CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 17, Number 11, 2014

ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2014.0139

Epidemiology of Internet Behaviors and Addiction

Among Adolescents in Six Asian Countries

Kwok-Kei Mak, PhD,1 Ching-Man Lai, MPhil,2 Hiroko Watanabe, PhD,3 Dong-Il Kim, PhD,4
Norharlina Bahar, MMed (Psych),5 Milen Ramos, PhD,6 Kimberly S. Young, PhD,7
Roger C.M. Ho, FRCPC,8 Na-Rae Aum, MA,9 and Cecilia Cheng, PhD1

Abstract
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Internet addiction has become a serious behavioral health problem in Asia. However, there are no up-to-date
country comparisons. The Asian Adolescent Risk Behavior Survey (AARBS) screens and compares the preva-
lence of Internet behaviors and addiction in adolescents in six Asian countries. A total of 5,366 adolescents aged
12–18 years were recruited from six Asian countries: China, Hong Kong, Japan, South Korea, Malaysia, and the
Philippines. Participants completed a structured questionnaire on their Internet use in the 2012–2013 school year.
Internet addiction was assessed using the Internet Addiction Test (IAT) and the Revised Chen Internet Addiction
Scale (CIAS-R). The variations in Internet behaviors and addiction across countries were examined. The overall
prevalence of smartphone ownership is 62%, ranging from 41% in China to 84% in South Korea. Moreover,
participation in online gaming ranges from 11% in China to 39% in Japan. Hong Kong has the highest number of
adolescents reporting daily or above Internet use (68%). Internet addiction is highest in the Philippines, according
to both the IAT (5%) and the CIAS-R (21%). Internet addictive behavior is common among adolescents in Asian
countries. Problematic Internet use is prevalent and characterized by risky cyberbehaviors.

Background the revised Diagnostic and Statistical Manual of Mental

Disorders (DSM-5).5 For instance, Internet game addicts
have cravings that are similar to smokers.6 A recent meta-
T he Internet is no longer merely an infrastructure; it
has become an unlimited space for information ex-
change, social networking, and the development of cyber-
analysis involving 1,641 patients and 11,210 controls found
significant associations between Internet addiction and al-
behaviors. Adolescence is a critical period for behavioral cohol abuse (odds ratio [OR] 3.05), attention deficit and
changes. Internet addiction in adolescents has become an hyperactivity (OR 2.85), depression (OR 2.77), and anxiety
urgent issue in the health education and promotion agenda,1 (OR 2.70).7 In addition, clinical evidence of the adverse ef-
particularly because of the potential links between sedentary fect of Internet addictive behavior on brain functions has
activities, especially technology use, and the pandemic of been reported.8,9 Various treatments for Internet addiction
obesity.2 Interventions to prevent prolonged screen time are a have been developed and evaluated.10 Nevertheless, the ef-
major component of obesity prevention programs in schools.3 fectiveness of interventions for Internet game disorder is
With the increasing infiltration of the Internet into daily life, unclear.11 Therefore, early assessment and prevention of
psychopathological symptoms of Internet addiction have also Internet and game addiction is necessary.
been observed in recent years.4 Specifically, some psychia- The prevalence of Internet addiction varies across different
trists have proposed that Internet gaming disorders should be scales, covering different dimensions of Internet addictive
classified under substance abuse and addictive disorders in behavior.12 The Internet Addiction Test (IAT) and the Chen

1
Department of Psychology, University of Hong Kong, Hong Kong.
2
Department of Psychology, Chinese University of Hong Kong, Hong Kong.
3
Department of Children and Women’s Health, Osaka University Graduate School of Medicine, Osaka, Japan.
4
Department of Education, Seoul National University, Seoul, Republic of Korea.
5
Department of Psychiatry and Mental Health, Hospital Selayang, Selayang, Malaysia.
6
Department of Psychiatry, National University of Manila, Manila, Philippines.
7
Center for Internet Addiction and Recovery, Bradford, Pennsylvania.
8
Department of Psychological Medicine, National University of Singapore, Singapore.
9
National Information Society Agency, Seoul, Republic of Korea.

