Internet addiction and emotional problems

Individual, environmental, and internet-specific predisposing factors have been implicated in the emergence and persistence of IA [20, 21]. The interaction of person-affect-cognition-execution (I-PACE) model [21] proposes a complicated interplay among cognitive, emotional, and behavioral factors in the development of addictive behaviors. I-PACE takes into account environmental factors and specific situations that arouse a person emotionally and suggests that these factors lead to an increase in the vulnerability of people exposed to potentially addictive behaviors. For example, experiencing high stress and anxiety can make people engage in IA behaviors as a coping mechanism [22]. In the same way, individuals with strong beliefs about the benefits of internet surfing and gaming might be prone to involve in these behaviors despite the adverse outcomes.

While anxiety and difficulty coping with it are known as predisposing factors of IA [23], evidence shows that IA also has a reciprocal effect on anxiety levels [4,24], depression [25] and also suicidal and non-suicidal self injury [26, 27]. Since adolescents in development of identity formation tend to be more self-expressive and focused on self-presentation, social media can provide a wide space for them [28]. In addition, they often seek to be part of peer groups for the group approval and to prevent rejection [29]. An additional dimension to the pressures adolescents face in their engagement with social media is that it often functions as a coping or avoidance mechanism, allowing them to relive from challenges [30]. The nature of social media also strengthens them to stay connected through continuous reinforcements [31]. For example, adolescents spending a long time on social media may experience constant comparison, social pressure, loneliness, and content that is not appropriate for their age [32].

Excessive or compulsive use of social media can significantly increase anxiety among adolescents [33]. Fear of missing out (FOMO) and social comparison are recognized as mediators of adolescents both persistent and unrestrained use of social media and anxiety [34]. When comparing their virtual selves to those of their peers, adolescents may experience feelings of inadequacy and low self-esteem [35]. Moreover, social media contributes to the amplification of FOMO because adolescents feel continuous pressure to stay on social media and update their events, which can increase fatigue and anxiety [36]. IA can also lead to disturbances in adolescent sleep patterns [37], which can further increase anxiety [38]. Excessive internet use may disrupt the pattern of falling asleep or staying asleep in adolescents, leading to sleep deprivation and fatigue [39]. Sleep deprivation increases anxiety by interfering with the body’s natural response system [40]. Activities such as internet surfing and other screen activities prior to bedtime can inhibit the secretion of melatonin, the hormone responsible for regulating sleep [41], which can result in difficulty falling asleep and increase anxiety [42]. In conclusion, social comparison, FOMO, and sleep disturbances are among the widely recognized mechanisms underlying adolescent anxiety.

In addition, adolescents with IA are at a greater risk for developing depressive symptoms such as hopelessness, sadness, and worthlessness than adolescents without IA [43, 44]. Excessive internet usage can lead to social isolation and feelings of loneliness [45]. Adolescent insomnia can contribute to depression among adolescents [46]. Depression can also play a role as an underlying factor in the onset and development of IA [3]. For example, adolescents with depressive symptoms may use compulsive online gaming to cope with negative emotions [47]. In a cyclical process, IA can exacerbate the symptoms of depression, and depression can lead to elevated involvement with the internet.

Internet addiction and mindfulness-based cognitive-behavioral therapy

The literature shows that non-pharmacological and non-invasive treatments for adolescent internet addiction tend to be preferred [48]. However, in case of severe symptoms of anxiety and depression, drug interventions should also be considered [49]. Cognitive-behavioral therapy (CBT) has significant effects on adolescents’ IA, as well as its associated emotional difficulties, although its effect size is considered to be moderate [50, 51]. Mindfulness-based interventions (MBIs) have also expanded to address the challenges faced by children and adolescents [52], resulting in a new approach to IA interventions. MBIs, particularly Mindfulness-Based Cognitive Therapy [MBCT; Teasdale, Segal, Williams, et al. 53] and Mindfulness-Based Stress Reduction [MBSR; Kabat-Zinn 54] are being considered as new intervention methods for IA [55, 56]. MBIs emphasize bringing attention to the present moment and recognizing and accepting thoughts, feelings and bodily sensations without judgment [57]. Mindfulness practices have the potential to enhance the capacity for patience and tolerance, which can counteract the immediate gratification associated with addictive behaviors [58]. Several studies have shown that the practice of mindfulness has a negative association with IA [59, 60], as well as being a protective factor against emotional problems, including anxiety and depression [61–63].

