ORIGINAL ARTICLE Print ISSN 1738-3684 / On-line ISSN 1976-3026

https://doi.org/10.30773/pi.2023.0178 OPEN ACCESS

Psychiatry Investig 2024 January 12 [Epub ahead of print]

Adolescent Screen Use: Problematic Internet Use and

the Impact of Gender
Sheila Rejane Niskier1,2 , Lindsey A. Snaychuk3, Hyoun S. Kim3,4,5,
Thiago T. da Silva1, Maria Sylvia de Souza Vitalle1, and Hermano Tavares2
1
Adolescent Medicine Outpatient Program, Pediatrics Department, Universidade Federal de Sao Paulo-Escola Paulista de Medicina, São Paulo, Brazil
2
Impulse Control Disorder and Behavioral Addictions Outpatient Unit (PRO-AMITI), Institute of Psychiatry (IPq), Hospital das Clínicas HCFMUSP,
Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
3
Department of Psychology, Toronto Metropolitan University, Toronto, Canada
4
University of Ottawa Institute of Mental Health Research at The Royal, Ottawa, Canada
5
Department of Psychology, University of Calgary, Calgary, Canada

Objective The relationship between screen use and problematic internet use (PIU; i.e., internet addiction) amongst adolescents has not
been sufficiently explored. Further, there is even less research on how gender is associated with this relationship. The goal of the study
was to examine adolescent screen use, PIU, and its impact on day-to-day routines of adolescents.
Methods Participants were recruited from an outpatient pediatric clinic in São Paulo, Brazil. A total of 180 adolescents completed ques-
tionnaires related to their screen use, extracurricular activities, and symptoms of PIU. Univariate and multivariate statistics were used to
determine correlates and predictors of PIU, and to explore gender differences.
Results A total of 26.1% of adolescents met the criteria for PIU. There were no significant differences between boys and girls in PIU se-
verity. However, there were significant gender differences in preferred use of the Internet, with boys being more likely to access the Inter-
net to play video games (odds ratio [OR]=27.1) and girls being more likely to socialize with friends (OR=4.51). PIU severity increased
proportionally to the number of hours of use of all screen devices with moderate-to-large effect sizes (η2=0.060–0.157). Using screens dur-
ing meals and missing extracurricular activities were both associated with PIU.
Conclusion Though gender was not associated with PIU, both excessive use of screen devices during meals and neglect of offline extra-
curriculars activities were identified as risk factors for PIU. Prevention measures should consider the impact of gender and associated pat-
terns of motivation and Internet use. Psychiatry Investig

Keywords Problematic internet use; Screen time; Internet addiction; Gender differences.

INTRODUCTION some, as scholars debated the potential harms of binge-watch-

ing TV and its addictive potential.1 A similar reaction is likely
The dawn of television (TV) transformed societies and their to occur every time new technology grows in popularity, even
relationship with information. Even the domestic space and comics were not free from public concern regarding their like-
family dynamics went through changes as TV sets became al- ly disturbing effects over youngsters’ minds.2
most ubiquitous in each household living-room. Parents and However, the post-modern era does seem to have amassed
children gathered around the “magic screen” that promised a not one, but a host of technological innovations that together
window to the world. The invention of TV was concerning to provide unprecedented social and behavioral changes at an
Received: June 1, 2023 Revised: August 21, 2023 accelerated pace that has never been seen before. First came
Accepted: September 13, 2023 personal computers, which became another omnipresent do-
 Correspondence: Sheila Rejane Niskier, MD, MSc
Adolescent Medicine Outpatient Program, Pediatrics Department, Universidade
mestic device, rapidly followed by more portable versions
Federal de Sao Paulo-Escola Paulista de Medicina, Rua Botucatu, 715, Vila Cle- (notebooks, tablets, etc.). Coupled with the Internet, the con-
mentino, São Paulo 04023-062, Brazil
Tel: +55-(11)-55764848 (VOIP: 3014), E-mail: [email protected] tent of such screen-based devices went through an exponen-
cc This is an Open Access article distributed under the terms of the Creative Commons tial growth, which is still ongoing. Then came the smartphone,
Attribution Non-Commercial License (https://creativecommons.org/licenses/by-
nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduc-
which combined the Internet and telecommunication all amal-
tion in any medium, provided the original work is properly cited. gamated in a single device.3

