'SIGNS' of Net addiction: Interview

Last year a person who works for a psychiatric hospital and specializes in adolescent care posted in our forum at ConnectSafely.org asking if anyone had developed screening for "Internet addiction." No one in the forum had, and I suspected this person was pioneering something, pointing to a challenge for social services and the health care profession for which there is little research. It has since occurred to me to put this question to Dr. Jerald Block, a psychiatrist in Portland, Ore., who has worked with patients on game addiction.

Here's our email conversation, illustrating the challenges this question poses to the medical profession (but stick with him, parents, because below the challenges is some helpful thinking for you):

NetFamilyNews: "Have you ever put together a screening list for 'Internet addiction' and 'online porn addiction' - what a parent or caregiver might look for to decide if a child needs help toward a better balance of activities? I'm sure there's the usual sleeplessness, suffering grades, etc., but I'd appreciate a comprehensive list if you have one. 'Game addiction' too - all three would be great, but especially this blanket term we're hearing, 'Internet addiction'."

Dr. Block: "I've given this a lot of thought and it is more difficult than I'd like to admit. I have made my own 'testing instrument' to detect 'Pathological Computer Use,' but it has not been 'standardized.' That is, essentially, the issue.

"Lacking clear diagnostic criteria, we also lack a scientific test. Also, even using proposed criteria, we still need to compare the test to the gold standard - a clinical interview. You have to do this with a great many people, and that many interviews cost money. It also takes effort to find the representative patients.

"The only people that have done this that I trust are the South Koreans, who have spent bundles on the issue, and some psychiatrists in Taiwan. Their clinical test has been standardized against and compared to the clinical interview. And, they have a variant that is meant to be used by the parent. However, the test is culture-specific and would not translate well to computer use in the US. [For a solid look at cultural differences in social Web use between the US and Korea, see this article about Korean social networking in the Journal of Computer-Mediated Communication.]

"That being said, I use a mnemonic to identify 'SIGNS' in at-risk people (kids or adults):

S = Sleep cycle is consistently advanced. Goes to sleep later and wakes later or is tired in the morning.
I = Irritable when not on the computer. Preoccupied thinking about the computer and their activities there (sex, gaming, browsing, tuning the system up, etc.). Can become enraged if told to stop using.
G = Guilty about his/her computer use so tries to hide evidence of 1) game/porn purchases, 2) online activities (deletes cache, uses encryption/passwords, etc.), and 3) logs on secretly, etc.; 4) defensive when confronted.
N = Nightmares. Dreams about his or her gaming/computer use.
S = Social dropouts - people who become more isolated by their computer use. This is seen when there is a consistent pattern of sacrificing real-life relationships to preserve virtual ones. Alternatively, seems to prefer living in virtual worlds more than their real one. These people become NEETs: 'Not in Employment, Education, or Training.'

"If one or more of these questions are answered 'yes' AND the person is having interpersonal problems, he/she is at risk."

NetFamilyNews: Following up, I asked Dr. Block, "Would you say the SIGNS mnemonic is for both 'computer addiction' and 'Internet addiction'?"

Dr. Block: "Yes. I consider Internet addiction a subset of PCU (pathological computer use), and the mnemonic screens for PCU."

NetFamilyNews: "Would it cover videogames and social-networking sites as well?"

Dr. Block: "Yes, I believe so."

NetFamilyNews: "If kids are at risk for one of these types of addiction, what do you recommend a parent do? Consider taking the child to a clinical psychologist or family therapist?"

Dr. Block: "I really don't know. I don't think anybody does. I would suggest that parents try to handle the situation themselves, initially. If that fails, I would consult a professional. The problem is that most professionals do not know what to do and are unacquainted and unequipped to manage the issue. In my experience, PCU is underdiagnosed, hard to treat, comorbid with other disorders, and often subject to relapse. Treatments tend to be long-term and, frankly, expensive. And clinical results are less than stellar. That is the international experience, not just the US's. It is a serious clinical problem, from many perspectives.

"An easier question is what NOT to do. DO NOT "cut the cord" unless in the context of an extended rehab-like setting. Cutting the child/adult off [from the computer, game, social-networking activity] can produce far worse outcomes (drug use, violence, depression, etc.). I differ in this from some practitioners who advocate for setting such firm limits. [See his commentary on this in the Rocky Mountain News or full-length analysis in "Related links" below.]

"Incidentally, probably the most effective treatment would be a 'retreat' or rehab-like setting for a minimum of 2 weeks. I think a full month is better [see this New York Times piece about a South Korean Internet addiction rehab camp]. But that is expensive and many would see it as overkill."

NetFamilyNews: "What do you think of applying the word 'addiction' to these non-chemical activities, or can they have a chemical impact on the brain?"

Dr. Block: "There is the concept of 'positive addictions' - people like 'workaholics,' avid readers, or model railroaders. At times, PCU might be more productive and be considered in that way (like for people employed in the industry, i.e., video game programmers).

"More generally, I think there is a common pathway with substance abuse. The issues around craving and the later phases of withdrawal appear to be very similar.

"That said, I avoid the use of the word 'addiction.' It is just too explosive, political, and packed with other meanings. I prefer to think of this as a compulsive-impulsive spectrum disorder, much like compulsive eating, gambling, pyromania, and trichotillomania."

Related links

Dr. Block's Web site

His editorial "Internet Addiction" in the latest issue of the American Journal of Psychiatry

"Net addiction rehab in Korea"

"Lessons from Columbine: Virtual and Real Rage," the last bullet under Computer Related - Research on Dr. Block's home page, makes reference to the teen shooters' home and school environments, and other detailed analysis

"Notable fresh videogame findings" (under this headline, the items "Columbine revisited" and "Pathological videogame use" link to findings on these subjects by Dr. Block).