1. Introduction

A smartphone is a device that combines mobile phone and internet functionality [1]. Smartphones were first introduced to the general public in the year 2007 [2]. The inability of an individual (behavioral addiction) to regulate themselves in their personal smartphone use is known as problematic smartphone use (PSU). Certain features of PSU make it distinct from normal smartphone use e.g. individuals suffering from PSU exhibit withdrawal symptoms, tolerance development, dangerous use and behavioral problems. PSU has various labels such as smartphone dependency, PSU, and smartphone overuse. Individuals who struggle with PSU face physiological, psychological, and social problems. Adolescents and young adults are particularly vulnerable to PSU [1, 3]. Moreover, during the recent pandemic PSU has increased [4]. The use of social networking services is a significant factor in predicting PSU [1]. Excessive use of social media is often associated with psychological distress and thoughts of self-harm [5–7]. PSU is positively correlated with increased daily smartphone usage, social media usage, time spent playing games, poor sleep quality, and the intensity of depressive symptoms [8, 9]. Compared to older people, adolescents and young adults are more vulnerable to PSU. Their social media usage and smartphone use can expose them to negative peer feedback, distorted body image perceptions, online harassment, and constant unhealthy comparison with others [10].

The strongest warning signs of PSU are observed in those who got their first phone before turning thirteen [4]. Children who started using a cell phone at a young age exhibited increased behavioral issues, including nervousness, irritability, cognitive distraction, and laziness. These problems were further exacerbated over time [1, 11]. Studies on cell phone addiction revealed that smartphone use poses a greater risk of road accidents compared to alcohol abuse [4]. Another study suggests connections between PSU, physical health, and mental health issues. Musculoskeletal discomfort and sleep difficulties are the most prevalent issues associated with PSU [4]. Excessive smartphone use is often linked to hand dysfunction, cervical, neck, back, and shoulder problems, as well as poor postures like forward head posture [2]. Among students, PSU is associated with poor physical and mental fitness and academic performance [12]. Depression and sleep problems are prevalent psychological issues related to PSU among university students [8]. Previous research indicates that an individual’s psychological characteristics can be discerned by analyzing their patterns of smartphone usage [13].

The degree to which college students effectively manage their smartphone usage can significantly impact their mental health outcomes. According to research, college students are more likely to use smartphones adversely, which can have detrimental effects on their physical and mental health [14]. Remarkably, several psychological problems, such as anxiety, depression, bipolar disorder, dependent personality disorder, obsessive personality disorder, and somatization, are significantly correlated with PSU [4, 15]. Attention deficit hyperactivity disorder (ADHD) is a psychiatric condition characterized by persistent challenges in sustaining attention, hyperactivity, and impulsivity, and is estimated to impact 7% of young individuals.¹⁹ ADHD can also be exacerbated by PSU because of factors like irregular sleep schedules, extended screen time, fast graphic changes, cravings for instant gratification, and an insatiable thirst for pleasure [9, 16–18]. Research findings suggest that adolescents with ADHD are more likely to experience PSU, with a prevalence rate of 42.0%. Furthermore, adolescents with more severe ADHD symptoms tend to encounter social difficulties and exhibit lower levels of optimism [19, 20].

According to epidemiological studies, the incidence of ADHD in children and adolescents worldwide ranges from 5 to 10%, but the prevalence in adults is roughly 2.8%. Adolescents with ADHD face increased risks of school rejection, lower educational attainment, and challenges in peer relationships. Additionally, they show a higher tendency to engage in dangerous activities, including drug abuse, reckless driving, and deviant sexual behavior [21]. Adolescents with ADHD may be more attracted to smartphone use due to its instant response, rewards, and portability [16]. In univariable analyses, ADHD prevalence was higher in the Middle East than in North America. Multivariable analysis studies in Europe reported lower ADHD prevalence compared to North America [22]. Research suggests that individuals with PSU may struggle to focus or sustain attention, exhibiting symptoms similar to ADHD. Post-hoc analyses indicate that ADHD symptoms are higher in the high-risk PSU group compared to normal users. According to a different study, smartphones with access to the internet can make it more likely that people will develop an online addiction and weaken their capacity for sustained concentration [23]. A study conducted with adolescent smartphone addicts seeking psychiatric outpatient care in Korea revealed a high prevalence of PSU symptoms related to depression and ADHD. Approximately 40% of ADHD patients in the study were identified as smartphone addicts, and their vulnerability to addiction was attributed to poor attention and inhibition [24].

