Multi-family group therapy for adolescent Internet addiction: Exploring the underlying mechanisms

Addictive Behaviors 42 (2015) 1–8

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Addictive Behaviors

Multi-family group therapy for adolescent Internet addiction: Exploring the underlying mechanisms Qin-Xue Liu a,b, Xiao-Yi Fang c,d,⁎, Ni Yan e, Zong-Kui Zhou a,b, Xiao-Jiao Yuan f, Jing Lan c, Chao-Ying Liu c a

Key Laboratory of Adolescent Cyberpsychology and Behavior (CCNU), Ministry of Education, Wuhan 430079, China School of Psychology, Central China Normal University, Wuhan 430079, China Institute of Developmental Psychology, Beijing Normal University, Beijing 100875, China d Academy of Psychology and Behavior, Tianjin Normal University, Tianjin 300387, China e Faculty of Psychology, Southwest University, Beibei 400700, China f School of Sociology and Psychology, Southwest University for Nationalities, Chengdu 610041, China b c

H I G H L I G H T S • • • •

We apply the MFGT to the Internet addiction for the first time. We examine changes in the measured variables to determine underlying mechanism. MFGT shows a significant effect on reducing Internet addiction. Parent–adolescent interaction and need satisfaction contribute to the effect.

a r t i c l e

i n f o

Available online 30 October 2014 Keywords: Multi-family group therapy Internet addiction Family relationships Need satisfaction Effectiveness mechanism

a b s t r a c t Objective: Internet addiction is one of the most common problems among adolescents and effective treatment is needed. This research aims to test the effectiveness and underlying mechanism of multi-family group therapy (MFGT) to reduce Internet addiction among adolescents. Method: A total of 92 participants consisting of 46 adolescents with Internet addiction, aged 12–18 years, and 46 their parents, aged 35–46 years, were assigned to the experimental group (six-session MFGT intervention) or a waiting-list control. Structured questionnaires were administered at pre-intervention (T1), post-intervention (T2) and a three-month follow-up (T3). Results: There was a significant difference in the decline both in the average score and proportion of adolescents with Internet addiction in MFGT group at post-intervention (MT1 = 3.40, MT2 = 2.46, p b 0.001; 100 versus 4.8%, p b 0.001) maintained for three months (MT3 = 2.06, p b 0.001; 100 versus 11.1%, p b 0.001). Reports from both adolescents and parents were significantly better than those in the control group. Further explorations of the underlying mechanisms of effectiveness based on the changed values of measured variables showed that the improvement in adolescent Internet use was partially explained by the satisfaction of their psychological needs and improved parent–adolescent communication and closeness. Conclusions: The six-session multi-family group therapy was effective in reducing Internet addiction behaviors among adolescents and could be implemented as part of routine primary care clinic services in similar populations. As family support system is critical in maintaining the intervention effect, fostering positive parent–adolescent interaction and addressing adolescents' psychological needs should be included in preventive programs for Internet addiction in the future. © 2014 Elsevier Ltd. All rights reserved.

1. Introduction With the rapid development of the Internet, Internet addiction has become a widespread and problematic phenomenon. Internet ⁎ Corresponding author at: Institute of Developmental Psychology, Beijing Normal University, Beijing 100875, China. Tel.: +86 10 5880 8232; fax: +86 10 5880 8232. E-mail address: [email protected] (X.-Y. Fang).

http://dx.doi.org/10.1016/j.addbeh.2014.10.021 0306-4603/© 2014 Elsevier Ltd. All rights reserved.

addiction, also known as Pathological Internet Use, Problematic Internet Use and Compulsive Internet Use, is characterized by excessive and compulsive Internet use and a preoccupation with and loss of control over this use that interferes with individuals' daily functioning (Caplan, 2002; Davis, 2001; Van den Eijinden, Meerkerk, Vermulst, Spijkerman, & Engles, 2008; Young & Abreu, 2011). Currently, it is one of the most common behavioral problems for adolescents, who are more exposed to Internet use and consequently more vulnerable than

