Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Contents lists available at ScienceDirect

Neuroscience and Biobehavioral Reviews

journal homepage: www.elsevier.com/locate/neubiorev

Review article

Systematic review and meta-analysis of epidemiology of internet addiction

Yuan-Chien Pan a, Yu-Chuan Chiu b, Yu-Hsuan Lin c, d, e, f, *
a
Department of Psychology, National Taiwan University, Taipei, Taiwan
b
Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan
c
Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
d
Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
e
Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
f
Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The field of internet addiction has experienced significant debates on conflicting epidemiology. This
Internet addiction meta-analysis investigated the prevalence rates of generalized internet addiction (GIA) and internet gaming
Generalized internet addiction disorder (IGD).
Internet gaming disorder
Methods: We included 113 epidemiologic studies covering 693,306 subjects published from 1996 to 2018 (for 31
Gaming disorder
Prevalence
nations) that reported prevalence rates for GIA or IGD. We examined pooled prevalence of GIA and IGD and the
Meta-analysis hypothesized moderators including year, geographic regions, types of scales, and sample representativeness.
Results: All 133 effect sizes included 53,184 subjects with GIA or IGD. Weighted average prevalence for GIA and
IGD were 7.02 % (95 % CI, 6.09 %–8.08 %) and 2.47 % (95 % CI, 1.46 %–4.16 %) respectively. For GIA,
prevalence was increased over time and prevalence rates variated among different scales. IGD prevalence was
neither moderated by year, regions, nor sample representativeness.
Conclusions: The prevalence of GIA was higher than the prevalence of IGD. The GIA prevalence was increasing
over time and variated with different assessments. Our results reveal that GIA may reflect a pattern of increasing
human-machine interaction.

1. Introduction developed based on the criteria of pathological gambling and substance

use disorder (Chen et al., 2003; King et al., 2020; Király et al., 2015;
Although Internet addiction has become a popular research topic for Young, 1998). Although internet addiction still lacked consistent diag­
more than two decades, the reported prevalence rates of internet nostic criteria, there were already a large amount studies that evaluated
addiction may still be influence by the wide range of conceptual ap­ the prevalence of internet addiction (Cheng and Li, 2014; Li et al., 2018;
proaches. Young (1996) first conceptualized internet addiction as a Shaw and Black, 2008).
generalized impulse control disorder based on its core psychopatholo­ In previous studies, the prevalence rates of internet addiction had
gy—impaired control. Griffiths (1996) described this kind of techno­ significant variance ranging from 0.8%–26.7 % (Kuss et al., 2014),
logical addiction as behavioral addiction that involves human-machine dependent on measurement and target population. Although the con­
interactions. Similarly, Beard (2005) claimed that internet addiction sequences of internet addiction have been widely researched in recent
should classify as a type of behavioral addition. In 2013, the American years, its prevalence and influencing factors are still unclear. For IGD
Psychiatric Association (APA) specified internet addiction as internet (APA, 2013) and Gaming Disorder (WHO, 2018), both diagnoses refer to
gaming disorder (IGD) in Section III research criteria of the DSM-5 (APA, functional impairments and unhealthy behaviors due to problematic
2013). The World Health Organization (WHO) has also listed “Gaming game use. A recent study found that 63.8 % participants with IGD also
Disorder” as a substance use and addictive disorders in the ICD-11 beta fulfilled the Gaming Disorder criteria (Ko et al., 2019). However, there
draft (WHO, 2018). However, the psychopathological foundation of remains uncertainty regarding optimal approaches to screening and
internet addiction is still controversial (King et al., 2018; Rumpf et al., assessment for IGD and Gaming Disorder (King et al., 2020; Ko et al.,
2018). Most self-report scales evaluating internet addiction were 2019). Most studies have evaluated IGD on the basis of nonstandard

* Corresponding author at: 35 Keyan Road, Zhunan, Miaoli County, 35053, Taiwan.
E-mail addresses: [email protected] (Y.-C. Pan), [email protected] (Y.-C. Chiu), [email protected] (Y.-H. Lin).

https://doi.org/10.1016/j.neubiorev.2020.08.013
Received 10 March 2020; Received in revised form 31 July 2020; Accepted 14 August 2020
Available online 25 August 2020
0149-7634/© 2020 Elsevier Ltd. All rights reserved.
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

approaches, such as questionnaires (Yao et al., 2017). Some researchers chapters were combed for other relevant studies. Epidemiologic studies
have cautioned against including Gaming Disorder in the ICD-11 published in English that reported prevalence rates of internet addiction
because of insufficient scientific evidence (van Rooij et al., 2018). were included. Authors made a consensus decision about any study with
Additionally, Griffiths and Pontes (2014) suggested that internet ambiguity about inclusion. Fig. 1 shows the flow diagram of literature
addiction and IGD may be different concepts. In a previous search. Some articles reported on more than one location of data
meta-analysis, Cheng and Li (2014) found that the pooled prevalence of collection (e.g. cross-country survey). In such cases, all reported effect
Internet addiction was 6.0 % in general population. Another recent sizes of prevalence rates were included in the meta-analysis. When more
meta-analysis investigated prevalence of IGD in adolescents and found than one study reported on the same sample, we chose the effect size
the pooled prevalence of IGD is 4.1 % (Fam, 2018). Previous empirical associated with the most recent and/or complete data from a given
research found that IGD was much more strongly associated with being study. The search was updated December 2018.
male. In addition, internet addiction was positively associated with
online chatting, online gaming, and social networking while IGD was 2.2. Study coding
only associated with online gaming (Király et al., 2014). A cross-cultural
study also suggested that internet addiction and IGD should be consid­ Data extraction and coding followed the same methods as a previous
ered separately as two constructs (Montag et al., 2015). All the evidence meta-analysis of the prevalence of Internet addiction (Cheng and Li,
was consistent with the viewpoint that specific internet addiction such 2014; Li et al., 2018). Data on prevalence of GIA and IGD, sample de­
as IGD should be distinguished from generalized internet addiction mographic data, country variables, assessment tools, cutoff point of
(Davis, 2001; Fineberg et al., 2018; Montag et al., 2015, 2019). To be assessment tools, sample representativeness were coded. The first author
clearer, we use “generalized internet addiction (GIA)” in the whole (YC Pan) and the corresponding author (YH Lin) in this study coded all
paragraph to represent the interchangeable terms usually described in studies.
previous studies such as internet addiction, internet addiction disorder,
or problematic internet use. 2.3. Meta-analysis
There was growing evidence that design features of studies, such as
year of surveys, geographical regions, assessment tools, and sample We used the metaphor and metaviz package in R to meta-analyze the
representativeness, may greatly influence the prevalence of GIA (Cheng data (Kossmeier et al., 2019; Viechtbauer, 2010). Prevalence rates were
and Li, 2014; Li et al., 2018; Rumpf et al., 2019). Recently, a transformed using logit transformation, in order to normalize the data
meta-analysis of GIA prevalence among university students observed distribution, with inverse variance weighting (Huedo-Medina et al.,
that prevalence rates were increasing year by year (Shao et al., 2018). 2006). A random effects model estimated the average weighted preva­
Among all countries, Asian countries have had the highest prevalence lence for GIA and IGD. We also calculated prevalence rates of GIA and
and the most significant problems with GIA (Aboujaoude et al., 2006; IGD for geographic regions separately. Cochran Q statistic assessed
Block, 2008; Ko et al., 2012). Previous reports showed that East Asian whether prevalence rates were homogeneous across samples. The de­
cultures have a higher prevalence rate of GIA than Western cultures, but gree of heterogeneity of estimates across studies is examined using I2
researchers suggested there was an inflated of prevalence rate in Eastern index (Huedo-Medina et al., 2006). The I2 value above 50 % and 75 %
culture studies (Kuss et al., 2014). In a meta-analysis covering studies signals the existence of heterogeneity and high heterogeneity respec­
from 31 countries to investigate geographical effect on GIA prevalence, tively (Higgins and Thompson, 2002). Mixed-effects meta-regression
the highest prevalence was in the Middle East (10.9 %) and the lowest in tested whether prevalence of GIA and IGD changed over time or across
Northern and Western Europe (2.6 %) in the general population (Cheng regions, controlling other design predictors. Meta-regression analyses
and Li, 2014). A recent survey for IGD showed prevalence varied were then carried out to identify moderators that explained the het­
significantly across different countries (Przybylski et al., 2017). In erogeneity of prevalence.
addition, the divergent prevalence rates could be explained by differ­
ences in assessment tools, cut-offs used, and sample representativeness. 3. Results
For example, a meta-analysis found GIA prevalence were significantly
higher in studies using 20-item Internet Addiction Test (IAT) and The search netted a total of 133 effect sizes from 31 different coun­
26-item Chen Internet Addiction Scale (CIAS) than those using 8-item tries, from studies conducted from 2003 to 2018, covering 53,184 cases
Young Diagnostic Questionnaire (YDQ) (Li et al., 2018). Furthermore, with GIA and IGD, with a total of 693,306 participants. Table 1 lists all
many current epidemiologic studies of GIA adopted non-representative the studies included in the analyses. Funnel plot and Egger test indicated
samples (which included the use of convenience samples or lack of publication bias, with a tendency to omit studies with high rates for both
proactive recruitment) and may have impacted the prevalence rates. GIA (t = -2.18, df = 114, p = .031) and IGD (t = -2.68, df = 15, p = .017).
Due to the impact of these factors on prevalence of GIA, it is necessary to The pooled prevalence for GIA and IGD were 7.02 % (95 % CI, 6.09 %–
re-examine these moderators of GIA and IGD prevalence with 8.08 %) and 2.47 % (95 % CI, 1.46 %–4.16 %), respectively. There was
meta-analysis. significant heterogeneity among GIA studies (QE = 28760.22, df = 115, p
In light with consideration, there is a need to examine prevalence of < .0001; H2 = 250.09, I2 = 99.60 %) and among IGD studies (QE =
GIA and IGD and corresponding moderators. Our primary aim was to 1512.96, df = 16, p < .0001; H2 = 94.56, I2 = 98.94 %). Forest plot of
determine the pooled prevalence rates of GIA and IGD around the world. GIA and IGD prevalence by study were shown in Figs. 2 and 3,
Moderators of interest included: 1) year of publication; 2) geographic respectively.
regions (i.e. Eastern vs. Western countries); 3) different tools for
assessing GIA; 4) sample representativeness (i.e. representative vs. non- 3.1. Meta-regression analyses
representative samples).
Table 2 shows GIA and IGD prevalence and the effect of hypothesized
2. Methods moderators. For studies reported prevalence rates of GIA (k = 117), the
prevalence of GIA significantly increases with year of publication (β =
2.1. Search strategy 0.006, p = .002). Fig. 4 demonstrates the change in prevalence rates of
GIA overtime. The pooled prevalence is 16.00 % for CIAS, 8.51 % for
Searches of PubMed and PsycINFO used the terms (epidemiology OR IAT, 5.06 % for YDQ, and 4.17 % for other tools. In addition, the pooled
prevalence) AND (internet addiction OR isnternet gaming disorder OR prevalence rates are significantly higher in studies using CIAS (β =
problematic internet use). Reference lists from related articles and 0.083, p = .002) than YDQ. For studies using IAT to assess rates of GIA (k