720
 INTERNET BEHAVIORS AND ADDICTION AMONG ASIAN ADOLESCENTS 721

Internet Addiction Scale (CIAS) are the two most common by individual bilingual translators, reviewers, and adjudica-
scales used to assess Internet addictive behaviors. The 20-item tors, followed by face validation conducted by the research-
IAT was developed by Young et al., and is a modification of ers. The questionnaires were administered in classes during
Young’s Diagnostic Questionnaire for Internet addiction, the 2012–2013 school year. Informed consent was obtained
which is based on the DSM-IV13 criteria for pathological from the students, and ethics approval was obtained from the
gambling.14 The IAT consists of three subscales: withdraw university and hospital ethic committees.
and social problem, time management and performance, and Students reported their demographic information and
reality substitute.15 The IAT has been translated into differ- computer ownership (no personal or shared computer, shared
ent Asian languages and used in Korean,16 Malay,17 and a computer with one sibling, shared a computer with more
Chinese18 speaking populations. The factor structure of the than one siblings, owned a personal computer), ownership of
IAT has been tested in Chinese adolescents.15 The Revised electronic devices such as an iPhone, iPad, iPod, Samsung
Chen Internet Addiction Scale (CIAS-R), consisting of 26 smartphone, HTC smartphone (yes or no), and the places they
items, was modified from the original CIAS. The CIAS-R most frequently used the Internet (cybercafé or other public
consists of five subscales, including the compulsive use (Sym- places, library, home, friends’ houses, school). Students were
C), withdrawal (Sym-W), tolerance symptoms of Internet also asked to report the frequency of their Internet behavior,
addiction (Sym-T), interpersonal and health-related problems including e-mail, instant messenger (e.g., MSN, ICQ, Yahoo,
(RP-IH), and time management problems (RP-TM). Studies QQ), social networking (e.g., Facebook, Twitter, Weibo),
using the CIAS-R have determined that Internet addiction is blogging, joining newsgroups/discussion groups/forums, vis-
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associated with suicidal behaviors in Taiwanese adolescents.19 iting particular leisure Web sites (e.g., sports Web sites, TV
The factor structure of the CIAS-R has been validated in Web sites, etc.), surfing the Web with no set purpose, online
Chinese adolescents.20 However, its use beyond Chinese shopping, downloading (e.g., pictures, games, music, videos,
populations has yet to be investigated. animation, text software), listening to online radio, and online
Although most of the available studies of pathological In- gaming. The possible answers were once per week, two to
ternet addiction have been conducted in Asia,21 Internet ad- three times per week, four to six times per week, once per day,
diction could be endemic. Cultural attitudes are one of the two to three times per day, and more than three times per day.
major determinants of the level of concern about Internet They were also asked to report if they had ever performed
addiction observed across countries.22 The prevalence of or experienced Internet misbehaviors or attended an Internet
Internet addiction reported in Western populations varies, safety course. The examples of Internet misbehaviors included
probably due to the characteristics of the respondents, the receiving false information in an e-mail or instant message,
scale used, and the timing of the measurements.23,24 In China, pretending to be a different person in an e-mail or instant
an incidence rate of 2.4% for Internet addiction has been re- message, sending e-mails or instant messages to someone they
ported in adolescents.25 Adaptive problems were found to be had never met, sending prank e-mails or an e-mail bomb to
the major predictor of Internet addiction in Chinese college someone, blocking an instant message from a person, and
students.26 Moreover, studies have shown that Chinese college giving a password to a friend (yes or no).
students who are Internet addicts are more likely to have Internet use patterns, including the average number of hours
eating disorders,27 and Chinese adolescents who are Internet a day spent online during school days and holidays, and the
addicts have a greater likelihood of suffering from depression frequency of Internet use were reported. Participants were
and anxiety.28 Despite these studies, there is no overview of required to respond to questions about the frequency of In-
Internet addictive behavior in Asia. This population-based ternet use on a 6-point scale ranging from 1 = ‘‘once a week or
epidemiological study screened and compared the Internet less’’ to 6 = ‘‘more than three times a day.’’ The IAT and
addictive behavior of adolescents from six Asian countries. CIAS-R were used to screen students for the symptoms of
addictive Internet use. According to Young et al.’s criteria,29
respondents who scored q70 were classified as addictive
Methods
Internet users who had encountered significant life problems
Participants were 5,366 adolescents aged 12–18 years due to excessive Internet use. Those with an IAT score of 40–
from six Asian countries (879 from China, 839 from Hong 69 were classified as problematic Internet users who had en-
Kong, 744 from Japan, 936 from South Korea, 969 from countered general life problems due to excessive Internet use.
Malaysia, and 999 from the Philippines) who took part in the Respondents with an IAT score of p39 or below were clas-
Asian Adolescent Risk Behavior Survey (AARBS). The sified as average Internet users, who only had some problems
schools were randomly selected from both rural and ur- controlling Internet use. In the CIAS-R, a higher score indi-
ban areas in the respective counties—Southern and Central cates a more severe addiction to Internet activities. The pos-
China, including Shenzhen and Hunan; Kowloon and New sible range of CIAS-R scores is 26–104. A higher score
Territories of Hong Kong; Western Japan, including Shiga; indicates a more severe level of Internet addiction. Following
Northern and Southern South Korea, including Seoul and a study of Taiwanese adolescents, in this study, a person with a
Pusan; Central Western Malaysia, including Selayang; and CIAS-R score of q64 was classified as an Internet addict.30
the Northern and Southern Philippines, including Kapitolyo, The prevalence of Internet behavior and addiction among
Manila, Marikina, Novaliches, and Obando. Students com- adolescents was compared between countries.
pleted a 40 minute structured questionnaire translated into
the languages used in their schools (Simplified Chinese for
Results
China; Traditional Chinese for Hong Kong; Japanese for
Japan; Korean for South Korea; Malay, English, and Sim- Table 1 shows that the prevalence of computer owner-
plified Chinese for Malaysia; and English for the Philippines) ship varies across countries. About half (51.1%) of Hong
 722 MAK ET AL.