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adults (Lortie & Guitton, 2013), with a prevalence rate higher than 8% in some countries (Cho, Kim, Kim, Lee, & Kim, 2008; Kuss, Griffiths, & Binder, 2013; Van den Eijnden, Spijkerman, Vermulst, van Rooij, & Engels, 2010). In China, approximately 10% of adolescents (approximately 20 million teenagers) reported a tendency towards or current diagnosis of Internet addiction (Block, 2008; China Internet Network Information Center, 2013). Internet addiction may cause psychological distress, personality development problems, social problems and poor school performance (Brezing, Derevensky, & Potenza, 2010; Young, Pistner, O'Mara, & Buchanan, 2000). In addiction, high comorbidity with effective disorders, impulse control disorders and substance abuse disorders has been reported (Petersen, Weymann, Schelb, Thiel, & Thomasius, 2009; Weinstein & Lejoyeux, 2010). There is significant research around the diagnosis, epidemiology, predicting factors and negative outcomes of Internet addiction, but little is known about treating it, which is an imperative for adolescents, families, schools and society, especially in China (King, Delfabbro, Griffiths, & Gradisar, 2011;Winkler, Dörsin, Rief, Shen, & Glombiewski, 2013). Petersen et al. (2009) conducted a survey at the request of the German health department and argued that clinical recommendations are not possible due to the lack of studies and that further research is urgently needed. In a systematic review of Internet addiction treatment, only eight studies were included. Half of them were psychological approaches, and two utilized cognitive-behavioral therapy (King et al., 2011). Peukert, Sieslack, Barth, and Batra (2010) also indicate cognitive-behavioral and pharmacological approaches as potentially effective treatments in their review. They suggest that interventions with family members could be useful. Winkler et al. (2013) further examine the efficacy of different treatments for Internet addiction (13 studies included) in their meta-analysis, and their results show that CBT did not perform significantly better than other psychological treatments, even though it appears to be the predominant approach for treating Internet addiction. They also suggest that both individual counseling and group therapy have their shortcomings and that further research around different approaches and modalities is needed. However, there is no study that examines which factors contribute to the efficacy of treatment or what predictors cause the behavior change to happen, which is very important to evaluate and improve interventions (Liu, Fang, & Zhou, 2011). Family plays a central role in the socializing process for adolescents, and parents provide emotional connection, behavioral constraints and modeling (Gray & Steinberg, 1999; Lau, Quadrel, & Hartman, 1990). Family-based intervention is the most thoroughly studied treatment modality for adolescent substance dependence and addiction, and there is a large body of research to support its efficacy (for a review, see Liddle, 2004). Previous research also proved that a good relationship and communication with parents are protective factors for adolescents from Internet addiction (Kim, Jeong, & Zhong, 2010; Van den Eijnden et al., 2010). Family members involved in interventions facilitate the process of recovery and help the addict maintain a lasting effect of intervention after sessions (Liddle, 2004; Zhong et al., 2011). Grounded in family system theory and integrated in family and group therapy, multi-family group therapy (MFGT) was proposed as a promising new approach to treat Internet addiction behaviors, but no empirical study was conducted (Liu et al., 2011). The effectiveness of MFGT has been empirically demonstrated among adolescents with psychological disorders (Chien & Chan, 2013; McDonell & Dyck, 2004), children at risk for special educational services (Kratochwill, McDonald, Levin, Scalia, & Coover, 2009) and in addiction related areas (Conner et al., 1998; Zubrick et al., 2005). In this field, Zhong et al. (2011) found that family-based intervention is more effective in reducing Internet addiction than group therapy that involved only the adolescents. The multi-family group offers both adults and adolescents the advantages of a peer group, which help them to get support and learn from peer confrontation. Transferential reactions occur not only