613
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Fig. 1. Flow Diagram of Literature Search.

= 61), there was a significant difference in prevalence between using prevalence is divergent among different tools used for assessing GIA.
strict (i.e. score more than 60) or broad (i.e. score more than 50) defi­ Almost all of them diagnosed GIA by self-reported scales rather than
nition of cutoff point (R2 = 38.07 %, QM = 22.513, p < .001). using structured interview based on diagnostic criteria. Previous studies
Geographic regions did not significantly explain variance in the rate of adopted different diagnostic models for evaluating core psychopathol­
GIA (β = –0.015, p = .377). Sample representativeness also did not ogy of GIA. For example, due to Young (1998) conceptualized GIA as a
significantly explain variance in the rate of GIA (β = –0.027, p = .119). generalized impulse control disorder, YDQ and IAT were further con­
For studies that reported prevalence rate of IGD (k = 16), year of structed based on the diagnostic criteria of pathological gambling in
publication (β = 0.008, p = .512), geographic regions (β = 0.008, p = DSM-IV-TR (Young, 1996, 1998). Another study developed diagnostic
.299), and sample representativeness (β = 0.006, p = .807) did not criteria for GIA based on the diagnostic framework of substance use
significantly explain variance in the rate of IGD (Table 2). disorders (Ko et al., 2005). Consist with our finding, a previous
meta-analysis also found IA prevalence were significantly higher in
4. Discussion studies using IAT and CIAS than those using YDQ (Li et al., 2018). YDQ
was comprised of eight core symptoms for GIA. In contrast, IAT and CIAS
To our knowledge, this is the first meta-analysis directly comparing included more peripheral symptoms other than impaired control, such
prevalence rates of GIA and IGD. We extend previous works on GIA or as time management and social problems, which may generate over­
IGD prevalence (Cheng and Li, 2014; Fam, 2018; Li et al., 2018), to estimated prevalence rates. In addition, we also found a significant
independently compare prevalence rates of GIA and IGD and to difference in prevalence between using strict or broad definition of
completely include studies from 1996 to 2018. The pooled prevalence cutoff point for IAT. It is consistent to the finding of previous
for GIA (7.02 %) was higher than which for IGD (2.47 %). The GIA meta-analysis (Li et al., 2018). The heterogeneous prevalence rates
prevalence increased over time. This trend was not shown for the could be explained by differences in assessment tools and cut-offs used.
prevalence of IGD. Although GIA was proposed and became a popular Our results reveal that prevalence rates of GIA are increasing over
research topic since 1990s, there has been no consistent diagnostic time. A meta-analysis of GIA prevalence among university students also
criteria. A recent meta-analysis investigated prevalence of IGD in ado­ observed the prevalence reveals an increasing trend year by year (Shao
lescents and found the pooled prevalence of IGD was 4.1 % (Fam, 2018). et al., 2018). Our findings further examine the moderation effect of year
This analysis also found that studies applied validated measures based and found that only GIA but not IGD shows a rising time trend on
on IGD in DSM-5 were likely to reported lower prevalence and narrower prevalence. This trend is consistent with the increasing exposure of
confidence interval than the GIA studies adopted measures developed screen time over past decades (Madigan et al., 2019). There is a growing
from DSM criteria of pathological gambling. body of evidence supports that psychology should start to move away
Our primary findings show that the prevalence rates are significantly from a behavioral framework when investigating technology use (Pan­
different between GIA and IGD. It is consistent with the viewpoint that ova and Carbonell, 2018). GIA represents a behavioral pattern or
specific internet gaming addiction should be distinguished from GIA habituation involving frequent human–machine interactions for digital
(Davis, 2001; Montag et al., 2015). A large international study investi­ generations, and could possibly not be conceptualized as addictive or
gated clinical phenomenon and prevalence of IGD symptoms. They problematic (Ellis et al., 2019). The prevalence estimates of GIA may be
found that a very small proportion (1 %) of the general population met affected by methodological inconsistencies. In addition, an emerging but
the diagnosis of IGD (Przybylski et al., 2017). It may indicate that IGD is crucial issue is the reliability of diagnosis. Even with proposed diag­
a distinct entity from GIA. In addition, our results reveal that pooled nostic criteria of IGD in DSM-5, there is a continual lack of consensus on

614
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Table 1
Studies included in meta-analysis.
First Author Year of Publication Prevalence Total N Location Region (East/West) Measures

Generalized Internet Addiction (k = 116)

Ak 2013 5.00 % 4311 Turkey E IAT
Al-Gama 2016 40.00 % 587 Jordan E IAT
An 2014 11.70 % 13,723 China E IAT
Bakken 2009 1.00 % 3393 Norway W YDQ
Bener 2018 17.70 % 2350 Turkey E IAT
Bhandari 2017 35.40 % 937 Nepal E IAT
Bruno 2014 3.90 % 1035 Italy W IAT
Canan 2012 9.70 % 1034 Turkey E Other
Cao 2007 2.40 % 2620 China E YDQ
Chen 2015 11.40 % 1153 Taiwan E CIAS
Chen 2016 8.70 % 5249 China E IAT
Chi 2016 15.20 % 1173 China E IAT
Choi 2009 2.50 % 2336 Korea E IAT
Christakis 2011 4.00 % 307 US W IAT
Di Nicola 2017 22.10 % 996 Italy W IAT
Dufour 2016 18.00 % 3938 Canada W IAT
Durkee 2012 3.10 % 943 Austria W YDQ
Durkee 2012 5.30 % 1034 Estonia W YDQ
Durkee 2012 2.60 % 1003 France W YDQ
Durkee 2012 4.80 % 1438 Germany W YDQ
Durkee 2012 1.60 % 1008 Hungary W YDQ
Durkee 2012 3.80 % 1067 Ireland W YDQ
Durkee 2012 11.80 % 951 Israel E YDQ
Durkee 2012 1.20 % 1188 Italy W YDQ
Durkee 2012 4.60 % 1136 Romania W YDQ
Durkee 2012 5.80 % 1164 Slovenia W YDQ
Durkee 2012 4.30 % 1024 Spain W YDQ
Frangos 2011 12.00 % 2293 Greece W YDQ
Fu 2010 6.70 % 208 Hong Kong E YDQ
Ghassemzadeh 2008 1.90 % 1968 Iran E IAT
Gómez 2017 16.30 % 40,955 Spain W Other
Gong 2009 5.50 % 3018 China E YDQ
Guo 2018 2.20 % 20,895 China E IAT
Gupta 2018 25.30 % 380 India E IAT
Ha 2014 2.80 % 56,086 Korea E Other
Huang 2009 9.60 % 3496 China E YDQ
Islam 2016 24.00 % 573 Bangladesh E IAT
Jiang 2012 6.90 % 697 China E CIAS
Johansson 2004 2.00 % 1591 Norway W YDQ
Kaess 2016 11.50 % 1572 Estonia W YDQ
Kaess 2016 5.10 % 2573 Germany W YDQ
Kaess 2016 4.40 % 2138 Italy W YDQ
Kaess 2016 8.70 % 1245 Romania W YDQ
Kaess 2016 7.20 % 1339 Spain W YDQ
Kaltiala-Heino 2004 1.50 % 7229 Finland W Other
Kawabe 2016 2.00 % 835 Japan E IAT
Kim 2005 2.90 % 769 Korea E YDQ
Kim 2006 1.50 % 1573 Korea E IAT
Kim 2016 9.30 % 6510 Korea E IAT
Kitazawa 2018 38.20 % 1258 Japan E IAT
Ko 2007 17.70 % 517 Taiwan E CIAS
Ko 2009 10.80 % 2162 Taiwan E CIAS
Lam 2009 0.60 % 1618 China E IAT
Lau 2017 16.00 % 8286 Hong Kong E CIAS
Lau 2018 28.10 % 9666 Hong Kong E CIAS
Lee 2014 2.40 % 1217 Korea E Other
Li 2014 6.30 % 24,013 China E YDQ
Lin 2011 15.30 % 3616 Taiwan E CIAS
Lin 2018 17.40 % 2170 Taiwan E CIAS
Liu 2011 4.00 % 3560 US W Other
Liu 2017 17.10 % 2479 Taiwan E CIAS
Lopez-Fernandez 2013 5.00 % 1131 Spain W Other
Lu 2018 14.10 % 1385 China E IAT
Macur 2016 3.10 % 6029 Slovenia W Other
Malak 2017 6.30 % 716 Jordan E IAT
Mei 2016 5.50 % 1552 China E YDQ
Mihara 2016 7.90 % 100,050 Japan E YDQ
Müller 2014 2.10 % 2512 Germany W Other
Müller 2017 2.60 % 9293 Germany W Other
Ni 2009 6.40 % 3557 China E IAT
Niemz 2005 18.30 % 371 British W Other
Pallanti 2006 5.40 % 275 Italy W IAT
Pan 2018 23.00 % 1507 Taiwan E CIAS
(continued on next page)