Copyright © 2024 Korean Neuropsychiatric Association 1

Gender Differences in Adolescent Screen Use

Consequently, new generations face unprecedented access addressed by approaches specific to the problematic behav-
to technological content, which may be associated with be- ior.15 Indeed, gender differences are evident with regards to
havioral challenges such as the excessive use of social media, use of digital technologies. Specifically, many studies have
video game playing, message exchange apps, relationship plat- found that girls tend to use the Internet primarily to access so-
forms, video streaming, consumption of pornography and on- cial media platforms and socialize, whereas boys tend to use
line sexual content, which may lead to addictive like behav- it more for entertainment purposes, such as playing video
iors.4 Screen-based activities such as TV, Internet browsing, games.16 However, research is mixed on whether the amount
videogame playing, and social network use are associated with of daily screen time differs between boys and girls. Generally,
inadequate lifestyle habits, such as poor sleep and sedentari- studies tend to suggest that boy adolescents spend more time
ness.5 Together they have been called the “invisible risks” as across devices,17,18 whereas other studies found no effect of
they are related to high levels of anxiety, depression and sui- gender on screen time at all.19 Among teenage populations,
cide attempts in adolescents and young adults.6 The afore- studies on specific uses of social media have also highlighted
mentioned cluster of activities has several designations, but it similar gender differences, with young girls using social me-
has been mostly recognized and described under the term dia at a greater rate and at an increased risk for developing
Problematic Internet Use (PIU). Conceptualized as a poten- adverse effects such as sedentariness, sleep impairment, neg-
tial behavioral addiction, PIU is defined by excessive online ative perception of their health, and low self-esteem.20 Despite
activity that is difficult to control.7 Research suggests that PIU higher rates of social media use in girls most research suggests
has implications for adolescent development and is associat- that PIU tends to be most prevalent among boys.21 Specifical-
ed with functional impairment, interpersonal difficulties and ly, Kim et al.22 found that in a sample of adolescents, boys who
decreased academic performance.8 Despite PIU being con- primarily use the Internet to play video games had the highest
sidered one of the most significant educational challenges for rate of PIU. Nonetheless, many studies did not find signifi-
parents and guardians, its specific consequences and associat- cantly different rates of PIU between genders.23
ed risk factors are not adequately understood. These mixed results demonstrate the need to further exam-
While the Internet can offer access to a vast array of content, ine gender differences in PIU in adolescents, considering their
there is the paradoxical concern that users could get trapped social and educational context. Furthermore, most contribu-
within algorithmic loops feeding them with a shallow and tions in the field of PIU and related behaviors come from the
narrow scope of interests.9 In youngsters, this could contrib- Northern Hemisphere of the globe, either from Asia, Europe,
ute to a loss in the breadth of their experiences beyond aca- or North America. Located in South America, Brazil is one of
demic performance.4 For instance, the engagement in extra- the most engaged countries in information and communica-
curricular activities has been reported as a protective factor tion technologies (ICT). From 2019 to 2020, Brazilian Internet
against PIU,10 although this association is not unequivocal in users increased, totaling 152 million, with 94% of the Brazil-
other reports.7 Extracurricular activities include various struc- ian adolescents being regular users of the Internet, making 22
tured social, sports, and cultural activities in parallel with the million users solely in the age bracket between 10–17 years.24
official school curriculum. They are considered an essential Considering the presence of ICT equipment, in 2019, almost
part of education and are vital to the expansion of education the entire population from 9 to 17 years old lived in house-
and major contributors to a sense of belonging and citizen- holds with a cell phone (98%) and TV (97%), with a ratio slight-
ship for the future adult.11 ly higher than one smartphone per inhabitant.25 Our invest-
Today, adolescents spend an unprecedented amount of time ment in ICT as a society contrasts with the paucity of information
in front of screens and on the Internet. According to the Pew on the impact of the rapid diffusion of Internet screen-based
Research Center (2018),12 nearly half of teens indicate that they device use amongst youth in Brazil. The goals of the present
use the Internet “almost constantly,” and most are worried study were: 1) to explore the relationship between PIU and
about the degree of their Internet usage. The current literature screen habits, 2) to explore the relationship between PIU and
is divided on whether to approach the problem based on the extracurricular habits, and 3) to determine if there was a sig-
specific activity such as Internet gaming disorder (IGD) or en- nificant effect of gender on these relationships in a sample of
compassing all screen and Internet activities under the um- Brazilian adolescents.
brella term of PIU.13 The main arguments in favor of a more
generalized addiction approach to Internet use is that it would METHODS
have great sensibility to a host of digital behaviors commonly
associated with each other.14 The counterargument is that be- Participants
havioral nuances and particular clinical needs could be better A total of 180 adolescents between 14 and 18 years old were

