Longer term effect of randomized, controlled

group cognitive behavioural therapy for Internet

addiction in adolescent students in Shanghai

Ya-song Du, Wenqing Jiang, Alasdair Vance

Objective: The aim of the present study was to evaluate the therapeutic effectiveness of
group cognitive behavioural therapy (CBT) for Internet addiction in adolescents.
Method: A total of 56 patients, who met Beard’s diagnostic criteria for Internet addiction, aged
12–17 years, were divided randomly into an active treatment group (n = 32) and a clinical
control group (n = 24). Participants in the active treatment group were treated with an eight-
session multimodal school-based group CBT while participants in the clinical control group
received no intervention. Internet use, time management, emotional, cognitive and behav-
ioural measures were assessed for both groups at baseline, immediately after the intervention
and at 6 month follow up by investigators blind to the participants’ group status.
Results: Internet use decreased in both groups while only the multimodal school-based
group CBT evinced improved time management skills and better emotional, cognitive and
behavioural symptoms.
Conclusions: Multimodal school-based group CBT is effective for adolescents with Inter-
net addiction, particularly in improving emotional state and regulation ability, behavioural
and self-management style.
Key words: group cognitive behavioural therapy; Internet addiction, randomized controlled
trial.

Australian and New Zealand Journal of Psychiatry 2010; 44:129–134

The Internet has become one of the most common,
expeditious and important communication tools of our
global society. Despite its manifest benefits, a particular
set of behavioural overuse problems, termed Internet
Alasdair Vance, Professor (Correspondence)
Academic Child Psychiatry Unit, Royal Children’s Hospital, University
of Melbourne, Gatehouse Street, Parkville, Vic. 3052, Australia. Email:
avance@unimelb.edu.au
Ya-song Du, Professor
Department of Child and Adolescent Psychiatry, Shanghai Mental
Health Center, Shanghai Jiao Tong University, Shanghai, China;
Academic Child Psychiatry Unit, Royal Children’s Hospital, University
of Melbourne, Murdoch Children’s Research Institute, Melbourne,
Victoria, Australia
Wenqing Jiang, Child and Adolescent Psychiatrist
Department of Child and Adolescent Psychiatry, Shanghai Mental
Health Center, Shanghai Jiao Tong University, Shanghai, China
Received 27 February 2009; accepted 10 June 2009.
addiction, have emerged, especially in the adolescent
population [1–5]. Internet addiction was initially
described by Young as a variant of pathological gambling
without an associated alcohol and/or substance depen-
dence disorder [2]. Beard and Wolf outlined some modi-
fications to Young’s approach that enhanced the validity
and reliability of the Internet addiction diagnosis [1].
These criteria have become established in the field.
Recently, the American Psychiatric Association recom-
mended that three or more of seven key criteria are
required for a diagnosis of Internet addiction disorder.
These include being preoccupied with the Internet (thinks
about previous online activity and/or is anticipating the
next online session); spending increasing amounts of
time on the Internet in order to feel satisfied; making
unsuccessful attempts to control, cut back or stop Internet
use; social, occupational, recreational activities decreased,

