1 Background

Internet-connected digital media provide an increasingly powerful, and engaging vehicle for entertainment, competition, creativity, commerce, social contact, and more. As Internet access and use increased over time, so did the recognition of IUDs [1, 2]. By the 2013 publishing of the Diagnostic and Statistical Manual, fifth edition (DSM-5), problematic video game use—“Internet Gaming Disorder”—was listed as a condition requiring further research [1]. In 2019, the World Health Organization (WHO) included “Gaming Disorder” as a recognized mental, behavioral, or neurodevelopmental disorder in the 11th revision of the International Classification of Diseases (ICD-11) [3]. Supported by the scientific evidence, formal recognition of this new condition was an important step toward meeting the growing IUD public health and clinical needs [4]. For those who struggle with IUDs in ways other than gaming, similar recognition and definition by diagnostic criteria is still needed [5].

Nearly three decades have passed since IUDs emerged as new mental disorders. During that time, scientific research and clinical investigation have focused on defining diagnostic nosology, identifying risk and protective factors, and developing effective treatments. Treatment approaches have often been based upon the framework of IUDs as behavioral addictions. This framework emphasizes the instant gratification and variable ratio reinforcement present in all Internet-delivered content [6].

An evolving understanding of the various forms of problematic screen use has led to debate among experts as to the validity of the initially adopted addiction model of IUDs; and whether the addiction model of IUDs is useful and adequate in influencing the treatment process [7]. Those struggling with IUDs represent a heterogenous population who develop the condition in the context of various combinations of biopsychosocial risk factors. Language devoid of reference to presumed psychopathology allows for a more nuanced understanding of IUDs as experienced by any individual presenting for care [8].

As we approach a formally agreed-upon definition and conceptual understanding of IUDs, demand for effective treatment already exists. While reported prevalence rates have varied significantly across time, methods, and geography, currently available research indicates that IUDs are common. A recent meta-analysis reported a prevalence of Generalized Internet Addiction of 4.6% in Western nations and 8.9% in Eastern nations and an Internet Gaming Disorder prevalence of 2.19% in Western nations and 3.1% in Eastern nations [9]. IUDs result in significant suffering and impairment and are associated with depression, anxiety, suicidality, aggression, relationship problems, sleep disruption, and academic underachievement [10]. The purpose of this chapter will be to explore the current research evidence on the treatment of IUDs, to propose questions for future research on treatment, and to recommend a course for the future of IUD treatment development.

2 Current State

2.1 Psychosocial Treatments

Most of the currently available evidence on treating IUDs is limited to treatment for Internet Gaming Disorder (IGD) [11] and, to a lesser extent, online pornography or social media addiction [12,13,14]. A few studies investigated other variables in treatment groups such as gender [15] or geographic factors [16]. The majority of studies on treatment are based on samples of adolescents and (young) adults.

In a recent systematic review of randomized controlled trials (RCTs) of 126 studies on IGD treatments, only seven met the proposed standard modeled after the Oxford Center for Evidence-Based Medicine (OCEBM) [17]. Three of these used group counseling, two employed manualized cognitive behavioral therapy (CBT), one utilized an Acceptance and Cognitive Restructuring Intervention Program (ACRIP) based on a cognitive behavioral and mindfulness model, and the last employed Craving Behavioral Intervention (CBI) [17]. All seven demonstrated positive findings. A CBT approach covering not only IGD but IUDs more generally reduced IGD symptoms (effect size d = 1.19), time spent online (d = 0.88), depression (d = 0.67), and increased psychosocial functioning (d = 0.64) [18].

Successful studies on the treatment of IUDs and IGD have also utilized modalities such as Motivational Interviewing (MI) [19,20,21], mindfulness [17, 19], and family interventions [19, 22]. Successful treatment outcomes were achieved in various reported therapeutic formats and settings: individual therapy, group therapy [19], specialty camps [23], inpatient [24], and school settings [25], but treatment setting is often not reported [19, 24]. In some studies, successful IUD treatment using the modalities above was related to improvement in comorbid conditions as well, such as ADHD, depression, and social anxiety [15, 26, 27].

The prevalence of IUDs among Eastern countries is reportedly equal to or greater than that of Western countries [9]. In light of potential sociocultural differences in risk exposures, the conceptualization of behavioral health problems, and healthcare delivery, it is informative to consider the similarities and differences between IUD treatment development in Eastern versus Western countries.