Table 1. Basic Characteristics and Internet Access of the Adolescents from Individual Countries
China Hong Kong Japan South Korea Malaysia Philippines
Sex, n (%)
Males 470 (53.5) 316 (37.7) 364 (48.9) 575 (61.4) 446 (46.0) 385 (38.5)
Females 409 (46.5) 523 (62.3) 380 (51.1) 361 (38.6) 523 (54.0) 614 (61.5)
Age, mean (SD) 15.1 (1.8) 15.8 (2.0) 16.5 (0.5) 13.7 (1.6) 14.7 (1.2) 16.4 (1.7)
Ownership of computer, n (%)
No 562 (66.0) 64 (7.7) 197 (26.5) 83 (9.0) 198 (20.8) 370 (37.2)
Shared with one sibling 112 (13.1) 232 (28.0) 249 (33.5) 394 (42.6) 201 (21.1) 174 (17.5)
Shared with more than one sibling 53 (6.2) 110 (13.3) 153 (20.6) 218 (23.6) 367 (38.6) 279 (28.1)
Own one personally 125 (14.7) 424 (51.1) 145 (19.5) 229 (24.8) 185 (19.5) 171 (17.2)
Ownership of electronic devices (multiple options), n (%)
iPhone 97 (11.0) 120 (14.3) 50 (6.7) 23 (2.5) 103 (10.6) 65 (6.5)
iPad 57 (6.5) 78 (9.3) 16 (2.2) 38 (4.1) 98 (10.1) 59 (5.9)
iPhone or iPad 116 (13.2) 166 (19.8) 62 (8.3) 54 (5.7) 172 (17.8) 118 (11.8)
iPod 45 (5.1) 180 (21.5) 373 (50.1) 25 (2.7) 57 (5.9) 54 (5.4)
Samsung 148 (16.8) 106 (12.6) 12 (1.6) 357 (38.1) 210 (21.7) 181 (18.1)
HTC 62 (7.1) 38 (4.5) 6 (0.8) 10 (1.1) 43 (4.4) 11 (1.1)
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Other smartphones 132 (15.0) 136 (16.2) 96 (12.9) 416 (44.4) 226 (23.3) 388 (38.8)
Any smartphone 357 (40.6) 467 (55.7) 475 (63.8) 790 (84.4) 549 (56.7) 671 (67.2)
Most common places for Internet access (multiple options), n (%)
Cybercafé or other public areas 199 (22.6) 16 (1.9) 8 (1.1) 41 (4.4) 237 (24.5) 438 (43.8)
Library 4 (0.5) 34 (4.1) 4 (0.5) 24 (2.6) 32 (3.3) 245 (24.5)
Home 393 (44.7) 768 (91.5) 714 (96.0) 808 (86.3) 761 (78.5) 194 (19.4)
Friends’ houses 45 (5.1) 38 (4.5) 18 (2.4) 89 (9.5) 138 (14.2) 72 (7.2)
School 41 (4.7) 22 (2.6) 19 (2.6) 50 (5.3) 48 (5.0) 21 (2.1)