615
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Table 1 (continued )
First Author Year of Publication Prevalence Total N Location Region (East/West) Measures

Park 2008 10.70 % 903 Korea E IAT

Park 2017 1.00 % 3723 Korea E YDQ
Poli 2012 0.80 % 2533 Italy W IAT
Poorolajal 2018 24.50 % 4261 Iran E IAT
Prabhakaran 2016 8.70 % 724 India E IAT
Reiner 2017 15.70 % 2410 Germany W Other
Rumpf 2014 1.00 % 14,022 Germany W Other
Sasmaz 2014 15.10 % 1156 Turkey E Other
Seyrek 2017 1.60 % 468 Turkey E IAT
Shek 2008 26.40 % 3328 Hong Kong E IAT
Shek 2016 17.00 % 3498 Hong Kong E IAT
Siomos 2012 16.10 % 1199 Greece W YDQ
Siomos 2008 8.20 % 2200 Greece W YDQ
Tabatabaee 2018 12.70 % 928 Iran E IAT
Takahashi 2018 5.40 % 8209 Japan E YDQ
Tang 2014 6.00 % 755 China E IAT
Tang 2018 8.00 % 1244 US W IAT
Tang 2018 9.30 % 1119 Singapore E IAT
Tang 2018 5.70 % 838 Hong Kong, Macau E IAT
Tang 2018 13.80 % 1090 China E IAT
Tang 2018 6.10 % 968 Korea E IAT
Tang 2018 6.50 % 1793 Taiwan E IAT
Tang 2018 12.90 % 1015 Japan E IAT
Tateno 2016 3.70 % 403 Japan E IAT
Tateno 2018 4.70 % 602 Japan E IAT
Thomas 2010 4.60 % 2031 Austria E YDQ
Tsai 2009 17.90 % 3806 Taiwan E CIAS
Ustinavičienė 2016 18.30 % 1806 Lithuania W YDQ
Vigna-Taglianti 2017 12.10 % 2022 Italy W IAT
Villella 2011 1.20 % 2853 Italy W IAT
Wang 2011 12.20 % 14,296 China E IAT
Wang 2016 16.00 % 9518 Hong Kong E CIAS
Wartberg 2015 3.20 % 1723 Germany W Other
Wartberg 2016 4.80 % 1444 Germany W YDQ
Whang 2003 3.50 % 13,588 Korea E IAT
Wu 2016 10.40 % 10,158 China E IAT
Wu 2016 25.30 % 2021 Hong Kong E IAT
Xin 2018 26.50 % 6468 China E IAT
Xu Xu et al., 2012 8.80 % 5122 China E Other
Yang 2018 15.50 % 4750 China E IAT
Yen 2007 17.90 % 2114 Taiwan E CIAS
Yoo 2014 3.00 % 74,980 Korea E Other
Zadra 2016 0.50 % 15,023 Germany W Other
Internet Gaming Disorder (k = 17)
Buiza-Aguado 2018 8.30 % 708 Spain W Gaming
Chiu 2018 3.10 % 8110 Taiwan E Gaming
De Pasquale 2018 14.90 % 221 Italy W Gaming
Evren 2018 1.00 % 1250 Turkey E Gaming
Männikkö 2015 8.20 % 293 Finland W Gaming
Milani 2018 2.10 % 612 Italy W Gaming
Pontes 2016 2.50 % 1071 Slovenia W Gaming
Przybylski 2017 1.00 % 1247 US W Gaming
Przybylski 2017 0.50 % 1899 UK W Gaming
Przybylski [Przybylski et al., 2017]2017 0.70 % 10,009 US, England W Gaming
Przybylski 2017 0.30 % 5888 US W Gaming
Rehbein [Rehbein et al., 2015]2015 1.20 % 11,003 Germany W Gaming
Wang [Wang et al., 2016]2018 10.80 % 7200 Korea E Gaming
Wartberg [Wartberg et al., 2017]2017 5.70 % 1531 Germany W Gaming
Wu [Wu et al., 2018]2018 2.00 % 1000 China E Gaming
Wu 2018 1.90 % 2147 Taiwan E Gaming
Yu [Yu and Cho, 2016]2016 5.90 % 2024 Korea E Gaming

Note. E, Eastern country; W, Western country; YDQ, Young diagnostic Questionnaire; IAT, Internet addiction test; CIAS, Chen Internet addiction scale.

how best to assess IGD (Pontes and Griffiths, 2014). It might explain why Eastern society are not more likely to develop GIA than people in
the heterogeneity is still high after considering design features of studies Western society in meta-regression model. Although there was signifi­
in the current analysis. Researchers and clinicians should begin to apply cant difference in GIA prevalence between Eastern (8.90 %) and Western
a common conceptualization to investigate GIA and IGD. Future (4.60 %) society in subgroup analysis, we found that people in Eastern
meta-analysis focused on the prevalence of IGD and Gaming Disorder is society are not more likely to develop GIA than people in Western so­
also crucial and urgently needed. ciety in meta-regression model. This result indicates that direct links
Previous studies have shown Eastern countries have higher preva­ between higher prevalence in Eastern countries to parenting attitude
lence rates of GIA than Western countries (Kuss et al., 2014). Such may be not a valid explanation. A previous meta-analysis also found that
cultural discrepancies have been linked to parenting attitude toward the pooled prevalence of GIA was 6.0 % in the general population with
Internet use (Griffiths et al., 2016). However, we found that people in the highest prevalence in the Middle East (10.9 %) and the lowest in

616
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Fig. 2. Forest Plot of GIA Prevalence by Study, Sorted by Year of Publication.

Northern and Western Europe (2.6 %) in the general population (Cheng countries is needed.
and Li, 2014). In addition, with the great demands for online activities in There are several methodological limitations that should be noted.
Eastern countries, it seems reasonable to see more addicted users in First, some factors were not reported in enough detail to be included as
these regions. Our results were inconsistent with other studies suggest­ moderators, such as symptom duration used in assessment tools. Second,
ing that GIA prevalence is inflated in Eastern oriental culture studies the current study did not account for the potential age differences in
(Cheng and Li, 2014; Fam, 2018). It is possible that, as progress of prevalence of GIA and IGD. Participants’ ages were initially coded in this
technology and time, the discrepancies of Internet use behaviors become study. However, comparison of the age groups is almost impossible due
similar worldwide. Therefore, more research on GIA and IGD in Eastern to inconsistent reports or lack of reports of age (i.e. 51 in 133 studies).

617
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Fig. 3. Forest Plot of IGD Prevalence by Study, Sorted by Year of Publication.