2 Psychiatry Investig
 SR Niskier et al.

invited to participate in the study between May and November Screen habits
2017 from an outpatient pediatric service. The outpatient ser- To assess screen habits and associated behaviors, a literature
vice is from the Federal University of São Paulo and is an open review was carried out to identify relevant questionnaires in
access, self or parent referral, free of charge treatment center the area and eight items were selected to cover the following
for the general population. The average age of participants area: number of hours a day spent watching TV, watching TV
was 13.7 (standard deviation [SD]=2.3) years. Fifty-four per- during meals, number of hours a day using a cell phone, us-
cent of the sample were girls. The demographic profiles of ing a cell phone during meals, number of hours a day playing
girls and boys were generally similar. However, girls were video games, number of hours a day using a computer, num-
slightly older than the boys. The main chronic disorders in ber of hours a day using tablets, neglecting extracurricular ac-
treatment were respiratory illnesses, mostly rhinitis, asthma, tivities to be online, or in other screen-related activity. Several
and bronchitis (Table 1). scales were reviewed to develop the questions used to assess
PIU behaviors. The IAT,26 validated for use in Brazil. The Smart-
Measures phone Addiction Scale (SAS),27 the Internet Gaming Disorder-
Short Form (IGDS-SF),28 and the Bergen Social Media Ad-
Demographics diction Scale (BSMAS)29 were also reviewed and items were
The demographic and clinical profile of participants were translated and adapted by the authors of the present study.
obtained during the initial consultation and included: age, Further, additional items covering the number of hours in
gender, years of formal education, religion, weight, height, front of the TV, cell phone, video game, computer and tablet30;
and presence of chronic disease (respiratory: rhinitis, asthma, use of screens, TV or cell phone during meals;31,32 searching
sinusitis, bronchitis; others: allergies, migraine, polycystic kid- for specific content and/or activities, including social net-
neys, etc.). works, games, chat, and other activities23,33 were selected from
other relevant studies conducted in local and international
PIU surveys.
To assess PIU, the Internet Addiction Test (IAT) was used.24
The IAT consists of 20 self-report Likert-style items ranging Extracurricular activities
from 1 (rarely) to 5 (always). A higher score on the IAT indi- The same procedure was used to assess the type and fre-
cates a greater degree of Internet addiction severity. Possible quency of extracurricular practices with the addition of items
scores on the IAT range from 0–100. Score ranges are as fol- inspired by previous work by the adolescent medicine outpa-
lows: normal (0–30), light addiction (31–49), moderate (50– tient team that investigated the relationship between out-of-
79), and severe (80–100). The IAT has been translated and school activities and TV use.34 The following extracurricular
validated for use in Portuguese and has satisfactory internal activities were assessed: regular practice of sports activities,
consistency.26 regular practice of non-sports extracurricular activities (includ-

Table 1. Demographic and clinical profiles of adolescents attending a general pediatric outpatient unit (N=180)
Characteristics Boys Girls Total Statistics p
Age (yr) 13.3±2.1 81 14.1±2.3 98 13.7±2.3 179 U=3.2 †
0.027*
Years of education (yr) 7.5±2.1 76 8.7±2.1 93 8.2±2.2 169 U=2.5† 0.001*
Religious affiliation χ =2.154
2
[2]
‡
0.341
Some practice - 66 (68.8) - 52 (65.8) - 118 (67.4)
No religion - 8 (8.3) - 12 (15.2) - 20 (11.4)
Affiliated but lapsed - 22 (22.9) - 15 (19.0) - 37 (21.1)
Weight (kg) 61.0±21.4 70 56.3±17.2 85 58.5±19.3 155 t=-1.526§ 0.129
Height (m) 1.6±0.1 64 1.6±0.1 78 1.6±0.1 142 t=-1.919§ 0.058
Body mass index (kg/m ) 2
23.2±6.7 62 22.3±5.9 77 23.1±6.3 139 t=-0.213 §
0.831
Chronic disease - 30 (37.0) - 37 (38.1) - 67 (37.6) χ2[1]=0.023‡ 0.879
Internet Addiction Test 27.2±15.1 81 26.6±16.9 99 26.9±16.1 180 t=-0.249 §
0.804
(score range: 0–100)
Values are presented as mean±standard deviation, number, or number (%). *denotes statistically significant p-values; †Mann-Whitney’s U;
‡Pearson’s chi-square test; §t-test

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Gender Differences in Adolescent Screen Use

ing languages), extracurricular courses, arts (music, dance, al.,35 which reported a mean IAT score of 34.14 (SD=11.23) in
and theater), and other social practices (dating and hanging a sample of adolescents. To detect if gender influenced PIU,
out with friends). Further, the potential impact of screen time we estimated a sample with the size necessary to detect a dif-
in these behaviors was included. Finally, as PIU in adolescents ference between means of at least half a standard deviation,
is associated with substance use,35 three additional questions setting the sample power values at 0.8 and significance at less
were included to assess alcohol, tobacco, and other substance than 0.05.36 The minimum estimated number per group was
use in the adolescent sample. 32 individuals for a total sample size of 64.