© 2010 The Royal Australian and New Zealand College of Psychiatrists

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130 GROUP CBT FOR ADOLESCENT INTERNET ADDICTION
given up or employment threatened by Internet use [1].
Recent studies in China have shown Internet addiction to
have the highest point prevalence in adolescence compared
to other life stages [3–5]. Further, there is a significant
positive correlation between the level of emotional and
behaviour problems and the severity of Internet addiction.
These problems include increased social anxiety, increased
irritability, increased hyperactivity, impulsiveness and
aggression, increased interpersonal sensitivity, increased
difficulties making and maintaining friendships and
decreased self-esteem. In addition, decreased organizational
and strategizing ability and time management skills char-
acterize the adolescents with Internet addiction [6,7].
To date, group cognitive behavioural therapy (CBT)
has been shown to be effective in aiding adolescents with
Internet addiction; in particular, a multimodal school-
based intervention [8–10]. This involves (i) group CBT for
adolescent students with Internet addiction; (ii) psychoed-
ucation for teachers on the recognition and psychological
treatment of Internet addiction; and (iii) group cognitive
behavioural parent training delivered at the same time as
for the adolescent Internet addiction group [8–10].
Improved impulse control, emotional stability and
decreased Internet addiction behaviours have been shown
immediately after the multimodal school-based interven-
tion. A maintenance effect for this intervention, however,
has not been demonstrated as yet. The purpose of the
present study was therefore to investigate whether a ran-
domized, controlled trial of this multimodal school-based
intervention is effective at 6 months after its delivery.
Methods
Participants
Fifty-six adolescent students with Internet addiction, according to
the Beard and Wolf criteria [1], were recruited from 10 secondary
schools in Shanghai, selected at random from the 100 available second-
ary schools. These students were spending approximately 6.53 ± 1.68 h
per day using the Internet online. The Principal of each school gave
permission for their school to be part of the study. Teachers in each
school gave information about the study to students in their classes.
This information was taken home by the students and read by them and
their parents/guardians. If the students and their parents/guardians
expressed interest in being involved, they met with the study staff at
their school for a screening session. A total of 224 students took part
in these screening interviews. Students were excluded if they had evi-
dence of any comorbid medical disorder, pre-existing psychiatric dis-
order and/or were taking any psychoactive medication.
Thirty-two students were randomly allocated to the multimodal
school-based intervention, while 24 students were randomly placed
in the control group. A random number generator computer program
was used to achieve randomization. We aimed to recruit 60 children,
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30 in each group. Power calculations based upon previous Internet
overuse self-rating scale studies yielded moderate effect sizes
(d = 0.55–0.85; d = M1-M2/σpooled, where spooled = s 2 ⫹s 2 / 2 and
1 2
M1 and M2 represent means in untreated and treated patient groups,
respectively) suggesting that 60 young people (30 active group) and
30 clinical control participants were required for an experimental
power of 0.80. There were 28 boys and four girls (mean age of
15.39 ± 1.69 years) in the active group and 17 boys and seven girls
(mean age of 16.63 ± 1.23 years) in the control group. The two groups
did not differ in age, gender composition or educational level. The
multimodal school-based intervention was completed in the active
group schools while there was no school-based intervention in the
control group schools.
Measures
Beard’s Diagnostic Questionnaire for Internet addiction
This scale has eight items in all, with a dichotomous (Yes/No) Lik-
ert scale [1]. Internet addiction is diagnosed when all of the first five
items and at least one of the next three items are met.
Internet Overuse Self-Rating Scale
This scale consists of 20 items in all and uses a 4 point Likert scale
[5,6]. The higher the score, the more severe the participant’s Internet
addiction. Validity and reliability are adequate for China.
Time Management Disposition Scale
The Time Management Disposition Scale (TMDS) has 44 items in
all, with three specific factors: the ‘worth of time’, ‘control over time’
and ‘efficacy of time’ [11]. The higher the score, the better time man-
agement reported. Validity and reliability are adequate for China.
Strength and Difficulties Questionnaire (Chinese edition)
This scale has 25 items in all and uses a 3 point Likert scale supporting
five factors: ‘emotional symptoms’, ‘conduct problems’, ‘hyperactivity
and attention deficit problems’, ‘peer relationship problems’ and ‘pro-
social behaviour’ [12]. For the first four factors, the lower the score,
the better, and for the last factor the higher the score, the better. Valid-
ity and reliability are adequate for China.
Screen for Child Anxiety Related Emotional Disorders
(SCARED)
The Screen for Child Anxiety Related Emotional Disorders (SCARED)
consists of 41 items in all and uses 3 point Likert sale supporting five factors:
‘somatic/panic’, ‘generalized anxiety’, ‘separation anxiety’, ‘social anxiety’
and ‘school anxiety’ [13]. The higher the score, the higher the level of a
given anxiety factor in a child. Validity and reliability are adequate for
China.
Procedure
The multimodal school-based intervention and control groups
were established through random ascertainment of first, the schools to
 Y-S. DU, W. JIANG, A. VANCE 131

Table 1. Internet Overuse Self-Rating Scale

Before intervention After intervention Six months later
Mean ± SD Mean ± SD Mean ± SD
Active group (n = 32) 40.57 ± 19.50 23.14 ± 11.88∗∗∗ 18.71 ± 12.01∗∗∗
Control group (n = 24) 30.38 ± 14.06 21.40 ± 13.26∗∗ 20.69 ± 14.94∗∗
Paired t-test before and after the intervention and at 6 months follow up: ∗∗p < 0.01, ∗∗∗p < 0.001.