Kong students but less than 15% of mainland Chinese also frequent places for Internet use for students in China
students own a computer personally. For smartphones, the (23%) and Malaysia (25%).
overall rate of ownership is about 62% for the studied Table 2 shows the relative frequency of the different types of
countries: 84% in South Korea, 67% in the Philippines, daily Internet behavior. E-mails (66%), instant messages (50%),
64% in Japan, 57% in Malaysia, 56% in Hong Kong, and blogging (25%), and visiting leisure Web sites (20%) are rela-
41% in China. Samsung Galaxy and Apple iPhone are the tively more common in Japan, whereas social networking
two most common models owned by students in most of the (65%), newsgroups/discussion groups/forums (19%), non-
countries. The home is the most frequent place for students purposive Web surfing (27%), online shopping (8%), and
to use the Internet in most countries, with a prevalence downloading (28%) are relatively more common in Hong
ranging from 45% to 96%, except in the Philippines where Kong. Furthermore, the prevalence of online gaming in de-
cybercafés and other public areas (44%) are the most pre- creasing order is Japan (39%), South Korea (20%), Malaysia
ferred by students. Cybercafés and other public areas are (19%), Philippines (18%), Hong Kong (17%), and China (11%).

Table 2. Prevalence of Internet Behaviors (Daily or More Frequent) of the Adolescents

from Individual Countries
China Hong Kong Japan South Korea Malaysia Philippines
n (%) n (%) n (%) n (%) n (%) n (%)
E-mail 20 (2.3) 154 (18.2) 490 (65.9) 52 (5.5) 113 (11.6) 176 (17.6)
Instant messenger (e.g., MSN, ICQ, 311 (35.1) 408 (48.3) 374 (50.3) 141 (15.0) 88 (9.0) 102 (10.2)
Yahoo, QQ)
Social networking (e.g., Facebook, 70 (7.9) 549 (65.0) 249 (33.5) 219 (23.3) 370 (37.9) 412 (41.2)
Twitter, Weibo)
Blogging 32 (3.6) 94 (11.1) 182 (24.5) 92 (9.8) 62 (6.4) 107 (10.7)
Joining newsgroups/discussion groups/forums 55 (6.2) 160 (19.0) 78 (10.5) 92 (9.8) 75 (7.7) 137 (13.7)
Visiting particular leisure websites 62 (7.0) 155 (18.4) 149 (20.0) 126 (13.4) 130 (13.3) 168 (16.8)
(e.g., Sports Web sites, TV Web sites, etc.)
Surfing the Web with no set purpose 45 (5.1) 229 (27.1) 104 (14.0) 101 (10.7) 135 (13.8) 202 (20.2)
Online shopping 33 (3.7) 71 (8.4) 11 (1.5) 47 (5.0) 53 (5.4) 65 (6.5)
Downloading (e.g., pictures, games, 100 (11.3) 237 (28.1) 134 (18.0) 226 (24.0) 183 (18.8) 250 (25.0)
music, videos, animation, text software)
Listening to online radio 51 (5.8) 94 (11.1) 22 (3.0) 37 (3.9) 98 (10.1) 191 (19.1)
Online gaming 101 (11.4) 144 (17.1) 287 (38.6) 191 (20.3) 184 (18.9) 175 (17.5)
 INTERNET BEHAVIORS AND ADDICTION AMONG ASIAN ADOLESCENTS 723