Ethics RESULTS
Informed consent was obtained from all parents and/or
guardians of each participant, and an assent form was com- One hundred eighty adolescents were included in the sam-
pleted by each adolescent participant following standards es- ple, 98 (54.4%) were girls. The demographic profile of girls and
tablished and approved by the local ethics and research com- boys was approximately similar. However, girls were about one
mittee. Adolescents lacking the capacity to understand the year older than boys (p=0.027, alternative D=0.40, moderate
nature of participation were excluded. This study involving effect size), had almost 14 more months of education (p=
human participants was in accordance with the ethical stan- 0.001, alternative D=0.35, small-to-moderate effect size) and
dards and have been approved by the Federal University of were slightly shorter (4 cm), although this difference did not
São Paulo/Unifesp Research Ethics Committee under num- reach significance (p=0.058, Cohen’s d=0.36, small-to-moder-
ber of CAAE: 79495817.0.0000.5505 and shared with the Re- ate effect size). Regarding the body mass index (BMI), there
search Ethics Committee of the University of São Paulo. was no significant difference between boys and girls, but con-
trasting the mean age with the BMI, boys could be considered
Data analysis overweight on average and girls close to the upper limit of the
Univariate statistics were used to assess participant demo- normal range of BMI. The main chronic diseases under treat-
graphics, IAT scores, screen habits, and practice/frequency of ment were respiratory diseases, mostly rhinitis, asthma, and
extracurricular activities. Continuous variables were tested for bronchitis, making up a total of 37.6% of the sample under
normality using the Kolmogorov–Smirnov test. Independent treatment for at least one chronic disease. Regarding the IAT
samples t-tests were carried out for normally distributed vari- score, no gender differences were observed, with a mean score
ables, and Mann–Whitney U tests were carried out when vari- of 26.9 (SD=16.1), which was within the healthy range, although
ables violated normality and for ordinal variables, effect sizes close to the upper limit (0–30). The division of the sample by
were estimated using Cohen’s d, or the alternative D coeffi- severity of PIU was: 116 individuals without PIU (64.4%), 47
cient for continuous variables without normal distribution, with mild PIU (26.1%), and 17 (9.4%) with moderate PIU. No
considering the following references: d<0.31=small, 0.30<d< participants’ IAT scores fell in the severe range. Full results
0.40=small-to-moderate, 0.39<d<0.70=moderate, 0.69<d<0.80= can be found in Table 1.
moderate-to-large, and d>0.79=large.36 Categorical variables
were compared using the chi-square test, or Fisher’s test when Screen habits
expected cell counts were less than five. Next, the variables In terms of screen habits, 38.4% of participants indicated
that reached significance in the previous univariate analysis that they watched TV for at least three hours a day, and 28.9%
were entered into a binary logistic regression model, where said they watched TV while having their meals. Sixty-six per-
gender (1-girls, 2-boys) was the dependent variable. cent of the sample used their mobiles for three or more hours
Associations between PIU, screen habits, and practice of per day, and nearly a quarter (23.9%) used them during meals.
extracurricular activities were assessed using bivariate corre- There was a significant difference regarding hours dedicated
lation analysis and linear models. Spearman’s Rho was used to video games, with 28.6% of boys reported playing video
for non-normally distributed continuous variables and ordi- games for three hours or more per day, compared to no girl
nal variables. For categorical variables, the t-test was used in participants exceeding the amount of two hours per day of
the case of two categories, and analysis of variance, in the case video game play (p<0.001, alternative Cohen’s d=0.79). Pre-
of more than two categories. Next, the variables that reached ferred online activities also differed by gender, with 60.5% of
significance in the previous univariate analysis stage were se- boys primarily accessing the Internet to play video games (p<
lected to compose a linear regression model, with the IAT 0.001), compared to 55.1% of girls primarily using the Inter-
score as the dependent variable. net to communicate with friends (p<0.001). Full results can
Power analysis was carried out based on a study by Choi et be found in Table 2.

4 Psychiatry Investig
 SR Niskier et al.

Extracurricular activities 0.63). Further, 57.6% of girls reported spending less than an
Boys reported a greater rate of regular involvement in sports hour a week engaged in physical activity. Girl adolescents re-
(65.4%) compared to girls (42.4%) (p=0.002, alternative D= ported greater engagement in dating at nearly three times the

Table 2. Screen habits of adolescents attending a general pediatric outpatient unit