The tremendous development in popularity of smartphones has made them a central device for accessing information and services via the internet. The incidence of PSU in teenagers in Taiwan fluctuates from 13.9% to 25.7% [25]. A previous study conducted in Korea found that 4.9% of middle school students and 10.6% of university students had PSU [16]. In 2014, there were 39 million smartphone users in South Korea. Present estimates indicate that the number is 53.5 million, which is 97% of the total population of Korea [26]. Smartphones are easily accessible, leading to PSU in children and adolescents. According to a study, the prevalence rate of PSU was considerably greater in the ADHD group than it was in the non-ADHD group (34.4% vs. 15.4%). Additionally, the ADHD group showed more disruptive behavior and decreased everyday performance [27, 28]. Research from America, Europe, and the Middle East showed that the average adult rate of ADHD was 3.4%; high-income countries had a higher prevalence (4.2%) than low-income countries (1.9%). An epidemiological study conducted on 4,512 South Korean adolescents assessed the associations among PSU, ADHD symptoms, depression, and anxiety. The study found that students with PSU had a higher prevalence of ADHD symptoms (47.8%) compared to low-use smartphone users (19.7%) [29]. PSU hasn’t been officially recognized as a disorder worldwide, even though it has a significant impact on human physiology, social behavior, and psychology. A study in 2022 found that the estimated global prevalence rate of PSU is around 27%. In terms of research volume, China had the highest number of articles published on PSU in international academic journals. In Bangladesh, the number of social media users was 24.49 million in 2022, and it is projected to reach 33.6 million by 2027. On the other hand, not much research is conducted about how these platforms are used and how they affect mental health problems. Unfortunately, mental health issues in Bangladesh continue to be stigmatized and receive little attention [30–32]. The number of smartphone users has been rising worldwide, with the fastest increase occurring in Asia and Europe [16]. To the best of our knowledge studies on PSU and ADHD in South Asian countries, particularly in Bangladesh, are not being conducted adequately, despite the increasing prevalence of PSU [17, 18]. Furthermore, a clear relationship between PSU and ADHD remains unclear due to a lack of adequate data. PSU is a significant concern as it is closely associated with mental health issues.

The rationale of this study is to investigate the prevalence of PSU and symptoms of ADHD among young adults and adolescents in Bangladesh, as well as the potential factors that contribute to these conditions. Specifically, we investigated the importance of age, education level, living with family, sleeping timing, smoking habit, physical disability, physical exercise, and residence area of respondents in correlating with PSU and ADHD. We hope this study’s findings will help create a better understanding of PSU, ADHD symptoms, and associated factors that might aid create a comprehensive intervention plan to manage these mental health disorders.

2. Methods

2.1 Study design and participants

Between January 1, 2023, and June 30, 2023, we performed this cross-sectional study among adolescents and young adults in Bangladesh. We assumed the response rate, confidence interval, and margin of error as 75%, 95%, and 5%, respectively. Based on the above assumptions, the present study required 384 responses. We applied stratified random sampling method to target potential respondents. We considered age, sex, and geographic location as stratification criteria. Initially, we approached 800 participants via face-to-face surveys. We got 578 responses from them, but after screening, 36 were excluded due to incomplete information. Finally, 542 responses (259 males and 283 females) were included in the final analysis (Fig 1). All participants live in Bangladesh and are of Bangladeshi descent. Before participation, they received an overview of the permission forms, eligibility requirements, procedures, and questionnaire. Once they were aware of the requirements for qualifying, they voluntarily provided their information. The volunteers received no payment for their participation in the study.