within one family but also across family lines, facilitating the group to serve both as an arena for cross transferences based on each person's introject and as a reality tester (Leichter & Schulman, 1974). Connection within family members is also helpful for high treatment attendance (Nieter, Thornberry, & Brestan-Knight, 2013). Moreover, family-oriented intervention might be particularly effective in Chinese culture, where the cohesion between family members is highly emphasized. Therefore, the present study aims to explore both the effectiveness of MFGT on Internet addiction and the underlying mechanisms of the effectiveness. One mechanism through which MFGT may effectively reduce Internet addiction is improving parent–adolescent communication and closeness. Compared with non-addicts, adolescents with Internet addiction have poorer communication with their parents (Park, Kim, & Cho, 2008) and are more likely to receive rejection and negative feedback from their parents (Van den Eijnden et al., 2010). Poor parent–adolescent communication and low perceived parent–adolescent closeness, in turn, predicted adolescents' Internet addiction (Liu, Fang, Deng, & Zhang, 2012; Liu, Fang, Zhou, Zhang, & Deng, 2013). According to the Circumplex Model of Marital and Family Systems proposed by Olson (Olson, 2000; Olson, Sprenkle, & Russell, 1974), family communication is critical in facilitating intimacy among family members and strengthening the family's adaptability to change. MFGT emphasizes improving family cohesion and motivation to change within the family; it not only focuses on the parent– adolescent interaction but also values the style and strength of attachment between family members (Dickerson & Crase, 2005). Therefore, it could be a well-suited approach to treat Internet addiction among adolescents. The second mechanism through which MFGT may take effect in treating adolescents' Internet addiction is by fulfilling their psychological needs through strengthening their communication and relationship with their parents. Psychological need is considered one of the most important driving forces that promotes behavioral change. Fulfillment of psychological needs through Internet use has been proposed as an internal motive in adolescents' Internet addiction (Morris & Ogan, 1996; Suler, 1999). Adolescents' unfulfilled needs for competence and relatedness in life and perceived need satisfaction online are the major precursors of their excessive Internet use (Cai, Cui, & Li, 2007; Shen, Liu, & Wang, 2013; Wan, Zhang, Liu, Deng, & Fang, 2010). Compared with non-addicts, Internet addicts perceived higher need satisfaction online and lower need satisfaction in real life (Deng, Fang, Wan, Zhang, & Xia, 2012). Therefore, if parent–adolescent communication practices and relationships are improved, adolescents’ psychological needs for relatedness or competence might be more easily fulfilled through their daily life interactions with their parents, which, in turn, could be helpful to reduce their reliance on the Internet for fulfilling their needs. As fundamental as these two underlying mechanisms appear to be in affecting adolescents' Internet addiction, they have nevertheless been barely examined explicitly in prior Internet addiction intervention studies. In this study, we include these two underlying mechanisms as major intervening variables to examine whether the effectiveness of family group intervention for adolescent Internet addiction depends on them. Based on a quasi-experimental design, the present study examines the effectiveness of the MFGT for adolescent Internet addiction among 46 pairs of adolescents and their parents. The study aims to examine three hypotheses: First, the intervention group shows a reduction in Internet addiction both at the end of the intervention and at a three-month follow-up compared with the control group. Second, adolescents in the intervention group show improved communication and relationship with their parents and psychological need satisfaction in real life. Third, the effectiveness of the intervention is partially explained by the improved parent–adolescent relationship and communication, and adolescents' psychological need satisfaction in real-life.

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2. Method

2.2. Procedures

2.1. Participants

First, the Manual of Adolescents Internet Addiction Family Group Therapy was developed with precision based on the theoretic framework of family group therapy, previous intervention practices, and empirical studies. Before the intervention was launched, a pilot study was implemented among six adolescents and their families to assess the operability of the intervention design, potential problems in administering the intervention, and smooth transitions between activity themes in each intervention session. With preliminary results, interview feedback from the pilot study and consultation with experts on the intervention team, the Manual of Adolescents Internet Addiction Family Group Therapy was modified and finalized. Then, recruited parents provided informed consent for their adolescent children's and their own participation. All participants were asked to complete assessments both before (T1) and after the intervention (T2), and at a three-month follow-up (T3) as well. Participants were assured of the confidentiality of their responses. Procedures were approved by the Institutional Review Board of the Institute of developmental Psychology, Beijing Normal University. The details of the procedures are presented in Fig. 1.

Participants were recruited through advertisements on school websites in Baotou City of Inner Mongolia in China. Related information about the research and a simplified scale of Internet addiction, which is used for clinical diagnosis, were included in the advertisement. Families who were interested and matched the diagnosis were welcome to sign up and have a face-to-face interview one by one. Among the 55 families who signed up for the intervention study, 46 families were selected based on the Adolescent Pathological Internet Use Scale (APIUS; detailed information about APIUS is provided in the measurement section) and inclusion criteria. The body screening scale, SCL-90 and simplified addiction screening scale were used to exclude participants who possessed physical disabilities, mental disorders or other addictive behaviors. Only one boy was excluded for depression. Twenty-one families were assigned to the intervention group because their schedules matched with the intervention arrangement and the other 25 families were included in the control group because they could not set up a continued intervention schedule. Families in the control group were added to the waiting-list for the intervention study after the informed consent from the parents and the adolescents. The intervention group had a dominant proportion of male (n = 17) over female (n = 4) with an average age of 15 years old (SD = 1.73). The female-to-male ratio of parents in the intervention group was 16:5 with an average age of 40.9 years old (SD = 2.85). Nine of them held a degree of college or above (42.9%); six of them obtained a high school degree (28.6%) and six of them did not obtain a high school degree (28.6%). The average monthly income ranges from 2000 to 10,000 Yuan with an average of 4685, which indicated middle-income families in the city. All parents were first-time married. The demographic compositions in the control group resembled those in the intervention group. Adolescents in the control group had a male-to-female ratio of 21:4 and the average age was 15.7 years old (SD = 1.2). Families in the control group did not show significantly differences from those in the intervention group.