Characteristics Boys Girls Total Statistics p
Number of hours per day watching TV U=3,781.5† 0.705
None 12 (15.4) 17 (18.1) 29 (16.9)
1–2 h/d 33 (42.3) 44 (46.8) 77 (44.8)
3–4 h/d 29 (37.2) 19 (20.2) 48 (27.9)
≥5 h/d 4 (5.1) 14 (14.9) 18 (10.5)
Watches TV during meals U=4,568.0† 0.086
Does not 17 (21.0) 26 (26.3) 43 (23.9)
Sometimes 35 (43.2) 50 (50.5) 85 (47.2)
Frequently 13 (16.0) 12 (12.1) 25 (13.9)
Always 16 (19.8) 11 (11.1) 27 (15.0)
Number of hours per day using mobile phone U=3,408.0† 0.415
None 1 (1.3) 8 (8.4) 9 (5.2)
1–2 h/d 24 (31.2) 25 (26.3) 49 (28.5)
3–4 h/d 26 (33.8) 15 (15.8) 41 (23.8)
≥5 h/d 26 (33.8) 47 (49.5) 73 (42.4)
Use of mobile during meals U=3,387.0† 0.057
No 39 (48.1) 34 (34.3) 73 (40.6)
Sometimes 27 (33.3) 37 (37.4) 64 (35.6)
Often 9 (11.1) 21 (21.2) 30 (16.7)
Always 6 (7.4) 7 (7.1) 13 (7.2)
Number of hours per day playing videogames U=5,622.0† <0.001*
None 27 (35.1) 84 (91.3) 111 (65.7)
1–2 h/d 28 (36.4) 8 (8.7) 36 (21.3)
3–4 h/d 19 (24.7) 0 19 (11.2)
≥5 h/d 3 (3.9) 0 3 (1.8)
Number of hours per day using the computer U=3,444.0† 0.834
None 42 (54.5) 47 (51.6) 89 (53.0)
1–2 h/d 23 (29.9) 32 (35.2) 55 (32.7)
3–4 h/d 9 (11.7) 7 (7.7) 16 (9.5)
≥5 h/d 3 (3.9) 5 (5.5) 8 (4.8)
Number of hours per day using tablets U=3,390.0† 0.905
None 62 (83.8) 77 (84.6) 139 (84.2)
1–2 h/d 10 (13.5) 11 (12.1) 21 (12.7)
3–4 h/d 2 (2.7) 2 (2.2) 4 (2.4)
≥5 h/d 0 1 (1.1) 1 (0.6)
What do you use your Internet for?
To enter social networks 36 (44.4) 54 (55.1) 90 (50.3) χ2[1]=2.02‡ 0.156
To play video games 49 (60.5) 27 (27.6) 76 (42.5) χ2[1]=19.70‡ <0.001*
To chat 21 (25.9) 54 (55.1) 75 (41.9) χ2[1]=15.06‡ <0.001*
Other activities 16 (19.8) 26 (26.5) 42 (23.5) χ2[1]=1.13‡ 0.287
Values are presented as number (%). *denotes statistically significant p-values; †Mann–Whitney’s U; ‡Pearson’s chi-square test

www.psychiatryinvestigation.org 5
Gender Differences in Adolescent Screen Use

rate of boy adolescents (18.9% vs. 6.6%, p=0.018). No other Binary logistic regression
gender differences were observed in extracurricular activities. Screen habits and extracurricular activities variables that
However, it is worth nothing that 40% of participants report- reached significance at the univariate level were included in a
ed engagement in regular practice of at least one extracurric- binary logistic regression model alongside the demographic
ular activity. More than 70% of participants reported spend- variables that varied between genders in a forward stepwise
ing after-school hours with friends. Roughly 9% reported fashion. The final model (Table 4) suggests that the main dif-
some use of alcohol, and 2.4% reported experimenting with ferences between girls and boys included video game playing
other psychoactive substances (Table 3). (27 times more frequent amongst boys compared to girls) and
Internet chatting (4.5 times more frequent amongst girls com-
pared to boys). The final logistic regression model was signif-

Table 3. Extracurricular activities and other habits of adolescents in a general pediatric outpatient unit
Characteristics Boys (N=81) Girls (N=99) Total (N=180) Statistics p
Regular practice of sports 53 (65.4) 42 (42.4) 95 (52.8) χ =9.462
2
[1]
‡
0.002*
Sports hours per week U=5,019.5† 0.002*
<1 h/wk 29 (35.8) 57 (57.6) 86 (47.8)
1–2 h/wk 27 (33.3) 28 (28.3) 55 (30.6)
3–4 h/wk 12 (14.8) 6 (6.1) 18 (10.0)
5–6 h/wk 7 (8.6) 2 (2.0) 9 (5.0)
>6 h/wk 6 (7.4) 6 (6.1) 12 (6.7)
Regular practice of other extracurricular activities 33 (41.8) 36 (37.1) 69 (39.2) χ2[1]=0.396‡ 0.529
Has a girlfriend/boyfriend 5 (6.6) 18 (18.9) 23 (13.5) χ2[1]=5.548‡ 0.018*
Friends’ companion during afterschool hours U=3,767.5 †
0.642
Alone, most of the time 27 (33.8) 25 (25.5) 52 (29.2)
Usually with one friend 14 (17.5) 20 (20.4) 34 (19.1)
Usually with two friends 9 (11.3) 20 (20.4) 29 (16.3)
Three or more friends 30 (37.5) 33 (33.7) 63 (35.4)
Neglects extracurricular activities for screen time U=4,220.0† 0.337
No 38 (47.5) 54 (55.1) 92 (51.7)
Sometimes 25 (31.3) 28 (28.6) 53 (29.8)
Often 13 (16.3) 8 (8.2) 21 (11.8)
Always 4 (5.0) 8 (8.2) 12 (6.7)
Alcohol drinking per week U=1,746.0† 0.228
Never 51 (94.4) 61 (88.4) 112 (91.1)
Sometimes 3 (5.6) 5 (7.2) 8 (6.5)
Always 0 3 (4.3) 3 (2.4)
Has already tried drugs (any other than alcohol) 0 3 (4.4) 3 (2.4) - 0.252
Values are presented as number (%). *denotes statistically significant p-values; Mann–Whitney’s U; Pearson’s chi-square test; Fisher’s test
† ‡ §