Table 3. Internet Misbehaviors and Safety Course Attendance (Ever) of the Adolescents
from Individual Countries
China Hong Kong Japan South Korea Malaysia Philippines
n (%) n (%) n (%) n (%) n (%) n (%)
Received false information about 50 (5.7) 55 (6.6) 23 (3.1) 239 (25.5) 97 (10.0) 467 (46.7)
the senders in an e-mail or instant message
Pretended to be a different person when 31 (3.5) 36 (4.3) 30 (4.0) 29 (3.1) 92 (9.5) 146 (14.6)
sending e-mail or instant messaging
to someone
Sent e-mail or instant messages 150 (17.1) 211 (25.1) 280 (37.6) 91 (9.7) 184 (19.0) 146 (14.6)
to someone never met before
Sent prank e-mail or an e-mail bomb 24 (2.7) 19 (2.3) 45 (6.0) 66 (7.1) 28 (2.9) 9 (0.9)
to someone
Blocked instant messages from a person 84 (9.6) 156 (18.6) 218 (29.3) 337 (36.0) 157 (16.2) 24 (2.4)
you did not want to hear from
Given your password to a friend 328 (37.3) 218 (26.0) 48 (6.5) 210 (22.4) 240 (24.8) 65 (6.5)
or someone you know
Attended an Internet safety course 382 (43.5) 116 (13.8) 632 (84.9) 591 (63.1) 690 (96.6) 825 (82.6)
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Table 3 shows that receiving false messages/accusations States (46%).31 The varying rates of smartphone ownership
(47%) and using a false online identity (15%) are relatively between the six Asian countries may suggest the relative
more common in the Philippines than in other countries. technological and economic advances in the individual
Communication with strangers is most common in Japan (38%), counties. At the same time, the high prevalence of smart-
and sharing passwords is most common in China (37%). phone ownership in South Korea, Japan, and China may
Spreading spam e-mails (7%) and blocking others (36%) reflect their status as major computer and smartphone pro-
are most common in South Korea. Only about 14% of the ducers, which are also equipped with good telecommuni-
students in Hong Kong and less than half (44%) of the cation infrastructures.
students in mainland China have ever attended Internet The prevalence of ownership of a personal computer in
safety courses. this study ranged from 15% to 51%, whereas it was 84% in
Table 4 shows that 68% of the students in Hong Kong, New York32 and 79% in Turkey.33 Students from Hong Kong
55% in Japan, 48% in the Philippines, 44% in Malaysia, 40% and Japan were relatively more likely to engage in daily
in South Korea, and 26% in China use the Internet at least Internet behaviors such as e-mails, instant messages, social
once daily. In all of the countries, students spend more time networking, blogging, and Web surfing. It is noteworthy that
on the Internet during holidays than on school days. Students online shopping was the most common in Hong Kong, but
from the Philippines have the longest and students from was still practiced by less than 10% of the students, perhaps
China have the shortest duration of Internet use on an aver- because of security concerns or technological difficulty.
age school day. Students from Hong Kong have the longest Moreover, small geographic areas do not attract online sales.
and students from Japan have the shortest duration of In- Daily online gaming is common in Japan (39%), South
ternet use on an average holiday. Regarding the IAT results, Korea (20%), and Malaysia (19%), perhaps because of the
ranking the six countries from the highest to lowest mean flourishing local development of the online game industry in
scores gives the following list: Philippines, Japan, Hong China, Japan, and South Korea.34 The bandwidth availability
Kong, Malaysia, China, and South Korea. As a screening tool, offered by local Internet providers and the connectivity in
the IAT suggests that the prevalence of addictive Internet use these countries are other possible factors.
ranges from 1% in South Korea to 5% in the Philippines, and Social networking addiction is another addictive behav-
the prevalence of problematic Internet use ranges from 13% ior.35 Mobile messenger service providers from China,
in South Korea to 46% in the Philippines. The mean CIAS-R Japan, and South Korea such as Kakao Talk, Line, and
scores in the six countries are, in order, Philippines, Hong WeChat have dominated the global market. These smart-
Kong, Malaysia, China, Japan, and South Korea. As a phone applications in many cases are culture specific. The
screening tool, the CIAS-R suggests that the prevalence of collectivistic characteristics of Asian young people and the
addictive Internet use in the six countries is Philippines (21%), individualist characteristics of Western young people have
Hong Kong (16%), Malaysia (14%), South Korea (10%), been found to affect their behavioral patterns on Face-
China (10%), and Japan (6%). book.36 We believe that such differences may also help to
explain the higher use of online social networking in Asian
adolescents. One cultural similarity across China, Japan,
Discussion
and South Korea is Neo-Confucianism, which may suppress
This epidemiological study indicates that Internet ad- individualism and the expression of individual creativity.
dictive behavior is common among Asian adolescents, The Internet has provided an ideal platform with unlimited
probably due to the popularity of computers and smart- space to conform to a traditional culture, but also to allow
phones. We also found a higher rate of smartphone use in individual adolescents to express their emotions outside of
most Asian countries (41% to 84%) compared to the United the family hierarchy system.37
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Table 4. Internet Use Patterns and Addiction Disorders Screened by the Internet Addiction Test (IAT)
and Revised Chen Internet Addiction Scale (CIAS-R)
China Hong Kong Japan South Korea Malaysia Philippines
Frequency of Internet use (%)
One a week or less 39.9 7.2 15.9 14.8 20.9 17.7
2–3 times a week 18.5 10.2 17.1 23.9 21.8 17.2
4–6 times a week 15.6 14.3 12.0 21.5 13.2 17.6
Once daily 10.0 20.7 13.2 18.1 10.1 15.5
2–3 times a day 4.4 8.6 9.0 8.0 10.3 9.2
More than 3 times a day 11.6 39.0 32.8 13.8 23.7 22.8
Duration of Internet use (hours/day), mean (SD)
School days 1.40 (2.93) 2.74 (2.95) 1.42 (1.37) 1.48 (1.70) 2.65 (4.32) 2.81 (2.23)
Holidays 3.42 (4.00) 4.82 (4.04) 2.25 (2.33) 2.43 (2.37) 4.31 (5.10) 4.57 (3.95)
IAT, mean (SD)
Withdraw and 13.31 (6.23) 15.19 (6.37) 15.33 (5.98) 12.55 (4.87) 15.63 (6.38) 17.84 (6.54)
social problems
Time management 9.91 (5.03) 12.50 (5.14) 14.11 (5.51) 9.98 (3.95) 12.21 (5.24) 12.99 (4.90)
Reality substitute 5.23 (2.60) 6.27 (2.84) 5.81 (2.66) 4.08 (1.80) 5.93 (2.84) 6.43 (2.86)