2.3. Intervention After the intervention began, the 21 families in the intervention condition were randomly divided into three intervention groups with seven families in each group. Two therapists were assigned to each group randomly and all therapists had the same clinical background under family and group therapy training. The intervention was given every three days, with each session lasting 2 h. Six sessions were administered for each grouped families. The intervention was tailored to strengthen parent–adolescent communication and relationships and shift adolescents' fulfillment of psychological needs from the Internet to interactions and building relationships with family members. Specific topics and activities were designed for each intervention session and connected with each other across six sessions, each of which included five parts in 2 h: a warmup exercise, feedback on homework from the last session (except the

Research design and intervention plan based on previous research and theory framework

Pilot study (n=6 family)

Expert consulting

Family Group Intervention Manual for Internet Addiction

Base-line assessment (N=46 Family)

Intervention group (n= 21)

Control group (n=25)

Post-assessment (N=46 Family)

3 month- follow up assessment 9 Intervention group (n=18) Control group (n=23) Fig. 1. The intervention process and participants flow diagram.

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Table 1 Comparisons of measured variables between the intervention group and control group at T1, T2 and T3.

Average APUIS

Internet use time

Parental reports

Addiction ratea

Intervention Control t Intervention Control t Intervention control t Intervention Control

T1

T2

T3

M(SD)

M(SD)

M(SD)

F1

F2

3.40(.27) 3.38(.20) −0.54 26.38 (9.6) 27.08(11.1) −0.21 3.37(.48) 3.36(.52) 0.01 100% 100%

2.46(.61) 3.59(.31) −7.79⁎⁎⁎ 11.43(5.75) 27.52(11.40) −4.73⁎⁎⁎

2.06(.73) 3.27(.26) −6.72⁎⁎⁎ 7.08(3.98) 22.29(6.0) −9.39⁎⁎⁎

38.31⁎⁎⁎ 7.62⁎⁎

65.98⁎⁎⁎ 2.50

40.16⁎⁎⁎ 2.21

56.65⁎⁎⁎ 3.03

3.13(.66) 3.45(.72) −4.12⁎⁎⁎ 4.8% 96%

2.70(.44) 3.20(.57) −5.26⁎⁎⁎ 11.1% 87%

6.05⁎⁎ 1.43

21.10⁎⁎⁎ 1.97

Note. F1 indicates F statistics from comparison among three assessments; F2 indicates the F statistics from the linear test. aFive parcitipants were missing at T3. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.

first session), a main structured activity, a brief summary and the family assignment. During the sessions, the following topics were focused on: understanding a family with Internet addict (session 1), parent–adolescent communication skills training (session 2), parent–adolescent communication practices on Internet addiction (sessions 2 and 3), parent– adolescent relationship building skills training (session 4), associations between psychological needs and Internet use and how to satisfy the unfulfilled need in the family relationships (session 5) and setting up appropriate and healthy expectations for the family system (session 6). One additional session at the three-month follow-up was designed to target potential relapse, discuss new issues and generate solutions to maintain the effectiveness of the intervention.

2.4.2. Parent–adolescent relationship Adolescents reported their relationships with the parent who participated in the intervention on nine items from the Closeness to Parents on a scale (Buchnan, Maccoby, & Dornbush, 1991) from 1 (not at all true) to 5 (very much true). Sample questions included “How openly do you talk with your mother (father)?” or “How close do you feel to your mother (father)?” A Chinese adaption of the scale has been used in previous study (Liu et al., 2013) and it has a high internal consistency in the study (α = .91). Average scores across the nine items were used to represent the adolescent's relationships with the mother or the father during the intervention.

2.4. Measurement

2.4.3. Parent–adolescent communication The Parent–Child Communication Scale (Barnes & Olson, 1985) was used to assess the adolescents' perception of their communication with the parent in the intervention. This scale contains 20 items on a scale from 1 (never) to 5 (always). It is composed of two dimensions that measure the degree of openness and the extent of problems in family communications. The responses were identified separately for fathers and mothers. The average score across both dimensions was used to represent the average level of parent–child communication in this study. A Chinese adaption of the scale has been used in previous study (Liu et al., 2012) and the α for the scale is 0.82 in the study.

