost equivalent or superior to real-life validation.[14],[23],[29]

Engagement

Boredom evasion is a common reason triggering internet use.[14]

Attitudes toward addiction

Adolescents with pathological video gaming perceive various benefits of gaming, including learning, positive interactions with players, and gaining self-esteem,[22] however, perceived adverse consequences are related to physical health[16] and mental health.[22]

Theme 3. Awareness

Awareness is defined as perception or knowledge of something, which in turn influences accurate reportability.[32] While attitudes and perspectives reflect on the developmental needs and social cues that influence behavior, awareness is a key factor that provides scope for intervention.

Awareness of the addictive nature

Awareness of addictive patterns of use, and individual needs met through these behavioral patterns, is a key discriminating factor between adaptive and maladaptive users.[14] Maladaptive users have low awareness and “no harm” perception. Adolescents with self-awareness of poor regulatory capacities, identify themselves as “excessive users” or “addicted,” and report need for external regulation to achieve moderation.[14]

Awareness of the “virtual space”

Permanency of online content is a key aspect contributing to lack of safety and adverse consequences including cyberbullying and impact on mental health. Many participants discussed the ease of sharing personal content even among strangers.[25],[30]

Awareness of the consequences

Influence on the developing sense of self

Many participants reported online posting and interactions result in cyberbullying or “being attacked” and “being judged by peers.”[23],[25],[29] Efforts to gain peer affiliation and perceived invalidation and rejection are key processes impacting the developing sense of self in the adolescent population.

Interference: Cognitive salience and wasting time

Addictive behaviors and related cognitions with their constant interference and “wasting time” are a primary source of conflict and negative personal consequences. Interference impedes effective time management and self-regulatory capacities, often extending the time spent online.[14],[16]

Constant social comparison

Visibility of social relationships and social status on networking sites has negative consequences. Quantification of likes or followers reinforces validation seeking in the online environment, resulting in upward social comparison with peers and super peers. Adolescents described how positive biases in online content influence self-esteem and self-perception.

Expanding and contracting social circles

While social media expands online peer circles, many adolescents reported substituting offline with online peer interactions. Differing perspectives were reported on the social boost and the superficial nature of online friendships and relationships.[14],[28],[31]

Power of anonymity

Anonymity on social networking platforms is a facilitator, as tasks are “easier” online.[14],[27] Communication through online platforms was perceived to bypass embarrassments and shyness in face-to-face communication. On the other hand, inappropriate content from strangers results in online victimization.[25],[27]

Theme 4. Perceived impact

Physical health

Young children have reported physical health problems such as eye strain, headache, tiredness as a direct impact of excessive technology use.[16],[17] Physical health experiences were linked to poor eating habits, because of playing online games for extended time.

Mental health

Mental health experiences included impact on self-esteem and mood,[22] cognitive salience experiences, such as interference from sexual or gory images and aggressive online content, and sleeping problems.[16],[17]

Self-concept

Losing, or peer judgment of performance, is a source of frustration, anger, and sadness resulting in lowered self-worth and social isolation.[22] Girls reported being dissatisfied with their overall attractiveness within the context of social comparison.[29]

Relationships

A study on impact of heavy gaming among peers and teachers reported problems related to affective regulation, self-control, communication issues, selective social relationships, and behavioral problems.[21] Social media allow easy communication, and initiation and maintenance of friendships,[27] while there is loss of real-life friendships. Heavy gamers who reported in physical assaults and bullying also had significant intra-familial conflicts.[22]

Theme 5. Perspectives regarding other's engagement in addictive behaviors

Perspective is defined as the capacity of an individual to take into account and potentially understand the perceptions, attitudes, or behaviors of himself or herself and of other individuals.[32]

Perspectives regarding adult behaviors

Understanding perspectives related to others' behaviors is essential, as it influences and shapes children's perception and attitudes toward addiction and reinforces addictive behaviors. Children felt that adults indulge in addictive behaviors for fun, to relieve stress or to win money; and they minimized these effects when it comes to their known persons.[18],[20]

Perspectives regarding peer behaviors

Children felt annoyed regarding peer's excessive gaming and social media presence. Some adolescents expressed that peers are more “media focused,” than building on self.[25],[27],[29] Perceived harmful effects were minimized when it came to themselves.[27] Peers' behavioral addiction was perceived to hamper their quality time and face-to-face communication. High engagement in virtual social connections impaired quality friendships and relationships.[15]


  Discussion Top


Our synthesis identifies attitudes, perspectives, and critical processes toward behavioral addiction in children and adolescents. The account of experiences and consequences ranges from positive experiences and adaptive reasons for use, among the moderate users, to perceiving negative consequences and more severe mental health impact, among maladaptive users. Awareness is a key factor influencing change readiness and motivation and lack of the same maintained addictive patterns.

Qualitative responses viewed from a developmental lens suggest that developmentally appropriate needs are being satisfied by engagement in addictive behaviors. Adolescents' online engagement and motivation for use are related to social connectedness, peer affiliation, validation, and emotional needs, providing a sense of self and belonging. The complementary and facilitative functionality of online environments (gaming, social networking, etc.) emphasize their appropriateness to the developmental context. Easy accessibility, exposure to behavioral addictions in family-friendly environments and being introduced to them as safe and friendly, in developmentally appropriate settings, results in positive perceptions. Watching adult behaviors and the perceived acceptance influences and shapes children's attitudes and perceptions.

Key concerns that emerged in our synthesis were a lack of awareness of the pathways to addiction, positive perception of addictive behaviors, and a desire to continue them in the future. “No harm perception” among excessive users was commonly attributed to the functional value and compensatory use of online platforms to satisfy their offline needs. This contrasts with the accumulating research on harms and adverse consequences experienced by children using online platforms and technologies.[33] There is a need to understand the critical processes leading to this perception to identify key intervention strategies.

Children and adolescents with better self-regulation capacities, adequate parental supervision, using online platforms for social facilitation supplementary to offline experiences were aware of the negative consequences. “Positive self bias” influences reporting adverse consequences for others and minimizing effects on self. Studies including adolescents with depression[25] have emphasized that high online engagement is a maladaptive coping pattern, and the complexity of the bidirectional influence is a maintaining factor for excessive use. Hence, it is crucial to screen for excessive internet, or social media use among the adolescents presenting with emotional disorders to the mental health services and vice versa.

Limitations of the review

This qualitative synthesis has focused only on perspectives and experiences of children and adolescents related to behavioral addictions. Parents' and stakeholder perspectives regarding this emerging problem were not reviewed. All the studies included in this review were conducted in high-income countries. Hence, the results may not be generalizable to societies with differing perspectives and exposures due to sociocultural variations.


  Conclusion Top


Understanding the perspectives of children and adolescents regarding behavioral addiction is critical to formulating appropriately tailored interventions. The findings of the synthesis have implications for public health policies such as promoting a supportive macrosystem while curtailing accessibility to activities and platforms of high addictive potentials. Future reviews in this area should focus on synthesizing findings from multiple stakeholder perspectives, perspectives of younger children and early adolescents, integration with quantitative findings, and studying the impact of particularly high-risk situations, such as the COVID-19 pandemic, to inform recommendations and policies, for comprehensive, multilevel, and multisystemic interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix I: Search strategy

We conducted a keywords search using the terms “Qualitative” AND (”Children” OR “adolescents” OR “young people”) AND (”internet” OR “internet addiction” OR “gaming addiction,” OR “smartphone addiction” OR “pathological gambling” OR “social media” OR “social media addiction” OR “behavioral addiction”) in the electronic databases PubMed and Google Scholar.



 
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