724
Total 31.02 (14.08) 37.45 (14.17) 39.99 (14.25) 29.57 (10.65) 37.14 (14.59) 41.66 (14.15)
IAT-defined addictive 2.2 (1.2–3.2) 3.0 (1.8–4.1) 3.1 (1.8–4.3) 1.2 (0.5–1.9) 2.4 (1.4–3.4) 4.9 (3.6–6.2)
Internet user, % (95% CI)
IAT-defined problematic 17.1 (14.6–19.7) 31.6 (28.4–34.7) 44.4 (40.8–47.9) 12.5 (10.4–14.6) 35.1 (32.1–38.1) 46.0 (42.9–49.1)
Internet user, % (95% CI)
IAT-defined average 80.7 (78.0–83.3) 65.4 (62.2–68.7) 52.5 (49.0–56.2) 86.3 (84.0–88.5) 62.5 (59.4–65.6) 49.1 (45.9–52.2)
Internet user % (95% CI)
CIAS-R, mean (SD)
Sym, compulsive use 11.29 (4.66) 11.74 (4.60) 9.76 (3.57) 10.22 (4.90) 11.78 (4.08) 13.06 (4.28)
Sym, withdrawal 8.13 (3.67) 9.08 (3.75) 7.52 (3.08) 7.56 (3.52) 8.33 (3.28) 9.32 (3.50)
Sym, tolerance 7.41 (3.34) 8.58 (3.61) 7.37 (2.84) 7.39 (3.64) 8.82 (3.44) 9.32 (3.29)
RP, interpersonal and 6.41 (2.93) 7.48 (3.03) 7.28 (3.02) 6.54 (2.93) 7.01 (2.87) 7.95 (2.88)
health-related problems
RP, time management problems 7.95 (3.59) 9.06 (3.72) 7.70 (3.20) 7.94 (3.14) 9.49 (3.85) 10.21 (3.56)
Total 41.03 (16.28) 45.94 (16.92) 39.63 (14.03) 39.52 (17.52) 45.31 (15.10) 49.74 (15.49)
CIAS-R-defined addictive 9.6 (7.6–11.6) 16.4 (13.9–19.0) 6.2 (4.4–7.9) 9.7 (7.1–12.3) 14.1 (11.9–16.3) 21.1 (18.6–23.7)
Internet user, % (95% CI)
CI, confidence interval; Sym, symptoms; RP, related problems.
 INTERNET BEHAVIORS AND ADDICTION AMONG ASIAN ADOLESCENTS 725