2.4.1. Adolescent Internet addiction Two indicators of Internet addiction were reported by adolescents themselves. First, they reported their average number of hours spent on the Internet per week over the past month. Second, they reported on their Internet addiction behaviors with the Adolescent Pathological Internet Use Scale (Lei & Yang, 2007). This scale contains 38 items with each item being rated from 1 to 5 (1 = not true at all; 5 = true all of the time). Six subscales were included: salience, social comfort, mood alteration, tolerance, compulsive Internet use and negative outcomes. The average scores across the 38 items were used as indicators of Internet addiction with higher scores indicating more serious Internet addiction. This scale has high internal consistency (α = .95 for the whole scale; α between .81 and .91 for all subscales) and high test–retest reliability (r = .86). Based on the APIUS average scores, adolescents with scores below 3 were considered to be normal Internet users, adolescents with scores between 3 and 3.15 were considered to have a tendency towards Internet addiction, and adolescents with scores higher than 3.15 were defined as having Internet addiction (Lei & Yang, 2007). The Internet addiction rate was calculated based on the number of adolescents defined as having a tendency towards or having Internet addiction (APIUS N 3) and is considered as one of the intervention effectiveness indicators in the study. Second, parents' reports of children's Internet use behaviors in the last month were used as a supplementary measure of adolescents' Internet use behaviors. Three items were reported: Internet use frequency (1 = “very rare” to 5 = “very frequently”), parents' observation about adolescents' Internet use appropriateness (1 = “very appropriate” to 5 = “not appropriate at all”), and parents' satisfaction towards children's Internet use behaviors (1 = “very satisfied” to 5 = “not satisfied at all”). The average score across the three items was used to present the parents' evaluation of children's Internet use behaviors. A higher score indicates more Internet use and lower behavior control.

2.4.4. Adolescent psychological needs Adolescents rated their psychological needs using a scale modified from the College Students' Psychological Needs and Fulfillment Scale (Wan et al., 2010). The scale is composed of three subscales: the degree of psychological needs; need satisfaction from real life, and need satisfaction from the Internet. Each subscale includes 35 items that tap into eight dimensions of the targeted subscale: need for autonomy, need for entertainment, need for interaction, need for achievement, need for impact, need for acknowledgement, need for expression and need for information. The rating for each item in the degree of psychological needs subscale ranges from 1 (not strong at all) to 5 (extremely strong). Ratings in the other two need satisfaction subscales range from 1 (very low) to 5 (very high). Unsatisfied psychological needs were calculated by subtracting the subscale scores on need satisfaction in real life from the subscale scores on the degree of psychological needs. The advantage of the Internet in satisfying needs was calculated by subtracting the subscale scores on need satisfaction in real life from the subscale scores on need satisfaction from the Internet. These two scores were two major process variables of interest in the study. The α for the scale is 0.97 in the study.

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Table 2 Comparisons on intervening process variables.

P–A relationship

Intervention Control t Intervention Control t Intervention Control t Intervention Control t

P–A communication

Unsatisfied needs

Advantage of Internet in satisfying need

T1

T2

T3

M(SD)

M(SD)

M(SD)

F1

F2

2.99(0.45) 2.96(0.44) 0.21 2.96(0.71) 2.94(0.44) 0.19 0.67(0.58) 0.65(0.37) 0.18 0.59(0.57) 0.58(0.44) 0.09

3.72(0.81) 2.99(0.49) 2.89⁎⁎ 3.71(0.49) 2.98(0.47) 4.08⁎⁎⁎

3.79(0.64) 3.05(0.48) 2.96⁎⁎ 3.83(0.62) 3.03(0.42) 3.97⁎⁎⁎

14.86⁎⁎⁎ 1.45

29.94⁎⁎⁎ 2.84

13.78⁎⁎⁎ 0.08

30.57⁎⁎⁎ 0.11

0.19(0.56) 0.47(0.25) −2.57⁎ −0.24(0.59) 0.46(0.25) −4.83⁎⁎⁎

−0.01(0.45) 0.48(0.29) −3.87⁎⁎ −0.81(0.58) 0.47(0.29) −7.78⁎⁎⁎

11.56⁎⁎⁎ 3.48

19.85⁎⁎⁎ 4.65

23.68⁎⁎⁎ 3.41

39.15⁎⁎⁎ 2.61

Note. P–A stands for parent–adolescent; F1 indicates F statistics from comparison among three assessments; F2 indicates the F statistics from the linear test. ⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.

