The complex and emerging field of problematic internet use (PIU), commonly dubbed ‘internet addiction’, requires a comprehensive, empathic and culturally-sensitive approach to assessment, before one can commence treatment, or therapy.

As indicated in my earlier article for Generation Next (January 2012), a few key points must be borne in mind during the assessment process:

 First, PIU, in common with most if not all mental health conditions, clearly falls along a ‘spectrum of severity’, ranging from mild, to moderate, then severe forms of problem behaviours. There is no clear ‘cut-off point’ where the client has, or has not, got a legitimate problem.

Second, PIU is probably best conceptualized as a complex end-point behavior of many predisposing or underlying factors, most notably mental health conditions such as depression and anxiety, or personal stresses such as domestic tensions, low self-esteem, or bullying at school. Clinical experience suggests that only very rarely does ‘internet addiction’ arise spontaneously following introduction to the world of computing and the Internet

Third, assessing a client requires time, empathy and the ability to explore his/her personal history, or ‘narrative’, to obtain clues as to what ultimately led to the problem behaviours. There are many ‘internet addiction tests’ available, many of which have been scientifically tested across numerous countries and cultures, but, as noted above, such tests or questionnaires often miss the subtleties and complexities of the individual, and are thus not recommended to assess, let alone provide a diagnosis, on their own. However, they can be useful in providing a ‘screening tool’ when surveying larger populations, such as those considering attending a specialist clinic, or in a school-based research project.

 Fourth, where possible, assessment should extend to the client’s family circle (particularly when assessing children or teenagers), and if consent is provided their teachers, school counselors, acquaintances or work colleagues. This will provide addition historical and social information to aid the formulation of the case, including the computing and Internet habits/time-spending in the client, which is often underestimated by the latter upon specific questioning. Clearly, the age of the client will determine how much weight is placed upon what psychiatrists call the ‘corroborative history’ – for example, in a 13yr old schoolboy, much emphasis will be placed on secondary sources, compared to a 21yr old single professional who may only see his parents or family rarely.

Fifth, another potentially important area to explore is the client’s ethnic or cultural background, and how this fits into the individual’s ‘narrative’, or personal story. In the past decade or so, there has been increasing interest in how transcultural phenomena affect or ‘shape’ one’s experience of a mental illness, and this is likely to be true in PIU, though I am not aware of specific international research that explores this intriguing area. For example, it is recognized that countries such as South Korea and Japan have highly ‘wired’ youth populations, who often live in dense, highly urbanized societies and have placed upon them major scholastic/ academic pressures that have recently become popularized as the ‘Tiger Mothers’ phenomenon. These considerations, though of course not unique to East Asian societies, may be a factor in the development of PIU, and could be explored in the assessment process.

 NIIRA has developed a brief, user-friendly ‘assessment tool’, known as IMPROVE, to facilitate a comprehensive assessment. Each letter stands for a key point in the assessing process, and thus goes beyond the limitations of a simple questionnaire as noted above:

I  :   take an Internet Inventory – list the common activities, websites and goals that the person uses.  Different types of IT usage (eg. Gaming vs. Social networking) will require differing approaches to treatment

M  :   Monitor  the usage and activities over time (eg. a 4 week period). A single ‘snapshot’ of usage may not suffice, as visited sites, or types of games, can vary widely over time.

P  :   Parenting factors:  examine the positive and negative effects of parenting and parent involvement in the core problems.

R  :   Real world activities: list and categorise the real-life activities, sports, hobbies that the client does through a typical week, particularly noting what activities may have been displaced by increasing computer time

O  :    Other mental health issues:  check for presence, or absence, of associated problems such as low mood, anxiety, social stresses, etc.

V  :    Vulnerability factors:  an extension of the above, this section examines any recent or past negative events, stresses, or difficulties that may predispose to PIU. May include personality or developmental factors

E   :    is there now Extra help needed, beyond just in-family measures:  eg. does the school counsellor, family doctor, or a clinical psychologist need to get involved?

 Please visit our website, www.niira.org.au for more details on the IMPROVE tool, and other aspects of assessment and treatment. The IMPROVE tool was designed to be easy to use, but to also encourage reflection and, possibly, facilitate change in the person completing it – this could be a parent, carer, or the client themselves. It could also be a useful document to bring to a formal assessment by a psychologist or psychiatrist, having been completed in advance.

A sophisticated and informed assessment and history is the basis to any successful therapy, and will indicate which specific type of therapy will be chosen for that individual client. There is currently a wide variety of treatment types in use internationally for PIU, and this will be the topic of our next article.

Dr. Philip Tam, Child/adolescent Psychiatrist, President/ co-founder of the Network for Internet Investigation and Research in Australia. He is a key speaker at the inaugural Kids in Cyberspace !