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Fig 1. Flowchart showing of data collection.

https://doi.org/10.1371/journal.pone.0308621.g001

3. Results

3.2 Prevalence and associated factors of problematic smartphone use

The prevalence of PSU symptoms among the participants was 61.44% (Fig 2). Our study finds that PSU significantly varies by age, education level, family type (nuclear/joint), sleeping timing, physical exercise, and residence area of respondents (Table 1). The proportions of respondents experiencing PSU symptoms were higher in (1) 26–30 years age group (76.92%) followed by 19–25 (64.78%) and 12–18 (53.03%). The proportion of participants who reported PSU symptoms from nuclear and joint families was 64.58% and 53.80%, respectively. Proportions of respondents with or without PSU symptoms having primary, secondary, graduation, master’s, or above the level of education were 45.45% vs. 54.55%, 46.62% vs. 53.38%, 30.13% vs. 69.87%, and 19.05% vs. 80.95%, respectively. We noticed the proportion of participants who reported PSU symptoms with or without being actively involved in physical exercise were 48.43% vs. 66.84%, respectively. Proportions of respondents with or without PSU symptoms between urban and rural areas were 66.50% vs. 46.76%, respectively. Also, we observed the prevalence of PSU was higher among individuals who go to sleep after midnight, need more time to fall asleep and wake up late. The Cronbach’s alpha for SAS-SV among the responses was 0.814 that confirms good reliability and internal consistency of PSU measures.

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Fig 2. Prevalence of problematic smartphone use and attention-deficit hyperactivity disorder among the young adults and adolescents in Bangladesh”.

https://doi.org/10.1371/journal.pone.0308621.g002

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Table 1. Proportion of participants reported symptoms of smartphone addiction and its association with demographic variables.

https://doi.org/10.1371/journal.pone.0308621.t001

3.3 Prevalence and associated factors of attention deficit hyperactivity disorder

We observed that the prevalence of ADHD symptoms among the participants was 37.45% (Fig 2). The prevalence of ADHD symptoms significantly varied by age, education level, living with family (yes/no), sleeping timing, smoking habit, physical disability, physical exercise, residence area, and PSU symptoms of respondents (Table 2). There was a greater percentage of responders reporting symptoms of ADHD in (1) the 26–30-year-old age group (76.92%), followed by 19–25 (40.30%), and 12–18 (26.52%). The proportion of participants living with or without families and showing ADHD symptoms was 35.37% and 46.53%, respectively. Proportions of respondents with or without ADHD symptoms having primary, secondary, graduation, master’s or above level of education were 45.45% vs. 54.55%, 30.25% vs. 69.75%, 44.10% vs. 55.90%, and 57.14% vs. 42.86%, respectively. We noticed the proportion of participants who reported ADHD symptoms was higher among individuals with smoking habits (54.90%) and physical disabilities (54.04%). Also, we observed the prevalence of ADHD symptoms was higher among individuals who go to sleep after midnight, need more time to fall asleep, wake up late in the morning, and spend more time in bed. The Cronbach’s alpha for ASRS among the responses was 0.798 that also confirms good reliability and internal consistency of ADHD measures.

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Table 2. Proportion of participants reported symptoms of attention deficit hyperactivity disorder and its association with demographic variables.