2.5. Analysis plan The data analysis proceeded in three steps. First, T tests and Repeated-Measures ANOVA analyses were conducted to test the effectiveness of the intervention based on the comparison among adolescents' Internet addiction measures in the intervention and control groups at T1, T2 and T3. Second, comparisons on all intervening variables between the two groups at T1, T2 and T3 were conducted, and changed values of the Intervening variables from T1 to T2 and T3 were created. Third, hierarchical multiple regression analyses were conducted to examine whether the change in adolescents' Internet addition behaviors is explained by the change in the measured intervening variables. 3. Results 3.1. Effectiveness of the intervention Before examining the effectiveness of the intervention, the Internet addiction measures at T1 were compared between the intervention and control groups and no significant difference was detected, indicating that the two groups were at the same or similar level of Internet addiction at the baseline of the study (see F values at T1 in Table 1). The effectiveness of the intervention was manifested in three aspects:

First, adolescents in the intervention group significantly reduced the time they spent on the Internet by the end of the intervention, spending about half of the time as adolescents in the control group did (see F values at T2 in Table 1). Second, comparisons of APIUS scores demonstrated that the intervention group experienced a decrease in their average APIUS scores from T1 to T2. Third, parents in the intervention group reported more satisfaction with adolescents' Internet use behaviors at the end of the intervention compared with both their satisfaction at the baseline and parents' satisfaction in the control group. In sum, based on reports from both adolescents and their parents, the intervention was effective in terms of reducing adolescents' Internet addiction behaviors by the end of the intervention. Results from the repeated measures ANOVA (see Table 1) showed that the differences in APIUS scores across the three measurements were significant(F (2, 78) = 38.31, p b .001) and also displayed a linear decrease over time from Time 1 to Time 3 (F (1, 39) = 65.98, p b .001), which indicates that the intervention effects remained at T3. Time spent on the Internet also displayed a significant decrease from T1 to T3 (F (2, 78) = 40.16, p b .001) with a linear decrease from T1 to T3 as well (F (1, 39) = 56.65, p b .001). In the control group, significant differences were found among the three APIUS assessments and a further paired sample t test showed that APIUS scores at T2 were significant higher than at T1(t = − 4.15, p b 0.001), but there was no linear tendency of APIUS scores from T1 to T3 (F (1, 39) = 2.50, p = 0.13).

Table 3 Regressions for changed values of measured variables at T2 and T3 ΔX = XT2 − XT1

ΔX = XT3 − XT1

β

t

R2

Step 1 Δ P–A relationship

−.56

−2.93⁎⁎

.31

8.55⁎⁎

.31

Step 2 Δ P–A relationship Δ P–A communication

−.03 −.78

−.13 −4.22⁎⁎

.65

16.99⁎⁎⁎

Step 3 Δ P–A relationship Δ P–A communication Δ Unsatisfied needs Δ Advantage of Internet in satisfying needs

.03 −.51 .02 .39

.17 −1.98⁎ .13 1.33

.70

7.07⁎⁎

Note. P–A stands for parent–adolescent. ⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.