Table 2
Generalized Internet Addiction and Internet Gaming Disorder Prevalence by Geographic Region, Measures, and Sample Representativeness.
Subgroups Categories k Prevalence (%) 95 % CI (%) I2 Q p-valuea

GIA 116 7.02 6.09–8.08 99.60 % 28760.22 < .001

Geographic region East 73 8.90 7.46–10.59 99.67 % 22086.54 < .001
West 43 4.60 3.47–6.08 99.36 % 6571.47 < .001
Measures YDQ 34 5.06 4.35–5.87 97.78 % 1488.67 < .001
IAT 51 8.51 6.95–10.39 99.41 % 8409.09 < .001
CIAS 13 16.00 13.40–18.99 98.59 % 852.85 < .001
Other 18 4.17 2.49–6.90 99.84 % 10493.12 < .001
Representative sample Yes 86 6.06 5.14–7.14 99.66 % 24674.31 < .001
No 30 10.63 8.32–13.49 98.86 % 2532.85 < .001
IGD 17 2.47 1.46–4.16 98.94 % 1512.96 < .001
Geographic region East 6 3.10 1.54–6.16 98.98 % 492.13 < .001
West 11 2.19 1.06–4.46 98.32 % 594.56 <. 001
Representative sample Yes 10 3.38 2.18–5.19 97.08 % 308.01 <. 001
No 7 1.55 0.39–5.91 99.34 % 913.45 <. 001

Note. GIA, generalized Internet addiction; IGD, Internet gaming disorder; YDQ, Young diagnostic Questionnaire; IAT, Internet addiction test; CIAS, Chen Internet
addiction scale.
a
p-value stands the significant heterogeneity.

Therefore, we decided to omit coding age in the current study. Future also increasing with time. Mobile games have become a crucial factor in
study should consider the influence of age on prevalence of GIA and IGD. smartphone use and may need to be discussed separately (Liu et al.,
Third, the elements of game design are somewhat different between 2016). Further meta-analysis focused on IGD or mobile gaming is
computer gaming and mobile gaming. The diversity of internet games is needed. Fourth, our search strategy may neglect some studies which did

618
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

An, J., Sun, Y., Wan, Y., Chen, J., Wang, X., Tao, F., 2014. Associations between
problematic internet use and adolescents’ physical and psychological symptoms:
possible role of sleep quality. J. Addict. Med. 8, 282–287. https://doi.org/10.1097/
adm.0000000000000026.
Anusha Prabhakaran, M., Patel, V., Ganjiwale, D., Nimbalkar, M., 2016. Factors
associated with internet addiction among school-going adolescents in Vadodara.
J. Family Med. Prim. Care 5, 765–769. https://doi.org/10.4103/2249-4863.201149.
Bakken, I.J., Wenzel, H.G., Gotestam, K.G., Johansson, A., Oren, A., 2009. Internet
addiction among Norwegian adults: a stratified probability sample study. Scand. J.
Psychol. 50, 121–127. https://doi.org/10.1111/j.1467-9450.2008.00685.x.
Beard, K.W., 2005. Internet addiction: a review of current assessment techniques and
potential assessment questions. Cyberpsychology Behav. 8, 7–14. https://doi.org/
10.1089/cpb.2005.8.7.
Bener, A., Yildirim, E., Torun, P., Catan, F., Bolat, E., Alıç, S., et al., 2018. Internet
addiction, fatigue, and sleep problems among adolescent students: a large-scale
study. Int. J. Ment. Health Addict. https://doi.org/10.1007/s11469-018-9937-1.
Bhandari, P.M., Neupane, D., Rijal, S., Thapa, K., Mishra, S.R., Poudyal, A.K., 2017. Sleep
quality, internet addiction and depressive symptoms among undergraduate students
in Nepal. BMC Psychiatry 17, 106. https://doi.org/10.1186/s12888-017-1275-5.
Block, J.J., 2008. Issues for DSM-V: internet addiction. Am. J. Psychiatry 165, 306–307.
https://doi.org/10.1176/appi.ajp.2007.07101556.
Bruno, A., Scimeca, G., Cava, L., Pandolfo, G., Zoccali, R.A., Muscatello, M.R.A., 2014.
Prevalence of internet addiction in a sample of southern Italian high school students.
Int. J. Ment. Health Addict. 12, 708–715. https://doi.org/10.1007/s11469-014-
9497-y.
Buiza-Aguado, C., Alonso-Canovas, A., Conde-Mateos, C., Buiza-Navarrete, J.J.,
Gentile, D., 2018. Problematic video gaming in a young Spanish population:
association with psychosocial health. Cyberpsychol. Behav. Soc. Netw. 21, 388–394.
https://doi.org/10.1089/cyber.2017.0599.
Fig. 4. Prevalence Rates for Generalized Internet Addiction. The change in Canan, F., Ataoglu, A., Ozcetin, A., Icmeli, C., 2012. The association between Internet
rates of generalized Internet addiction is significant over time. Circle size in­ addiction and dissociation among Turkish college students. Compr. Psychiatry 53,
422–426. https://doi.org/10.1016/j.comppsych.2011.08.006.
dicates the weight due to sample size and precision of estimates. The solid line
Cao, F., Su, L., 2007. Internet addiction among Chinese adolescents: prevalence and
indicates the prevalence over time. The point line indicates the overall preva­ psychological features. Child Care Health Dev. 33, 275–281. https://doi.org/
lence of GIA (7.02 %). The dash lines indicate 95 % confidence interval 10.1111/j.1365-2214.2006.00715.x.
of prevalence. Chen, S.H., Weng, L.J., Su, Y.J., Wu, H.M., Yang, P.F., 2003. Development of a Chinese
internet addiction scale and its psychometric study. Chin. J. Psychol. 45, 279–294.
Chen, Y.L., Chen, S.H., Gau, S.S., 2015. ADHD and autistic traits, family function,
report the proportion of GIA or IGD but not use the word “prevalence” or parenting style, and social adjustment for Internet addiction among children and
“epidemiology” in the abstract. This strategy may avoid enhancing adolescents in Taiwan: a longitudinal study. Res. Dev. Disabil. 39, 20–31. https://
doi.org/10.1016/j.ridd.2014.12.025.
heterogeneity but may also omit some potential prevalence data.
Chen, Y., Kang, Y., Gong, W., He, L., Jin, Y., Zhu, X., Yao, Y., 2016. Investigation on
In conclusion, the prevalence of GIA is higher than the prevalence of internet addiction disorder in adolescents in Anhui, People’s Republic of China.
IGD. For GIA, the prevalence rates variated with year and are different Neuropsychiatr. Dis. Treat. 12, 2233–2236. https://doi.org/10.2147/ndt.S110156.
among assessment tools. For IGD, the prevalence was neither moderated Cheng, C., Li, A.Y., 2014. Internet addiction prevalence and quality of (real) life: a meta-
analysis of 31 nations across seven world regions. Cyberpsychol. Behav. Soc. Netw.
by year nor countries. The high heterogeneity of GIA prevalence may 17, 755–760. https://doi.org/10.1089/cyber.2014.0317.
due to methodological inconsistencies. For future prevalence study of Chi, X., Lin, L., Zhang, P., 2016. Internet addiction among college students in China:
GIA, it is crucial to adopted a consistent and precise assessment tool prevalence and psychosocial correlates. Cyberpsychol. Behav. Soc. Netw. 19,
567–573. https://doi.org/10.1089/cyber.2016.0234.
focused on core symptoms of GIA rather than time spent on internet. IGD Chiu, Y.C., Pan, Y.C., Lin, Y.H., 2018. Chinese adaptation of the Ten-Item Internet
is comparatively a more stable diagnostic concept, which is more Gaming Disorder Test and prevalence estimate of Internet gaming disorder among
appropriate to be applied to cross-cultural studies. adolescents in Taiwan. J. Behav. Addict. 7, 719–726. https://doi.org/10.1556/
2006.7.2018.92.
Choi, K., Son, H., Park, M., Han, J., Kim, K., Lee, B., Gwak, H., 2009. Internet overuse and
Financial support excessive daytime sleepiness in adolescents. Psychiatry Clin. Neurosci. 63, 455–462.
https://doi.org/10.1111/j.1440-1819.2009.01925.x.
Christakis, D.A., Moreno, M.M., Jelenchick, L., Myaing, M.T., Zhou, C., 2011.
This study was supported by grant from National Health Research Problematic internet usage in US college students: a pilot study. BMC Med. 9, 77.
Institutes of Taiwan (09A1-PHPP20-014). https://doi.org/10.1186/1741-7015-9-77.
Davis, R.A., 2001. A cognitive-behavioral model of pathological Internet use. Comput.
Human Behav. 17, 187–195. https://doi.org/10.1016/S0747-5632(00)00041-8.
Declaration of Competing Interest De Pasquale, C., Dinaro, C., Sciacca, F., 2018. Relationship of Internet gaming disorder
with dissociative experience in Italian university students. Ann. Gen. Psychiatry 17,
All authors declare that they have no conflict of interest. 28. https://doi.org/10.1186/s12991-018-0198-y.
Di Nicola, M., Ferri, V.R., Moccia, L., Panaccione, I., Strangio, A.M., Tedeschi, D., et al.,
2017. Gender differences and psychopathological features associated with addictive
Acknowledgement behaviors in adolescents. Front. Psychiatry 8, 256. https://doi.org/10.3389/
fpsyt.2017.00256.
Dufour, M., Brunelle, N., Tremblay, J., Leclerc, D., Cousineau, M.M., Khazaal, Y., et al.,
We thank Ms. Hsiao-Han Lin’s excellent technical assistance. 2016. Gender difference in internet use and internet problems among Quebec high
school students. Can. J. Psychiatry 61, 663–668. https://doi.org/10.1177/
References 0706743716640755.
Durkee, T., Kaess, M., Carli, V., Parzer, P., Wasserman, C., Floderus, B., et al., 2012.
Prevalence of pathological internet use among adolescents in Europe: demographic
Aboujaoude, E., Koran, L.M., Gamel, N., Large, M.D., Serpe, R.T., 2006. Potential
and social factors. Addiction 107, 2210–2222. https://doi.org/10.1111/j.1360-
markers for problematic internet use: a telephone survey of 2,513 adults. CNS
0443.2012.03946.x.
Spectr. 11, 750–755.
Ellis, D.A., Davidson, B.I., Shaw, H., Geyer, K., 2019. Do smartphone usage scales predict
Ak, S., Koruklu, N., Yilmaz, Y., 2013. A study on Turkish adolescent’s Internet use:
behavior? Int. J. Hum. Stud. 130, 86–92. https://doi.org/10.1016/j.
possible predictors of Internet addiction. Cyberpsychol. Behav. Soc. Netw. 16,
ijhcs.2019.05.004.
205–209. https://doi.org/10.1089/cyber.2012.0255.
Evren, C., Dalbudak, E., Topcu, M., Kutlu, N., Evren, B., Pontes, H.M., 2018.
Al-Gamal, E., Alzayyat, A., Ahmad, M.M., 2016. Prevalence of internet addiction and its
Psychometric validation of the turkish nine-item internet gaming disorder scale-
association with psychological distress and coping strategies among university
short form (IGDS9-SF). Psychiatry Res. 265, 349–354. https://doi.org/10.1016/j.
students in Jordan. Perspect. Psychiatr. Care 52, 49–61. https://doi.org/10.1111/
psychres.2018.05.002.
ppc.12102.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental
Disorders, 5th edition.

