It’s 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 harm on an individual and societal level1, low levels of technology use are not always harmful and may have some benefits (e.g., social, cognitive, perceptive, etc.).2, 3, 4
Interaction with digital technology has been rapidly increasing around the world.5 Although many changes associated with technology have been positive6, there are negative impacts, particularly for certain segments of the population.7 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.8, 9 While these examples show a trend in how technology is typically viewed (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 (e.g., colours, sounds, etc.) also promotes increased use. This might look like social media platforms making recommendations for videos or posts that keep you on the platform for longer periods of time, or games using bright colors paired with a sound after completing a task, which may 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 increased use.10
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 the following:
- Internet addiction (IA)
- Technology-based addiction
- Pathological technology use
- Pathological internet use.
More specific terms have also been used for different aspects of technology such as “pathological video gaming,” “excessive gaming,” “dependent gaming,” “social networking addiction,” “social media addiction,” and many others.11
The Centre for Addiction and Mental Health (CAMH) uses “problem technology use” as it helps reduce stigma compared to other terms, 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.11, 12, 13 Although the debate is complex and nuanced, some areas where there is a lack of consensus are:
- 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 don’t have to take responsibility for problem gamers?
- Both sides provide compelling evidence, but these issues are still unresolved14. 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 eight per cent met the criteria for moderate to severe problematic use. In addition, almost 30 per cent had tried to cut back on their use of electronic devices, suggesting a need for intervention and support.15 About 30 per cent of students report spending five or more hours per day on the use of electronic devices (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 four per cent increase from 2015 and a nine per cent increase since 2013.16 Most recently, five 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, studies in this section should be interpreted with caution, as they were primarily conducted in Ontario and relied upon self-report; these results may not be able to be generalized to other provinces or countries, and need to be supplemented with other types of data, including objective indicators (e.g., mobile phone usage data).17
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.18
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. Their 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 may have further increased risk with individuals who have access to media in their bedrooms.19, 20
Gender can be a risk factor that is different for different technologies. Males have been found to be 2–5 times more likely to be at risk than females for problem gaming.21 In comparison, females are more at risk for problem social media use.22, 23
Co-occurring disorders are a major risk factor for PTU. At this time, it is unclear if these also increase the likelihood of developing PTU further as well. Common disorders include: 24, 25, 26
- 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, 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).27, 28, 29, 30
Life satisfaction and meaningful activities are important protective factors, reducing the risk of developing PTU. If there are few meaningful activities or a low level of satisfaction, individuals may be more likely to use technology in harmful ways. 31, 32
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.10, 33, 34, 35
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.36
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). 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.37
Given the high rate of co-occurring mental health problems associated with problem technology use,24, 25, 26
it can be helpful to screen for mental health problems and other functional difficulties.38
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
outlines how to use and interpret the GAIN–SS.
Some specific screeners exist for problem gaming such as the internet gaming disorder scale (IGDS)39, the internet gaming cognition scale (IGCS)40, 41 and the gaming-contingent self-worth scale (GCSW)42. Problem social media use also has some tools such as the Bergen social media addiction scale (BSMAS)43 and the social media disorder scale (SMDS)44. However, these tools are not open access at this time.
Recommendations for young children
The Canadian Paediatric Society (CPS) recommends imposing limits on screen time in children.45 It discourages technology-based activities for children less than two years old and recommends limiting recreational technology use to less than one hour per day for children two to five years old.
Although these limits may be difficult for parents to enforce, the CPS recommendations state that parents should focus on monitoring how and when children use technology rather than the amount of time they spend using technology. Read the full CPS recommendations
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: 46
- 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, establish a support group and others stories may be helpful for individuals to develop insight into their own problems 44. Within a controlled research setting, the inclusion of families into treatment planning was also successful and is recommended. Although these results are promising, several studies did not include a control group, had small sample sizes or selection bias concerns, and further research in this area is required.
Stevens and colleagues47 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 appear to be doing well initially. 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 colleagues48 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 don’t currently understand about the topic, it’s important that clinicians start to act on the things that we do know and understand.
Clinical simulation video
Download video transcript
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.