ΔR2

F

β

t

R2

8.55⁎⁎

−.61

−2.62⁎

.36

.34

17.87⁎⁎

−.03 −.73

−.11 −2.19⁎

.05

.82

.00 −.53 .34 .88

.01 −1.98⁎ 1.00 3.44⁎⁎

ΔF

ΔR2

ΔF

6.76⁎

.36

6.76⁎

.55

6.79⁎

.19

4.74⁎

.83

10.01⁎⁎

.27

6.49⁎

F

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Parents' reports on adolescent Internet addiction at the three-month follow-up also substantiated the effect of the intervention. At 3 months after the intervention, parents still reported a significant reduction in their perception of their children's Internet addiction, revealing a significant linear decrease from T1 to T3. As an important indicator of intervention effectiveness in the whole intervention group, the Internet addiction rate yielded from the APIUS average scores was also compared across the intervention and control groups over time. As displayed in Table 1, all adolescents in both groups were either addicted to the Internet or had the tendency towards Internet addiction before the intervention. By the end of the intervention, only 1 out of 21 adolescents (4.8%) in the intervention group was still addicted to the Internet, compared with as many as 24 out of 25 (96%) in the control group. At the three-month follow-up, two adolescents in the intervention group showed a relapse. However, the intervention effects remained as only 11.1% of adolescents in the intervention group remained addicted after the intervention ended, compared with 87% of their counterparts in the control group. 3.2. Examining mediating effects of intervening variables Because we measured the perception of parent–adolescent interaction and psychological need that is deeply inside of adolescents, we used the reports from the adolescents themselves to examine the change process of adolescent Internet behaviors. To examine the second hypothesis (that the intervention effects are mediated through major process variables), we first examined the change in parent–adolescent relationships, parent–adolescent communication and adolescents' psychological needs. We measured these attributes at their baseline, at the end of the intervention, and at a three-month followup for both the intervention and control groups. As displayed in Table 2, the measured variables did not differ significantly between the intervention and control groups at T1, but did differ significantly at T2 and T3. Adolescents in the intervention group demonstrated improvement in their relationship and communication with their parents, an increase in their fulfillment of needs, a decrease in Internet use' advantage in fulfilling their needs in a linear function. With the demonstration of improvement on all process variables in the intervention group, we continued to examine whether the change in those process variables accounted for change in adolescents' Internet addiction behaviors. Before examining those mediating effects, change values (Δ X) were created for adolescent reported Internet addiction behaviors, parent–adolescent communication and relationship, and psychological needs by subtracting the post-intervention assessment values from the baseline values (ΔX = XT2 − XT1). To examine the contribution of those process variables in the explanation of intervention effectiveness on adolescents' Internet addiction, a hierarchical multiple regression analysis was performed. Process variables were entered in three steps: In step 1, ΔAPIUS was the dependent variable and Δ parent–adolescent relationship was the independent variable. In step 2, Δ parent–adolescent communication was entered into the step 1 equation. In step 3, two indicators of Δ adolescents' psychological needs were added in the equation in step 2. The results of step 1 (Table 3) indicated that 31% of the variance in the change in adolescents' Internet addiction (R2 = .31) was accounted for by improvements in the parent–adolescent relationship. In step 2, after entering changes in mother–adolescent communication, an additional 34% of the variance in the change in adolescents' Internet addiction was explained(ΔR2 = .34) and this change in R2 was significant. In step 3, the addition of psychological needs did not explain additional variance in the dependent variable. To examine the mediating effects of process variables from T1 to T3, change values (Δ X) were created by following the same procedure: subtracting the three-month follow-up assessment values from the baseline values (ΔX = XT3 − XT1). A hierarchical multiple regression analysis was again performed (see the right half of Table 3). First, the

results of the hierarchical analysis revealed that changes in parent–adolescent communication and relationships explaining significant variance in adolescents' Internet addiction from T1 to T3. Moreover, when predicting longer term effects in reducing Internet addiction, changes in adolescents' psychological needs also added significant prediction of variance in the Internet addiction change (Δ R2 = .27). This was in large part due to changes in adolescents' satisfaction of their psychological needs through the Internet (β = .88, p b .01).

4. Discussion The current study represents a practical clinical trial of treating adolescents' Internet addiction using the multi-family group approach. Based on prior family group intervention practices in treating adolescent psychopathology (Chien & Chan, 2013; McDonell & Dyck, 2004; Zhong et al., 2011), the current study is the first to our knowledge to apply the approach of MFGT in treating adolescents' Internet addiction. The adolescents' Internet addiction rate dropped from 100% at the baseline assessment to 4.8% at the end of the intervention and remained at 11.1% at the three-month follow-up assessment. Time spent on Internet in the intervention group also significantly declined throughout the intervention until the three-month follow-up. Analyses of the value changes in measured variables indicated which factors were associated with the decrease of adolescent Internet addiction. Improved parent– adolescent communication and need satisfaction in real life were associated with decrease in Internet addiction. If adolescents in the intervention group perceived an improvement in their communication and relationships with parents, learned alternative ways to fulfill their needs and felt less reliance on the Internet, this might promote their motivation to sustainably change their behavior. The results are consistent with prior evidence suggesting the role of feeling supported and trusted in improving the effectiveness of family group intervention (Dickerson & Crase, 2005). These findings corroborate the idea that intervention programs for adolescents need to get parents actively involved and include them as part of the solution. The family system approach shifts the emphasis on individual family members to the entire family as a unit and the dynamic interactions between family members (Dickerson & Crase, 2005). Further, multi-family group is very helpful in the lasting the effective of intervention. In the multi-family group, each family represents a subsystem with a shared history and current life situation which makes for an enriching and complex process. Then, the multi-group serves both the family system and individual as an arena for cross transferences and as a reality tester (Leichter & Schulman, 1974). Moreover, the participation of other family members in the intervention can create a more supportive environment in which the participants' behavioral changes are valued, encouraged, and maintained even after the intervention ends (McDonell & Dyck, 2004). The present study takes a further step in unraveling the underlying mechanism through which MFGT took effects. Parent–adolescent interactions and relationship quality and adolescents' increasing satisfaction of psychological needs in real life partially accounted for the effectiveness of the intervention in reducing adolescents' Internet addiction, further supporting prior findings (Liu et al., 2012, 2013; Olson et al., 1974). Consistent with previous studies, perceived positive interaction with parents protected adolescents from Internet addiction (Liu et al., 2013; Van den Eijnden et al., 2010). Positive communication facilitated emotional connections between family members and helped them to understand and clarify their needs (White, 2000). The alternative ways and skills of need satisfaction that adolescents and parents learned from the sessions would also expand the degree of communication and interaction within the family. All of these changes could be helpful to keeping children away from Internet addiction. However, the decrease in advantage of Internet in satisfying need did not predict change in Internet use behaviors until the three-month follow-up assessment.