Table 4. Final model for differences between boys and girls (forward stepwise logistic regression)†
Gender (1=girl; 2=boy) Wald’s χ2 p Odds ratio 95% CI
Number of hours per day playing videogames 21.033 <0.001* 27.103 6.616 to 111.031
Uses the Internet to play games 5.748 0.017* 0.226 0.067 to 0.762
Uses the Internet to chat with friends 6.094 0.014* 4.507 1.364 to 14.893
Constant 13.639 <0.001* - -
*denotes statistically significant p-values; final model information: χ =83.071, p<0.001, R Nagelkerke=0.668, height and years of education
† 2
[4]
2

entered the initial model to control for differences in the demographic and clinical profiles between girls and boys, only height remained in
the final model (χ2=9.626, p=0.002). CI, confidence interval

6 Psychiatry Investig
 SR Niskier et al.

Table 5. Association between health factors, screen habits, and the Internet Addiction Test (IAT) score
Characteristics N IAT score Statistics p
Chronic disease t=-2.093 †
0.038*
Yes 67 23.7±15.7
No 111 28.8±16.1
Regular engagement with sports t=2.113† 0.036*
Yes 95 24.5±14.5
No 85 29.5±17.4
Alcohol drinking per week F[2]=3.0‡ 0.055
Never 112 26.0±16.4
Sometimes 8 23.3±9.2
Always 3 47.7±18.9
Number of hours per day watching TV F[3]=3.5‡ 0.017*
None 29 22.9±12.0
1–2 h/d 77 25.2±17.0
3–4 h/d 48 27.1±15.2
≥5 h/d 18 37.3±17.2
Watches TV during meals F[3]=4.0‡ 0.009*
Does not 43 23.3±14.4
Sometimes 85 24.6±14.7
Frequently 25 30.8±16.7
Always 27 35.9±18.8
Number of hours per day using mobile phone F[3]=6.7‡ <0.001*
None 9 15.2±14.9
1–2 h/d 49 21.1±15.4
3–4 h/d 41 26.9±12.9
≥5 h/d 73 32.9±16.4
Use of mobile during meals F[3]=14.4‡ <0.001*
Does not 73 22.1±14.1
Sometimes 64 23.9±13.5
Frequently 30 36.5±14.6
Always 13 46.0±19.5
Number of hours per day playing videogames F[3]=5.3‡ 0.002*
None 111 25.3±16.2
1–2 h/d 36 23.8±10.3
3–4 h/d 19 31.8±19.8
≥5 h/d 3 56.7±10.1
Number of hours per day using the computer F[3]=8.7‡ <0.001*
None 89 24.3±14.0
1–2 h/d 55 23.7±16.0
3–4 h/d 16 42.6±17.4
≥5 h/d 8 35.9±15.7
Uses Internet for social networking t=-2.843† 0.005*
Yes 90 30.2±16.8
No 89 23.5±14.7
Neglects extracurricular activities to stay online F[3]=10.6‡ <0.001*
No 92 21.6±15.0
Sometimes 53 29.4±13.1
Often 21 33.8±14.2
Always 12 44.1±22.1
Values are presented as number or mean±standard deviation. *denotes statistically significant p-values; †t-test; ‡analysis of variance

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Gender Differences in Adolescent Screen Use

icant (p<0.001), with an overall classification accuracy (85.0%), Table 6. Final model for factors associated with problematic Inter-
net use (forward stepwise linear regression)†
albeit a little higher for girls (92.4%) compared to boys (75.9%).
An alternative model was conducted using a backward step- Factors Standardized β t p
wise method, with no significant material changes in the re- Use of mobile during meals 0.255 2.698 0.008*
sults. Table 4 shows the main results of the final regression Watches TV during meals 0.279 3.313 0.001*
model for comparing screen habits of girls and boys. Neglects extracurricular 0.286 3.084 0.003*
activities to stay online
Correlates of PIU Constant - 4.430 <0.001*
Regarding factors that could potentially impact PIU (Table *denotes statistically significant p-values; final model information:
†

