Problem technology use (PTU) is an umbrella term that refers to the use of digital technology (e.g., gaming, social media use and consumption of digital content) in a manner that is associated with biopsychosocial harms to the individual using that technology.
It is important to note that many people use technology in a way that does not cause them harm. Unlike alcohol and other drugs where even low levels may cause individual and societal harm (Van Amsterdam et al., 2010), low levels of technology use are not always harmful and may have some benefits, such as socially, cognitively and on individual perspectives (Bediou et al., 2018; Kovess-Masfety et al., 2016; Velez et al., 2014).
Interaction with digital technology has been rapidly increasing around the world (Giedd et al., 2012). Although many changes associated with technology have been positive (Pinker, 2018), there are also negative impacts particularly for certain segments of the population (Griffiths, 2005a). Historically, many concerns have been raised about the impacts of changes in technology, such as Plato criticizing the shift to writing instead of public debate and panic about the printing press (Edgerton, 2007; Ong, 2006). While these examples show a trend in how technology is typically viewed initially (i.e., with caution and negativity), today’s digital technology is different compared to previous eras’ technology.
One major difference in today’s technology is that it has been designed to promote ongoing usage through mechanisms such as algorithms (e.g., search engines, video providers and social media recommendations). Sophisticated manipulation of stimuli, such as colours and sounds, also promotes increased use. For example, social media platforms can make recommendations for videos or posts that keep you on the platform for longer periods of time, or games use bright colours paired with a sound after completing a task to help promote continued play. These features may contribute to increased use of technology and negative outcomes, especially if other important aspects of life are replaced with this increased use (King & Delfabbro, 2019).
As there is currently no formally recognized diagnosis for PTU, several terms have been used to describe the same/similar issue in relation to mental health. These terms include broad terms such as:
- Internet addiction (IA)
- technology-based addiction
- pathological technology use
- pathological internet use.
More specific terms are also used for different aspects of technology, such as “pathological video gaming,” “excessive gaming,” “dependent gaming,” “social networking addiction,” “social media addiction,” and many others (Paulus et al., 2018).
The Centre for Addiction and Mental Health (CAMH) uses the term “problem technology use” as it helps reduce stigma compared to other terms. For example, it is more inclusive of those who may be experiencing difficulties without reaching the clinical threshold of pathology and uses language similar to other areas such as problem gambling.
Although there is no formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) or International Classification of Diseases 11th Revision (ICD-11) related to the broader issue of PTU, gaming disorder has been recognized in the ICD-11. Criticism and debate followed its inclusion (Paulus et al., 2018; Van Rooij et al., 2018; Wood, 2008). Although the debate is complex and nuanced, some areas where there is a lack of consensus include the following:
- Conceptualization: Is problem gaming a separate and distinct mental illness, symptoms of an underlying issue (e.g., depression, anxiety), a coping mechanism, an addiction or something else?
- Definitions and boundaries: Will the current definitions problematize normal or healthy levels of gaming (particularly for youth) and what is the boundary between healthy and unhealthy usage?
- Motivations: Are the motivations for making problem gaming formalized due to moral panic, or are gaming industries trying to prevent the inclusion so they do not have to take responsibility for problem gamers?
Both sides provide compelling evidence, but these issues are still unresolved (Ferguson & Cowell, 2019). The DSM-5 has also considered Internet gaming disorder as a condition that warrants further study, but has not yet made it a formal diagnosis.
What does the evidence say?
Evidence indicates that a significant portion of the population has experienced or currently meets the criteria for PTU. A 2016 study of Ontario adults showed that about 40 per cent met the criteria for any form of problematic use of technology and about 8 per cent met the criteria for moderate to severe problematic use. Almost 30 per cent had tried to cut back on their use of electronic devices, suggesting a need for intervention and support (Lalomiteanu et al., 2018). Similarly, about 30 per cent of students report spending five or more hours per day using electronic devices (i.e., smartphones, tablets, laptops, computers, gaming consoles, etc.). In addition, 20 per cent of students spend at least five hours per day using social media, a 4 per cent increase from 2015 and a 9 per cent increase since 2013 (Boak et al., 2018). Most recently, 5 per cent of Ontario high school students have symptoms that are consistent with PTU, such as a preoccupation with technology, loss of control, withdrawal symptoms and problems with family and friends.
However, these studies should be interpreted with caution, as they were primarily conducted in Ontario and relied upon self-report. These results may not be generalizable to other provinces or countries and need to be supplemented with other types of data, including objective indicators (e.g., mobile phone usage data) (CAMH, 2018).
Biopsychosocial + risk factors
There is a complex interaction between biological, psychological, social and technology-specific factors that combine within an individual to cause potential harm. It can therefore be useful to consider each of these risk factors, in line with a biopsychosocial + model (Kourgiantakis et al., 2017).
Age can be a risk factor for several different types of technology, particularly for gaming and social media use. In general, risk is lower with those who are very young, as their environments are generally controlled by caregivers. The risk for harm begins to increase in adolescence and then starts to decrease in their late 20s. Individuals aged 12–18 are at an increased risk and there may be further increased risk for individuals who have access to media in their bedrooms (Gentile et al., 2017;Kuss & Griffiths, 2012).
Gender can be a risk factor that is different for different types of technologies. Males have been found to be 2–5 times more likely to be at risk than females for problem gaming (Durkee et al., 2012). In comparison, females are more at risk for problem social media use (Andreassen et al., 2016; Boak et al., 2018)
Co-occurring disorders are a major risk factor for PTU. Currently it is unclear if these also increase the likelihood of developing PTU further as well. Common disorders include (Andreassen & Pallesen, 2013; Andreassen et al., 2017; Torres-Rodríguez et al., 2018):
- anxiety disorders
- mood disorders
- behavioural disorders
- autism spectrum disorder
- attention deficit hyperactivity disorder
- personality disorders.