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This delayed effect has been reported before in interventions targeted to treating adolescents' affective disorders (Goldberg-Arnold, Fristad, & Gavazzi, 1999). It suggests that improvement in adolescents' satisfaction of psychological needs through real life interactions may take time to occur. The positive and effective interaction skills and patterns between adolescents and parents need to be practiced before adolescents gradually feel comfortable and natural enough to get used to them. It also may take time for adolescents to change and adapt their need satisfaction habits, which may be a potential advantage of MFGT as it may have lasting intervention effects. Once a benign interaction and relationship pattern is established, the family obtains a built-in force to sustain the intervention effects (McDonell & Dyck, 2004). Some factors limit the conclusions that can be drawn from these data. First, the study did not take other competing intervention models into consideration. It has been recommended in intervention studies to compare across multiple intervention paradigms to better evaluate the effectiveness of certain intervention approach. For example, a family therapy approach or group intervention approach could be incorporated in a comparison group to further evaluate the effectiveness of the MFGT paradigm. Second, the gender ratio of parents was not balanced, as most of the participating parents were mothers. This might be an obstacle in clarifying the unique role of the mother–adolescent relationship or father–adolescent relationship in preventing Internet addiction among adolescents, as the impact of their relationship with their father and mother differed with adolescent genders on Internet addiction (Liu et al., 2013). It would be clearer if further clinical studies endeavored to recruit parents of both genders. Third, based on a quasi-experimental design, participants were not randomly assigned to an intervention or control group. However, the baseline comparison between the groups did not show a significant difference and indicate that the results of the study are reliable. Fourth, the data were mainly from questionnaires, and social desirability might influence adolescents' reports of their Internet use behavior. Future studies should assess Internet addiction through psychological interviews. Additionally, the present study only measured general Internet use and addiction, limiting the generalization of results to specific Internet addiction. It would be helpful to improve intervention if further studies paid attention to the treatment of subtypes of Internet addiction. Given the different characteristics of adolescents and their families, multiple dimensions of multi-family group therapy might be more complex and require exploration in future studies. The existence of equifinality in adolescents' Internet addiction behaviors also indicates that multiple factors, including personal, interpersonal and environmental factors, could lead to the emergence of Internet addiction among adolescents. For example, individual differences among children in basic need satisfaction in daily real life were associated with the way in which they engage with the Internet (Shen et al., 2013). Therefore, multi-family group interventions that tailor to different etiologies of Internet addiction might improve its effectiveness. In the addiction field, prevention is more important than intervention. Future studies might explore the possibility and feasibility of an integrated preventive intervention framework including school, community and family, based on evidence from other related adolescent health-related domain (Dodge & Godwin, 2013; Lovato et al., 2013). In consideration of the particularity of Internet addiction behaviors, namely that Internet serves as a necessary part of life and Internet use cannot be completely cut off but only be guided to a rational and controllable level, it is very important to discern how to guide youth use of the Internet appropriately and optimize the benefits of the Internet for adolescents and children. Role of funding sources This study was funded by Project of Social Sciences for Young Scholars from Ministry of Education in China (Project No. 12YJC190023), China National Science Foundation (Project No. 31170990), the Program for Changjiang Scholars, and the Fundamental Research Funds of Central China Normal University (CCNU13A05046). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Contributors Dr. Xiaoyi Fang generated the idea for the study and designed the study and intervention program. Dr. Qinxue Liu conducted all the interventions and statistical analyses as well as wrote the full manuscript. Ni Yan contributed the English Writing, methods and discussion. Zongkui Zhou contributed the modification of discussion. Xiaojiao Yuan, Jing Lan and Chaoying Liu participated in the intervention delivery and manuscript preparation. All authors contributed to and approved the final manuscript. Conflict of interest All authors declare they have no conflicts of interest.

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