The majority of IUD treatments studied in Eastern countries overlap with those investigated in the West. For example, numerous Chinese trials of CBT have demonstrated benefits for IUDs. In a 2017 meta-analysis of treatment interventions in China and Korea, CBT was shown to have a large, significant effect on IUDs and improvements in co-occurring mental conditions. The benefits of CBT for IUDs were demonstrated in both individual and group treatment formats [28]. Another Chinese study demonstrated the effectiveness of CBT with Motivational Interview (MI) provided through online assessment and intervention modules based on psychotherapeutic principles [29]. Also consistent with treatment development in the West, family therapy has been evaluated as a treatment for IUDs. In one study, a group of Chinese adolescents and their families participated in multi-family group therapy for adolescent Internet addiction. Participants in the treatment group experienced significantly reduced Internet use time as well as improvement in parent-child communication, and relationships [30].

A notable example of differences between Eastern and western IUD treatment development is the emphasis on exercise as an intervention. A 2023 meta-analysis by Zhang included 39 randomized controlled trials of exercise for the treatment of IUDs and associated conditions. Studies analyzed not only the benefits of exercise, but also the relative strength of effects based on the categorization of exercise as single, double, or team sport. Exercise significantly reduced IUD symptoms as well as loneliness, anxiety, depression, and interpersonal sensitivity [31].

2.2 Abstinence and Restricting Screen Time

Because the studies above usually describe treatment modalities more than specific protocols, the question remains of how much direct regulation of screen time as a behavioral intervention should play a role in various forms of treatment. Fortunately, a few studies specifically examined the idea of temporary abstinence from all or specific types of screen use. A review of studies on voluntary temporary abstinence from digital devices, or “digital detoxes,” found that while the benefits varied, these interventions usually resulted in reduced use following the period of abstinence [32]. One such study found that an 84-hour period of Internet gaming abstinence improved outcomes in an IGD group [33]. While temporary abstinence is just one way of moderating use, a 2024 workshop examined multiple self-regulatory interventions for reducing screen time and screen distractions in Oxford University students. These interventions, which included time-limiting apps and other motivational techniques to voluntarily place restrictions on screen time, led most students in the study to continue to benefit from controlling their digital device use after the workshop was completed [34].

2.3 Pharmacotherapy

The dopaminergic and noradrenergic antidepressant medication bupropion has been shown effective for IGD in multiple trials, comorbid with or independent of depression [27]. Medications used to treat ADHD such as methylphenidate and atomoxetine are effective for IGD, as well as decreasing impulsivity and inattentiveness in patients with comorbid ADHD. A recent meta-analysis of 124 studies on the treatment of all types of IUDs suggested combining CBT or multi-level counseling with medication management was more effective than either approach alone [28].

2.4 Prevention

The increased demand for treatment of IUDs during the pandemic led one international group of leading researchers to publish consensus guidance on preventing problematic Internet use in the home setting where youth were quarantined [35]. Recommendations included an emphasis on routine, structure, and scheduling, frequent off-screen social and stress-reducing activities, use of analog technical tools, physical activity, and parental role modeling of moderate Internet use. The school setting is of outstanding value in reaching children and adolescents to provide universal as well as selective and indicative prevention for IUDs. A systematic review and meta-analysis on the effectiveness of primary prevention approaches for PUI in adolescents and youths found five studies in which the single studies showed effectiveness, but the pooled results did not [30], which leads to the conclusion that additional research is needed. A meta-analysis in 2021 suggested that prevention begins when children are quite young by “establishing healthy online habits” [36] (p. 12).

2.5 Limitations

Interpreting the results of these studies is limited by problems such as inadequate subject numbers, patient noncompliance, and varying outcome measures, making it difficult to determine which of these treatments is the most effective [15, 17, 25]. Although the various forms of IUDs all theoretically involve the same limbic reward neurocircuitry [1], the lack of uniformity concerning inclusion criteria and treatment protocols also makes the interpretation of findings a challenge [15, 17, 25]. Treatments are typically defined in the literature as “effective” based on a reduction of scores on various scales assessing symptoms, without necessarily establishing long-term outcomes [15]. A frustrating confounding variable in the studies referenced in this chapter is the lack of treatment details provided by investigators, such that it is often unclear whether temporary abstinence from Internet use was a requirement to participate in either the treatment or the control group, and if so, whether this contributed to the success of treatments. Finally, various treatments of different behavioral disorders used in studies are sometimes administered online [21], therefore, it must be examined how such interventions can be used as stand-alone approaches or might be combined in blended treatments.

Regarding treatment recommendations specified for children and adolescents, current evidence is inadequate. Since most of the samples have included adolescents or (young) adults, there is at least partial evidence that some of the approaches work in younger age groups. However, there is a need for treatment studies testing specifically designed treatments for younger age groups. In addition, effective prevention and early intervention studies are of special importance and still not fully developed within high-quality studies.