619
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

Fam, J.Y., 2018. Prevalence of internet gaming disorder in adolescents: a meta-analysis King, D.L., Chamberlain, S.R., Carragher, N., Billieux, J., Stein, D., Mueller, K., et al.,
across three decades. Scand. J. Psychol. 59, 524–531. https://doi.org/10.1111/ 2020. Screening and assessment tools for gaming disorder: A comprehensive
sjop.12459. systematic review. Clin. Psychol. Rev. 77, 101831 https://doi.org/10.1016/j.
Fineberg, N.A., Demetrovics, Z., Stein, D.J., Ioannidis, K., Potenza, M.N., Grünblatt, E., cpr.2020.101831.
et al., 2018. Manifesto for a European research network into Problematic Usage of Király, O., Griffiths, M., D, Urban, R., Farkas, J., Kokonyei, G., Elekes, Z., et al., 2014.
the Internet. Eur. Neuropsychopharmacol. 28, 1232–1246. https://doi.org/10.1016/ Problematic internet use and problematic online gaming are not the same: findings
j.euroneuro.2018.08.004. from a large nationally representative adolescent sample. Cyberpsychol. Behav. Soc.
Frangos, C.C., Frangos, C.C., Sotiropoulos, I., 2011. Problematic internet use among Netw. 17, 749–754. https://doi.org/10.1089/cyber.2014.0475.
Greek university students: an ordinal logistic regression with risk factors of negative Király, O., Griffiths, M.D., Demetrovics, Z., 2015. Internet gaming disorder and the DSM-
psychological beliefs, pornographic sites, and online games. Cyberpsychol. Behav. 5: conceptualization, debates, and controversies. Curr. Addict. Rep. 2, 254–262.
Soc. Netw. 14, 51–58. https://doi.org/10.1089/cyber.2009.0306. https://doi.org/10.1007/s40429-015-0066-7.
Fu, K.W., Chan, W.S., Wong, P.W., Yip, P.S., 2010. Internet addiction: prevalence, Kitazawa, M., Yoshimura, M., Murata, M., Sato-Fujimoto, Y., Hitokoto, H., Mimura, M.,
discriminant validity and correlates among adolescents in Hong Kong. Br. J. et al., 2018. Associations between problematic Internet use and psychiatric
Psychiatry 196, 486–492. https://doi.org/10.1192/bjp.bp.109.075002. symptoms among university students in Japan. Psychiatry Clin. Neurosci. 72,
Ghassemzadeh, L., Shahraray, M., Moradi, A., 2008. Prevalence of internet addiction and 531–539. https://doi.org/10.1111/pcn.12662.
comparison of internet addicts and non-addicts in Iranian high schools. Ko, C.H., Yen, J.Y., Chen, C.C., Chen, S.H., Yen, C.F., 2005. Proposed diagnostic criteria
Cyberpsychology Behav. 11, 731–733. https://doi.org/10.1089/cpb.2007.0243. of Internet addiction for adolescents. J. Nerv. Ment. Dis. 193, 728–733. https://doi.
Gómez, P., Rial, A., Braña, T., Golpe, S., Varela, J., 2017. Screening of problematic org/10.1097/01.nmd.0000185891.13719.54.
internet use among Spanish adolescents: prevalence and related variables. Ko, C.H., Yen, J.Y., Yen, C.F., Lin, H.C., Yang, M.J., 2007. Factors predictive for incidence
Cyberpsychol. Behav. Soc. Netw. 20, 259–267. https://doi.org/10.1089/ and remission of internet addiction in young adolescents: a prospective study.
cyber.2016.0262. Cyberpsychology Behav. 10, 545–551. https://doi.org/10.1089/cpb.2007.9992.
Gong, J., Chen, X., Zeng, J., Li, F., Zhou, D., Wang, Z., 2009. Adolescent addictive Ko, C.H., Yen, J.Y., Chen, C.S., Yeh, Y.C., Yen, C.F., 2009. Predictive values of psychiatric
internet use and drug abuse in Wuhan, China. Addict. Res. Theory 17, 291–305. symptoms for internet addiction in adolescents: a 2-year prospective study. Arch.
https://doi.org/10.1080/16066350802435152. Pediatr. Adolesc. Med. 163, 937–943. https://doi.org/10.1001/
Griffiths, M.D., 1996. Gambling on the internet: a brief note. J. Gambl. Stud. 12, archpediatrics.2009.159.
471–473. https://doi.org/10.1007/BF01539190. Ko, C.H., Yen, J.Y., Yen, C.F., Chen, C.S., Chen, C.C., 2012. The association between
Griffiths, M.D., Pontes, H., 2014. Internet addiction disorder and internet gaming Internet addiction and psychiatric disorder: a review of the literature. Eur.
disorder are not the same. Addict. Res. Theory 5, e124. https://doi.org/10.4172/ Psychiatry 27, 1–8. https://doi.org/10.1016/j.eurpsy.2010.04.011.
2155-6105.1000e124. Ko, C.H., Lin, H.C., Lin, P.C., Yen, J.Y., 2019. Validity, functional impairment and
Griffiths, M.D., Kuss, D.J., Billieux, J., Pontes, H.M., 2016. The evolution of Internet complications related to Internet gaming disorder in the DSM-5 and gaming disorder
addiction: a global perspective. Addict. Behav. 53, 193–195. https://doi.org/ in the ICD-11. Aust. N. Z. J. Psychiatry 54, 707–718. https://doi.org/10.1177/
10.1016/j.addbeh.2015.11.001. 0004867419881499.
Guo, L., Luo, M., Wang, W.X., Huang, G.L., Xu, Y., Gao, X., et al., 2018. Association Kossmeier, M., Tran, U.S., Voracek, M., 2019. Visual inference for the funnel plot in
between problematic Internet use, sleep disturbance, and suicidal behavior in meta-analysis. Zeitschrift für Psychologie 227, 83–89. https://doi.org/10.1027/
Chinese adolescents. J. Behav. Addict. 7, 965–975. https://doi.org/10.1556/ 2151-2604/a000358.
2006.7.2018.115. Kuss, D.J., Griffiths, M.D., Karila, L., Billieux, J., 2014. Internet addiction: a systematic
Gupta, A., Khan, A., Rajoura, O., Srivastava, S., 2018. Internet addiction and its mental review of epidemiological research for the last decade. Curr. Pharm. Des. 20,
health correlates among undergraduate college students of a university in North 4026–4052.
India. J. Family Med. Prim. Care 7, 721–727. https://doi.org/10.4103/jfmpc.jfmpc_ Lam, L.T., Peng, Z., Mai, J., Jing, J., 2009. The association between internet addiction
266_17. and self-injurious behaviour among adolescents. Inj. Prev. 15, 403–408. https://doi.
Ha, Y.-M., Hwang, W.J., 2014. Gender differences in internet addiction associated with org/10.1136/ip.2009.021949.
psychological health indicators among adolescents using a national web-based Lau, J.T.F., Gross, D.L., Wu, A.M.S., Cheng, K.M., Lau, M.M.C., 2017. Incidence and