The prevalence of problematic or addictive Internet use, as search attention to the study of smartphone and video game
defined by the IAT, was highest in the Philippines (51%) and addiction.55 The present results should be interpreted with
Japan (48%). In China, we found a prevalence of 17% caution, as nowadays people can go online using mobile
problematic and 2% addictive Internet use; this contrasts communication devices such as smartphones, in addition to
with the 8% reported in another study that used the IAT in the traditional fixed-line communication devices. Therefore,
eight Chinese cities in 200838 and 6% in a more recent study the Internet overuse reported may just be common among
in Wuhan, China, in 2010.39 Moreover, we found that about smartphone users nowadays. With the development of scales
32% and 3% of Hong Kong students have IAT-defined for measuring specific smartphone and online videogame
problematic or addictive Internet use respectively. Fur- addiction problems among young people,56–58 future studies
thermore, 16% were defined as Internet addicts by the may also explore these domains across populations. On the
CIAS-R, which was comparable to another study in Hong other hand, adolescents from rural areas of the countries
Kong (17%).40 A previous study in Hong Kong also re- should be included to increase the representativeness of the
ported that 72%, 22%, and 7% of adolescents exhibited 0–2, results, especially in China where socioeconomic differ-
3–4, and q5 symptoms of Internet addiction.41 In South ences between urban and rural areas could have a large
Korea, we found that 14% scored at least 70 in the IAT, effect on the presence of Internet addictive behavior among
which is similar to a previous study in 2005 that found 11% adolescents.59
had such scores.42 A 2006 study conducted in one school in Furthermore, an electroencephalogram study found higher
Gwangju reported the proportions of IAT-determined se- impulsiveness in young adults who are Internet addicts.60
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vere addicts and moderate addicts as 3% and 54% in boys It would not be surprising if Internet-addicted adolescents
and 2% and 39% in girls respectively.43 Another recent were found to have a different personality profile than others,
survey using the South Korean Internet Addiction Self- with lower extraversion and higher neuroticism and psy-
Assessment Tool reported a potential Internet addiction rate choticism.61 Behavioral and emotional problems are more
of 15% and an Internet addiction rate of 3% in 2010.44 The common in adolescents who are addicted to Internet use than
relatively low prevalence in South Korea observed in this in their peers.62 Adolescents with Internet use problems are
study may be explained by the shutdown law that went into also more prone to other addictive behaviors such as sub-
effect in 2011. According to this law, all children under the stance abuse63 and gambling.64 Appropriate use of the In-
age of 16 years are forbidden to access online games be- ternet may help to alleviate the situation; for instance, both
tween midnight and 6 am. online and offline social support are important to rec-
There have been no recent studies of Japanese, Malaysian, tify cyber-misbehaviors.65 Cognitive–behavioral approaches
or Filipino adolescents using the IAT or CIAS-R. The prev- may be suitable treatments for adolescent Internet addicts.66
alence of IAT-defined Internet addiction in Asian countries According to recent research, cognitive–behavioral ap-
found in this study was relatively higher than the prevalence proaches work with adult populations, and further studies
reported in Europe. The IAT-defined Internet addiction among may test these approaches for adolescents.67,68 A prospective
adolescents was 1% in Italy45 and 4% in Turkey.46 Studies study in Taiwan suggested that psychiatric symptoms could
using Young’s Diagnostic Questionnaire found the prevalence actually lead to Internet addiction.69 Therefore, given the
of Internet addiction in adolescents to be 3% in Greece,47 2% high prevalence of Internet addiction among Asian youth
in Norway,48 and 2% in boys and 1% in girls in Finland.49 found in this study, these six countries should examine the use
This study has several limitations. Until now, the IAT scale of cognitive–behavioral therapies that provide social support
has been validated only in Hong Kong Chinese adolescents,15 and prevent youth from becoming addicted to the Internet.
and in South Korean50 and Malaysian college students.17 A Holistic prevention programs should be used, as psychiatric
version of the IAT that focuses on the Internet addictive illness could also accompany Internet addiction among youth.
behaviors of adolescents may be required for more accurate A recent study of Australian adolescents also suggested that
results. The CIAS-R was found to contain more information adolescents with pathological Internet use had a relatively
than the IAT in Chinese students using the item response higher risk of axis I comorbidity than those with pathological
analysis.51 Similar analyses are necessary in other Asian video gaming behavior.70 Therefore, it is reasonable to be-
populations. The CIAS-R may overestimate the prevalence of lieve that early prevention and detection of Internet addiction
Internet addiction in adolescents. The prevalence of CIAS-R- among Asian children and adolescents should be given pri-
defined Internet addicts within each country was consistently ority in terms of health education resources.
within the interval between the prevalence of IAT-defined It is necessary to study the incidence as well of the re-
problematic and addictive Internet users. This may suggest mission of Internet addiction in adolescents.71 Childhood
that CIAS-R-defined Internet addiction should be restated as behavioral problems are mostly associated with Internet
problematic Internet use. Clinically, the cutoff of 70 for IAT addiction in adolescents.72 Early intervention is needed to
was less stringent for diagnosis, as revealed by a youth study prevent the development of Internet addiction in adoles-
conducted in South Korea,52 whereas the cutoff of 75th per- cence. Parents could play an important role in the prevention
centile for CIAS (not CIAS-R) was used in another adoles- of Internet addiction among adolescents. Lack of parental
cent study in Taiwan.53 monitoring is a major factor in addictive Internet behavior.73
The instability of Internet and game addiction behavior in Therefore, educating parents about healthy Internet use is
adolescents also contributes to the difficulty of assessment.54 also urged. In addition to childhood problems, parents’ risky
Nevertheless, the use of a universal scale makes these behaviors, such as alcohol abuse, could lead to Internet ad-
comparisons across countries valid and useful for future diction in adolescence.74 Perhaps governments in Asia
reference. Most current literature focused on generalized should pay more attention to Internet addiction, just as they
Internet addiction problems, but there is relatively scant re- do to other addictive behaviors such as substance use.63
 726 MAK ET AL.