3 Future Research

3.1 Clinical Treatments

Which therapeutic interventions are most useful across different IUDs, patient populations, including children and adolescents, and treatment settings? How can researchers obtain more comparative data on efficacy among treatments using similar settings and admission criteria? How does successful treatment of IUDs impact common comorbidities such as depression and social anxiety? Should treatment protocols include a stepwise progression, from evaluation, to establishment of therapeutic alliance and motivation, to skill building, and finally maintenance, upon return to adaptive functioning? Should screening for IUDs become a standard part of all pediatric or mental health evaluations?

3.2 Addressing IUDs Outside of the Clinic

How do we best reach and motivate children and adolescents with IUDs to participate in treatment? What are the most effective specific strategies and interventions for their parents? What consideration should be given to limits on screen time and developmentally inappropriate content, independence, privacy, and supporting self-regulation? How should strategies be adjusted for differences in culture and family values? Under what circumstances and for what duration is voluntary or enforced abstinence effective for IUDs?

3.3 Prevention

What specific strategies can families use to weigh the benefits of screen media use with the risk of excessive use? What simple interventions, such as programming more off-screen activities into a child’s day, can prevent IUDs? Which other risk factors are modifiable in the course of developing IUDs? How will preventive measures change as digital technology and its impact on humans change?

4 Recommendations

4.1 For Clinicians

  • Despite the greater demand than supply of care for IUDs, providers in all child and adolescent care settings must be able to identify available treatment options and levels of care currently available to patients with IUDs. For now, we recommend obtaining a detailed biopsychosocial assessment of the factors involved in the development and persistence of IUDs and a customized treatment approach that may utilize multiple treatment modalities and multiple settings and include the entire family.

  • Young people entering treatment for IUDs have often experienced interpersonal conflict with parents and authority figures and often respond with opposition to any effort for change. A priority for clinicians is to build and maintain a therapeutic alliance with the youth, their parent(s), and other treatment providers while supporting cooperation between these parties. Motivational enhancement approaches should be utilized in the process of goal setting.

  • Lifelong abstinence from screen media use is impractical because of the ubiquitous nature of online interactions in contemporary society. Sustained abstinence may even conflict with the ultimate goal of treatment: a balance of immediately gratifying screen media and activities requiring delayed gratification. Such a balance may foster self-regulation via inhibitory prefrontal cortical functioning, improving mindful and sustainable media use [7]. As referenced above, however, some experts recommend an initial period of enforced abstinence from screen media, or “digital detoxification,” to address tolerance, withdrawal, and cravings in a manner similar to detoxification from substances. Others warn such an intervention risks damage to treatment alliances. Regardless, residential centers, wilderness programs, and therapeutic summer camps typically utilize enforced abstinence as an initial treatment phase, and some outpatient providers advise brief periods of abstinence, such as those enabled by a family camping trip.

  • As a young person achieves greater regulation of screen media use, treatment efforts should include efforts to address remaining barriers to adaptive functioning, such as school truancy and erratic sleep patterns. Processing instances of failure to achieve treatment goals helps identify personal and family system vulnerabilities underlying IUDs. For example, IUDs driven by inhibitory control weakness may result in a different treatment barrier than that driven by a need for social connection.

4.2 For Parents

  • Parents and caregivers may recognize screen media as a set of tools requiring skills to properly operate. From a child’s first screen media exposure, skill development requires active, intentional parental involvement. As they mature and demonstrate the ability to use responsibly, children may be allowed greater screen media access to support independence.

  • Parents and caregivers should understand the functionality and features of devices and applications before granting access and should consider privacy and content settings for children and young adolescents.

  • Parents should maintain open dialogue to guide their children on media content choices, experiences, online interpersonal communications (including the sharing of personal information), time management, and balance. During adolescence, parent guidance may facilitate increasing autonomy, privacy, and control as needed to foster a successful transition to adulthood with the skills needed to self-regulate electronic screen media and adjust to future technological advancements.

  • Parents of children with IUDs often find themselves drawn towards unhelpful extremes of micromanagement or enabling and require more effective strategies. Parents should work with clinicians and community resources to set appropriate screen use intervals, help children disengage from screen media, use positive and negative consequences to incentivize healthy use, and encourage diverse leisure and entertainment activities offline in addition to screen activities, adjusting environmental cues and Internet access accordingly. Successful treatment usually requires consistent family investment, including therapy attendance as needed and the adoption of adaptive screen use patterns for all.

Conflict of Interest and Funding Disclosures

No funding was secured for this report. The work of HJR on this chapter was carried out in the context of the Research Unit ACSID, FOR2974, funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) and the German Innovation Fund (01NVF19029).