survey. Int. J. Ment. Health Addict. 12, 660–669. https://doi.org/10.1007/s11469- predictive factors of Internet addiction among Chinese secondary school students in
014-9500-7. Hong Kong: a longitudinal study. Soc. Psychiatry Psychiatr. Epidemiol. 52, 657–667.
Higgins, J.P.T., Thompson, S.G., 2002. Quantifying heterogeneity in a meta-analysis. https://doi.org/10.1007/s00127-017-1356-2.
Stat. Med. 21, 1539–1558. https://doi.org/10.1002/sim.1186. Lau, J.T.F., Walden, D.L., Wu, A.M.S., Cheng, K.M., Lau, M.C.M., Mo, P.K.H., 2018.
Huang, R.L., Lu, Z., Liu, J.J., You, Y.M., Pan, Z.Q., Wei, Z., et al., 2009. Features and Bidirectional predictions between Internet addiction and probable depression among
predictors of problematic internet use in Chinese college students. Behav. Inf. Chinese adolescents. J. Behav. Addict. 7, 633–643. https://doi.org/10.1556/
Technol. 28, 485–490. https://doi.org/10.1080/01449290701485801. 2006.7.2018.87.
Huedo-Medina, T.B., Sanchez-Meca, J., Marin-Martinez, F., Botella, J., 2006. Assessing Lee, J.Y., Shin, K.M., Cho, S.M., Shin, Y.M., 2014. Psychosocial risk factors associated
heterogeneity in meta-analysis: Q statistic or I2 index? Psychol. Methods 11, with internet addiction in Korea. Psychiatry Investig. 11, 380–386. https://doi.org/
193–206. https://doi.org/10.1037/1082-989x.11.2.193. 10.4306/pi.2014.11.4.380.
Islam, M.A., Hossin, M.Z., 2016. Prevalence and risk factors of problematic internet use Li, Y., Zhang, X., Lu, F., Zhang, Q., Wang, Y., 2014. Internet addiction among elementary
and the associated psychological distress among graduate students of Bangladesh. and middle school students in China: a nationally representative sample study.
Asian J. Gambl. Issues Public Health 6, 11. https://doi.org/10.1186/s40405-016- Cyberpsychol. Behav. Soc. Netw. 17, 111–116. https://doi.org/10.1089/
0020-1. cyber.2012.0482.
Jiang, D., Zhu, S., Ye, M., Lin, C., 2012. Cross-sectional survey of prevalence and Li, L., Xu, D.D., Chai, J.X., Wang, D., Li, L., Zhang, L., et al., 2018. Prevalence of Internet
personality characteristics of college students with internet addiction in Wenzhou, addiction disorder in Chinese university students: A comprehensive meta-analysis of
China. Shanghai Arch. Psychiatry 24, 99–107. https://doi.org/10.3969/j.issn.1002- observational studies. J. Behav. Addict. 7, 610–623. https://doi.org/10.1556/
0829.2012.02.005. 2006.7.2018.53.
Johansson, A., Gotestam, K.G., 2004. Internet addiction: characteristics of a Lin, M.P., Ko, H.C., Wu, J.Y., 2011. Prevalence and psychosocial risk factors associated
questionnaire and prevalence in Norwegian youth (12-18 years). Scand. J. Psychol. with internet addiction in a nationally representative sample of college students in
45, 223–229. https://doi.org/10.1111/j.1467-9450.2004.00398.x. Taiwan. Cyberpsychol. Behav. Soc. Netw. 14, 741–746. https://doi.org/10.1089/
Kaess, M., Parzer, P., Brunner, R., Koenig, J., Durkee, T., Carli, V., et al., 2016. cyber.2010.0574.
Pathological internet use is on the rise among European adolescents. J. Adolesc. Lin, M.-P., Wu, J.Y.-W., You, J., Hu, W.-H., Yen, C.-F., 2018. Prevalence of internet
Health 59, 236–239. https://doi.org/10.1016/j.jadohealth.2016.04.009. addiction and its risk and protective factors in a representative sample of senior high
Kaltiala-Heino, R., Lintonen, T., Rimpelä, A., 2004. Internet addiction? Potentially school students in Taiwan. J. Adolesc. 62, 38–46. https://doi.org/10.1016/j.
problematic use of the Internet in a population of 12–18 year-old adolescents. adolescence.2017.11.004.
Addict. Res. Theory 12, 89–96. https://doi.org/10.1080/1606635031000098796. Liu, T.C., Desai, R.A., Krishnan-Sarin, S., Cavallo, D.A., Potenza, M.N., 2011. Problematic
Kawabe, K., Horiuchi, F., Ochi, M., Oka, Y., Ueno, S.-i., 2016. Internet addiction: Internet use and health in adolescents: data from a high school survey in
prevalence and relation with mental states in adolescents. Psychiatry Clin. Neurosci. Connecticut. J. Clin. Psychiatry 72, 836–845. https://doi.org/10.4088/
70, 405–412. https://doi.org/10.1111/pcn.12402. JCP.10m06057.
Kim, J.S., Chun, B.C., 2005. Association of internet addiction with health promotion Liu, C.H., Lin, S.H., Pan, Y.C., Lin, Y.H., 2016. Smartphone gaming and frequent use
lifestyle profile and perceived health status in adolescents. J. Prev. Med. Public pattern associated with smartphone addiction. Medicine 95, e4068. https://doi.org/
Health 38, 53–60. 10.1097/md.0000000000004068.
Kim, K., Ryu, E., Chon, M.Y., Yeun, E.J., Choi, S.Y., Seo, J.S., Nam, B.W., 2006. Internet Liu, H.-C., Liu, S.-I., Tjung, J.-J., Sun, F.-J., Huang, H.-C., Fang, C.-K., 2017. Self-harm
addiction in Korean adolescents and its relation to depression and suicidal ideation: and its association with internet addiction and internet exposure to suicidal thought
a questionnaire survey. Int. J. Nurs. Stud. 43, 185–192. https://doi.org/10.1016/j. in adolescents. J. Formos. Med. Assoc. 116, 153–160. https://doi.org/10.1016/j.
ijnurstu.2005.02.005. jfma.2016.03.010.
Kim, B.-S., Chang, S.M., Park, J.E., Seong, S.J., Won, S.H., Cho, M.J., 2016. Prevalence, Lopez-Fernandez, O., Freixa-Blanxart, M., Honrubia-Serrano, M.L., 2013. The
correlates, psychiatric comorbidities, and suicidality in a community population problematic internet entertainment use scale for adolescents: prevalence of problem
with problematic Internet use. Psychiatry Res. 244, 249–256. https://doi.org/ internet use in Spanish high school students. Cyberpsychol. Behav. Soc. Netw. 16,
10.1016/j.psychres.2016.07.009. 108–118. https://doi.org/10.1089/cyber.2012.0250.
King, D.L., Delfabbro, P.H., Potenza, M.N., Demetrovics, Z., Billieux, J., Brand, M., 2018. Lu, L., Xu, D.D., Liu, H.Z., Zhang, L., Ng, C.H., Ungvari, G.S., et al., 2018. Internet
Internet gaming disorder should qualify as a mental disorder. Aust. N. Z. J. addiction in Tibetan and Han Chinese middle school students: prevalence,
Psychiatry 52, 615–617. https://doi.org/10.1177/0004867418771189.