receive Beard’s Diagnostic Questionnaire for Internet addiction, and sec-
ond, the adolescents and schools to be in the active versus the control
groups. The immediate post-intervention assessment was conducted
blind to the individual’s group status, as was the 6 month follow up
assessment. All students, their parents and teachers attended and
completed all sessions.
Multimodal school-based intervention
(1) Group CBT was delivered to adolescent students with Internet
addiction: 6–10 students with Internet addiction participated in an
eight-session group CBT run by two child and adolescent psychia-
trists. Each session lasted 1.5–2 h. In each session of group therapy,
a different topic was discussed. These topics included how to recog-
nize and control your feelings; principles of healthy communication
between parents and children; techniques for dealing with relation-
ships developed via the Internet; techniques for dealing with content
experienced via the Internet; techniques for controlling your impulses;
techniques for recognizing when addictive behaviour is occurring;
and how to stop addictive behaviour. The last session was a review
session.
(2) Group cognitive behavioural parent training was delivered at
the same time as adolescent group CBT. Topics covered were prin-
ciples and techniques for recognizing your child’s feeling states; prin-
ciples and techniques for good communication between family
members; problem-solving principles and techniques; principles
and techniques for controlling your own feelings and behaviour; and
principles and techniques for managing adolescents with Internet
addiction.
(3) Psychoeducation for delivered to teachers regarding the recogni-
tion and psychological treatment of Internet addiction. This treatment
package contained all the elements of both the adolescent and parent
groups. It was delivered to teachers through workshops that were part
of their professional development. Each workshop contained didactic
teaching, analysis and discussion of case examples and reflective role
plays.
Statistical analysis
SPSS 11.5-derived paired t-tests were used to examine the relation-
ship between continuous variables (SPSS, Chicago, IL, USA). The
effect sizes of variables that significantly differed were calculated using
the Cohen’s d statistic: the range for a small effect is 0.20–0.50; for a
medium effect it is 0.50–0.80; and for a large effect it is ≥0.8 [14].
Paired t-tests rather than analysis of covariance were used because
of the potential for baseline values to not be equal between groups
[15]. Hence, ANCOVA could mislead. Therefore, even though paired
t-tests have a higher variance, they remain unbiased in such circum-
stances.
Results
The Internet Overuse Self-Rating Scale did not differ between the
active and the control groups at baseline, immediately after the inter-
vention or at 6 month follow up. Both groups decreased immediately
after the intervention and at 6 month follow up compared to before the
intervention. The active group effect sizes both immediately and at
6 month follow up, however, were large (Cohen’s d = 1.08, 1.35) com-
pared to those of the control group (Cohen’s d = 0.66, 0.67; Table 1).
The active and control groups did not differ at baseline or immedi-
ately after the intervention, but did have higher scores on all subscales
of the TMDS at 6 month follow up. Effect sizes were predominantly
small on all the subscales (Cohen’s d = 0.41–0.54). The active group
decreased immediately after the intervention and at 6 month follow
up compared to before the intervention on the ‘efficacy of time’ and

Table 2. Time Management Disposition Scale

Before intervention After intervention Six months later
Mean ± SD Mean ± SD Mean ± SD

Worth of time Study group (n = 32) 32.68 ⫾ 8.87 35.53 ⫾ 8.02 36.30 ⫾ 8.70
Control group (n = 24) 33.76 ⫾ 7.30 32.92 ⫾ 7.35 32.88 ⫾ 7.87
Efficacy of time Study group (n = 32) 28.21 ⫾ 6.96 33.60 ⫾ 7.51∗∗ 34.48 ⫾ 6.79∗∗
Control group (n = 24) 30.62 ⫾ 5.46 32.90 ⫾ 6.80 31.01 ⫾ 5.95
Control over time Study group (n = 32) 64.95 ⫾ 14.18 76.08 ⫾ 16.19∗∗ 76.09 ⫾ 16.93∗∗
Control group (n = 24) 67.86 ⫾ 13.46 69.97 ⫾ 13.04 69.28 ⫾ 12.61

Paired t-test before and after the intervention and at 6 months follow up: *p < 0.05, **p < 0.01.