5), we found no meaningful associations with demographic R2=0.315, F[3,103]=15.80, p<0.001

variables. Interestingly, there was a significant association be-
tween the IAT score and the presence of chronic disease, with DISCUSSION
those who had a chronic disease reporting a lower score than
those who had not (p=0.038, Cohen’s d=0.32). The regular prac- The main goals of the present study were to compare screen
tice of sports also appeared to be a protective against PIU, as and other extracurricular habits among girl and boy adoles-
those who consistently engaged in physical activity scored cents in addition to investigating their potential relationship
lower than those who were not (p=0.036, Cohen’s d=0.32). with PIU. The demographic profiles of boys and girls were sim-
Amongst other extracurricular activities and habits, alcohol ilar, with minor differences in age and education. When refer-
use appeared to have an association with PIU, though it did ring to general screen use no differences were found. However,
not reach significance (p=0.055, η2=0.048). The most mean- being a boy was associated with a 27-fold increase in the amount
ingful PIU associations were with screen devices and related of time playing video games per day, which is in line with pre-
habits. IAT scores increased accordingly to the number of vious findings in the literature.16
hours per day of use of all screen devices such as TV (p=0.017, There were no significant differences in IAT scores between
η2=0.060; moderate-to-large effect size), mobile devices (p< boys and girls, suggesting that PIU was not associated with
0.001, η2=0.108), videogame (p=0.002, η2=0.089), and com- gender in our sample. This finding is in contrast with most of
puters (p<0.001, η2=0.139). Moreover, the IAT score was sig- the literature suggesting that boy adolescents are at increased
nificantly associated with watching TV (p=0.009, η2=0.066) risk for developing PIU.21,22 But then again, most studies re-
and using mobile devices during meals (p<0.001, η2=0.201). porting greater frequency of Internet-related problems in boys
Finally, high scores at the IAT were associated with engage- compared to girls fail to discriminate between PIU, IGD, and
ment in social networks (p=0.005, Cohen’s d=0.43) and ne- gaming related problems. While there are valid arguments to
glect of extracurricular activities (p<0.001, η2=0.157) (Table 5). approach PIU as an “umbrella” term most authors now em-
phasize that PIU and IGD are different constructs, perhaps
Multiple linear regression representing different nosological entities.37 When compar-
The variables that were statistically significant with the IAT ing PIU and IGD, IGD is associated with boy gender and
score were entered into a linear regression model in a forward greater time spent playing games, while PIU is associated
stepwise fashion. The final model (Table 6) was significant (p< with online chatting and social networking, which is in line
0.001), but with a limited proportion of variance (31.5%) (R2= with our findings.38 Indeed, our study found gender differenc-
0.315). The factors remaining in the final model were use of es within specific Internet behaviors. For instance, girl ado-
mobile during meals (β=0.255, p=0.008), watching TV dur- lescents were more likely to use the Internet to communicate
ing meals (β=0.279, p=0.001) and neglect of extracurricular with their friends, and boys were more likely to play games.
activities to stay online (β=0.286, p=0.003) (Table 6). An al- These specific findings were both consistent with existing re-
ternative model was also built using a backward stepwise search on gendered Internet use habits.16 These results were
method for the factors introduced in the model. The final consistent in our multivariate analyses.
model was similar to the first (R2=0.386, F[6,100]=10.48, p<0.001), We also identified gender differences in extracurricular ac-
however three additional variables remained including num- tivities. In this study, boy adolescents spent more time regu-
ber of hours per day playing videogames (β=0.190, p=0.024), larly engaging in sports (two-thirds active) compared to girls
use of Internet to enter social networks (β=0.182, p=0.032), (two-thirds inactive) which is consistent with previous litera-
and number of hours per day watching TV, which approached ture.17 In contrast, girls were more likely to report being in a
significance (β=0.137, p=0.099). relationship (three times more), which is consistent with them
being more social. These findings were also supported in the