Moreover, other Internet addiction-related behaviors in- 12. Lortie CL, Guitton MJ. Internet addiction assessment tools:
cluding online gambling,75 bullying, and stealing are worth dimensional structure and methodological status. Addiction
exploring in future studies. The cultural influences on per- 2013; 108:1207–1216.
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15. Lai CM, Mak KK, Watanabe H, et al. Psychometric
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This population-based study reported the prevalence of cents. Journal of Pediatric Psychology 2013; 38:794–807.
Internet addictive behavior in six Asian countries. The two 16. Kim HS. (2000) Internet addiction. Seoul: Nanum Press.
most common assessment tools for Internet addiction were 17. Chong Guan N, Isa SM, Hashim AH, et al. Validity of the
administered to adolescent samples in these populations. The Malay version of the Internet Addiction Test: a study on a
study found that problematic Internet use is prevalent in all group of medical students in Malaysia. Asia-Pacific Journal
six countries, and is characterized by risky cyberbehaviors. of Public Health 2012; 20:1–10.
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No competing financial interests exist. 19. Lin IH, Ko CH, Chang YP, et al. The association between
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2007; 10:545–551. Department of Psychology
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childhood predict Internet addiction in male adolescents? Pokfulam Road

Child Psychiatry & Human Development 2013; 44:549–555. Hong Kong
73. Yen CF, Ko CH, Yen JY, et al. Multi-dimensional dis-
criminative factors for Internet addiction among adolescents E-mail: [email protected]