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132 GROUP CBT FOR ADOLESCENT INTERNET ADDICTION

Table 3. Strengths and Difficulties Questionnaire (Chinese version)

Before intervention After intervention Six months later
Mean ± SD Mean ± SD Mean ± SD
Emotional symptoms Active group (n = 32) 3.30 ⫾ 2.23 2.35 ⫾ 1.74∗ 1.77 ⫾ 1.93∗∗
Control group (n = 24) 3.13 ⫾ 2.47 2.96 ⫾ 2.22 2.33 ⫾ 2.26
Conduct problems Active group (n = 32) 3.53 ⫾ 1.90 2.73 ⫾ 1.72∗ 2.42 ⫾ 1.80∗∗
Control group (n = 24) 3.00 ⫾ 1.64 2.79 ⫾ 1.59 2.29 ⫾ 1.60
Hyperactivity and attention-deficit Active group (n = 32) 5.16 ⫾ 2.80 3.54 ⫾ 2.50∗∗ 3.61 ⫾ 2.27∗∗
problems Control group (n = 24) 3.56 ⫾ 2.19 4.04 ⫾ 1.85 3.21 ⫾ 2.08∗
Peer relationships Active group (n = 32) 3.50 ⫾ 1.46 2.71 ⫾ 1.37∗ 2.56 ⫾ 1.70∗
Control group (n = 24) 2.75 ⫾ 1.48 3.08 ⫾ 1.14 2.83 ⫾ 1.37
Prosocial behaviours Active group (n = 32) 6.41 ⫾ 2.18 7.25 ⫾ 1.83∗ 7.42 ⫾ 1.94∗
Control group (n = 24) 6.42 ⫾ 2.15 6.96 ⫾ 1.94 7.04 ⫾ 2.24

Paired t-test before and after the intervention and at 6 months follow up: ∗p < 0.05, ∗∗p < 0.01.

‘control over time’ TMDS subscales. Effect sizes were predominantly
medium for the two follow up time points on the two subscales (Cohen’s
d = 0.70–0.91). In contrast, the control group did not differ on any of
the TMDS subscales from baseline to immediately after the interven-
tion to 6 month follow up (Table 2).
The active and control groups did not differ at baseline, immediately
after the intervention or at 6 month follow up on the emotional symp-
toms, conduct problems or prosocial behaviour scales of the Strength
and Difficulties Questionnaire (SDQ) (Chinese version). The active
group, however, had more hyperactivity and attention deficit problems
and peer relationship problems at baseline than the control group,
although the groups did not differ on these measures immediately after
the intervention or at 6 month follow up. The active group decreased
immediately after the intervention and at 6 month follow up compared
to before the intervention on the emotional symptoms, conduct prob-
lems, hyperactivity and attention deficit problems and peer relationship
problems scales. Further, they demonstrated a similar pattern of increase
in the prosocial behaviour scales from baseline to 6 month follow up.
In contrast, the control group did not differ on any of the SDQ (Chinese
version) scales from baseline to immediately after the intervention to
6 month follow up. The active group effect sizes were uniformly small
(Cohen’s d = 0.44–0.59), except for the emotional symptoms, conduct
problems and hyperactivity and attention-deficit problems scales at
6 month follow up, and the hyperactivity and attention-deficit problems
scale immediately after the intervention, which were medium (Cohen’s
d = 0.73/0.60/0.61/0.61, respectively; Table 3).
The active and control groups did not differ at baseline, except for
the school anxiety subscale of the SCARED, for which the active
group reported higher levels of school anxiety. In contrast, the active
group demonstrated lower scores on all scales compared to the control
group, immediately after the intervention and at 6 month follow up,
except for the school anxiety scale immediately after the intervention.
Effect sizes were predominantly small immediately after the interven-
tion (Cohen’s d = 0.4–0.48) and medium at 6 month follow up
(Cohen’s d = 0.61–0.79). The active group decreased immediately
after the intervention and at 6 month follow up compared to before
the intervention on all the SCARED subscales. Effect sizes were pre-
dominantly medium (Cohen’s d = 0.62–0.93). In contrast, the control
group did not differ on any of the SCARED scales from baseline to
immediately after the intervention to 6 month follow up (Table 4).
Discussion
The Internet Overuse Self-Rating Scale is similar to
Young’s Internet Addiction Screening Scale [2] in
number and content of items. Interestingly, both the
active group and the control group improved over time,
with no difference evident between them. This implies
that regardless of the multimodal school-based inter-
vention, Internet addiction behaviour has the potential
to change and improve. There was a larger effect size
evident, however, in the active group over time, which
suggests that changes in associated emotional, cogni-
tive and behavioural problems may have had an influ-
ence. Such an association has been suggested in
previous treatment studies [8–10].
In contrast, the TMDS showed only that the multi-
modal school-based intervention group had an improved
use of time (‘efficacy of time’) and control over time
usage (‘control over time’) at the 6 month follow up.
This suggests that the multimodal school-based inter-
vention did uniquely aid the improved Internet addic-
tion behaviour. Internet addiction adolescents’ valuing
of time (‘worth of time’), however, did not differ
between the two groups. This implies that their assess-
ment of time’s value is not related to their efficient use
of time and control over its use. Recent studies have
shown that time management is positively correlated
with a given individual’s feeling of happiness in
life and self-satisfaction, and negatively correlated
with anxiety and depression [16]. It has also been
reported that one’s attitude toward time is
congruent with one’s personality and/or temperament
characteristics [17].
Consistent with these reported associations, we
found that only the active group demonstrated
decreased emotional (particularly anxiety), hyperac-
tive and inattentive, conduct and peer relationship