https://doi.org/10.1371/journal.pone.0308621.t002

3.4 Regression analysis

Binary logistic regression analyses were used to ascertain the relationship between PSU and ADHD symptoms with sociodemographic profile of participants (Table 3). Those who are in the secondary level of education reported being 0.213 times less likely than those with a master’s degree or above to experience PSU symptoms (OR = 0.213; 95% CI = 0.048–0.954, p = 0.043). Married respondents were 0.387 times less likely to get addicted to smartphones compared to unmarried respondents (OR = 0.387; 95% CI = 0.153–0.974, p = 0.044). Respondents engaged in physical activity were 0.663 times less likely to suffer from PSU compared to physically inactive individuals (OR = 0.663, 95% C = 0.412–1.067, p = 0.090). Respondents residing in rural areas are 0.364 times less likely to develop PSU compared to urban residents (OR = 0.364, 95% C = 0.170–0.779, p = 0.009). The chances of developing ADHD symptoms were found to be 0.190 times lower in those aged 19–25 than in individuals aged between 26–30 (OR = 0.190; 95% CI = 0.050–0.725, p = 0.015). Males had a 0.510 times lower prevalence of ADHD symptoms compared to females (OR = 0.510; 95% CI = 0.319–0.816, p = 0.005). Our data on gender differences in ADHD symptoms is in contrast to previous literature studies where males exhibited higher prevalence of ADHD symptoms than females. However, such a conclusion is not definite and still under active research studies as exemplified by the work of Rucklidge et. al. who found that gender differences in ADHD symptoms are somewhat more similar than different [35]. Moreover, such gender differences might be demographic dependent altogether as might be in the case of the Bangladeshi youth population. Non-smokers are 0.321 times less likely to develop ADHD symptoms compared to smokers (OR = 0.190; 95% CI = 0.155–0.667, p = 0.002). Also, we noticed that PSU and ADHD symptoms were positively correlated with each other (r = 468, p<0.001).

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Table 3. Logistic regression analysis of demographic variables for symptoms of problematic smartphone use and attention deficit hyperactivity disorder.

https://doi.org/10.1371/journal.pone.0308621.t003

4. Discussion

With over 165.5 million inhabitants, Bangladesh is one of the most densely populated countries in the world, which has contributed to the steady rise in internet usage [36]. In Bangladesh, social media usage has increased dramatically, but there haven’t been much in-depth studies on how these platforms affect mental health [37, 38]. Lately, a few studies have found that young individuals who use social networking sites for more than two hours a day frequently have poor mental health, psychological discomfort, suicidal thoughts, and unmet psychiatric requirements [39–41]. Mental illnesses have high impact on the public health system and significantly contribute to the worldwide disease burden [42–46]. It is regrettable that the stigma and attention associated towards mental health issues still persists in Bangladesh [47]. According to the WHO assessment, only 7.7% of people in Bangladesh with mental health issues receive the appropriate care leaving a large volume of mental health patients with treatment gap [48].

Our current work thoroughly analyzed PSU symptoms, associated factors and the connection between PSU and ADHD symptoms among adolescents and young adults. Results indicate that there is a strong correlation between symptoms ADHD and PSU in adolescents and young adults. The study also identified several factors that influence PSU and ADHD symptoms such as education level, gender role, physical activity, marital status, residence area, smoking habits, sleeping time and living status. Based on these factors, preliminary interventionist methods to overcome or reduce PSU symptoms in children and young adults might be advised but further studies are required to validate treatment options since the cause for PSU are not fully understood yet. For example, we suggest children and young adults may engage in more social interactions and actively involve friends and family members in their activities that might have some positive spillover effect to counter PSU. Limiting smartphone usage and dedicating more time to outdoor games and physical exercise might be beneficial as well. Effective time management might play a crucial role in combating PSU. Alongside internet usage, we suggest adults might create schedules that prioritize a variety of activities, which might be likely to reduce the urge to constantly check their phones. We also advise seeking counseling as an option for adolescents to express their emotions and address the underlying causes of excessive online behavior. Individuals with mental health conditions aren’t aware of the fact that PSU can significantly contribute to their mental health problems. Additionally, both urban and rural populations in Bangladesh are increasingly susceptible to mental health problems and social hazards [49–53]. We expect that our study will help raise awareness on PSU and the mental health status, specifically ADHD, of the Bangladeshi population.

According to the findings, female students exhibit a higher frequency of mobile phone usage compared to males. The results of this study align with previous research, indicating a significant correlation between female gender and mobile phone addiction. An earlier study emphasized that gender is a crucial factor in predicting cell phone addiction, highlighting that women are more prone to becoming addicted than men [54]. Moreover, several studies have shown that women have higher rates of mobile phone dependence and problematic use compared to men [55–57]. This may be explained by the fact that women are more likely to have PSUs due to their demographic profiles and social structure. Another study highlighted the association between virtual spaces, such as mobile phones and the internet, with conditions like depression, anxiety, dependency, and addiction [15, 57]. Other research has demonstrated that residing in a nuclear family is also associated with PSU [38]. In line with prior studies, this investigation discovered that PSU is more likely to be linked with sedentary behavior and being overweight or obese [38, 58, 59]. Other studies have also indicated no correlation between smartphone use and sleep duration [39, 60, 61]. A Korean longitudinal study by Lee et al. discovered that PSU is associated with worse sleep quality but has no effect on how long people sleep [39, 60]. In this study, PSU emerged as one of the most significant predictors of ADHD, consistent with findings from other literature studies [39,58, 62]. There was a strong correlation found between symptoms of ADHD and poor sleep quality [63]. Addicts to smartphones have trouble focusing or maintaining their attention, and they often show symptoms of ADHD [23, 64].