Self-esteem and efficacy have been related to PTU, as those who have a poor sense of competency, self-esteem or attachment or body image issues may be more likely to either gravitate to technology as a way to cope (e.g., playing games to distract) or to develop problems from their use (e.g., comparing to others on social media) (Jeong & Kim, 2011; Oldmeadow et al., 2013; Stentina et al., 2011; Sidani et al., 2016).
Life satisfaction and meaningful activities are important protective factors that reduce the risk of developing PTU., Individuals may be more likely to use technology in harmful ways if they have few meaningful activities or a low level of satisfaction (Allen & Anderson, 2018; Bender & Gentile, 2019).
Family and peer influences may influence someone to use technology more or less and may act as a support or stressor in developing PTU. Social exclusion, family stress, peer-pressure or relationships all impact use of technology and how problematic that use becomes (Choo et al., 2015; King & Delfabbro, 2019; Li et al., 2018a; Schneider et al., 2017).
How do I put the evidence into practice?
How to screen for PTU
Screening for PTU can be either informal or formal. In an informal screen, ask the client a few initial questions to open the discussion and probe for any potential signs of problem technology use (Young, 2011).
Ask one or two direct questions, such as:
- How do you feel about your technology use?
- Has a friend or family member suggested you cut down on your technology use?
Several research-validated screening tools are available to identify PTU. One example is the Problematic Internet Use Questionnaire (18 questions; developed by Professor Gijsbert Stoet and hosted on PsyToolkit). This open-access, self-administered tool assesses harms such as preoccupation with online use, neglect of non-online activities and inability to stop using the Internet (Demetrovics, 2008).
Given the high rate of co-occurring mental health problems associated with problem technology use (Andreassen & Pallesen, 2013; Andreassen et al., 2017; Torres-Rodríguez et al., 2018), it can be helpful to screen for mental health problems and other functional difficulties (Shaw & Black, 2008). It may be helpful to have regular, universal screening for mental health and addictions concerns (including PTU) as this may support health promotion and enable early intervention, if appropriate. A useful tool for this purpose is the global appraisal of individual needs – short screener (GAIN–SS). The staged screening and assessment for addictions guide (CAMH) outlines how to use and interpret the GAIN–SS.
Some specific screeners exist for problem gaming such as the Internet Gaming Disorder Scale (IGDS) (Lemmens et al., 2015), the Internet Gaming Cognition Scale (IGCS) (King & Delfabbro, 2014; King & Delfabbro, 2016) and the Gaming-Contingent Self-Worth Scale (GCSW) (Beard & Wickham, 2016). Tools are also available to assess problem social media use, such as the Bergen Social Media Addiction Scale (BSMAS) (Andreassen et al., 2016) and the Social Media Disorder Scale (SMDS) (van den Eijnden et al., 2016). However, these tools are not currently open access.
There is limited research on the treatment of PTU, which makes it difficult to form definitive conclusions surrounding best practices for treatment. A recent systematic review found the following approaches to be effective (Kuss & Lopez-Fernandez, 2016):
- psychological therapies
- a combination of different approaches (e.g., psychological therapies combined with medications).
The majority of studies using a psychological therapy approach used group therapy rather than individual therapy, as group therapy may create a safe environment and establish a support group. In addition, hearing the stories of others may be helpful for individuals to develop insight into their own problems (van den Eijnden et al., 2016). Within a controlled research setting, the inclusion of families in treatment planning was also successful and is recommended. Although these results are promising, several studies did not include a control group and had small sample sizes or selection bias concerns. Further research in this area is required.
Stevens and colleagues (2019) conducted a similar systematic review and meta-analysis for problem gaming. They found similar results, with cognitive-behavioural therapy (CBT) being highly effective at reducing IGD and depression symptoms. However, the effects of CBT were reduced or did not last during follow-up despite being initially effective. This is an important consideration that warrants further investigation and may influence how long clinicians should engage with clients who initially appear to be doing well. Future research regarding methods to evaluate and promote more sustained benefits is also required.
Although there is less research on mindfulness and PTU, results have been promising in this area. For example, Li and colleagues (2018b) conducted a mindfulness-oriented recovery enhancement (MORE) protocol for adult clients with IGD over eight weeks. Participants had significant reductions that were maintained at a three-month follow-up. Although these results are promising, it is important to recognize that they are preliminary and come from a single study. Overall, PTU is an increasingly important area with research just starting to emerge. Although there is much we do not currently understand about the topic, it is important that clinicians start to act on the available information.
Clinical simulation video
This video clip shows a fictitious therapist and client session for teaching purposes.
The scenario shows a typical cognitive-behavioural therapy session with a client (Bart) who is trying to maintain his changes related to problem gaming. The client and his therapist are discussing a recent lapse. The therapist works collaboratively with him to complete the Learning from Slips and Relapses handout and find alternate activities and coping strategies for triggers that may lead to excessive video gaming.
Recommendations for young children
The Canadian Paediatric Society (CPS) recommends imposing limits on screen time in children. It discourages technology-based activities for children under two years of age and recommends limiting recreational technology use to less than one hour per day for children aged two to five years (CPS, 2017).
The CPS recommendations state that although these limits may be difficult for parents to enforce, parents should focus on monitoring how and when children use technology rather than the amount of time they spend using technology. Read the fill CPS recommendations.
For more detailed information on PTU, consider taking our course on problem technology use.
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