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 Y-S. DU, W. JIANG, A. VANCE 133

Table 4. Screen for Child Anxiety Related Emotional Disorders

Before intervention After intervention Six months later

Mean ± SD Mean ± SD Mean ± SD

Somatic/panic Study group (n = 32) 7.37 ⫾ 4.80 4.21 ⫾ 3.61∗∗ 3.56 ⫾ 3.56∗∗
Control group (n = 24) 5.81 ⫾ 4.57 5.79 ⫾ 4.46 6.77 ⫾ 4.63
Generalized anxiety Study group (n = 32) 7.11 ⫾ 4.53 4.68 ⫾ 3.84∗∗ 3.98 ⫾ 3.74∗∗
Control group (n = 24) 5.46 ⫾ 4.52 6.49 ⫾ 3.61 6.28 ⫾ 4.46
Separation anxiety Study group (n = 32) 3.87 ⫾ 2.60 2.64 ⫾ 2.99∗ 2.42 ⫾ 1.81∗
Control group (n = 24) 2.92 ⫾ 2.38 3.75 ⫾ 2.27 3.75 ⫾ 2.45
School anxiety Study group (n = 32) 2.47 ⫾ 1.81 1.29 ⫾ 1.60∗∗ 1.09 ⫾ 1.06∗∗
Control group (n = 24) 1.58 ⫾ 1.47 1.33 ⫾ 1.27 1.88 ⫾ 1.54
Social anxiety Study group (n = 32) 7.04 ⫾ 4.22 5.45 ⫾ 3.55∗ 4.72 ⫾ 3.17∗
Control group (n = 24) 6.67 ⫾ 3.57 8.12 ⫾ 3.72 6.50 ⫾ 3.59

Paired t-test before and after the intervention and at 6 months follow up: ∗p < 0.05, ∗∗p < 0.01.

problems, with a commensurate increase in manifest
prosocial behaviour, over time. This is an important
finding for the multimodal school-based intervention
because Internet addiction is known to have a
greater-than-chance association with anxiety, espe-
cially social anxiety, and impulsiveness, hyperactiv-
ity and inattention [18–20]. Interestingly, all these
symptom domains demonstrated a large effect size
improvement only with the multimodal school-based
intervention.
In summary, the multimodal school-based interven-
tion did lead to an improved emotional state and regula-
tion ability, behavioural and self-management style in
the adolescents identified with Internet addiction. The
generalizability of these findings, however, are limited
by the absence of pre-existing comorbid conditions
such as high- and low-prevalence psychiatric disorders
and language learning disorders (reading/spelling/arith-
metic/writing), verbal and visuospatial IQ data and key
motor, speech and language developmental milestones
data. Such information could allow us to examine the
possible differential response of adolescents with Inter-
net addiction in the context of these key comorbid con-
ditions and developmental risk factors. This should
be a focus of future randomized, controlled studies
of Internet addiction, along with investigation of
younger and older cohorts from different developmental
periods.
Acknowledgements
The authors would like to acknowledge the hard work
of the staff of the Shanghai Mental Health Center and
the adolescents and their families who took part in this
study. This research was funded by the Shanghai
Mental Health Center. Professor Yasong Du has
received research funding from Xi’an-Janssen
Pharmaceutical, Eli Lilly, and Shanxi Ruifulai
Pharmaceutical.
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