8 Psychiatry Investig
 SR Niskier et al.

regression model which suggested that girls are five times as are more factors at play to explain PIU in adolescents. Some
likely to use the Internet for socializing compared to boys. How- examples may include psychiatric comorbidities such as affec-
ever, it is worth noting that this finding may be impacted by tive disorders, anxiety, depression, and attention-deficit hy-
the slightly older average age of girls in this sample compared peractivity disorder,33 in addition to family dynamics and ex-
to boys and therefore more advanced puberty as well. Although panded psychosocial context.39,40 Further, it is important to
there were no differences between boys and girls in their ne- note that the data used in this study was collected prior to the
glect of extracurricular activities due to screen time, nearly half coronavirus disease-2019 (COVID-19) pandemic. The lock-
the sample (48.3%) indicated that they did it occasionally. down measures and implications of social isolation as a result
In terms of the relationship between PIU and screen-related of COVID-19 pandemic are likely to impact Internet use be-
habits, using mobile devices during meals and watching TV havior. Finally, the cross-sectional nature of the study design
during meals were both significant predictors of PIU. These prevents the establishment of causal inferences between the
results are supported in the literature by Martins et al.,39 who PIU and associated factors.
found that adolescents who use the Internet during meals are In conclusion, understanding nuances between boy and
three times more likely to have PIU. The third main predictor girl adolescents across Internet behaviors addresses a gap in
of PIU in this sample was neglecting offline extracurricular the literature identified by Su et al.,16 who stress the importance
activities in favor of online activities. In the alternative back- of examining different types of PIU behaviors rather that ex-
ward stepwise linear regression, dedication to video games clusively assessing PIU as a whole. Though the results of this
and social media also remained in the final model. This find- study ultimately suggest that PIU is comparable between boy
ing, combined with the previously described differences be- and girl adolescents, they also demonstrate the nuance in the
tween boys and girls reinforces the perception that, although impact of gender on Internet use. Specifically, patterns of In-
we did not find any difference in the IAT score between gen- ternet use and differences in motivation were identified be-
der, PIU may be present within the context of certain Internet tween genders. Moreover, PIU was associated with increased
behaviors, which may be dependent on gender. screen time and neglect of extracurricular activities. There-
Finally, it is worth noting that there was a small-to-moder- fore, these findings can serve to inform the development and
ate effect between the occurrence of chronic diseases and a implementation of prevention measures to protect against
lower score on the IAT. This factor was ultimately not includ- PIU and guide future guidelines for a healthy usage of screen
ed in the final regression model so any conclusion about the devices.
robustness of this association is speculative. Previous research
suggests that involvement in sports and physical activity can Availability of Data and Material
The data underlying this present research will be made available upon
protect against PIU.10 Though the regular practice of physical request. To request data, please email the Faculty of Medicine at University
activity was negatively associated with PIU at the univariate of São Paulo’s Ethics Board (email: [email protected]). The data has
level in this study, it did not significantly contribute to the fi- not been uploaded in a public repository.
nal regression model. However, the popularity of sports activ- Conflicts of Interest
ities among boys suggests that they should be further explored The authors have no potential conflicts of interest to disclose.
as a strategy to promote time away from the screen and thus
prevent complications from their overuse, including PIU. Author Contributions
The present study has several limitations worth noting. The Conceptualization: Sheila Rejane Niskier, Hermano Tavares. Data cura-
tion: Sheila Rejane Niskier. Formal analysis: Hermano Tavares, Hyoun S.
first limitation is the use of convenience sampling methods Kim. Investigation: Sheila Rejane Niskier, Maria Sylvia de Souza Vitalle,
which can impact generalizability. A potential limitation is the Thiago T. da Silva. Methodology: Sheila Rejane Niskier, Hermano Tavares.
use of the IAT as an instrument for measuring PIU. Though Software: Hermano Tavares. Validation: Sheila Rejane Niskier, Hermano
Tavares. Writing—original draft: Sheila Rejane Niskier, Lindsey A. Snayshuk.
the IAT is still the most widely used test for this purpose, it Writing—review & editing: Hermano Tavares, Hyoun S. Kim, Sheila Rejane
may be considered outdated (mention of email use etc.) and Niskier, Lindsey A. Snaychuk.
not representative of the more common Internet behaviors
ORCID iDs
today. Having said that, we used the IAT to assess PIU given
Sheila Rejane Niskier https://orcid.org/0000-0001-5017-4680
that it was the only instrument validated in Brazilian Portu- Lindsey A. Snaychuk https://orcid.org/0000-0003-1443-4611
guese26 at the time the sample was collected. Moreover, the Hyoun S. Kim https://orcid.org/0000-0002-0804-0256
current study used a questionnaire composed of items de- Thiago T. da Silva https://orcid.org/0009-0004-9171-9439
Maria Sylvia de Souza Vitalle https://orcid.org/0000-0001-9405-4250
rived from other instruments, only some of which were vali- Hermano Tavares https://orcid.org/0000-0002-6632-2745
dated for use in Brazil. Finally, the degree of variance in PIU
accounted for in the final regression model suggests that there

www.psychiatryinvestigation.org 9
Gender Differences in Adolescent Screen Use

Funding Statement chol Rep 2021;124:1031-1048.

None 21. Tóth-Király I, Morin AJS, Hietajärvi L, Salmela-Aro K. Longitudinal
trajectories, social and individual antecedents, and outcomes of prob-
lematic internet use among late adolescents. Child Dev 2021;92:e653-
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