620
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

demographics and quality of life. Psychiatry Res. 268, 131–136. https://doi.org/ Reiner, I., Tibubos, A.N., Hardt, J., Muller, K., Wolfling, K., Beutel, M.E., 2017. Peer
10.1016/j.psychres.2018.07.005. attachment, specific patterns of internet use and problematic internet use in male
Macur, M., Kiraly, O., Maraz, A., Nagygyorgy, K., Demetrovics, Z., 2016. Prevalence of and female adolescents. Eur. Child Adolesc. Psychiatry 26, 1257–1268. https://doi.
problematic internet use in Slovenia. Zdr Varst 55, 202–211. https://doi.org/ org/10.1007/s00787-017-0984-0.
10.1515/sjph-2016-0026. Rumpf, H.J., Vermulst, A.A., Bischof, A., Kastirke, N., Gurtler, D., Bischof, G., et al.,
Madigan, S., Browne, D., Racine, N., Mori, C., Tough, S., 2019. Association between 2014. Occurence of internet addiction in a general population sample: a latent class
screen time and children’s performance on a developmental screening Test analysis. Eur. Addict. Res. 20, 159–166. https://doi.org/10.1159/000354321.
Association between screen time and child Development Association between screen Rumpf, H.J., Achab, S., Billieux, J., Bowden-Jones, H., Carragher, N., Demetrovics, Z.,
time and child development. JAMA Pediatr. 173, 244–250. https://doi.org/ et al., 2018. Including gaming disorder in the ICD-11: The need to do so from a
10.1001/jamapediatrics.2018.5056. %J JAMA Pediatrics. clinical and public health perspective. J. Behav. Addict. 7, 556–561. https://doi.org/
Malak, M.Z., Khalifeh, A.H., Shuhaiber, A.H., 2017. Prevalence of Internet Addiction and 10.1556/2006.7.2018.59.
associated risk factors in Jordanian school students. Comput. Human Behav. 70, Rumpf, H.J., Brandt, D., Demetrovics, Z., Billieux, J., Carragher, N., Brand, M., et al.,
556–563. https://doi.org/10.1016/j.chb.2017.01.011. 2019. Epidemiological challenges in the study of behavioral addictions: a call for
Mannikko, N., Billieux, J., Kaariainen, M., 2015. Problematic digital gaming behavior high standard methodologies. Curr. Addict. Rep. 6, 331–337. https://doi.org/
and its relation to the psychological, social and physical health of Finnish 10.1007/s40429-019-00262-2.
adolescents and young adults. J. Behav. Addict. 4, 281–288. https://doi.org/ Sasmaz, T., Oner, S., Kurt, A.O., Yapici, G., Yazici, A.E., Bugdayci, R., Sis, M., 2014.
10.1556/2006.4.2015.040. Prevalence and risk factors of Internet addiction in high school students. Eur. J.
Mei, S., Yau, Y.H.C., Chai, J., Guo, J., Potenza, M.N., 2016. Problematic Internet use, Public Health 24, 15–20. https://doi.org/10.1093/eurpub/ckt051.
well-being, self-esteem and self-control: data from a high-school survey in China. Seyrek, S., Cop, E., Sinir, H., Ugurlu, M., Senel, S., 2017. Factors associated with Internet
Addict. Behav. 61, 74–79. https://doi.org/10.1016/j.addbeh.2016.05.009. addiction: cross-sectional study of Turkish adolescents. Pediatr. Int. 59, 218–222.
Mihara, S., Osaki, Y., Nakayama, H., Sakuma, H., Ikeda, M., Itani, O., et al., 2016. https://doi.org/10.1111/ped.13117.
Internet use and problematic Internet use among adolescents in Japan: a nationwide Shao, Y.J., Zheng, T., Wang, Y.Q., Liu, L., Chen, Y., Yao, Y.S., 2018. Internet addiction
representative survey. Addict. Behav. Rep. 4, 58–64. https://doi.org/10.1016/j. detection rate among college students in the People’s Republic of China: a meta-
abrep.2016.10.001. analysis. Child Adolesc. Psychiatry Ment. Health 12, 25. https://doi.org/10.1186/
Milani, L., La Torre, G., Fiore, M., Grumi, S., Gentile, D.A., Ferrante, M., et al., 2018. s13034-018-0231-6.
Internet gaming addiction in adolescence: risk factors and maladjustment correlates. Shaw, M., Black, D.W., 2008. Internet addiction: definition, assessment, epidemiology
Int. J. Ment. Health Addict. 16, 888–904. https://doi.org/10.1007/s11469-017- and clinical management. CNS Drugs 22, 353–365. https://doi.org/10.2165/
9750-2. 00023210-200822050-00001.
Montag, C., Bey, K., Sha, P., Li, M., Chen, Y.F., Liu, W.Y., et al., 2015. Is it meaningful to Shek, D.T.L., Yu, L., 2016. Adolescent internet addiction in Hong Kong: prevalence,
distinguish between generalized and specific Internet addiction? Evidence from a change, and correlates. J. Pediatr. Adolesc. Gynecol. 29, S22–S30. https://doi.org/
cross-cultural study from Germany, Sweden, Taiwan and China. Asia-pacific 10.1016/j.jpag.2015.10.005.
Psychiatry 7, 20–26. https://doi.org/10.1111/appy.12122. Shek, D.T., Tang, V.M., Lo, C.Y., 2008. Internet addiction in Chinese adolescents in Hong
Montag, C., Wegmann, E., Sariyska, R., Demetrovics, Z., Brand, M., 2019. How to Kong: assessment, profiles, and psychosocial correlates. Sci. World J. 8, 776–787.
overcome taxonomical problems in the study of Internet use disorders and what to https://doi.org/10.1100/tsw.2008.104.
do with “smartphone addiction”? J. Behav. Addict. 1–7. https://doi.org/10.1556/ Siomos, K.E., Dafouli, E.D., Braimiotis, D.A., Mouzas, O.D., Angelopoulos, N.V., 2008.
2006.8.2019.59. Internet addiction among Greek adolescent students. Cyberpsychology Behav. 11,
Muller, K.W., Dreier, M., Duven, E., Giralt, S., Beutel, M.E., Wolfling, K., 2017. Adding 653–657. https://doi.org/10.1089/cpb.2008.0088.
clinical validity to the statistical power of large-scale epidemiological surveys on Siomos, K., Floros, G., Fisoun, V., Evaggelia, D., Farkonas, N., Sergentani, E., et al., 2012.
internet addiction in adolescence: a combined approach to investigate Evolution of Internet addiction in Greek adolescent students over a two-year period:
psychopathology and development-specific personality traits associated with the impact of parental bonding. Eur. Child Adolesc. Psychiatry 21, 211–219. https://
internet addiction. J. Clin. Psychiatry 78, e244–e251. https://doi.org/10.4088/ doi.org/10.1007/s00787-012-0254-0.
JCP.15m10447. Tabatabaee, H.R., Rezaianzadeh, A., Jamshidi, M., 2018. Mediators in the relationship
Müller, K.W., Glaesmer, H., Brähler, E., Woelfling, K., Beutel, M.E., 2014. Prevalence of between internet addiction and body mass index: a path model approach using
internet addiction in the general population: results from a German population- partial least square. J. Res. Health Sci. 18, e00423.
based survey. Behav. Inf. Technol. 33, 757–766. https://doi.org/10.1080/ Takahashi, M., Adachi, M., Nishimura, T., Hirota, T., Yasuda, S., Kuribayashi, M.,
0144929X.2013.810778. Nakamura, K., 2018. Prevalence of pathological and maladaptive Internet use and
Ni, X., Yan, H., Chen, S., Liu, Z., 2009. Factors influencing internet addiction in a sample the association with depression and health-related quality of life in Japanese
of freshmen university students in China. Cyberpsychology Behav. 12, 327–330. elementary and junior high school-aged children. Soc. Psychiatry Psychiatr.
https://doi.org/10.1089/cpb.2008.0321. Epidemiol. 53, 1349–1359. https://doi.org/10.1007/s00127-018-1605-z.
Niemz, K., Griffiths, M., Banyard, P., 2005. Prevalence of pathological Internet use Tang, J., Yu, Y., Du, Y., Ma, Y., Zhang, D., Wang, J., 2014. Prevalence of internet
among university students and correlations with self-esteem, the General Health addiction and its association with stressful life events and psychological symptoms
Questionnaire (GHQ), and disinhibition. Cyberpsychology Behav. 8, 562–570. among adolescent internet users. Addict. Behav. 39, 744–747. https://doi.org/
https://doi.org/10.1089/cpb.2005.8.562. 10.1016/j.addbeh.2013.12.010.
Pallanti, S., Bernardi, S., Quercioli, L., 2006. The shorter PROMIS Questionnaire and the Tang, C.S.K., Wu, A.M.S., Yan, E.C.W., Ko, J.H.C., Kwon, J.H., Yogo, M., et al., 2018.
Internet Addiction Scale in the assessment of multiple addictions in a high-school Relative risks of Internet-related addictions and mood disturbances among college
population: prevalence and related disability. CNS Spectr. 11, 966–974. students: a 7-country/region comparison. Public Health 165, 16–25. https://doi.org/
Pan, P.-Y., Yeh, C.-B., 2018. Internet addiction among adolescents may predict Self- 10.1016/j.puhe.2018.09.010.
Harm/Suicidal behavior: a prospective study. J. Pediatr. 197, 262–267. https://doi. Tateno, M., Teo, A.R., Shirasaka, T., Tayama, M., Watabe, M., Kato, T.A., 2016. Internet
org/10.1016/j.jpeds.2018.01.046. addiction and self-evaluated attention-deficit hyperactivity disorder traits among
Panova, T., Carbonell, X., 2018. Is smartphone addiction really an addiction? J. Behav. Japanese college students. Psychiatry Clin. Neurosci. 70, 567–572. https://doi.org/
Addict. 7, 252–259. https://doi.org/10.1556/2006.7.2018.49. 10.1111/pcn.12454.
Park, S.K., Kim, J.Y., Cho, C.B., 2008. Prevalence of Internet addiction and correlations Tateno, M., Teo, A.R., Shiraishi, M., Tayama, M., Kawanishi, C., Kato, T.A., 2018.
with family factors among South Korean adolescents. Adolescence 43. Prevalence rate of Internet addiction among Japanese college students: Two cross-
Park, S., Jeon, H.J., Bae, J.N., Seong, S.J., Hong, J.P., 2017. Prevalence and psychiatric sectional studies and reconsideration of cut-off points of Young’s Internet Addiction
comorbidities of internet addiction in a nationwide sample of Korean adults. Test in Japan. Psychiatry Clin. Neurosci. 72, 723–730. https://doi.org/10.1111/
Psychiatry Investig. 14, 879–882. https://doi.org/10.4306/pi.2017.14.6.879. pcn.12686.
Poli, R., Agrimi, E., 2012. Internet addiction disorder: prevalence in an Italian student Thomas, N.J., Martin, F.H., 2010. Video-arcade game, computer game and Internet
population. Nord. J. Psychiatry 66, 55–59. https://doi.org/10.3109/ activities of Australian students: participation habits and prevalence of addiction.
08039488.2011.605169. Aust. J. Psychol. 62, 59–66. https://doi.org/10.1080/00049530902748283.
Pontes, H.M., Griffiths, M.D., 2014. Assessment of internet gaming disorder in clinical Tsai, H.F., Cheng, S.H., Yeh, T.L., Shih, C.C., Chen, K.C., Yang, Y.C., Yang, Y.K., 2009.
research: past and present perspectives. Clin. Res. Regul. Aff. 31, 35–48. https://doi. The risk factors of Internet addiction—a survey of university freshmen. Psychiatry
org/10.3109/10601333.2014.962748. Res. 167, 294–299. https://doi.org/10.1016/j.psychres.2008.01.015.
Pontes, H.M., Macur, M., Griffiths, M.D., 2016. Internet gaming disorder among Ustinaviciene, R., Skemiene, L., Luksiene, D., Radisauskas, R., Kaliniene, G.,
Slovenian primary schoolchildren: findings from a nationally representative sample Vasilavicius, P., 2016. Problematic computer game use as expression of Internet
of adolescents. J. Behav. Addict. 5, 304–310. https://doi.org/10.1556/ addiction and its association with self-rated health in the Lithuanian adolescent
2006.5.2016.042. population. Medicina (Kaunas) 52, 199–204. https://doi.org/10.1016/j.
Poorolajal, J., Mohammadi, Y., Soltanian, A.R., Ahmadpoor, J., 2018. The top six risky medici.2016.04.002.
behaviors among Iranian university students: a national survey. J. Public Health van Rooij, A.J.E., Ferguson, C.J.E., Colder Carras, M., Kardefelt-Winther, D., Shi, J.,
(Oxf). https://doi.org/10.1093/pubmed/fdy204. Aarseth, E.E., et al., 2018. A weak scientific basis for gaming disorder: let us err on
Przybylski, A.K., Weinstein, N., Murayama, K., 2017. Internet gaming disorder: the side of caution. J. Behav. Addict. 7, 1–9. https://doi.org/10.1556/
investigating the clinical relevance of a new phenomenon. Am. J. Psychiatry 174, 2006.7.2018.19.
230–236. https://doi.org/10.1176/appi.ajp.2016.16020224. Viechtbauer, W., 2010. Conducting meta-analyses in r with the metafor package. J. Stat.
Rehbein, F., Kliem, S., Baier, D., Mossle, T., Petry, N.M., 2015. Prevalence of Internet Softw. 36 (2010), 1–48. https://doi.org/10.18637/jss.v036.i03.
gaming disorder in German adolescents: diagnostic contribution of the nine DSM-5 Vigna-Taglianti, F., Brambilla, R., Priotto, B., Angelino, R., Cuomo, G., Diecidue, R.,
criteria in a state-wide representative sample. Addiction 110, 842–851. https://doi. 2017. Problematic internet use among high school students: prevalence, associated
org/10.1111/add.12849.