The prevalence of PSU and ADHD are increasing worldwide, and the COVID-19 pandemic has augmented these issues. Many earlier studies report that adolescents and young adults in Bangladesh are suffering from several mental health issues. The present study revealed that a large proportion of adolescents and young adults in Bangladesh reported PSU and ADHD symptoms. A number of demographic and lifestyle-related factors were estimated as associated risk factors for PSU and ADHD among adolescents and young adults based on logistic regression model. The present findings highlight the importance of PSU and ADHD in creating a context-specific, inclusive interventional approach, adding to the body of evidence already in existing literature. Addressing PSU and ADHD could play a significant role in mitigating related mental health problem of adolescents and young adults in Bangladesh. This study has the potential to convey a message to the world regarding the smartphone usage and ADHD symptoms of the Bangladeshi population. The results of this study have wide-ranging implications for psychology, health, and academia. These findings can be used by parents and educational institutions to help youth, especially those with mental health issues. Regulatory organizations can consider implementation strategies, such as server access control during specific times (frequently at night), to mitigate addictive smartphone usage. Psychotherapists can also derive valuable insights from these studies to enhance their treatment approaches. The government may also adopt policies to prioritize the mental health of young adults to safeguard their well-being.

This study has several significant points. Firstly, it examines the connection between PSU and ADHD, taking into account demographic profiles among young people in Bangladesh. Secondly, the study aims to understand the association between PSU and ADHD. Thirdly, the data collection from across Bangladesh allowed for diverse socioeconomic backgrounds. The translated Bangla questionnaire ensured a proper understanding of the questions. Lastly, the findings of this study have broader implications for future context-specific research on PSU and ADHD, highlighting the importance of comprehensive mental health assessment and further investigation among young adults in Bangladesh.

Our present study has some limitations as well and we would like to discuss these limitations here. Firstly, the cross-sectional nature of the study is not applicable for the impact measurement of the PSU related parameters we found over time. As mentioned in the introduction, future work in PSU and ADHD symptoms using a longitudinal study approach is imperative and would provide further validation of our current work. Secondly, although the current study found signification correlation between PSU and factors e.g. education level, family status, gender roles, residence area, sleeping habits etc., the potential working mechanisms (routes) via which these variables affect PSU is not examined here and beyond the scope of our present investigation. Thirdly, we assessed PSU and ADHD symptoms only among the young generations in Bangladesh and a natural extrapolation would be to assess these underexplored diseases to other age groups in the country as well. Finally, the piloting of the study sometimes does not provide accurate information about the understanding of questions among the respondents.

5. Conclusion

In our current study, we have observed a substantial prevalence of PSU among young adults with ADHD in Bangladesh. Therefore, in Bangladesh, the promotion of mental health among children, adolescents, and young people must be given top priority by healthcare authorities and policymakers. Our results highlight the necessity for all-encompassing approaches to address the issues related to ADHD and PSU on a national and worldwide scale. To decrease excessive smartphone use, national and international public health organizations should work together to produce policies and guidelines. Furthermore, it is necessary to increase public awareness of the possible long-term effects PSU on young adults by community-based programs. We suggest education clinical psychiatrists and psychotherapists need to take this into account while interacting with patients and carrying out intervention procedures. However, further research with enhanced study designs is necessary to confirm these preliminary results.

Supporting information

Acknowledgments

All the authors are thankful to the participants for their cooperation to conduct this study.