621
Y.-C. Pan et al. Neuroscience and Biobehavioral Reviews 118 (2020) 612–622

factors and gender differences. Psychiatry Res. 257, 163–171. https://doi.org/ Wu, A.M.S., Chen, J.H., Tong, K.K., Yu, S., Lau, J.T.F., 2018. Prevalence and associated
10.1016/j.psychres.2017.07.039. factors of Internet gaming disorder among community dwelling adults in Macao,
Villella, C., Martinotti, G., Di Nicola, M., Cassano, M., La Torre, G., Gliubizzi, M.D., et al., China. J. Behav. Addict. 7, 62–69. https://doi.org/10.1556/2006.7.2018.12.
2011. Behavioural addictions in adolescents and young adults: results from a Wu, C.-Y., Lee, M.-B., Liao, S.-C., Ko, C.-H., 2019. A nationwide survey of the prevalence
prevalence study. J. Gambl. Stud. 27, 203–214. https://doi.org/10.1007/s10899- and psychosocial correlates of internet addictive disorders in Taiwan. J. Formos.
010-9206-0. Med. Assoc. 118, 514–523. https://doi.org/10.1016/j.jfma.2018.10.022.
Wang, H., Zhou, X., Lu, C., Wu, J., Deng, X., Hong, L., 2011. Problematic internet use in Xin, M., Xing, J., Pengfei, W., Houru, L., Mengcheng, W., Hong, Z., 2018. Online
high school students in Guangdong Province, China. PLoS One 6, e19660. https:// activities, prevalence of Internet addiction and risk factors related to family and
doi.org/10.1371/journal.pone.0019660. school among adolescents in China. Addict. Behav. Rep. 7, 14–18. https://doi.org/
Wang, Y., Wu, A.M.S., Lau, J.T.F., 2016. The health belief model and number of peers 10.1016/j.abrep.2017.10.003.
with internet addiction as inter-related factors of Internet addiction among Xu, J., Shen, L.X., Yan, C.H., Hu, H., Yang, F., Wang, L., Kotha, S.R., Zhang, L.N., Liao, X.
secondary school students in Hong Kong. BMC Public Health 16, 272. https://doi. P., Zhang, J., Ouyang, F.X., Zhang, J.S., Shen, X.M., 2012. Personal characteristics
org/10.1186/s12889-016-2947-7. related to the risk of adolescent internet addiction: a survey in Shanghai, China. BMC
Wang, H.R., Cho, H., Kim, D.J., 2018. Prevalence and correlates of comorbid depression Public Health 12, 1106. https://doi.org/10.1186/1471-2458-12-1106.
in a nonclinical online sample with DSM-5 internet gaming disorder. J. Affect. Yang, J., Guo, Y., Du, X., Jiang, Y., Wang, W., Xiao, D., et al., 2018. Association between
Disord. 226, 1–5. https://doi.org/10.1016/j.jad.2017.08.005. problematic internet use and sleep disturbance among adolescents: the role of the
Wartberg, L., Kriston, L., Kammerl, R., Petersen, K.U., Thomasius, R., 2015. Prevalence of child’s sex. Int. J. Environ. Res. Public Health 15. https://doi.org/10.3390/
pathological internet use in a representative German sample of adolescents: results ijerph15122682.
of a latent profile analysis. Psychopathology 48, 25–30. https://doi.org/10.1159/ Yao, Y.W., Potenza, M.N., Zhang, J.T., 2017. Internet gaming disorder within the DSM-5
000365095. framework and with an eye toward ICD-11. Psychiatry 174, 486–487. https://doi.
Wartberg, L., Brunner, R., Kriston, L., Durkee, T., Parzer, P., Fischer-Waldschmidt, G., org/10.1176/appi.ajp.2017.16121346.
et al., 2016. Psychopathological factors associated with problematic alcohol and Yen, J.Y., Ko, C.H., Yen, C.F., Wu, H.Y., Yang, M.J., 2007. The comorbid psychiatric
problematic Internet use in a sample of adolescents in Germany. Psychiatry Res. 240, symptoms of Internet addiction: attention deficit and hyperactivity disorder (ADHD),
272–277. https://doi.org/10.1016/j.psychres.2016.04.057. depression, social phobia, and hostility. J. Adolesc. Health 41, 93–98. https://doi.
Wartberg, L., Kriston, L., Thomasius, R., 2017. The prevalence and psychosocial org/10.1016/j.jadohealth.2007.02.002.
correlates of internet gaming disorder. Dtsch. Arztebl. Int. 114, 419–424. https:// Yoo, Y.S., Cho, O.H., Cha, K.S., 2014. Associations between overuse of the internet and
doi.org/10.3238/arztebl.2017.0419. mental health in adolescents. Nurs. Health Sci. 16, 193–200. https://doi.org/
Whang, L.S., Lee, S., Chang, G., 2003. Internet over-users’ psychological profiles: a 10.1111/nhs.12086.
behavior sampling analysis on internet addiction. Cyberpsychology Behav. 6, Young, K.S., 1996. Psychology of computer use: XL. Addictive use of the Internet: a case
143–150. https://doi.org/10.1089/109493103321640338. that breaks the stereotype. Psychol. Rep. 79, 899–902. https://doi.org/10.2466/
World Health Organization, 2018. International Classification of Diseases for Mortality pr0.1996.79.3.899.
and Morbidity Statistics (11th Revision). Retrieved from. https://icd.who. Young, K.S., 1998. Internet addiction: the emergence of a new clinical disorder.
int/browse11/l-m/en. Cyberpsychology Behav. 1, 237–244. https://doi.org/10.1089/cpb.1998.1.237.
Wu, C.S.T., Wong, H.T., Yu, K.F., Fok, K.W., Yeung, S.M., Lam, C.H., Liu, K.M., 2016a. Yu, H., Cho, J., 2016. Prevalence of internet gaming disorder among Korean adolescents
Parenting approaches, family functionality, and internet addiction among Hong and associations with non-psychotic psychological symptoms, and physical
Kong adolescents. BMC Pediatr. 16, 130. https://doi.org/10.1186/s12887-016- aggression. Am. J. Health Behav. 40, 705–716. https://doi.org/10.5993/
0666-y. AJHB.40.6.3.
Wu, X.S., Zhang, Z.H., Zhao, F., Wang, W.J., Li, Y.F., Bi, L., et al., 2016b. Prevalence of Zadra, S., Bischof, G., Besser, B., Bischof, A., Meyer, C., John, U., Rumpf, H.-J., 2016. The
Internet addiction and its association with social support and other related factors association between Internet addiction and personality disorders in a general
among adolescents in China. J. Adolesc. 52, 103–111. https://doi.org/10.1016/j. population-based sample. J. Behav. Addict. 5, 691–699. https://doi.org/10.1556/
adolescence.2016.07.012. 2006.5.2016.086.

622