MBCT integrates psychoeducation, mindfulness meditation and cognitive therapy techniques [64]. It aims to instruct patients to non-judgmentally observe uncomfortable mental processes, such as unpleasant thoughts and emotions, without engaging in reactive responses [65]. While MBCT was not originally designed to address IA, it teaches skills that can be used to overcome daily obstacles, as opposed to maintaining unhelpful coping behaviors [66]. One study with college students suggested that using mindfulness meditation and cognitive techniques, MBCT may help individuals with IA how to become aware of their internet-related thoughts, emotions, and behaviors [67]. MBCT can also contribute to the development of healthier coping mechanisms and a higher level of well-being [68]. To achieve these goals in children and adolescents, it is necessary to use MBCT programs tailored to them. MBCT for Children (MBCT-C) is a manualized, evidence-based program that teaches mindfulness practices in developmentally appropriate ways [69]. Studies related to the effectiveness of MBCT-C are listed in Table 1.

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Table 1. Summary of studies conducted using the MBCT-C protocol for children and adolescents.

https://doi.org/10.1371/journal.pone.0317824.t001

Study Context

One national study found that 22% of Iranian teenagers are addicted to the internet [77]. Although this is consistent with the prevalence rates of IA worldwide, it is worrying for a country that has a limited psychological service for children and adolescents with mental problems [78], particularly when IA is related to other psychological problems. Data has indicated a correlation between IA and anxiety, obsessive-compulsive disorder, physical complaints, depression, interpersonal conflicts, hostility, social anxiety, and adolescent psychosis [79]. In addition, there is a growing interest in developing and facilitating effective interventions for children and adolescents through school-based counseling centers [80].

Preliminary evidence suggests promising results with MBCT for Iranian children and adolescents. A study conducted with teens demonstrated the effectiveness of MBCT in reducing rumination and social anxiety among high school students with social anxiety [81]. A clinical trial involving high school students found that MBCT effectively improved cognitive strategies related to positive emotion regulation while reducing negative cognitive strategies related to emotion regulation [82]. Another investigation showed the efficacy of MBCT in reducing IA among teenagers [83]. MBCT has also been shown to play a significant role in reducing addiction to online games among male teenagers [84].

Most of these studies used adult protocols for children and adolescents, while MBCT-C efficacy studies are more limited [70,85]. There is little clinical data supporting the efficacy of MBCT-C in reducing anxiety and depression among adolescents. Finally, examining the satisfaction of treatments for adolescents and their parents is not well understood. The current study aimed to address these gaps. To control the effect of non-specific therapeutic factors such as the presence of the therapist, empathy, and being with other peers with IA, instead of a wait-listed control condition, we will include an active control group (ACG) using a Life Skills Training (LST) program [86]. Research has shown that as a general intervention, LST can positively impact adolescents’ individual and interpersonal skills. However, its components are not specifically designed to address emotional and behavioral issues in this population. The hypotheses of this study are:

1. Participants in MBCT-C groups will report greater reductions in IA than participants attending LST groups as measured by the Internet Addiction Test (IAT).
2. Participants in MBCT-C groups will report greater improvement in mindfulness than participants attending LST groups as measured by the Mindful Attention Awareness Scale (MAAS).
3. Participants in MBCT-C groups will report greater reductions in state and trait anxiety than participants attending LST groups as measured by the State-Trait Anxiety Inventory for Children (STAI-C).
4. Participants in MBCT-C groups will report greater reductions in depressive symptoms than participants attending LST groups as measured by the Reynolds Depression Scale (RADS).
5. Participants who achieve greater changes in mindfulness, anxiety, or depression achieve greater changes in IA.
6. MBCT-C will be satisfactory to participants and their parents as measured by attendance rates, drop-out rates, and a satisfaction questionnaire.

Design

The study design will be a randomized controlled trial with both an MBCT-C intervention group and the LST active control group. Assessments will be collected before the intervention (T1), after the intervention (T2), and at three-months following the interventions (T3). All tools will be utilized at each stage of the assessment process, except for the mindfulness program satisfaction questionnaire (MPSQ), which will be administered solely at the post-treatment assessments. This study is registered with the Iranian Registry of Clinical Trials (IRCT), which is a primary registry within the World Health Organization (WHO) Registry Network (IRCT: ID: IRCT20230102057027N1).

Sample Size

The sample size for both groups was determined using the “a priori: compute required sample size” function in G * Power [87], specifically for a repeated measures ANOVA design with three time points. The function’s inputs were set as follows: effect size (f) = .20 [88], error probability (α) = .05, power =  0.80, degree of freedom of the model (df) =  2, and the number of groups =  2. An Intraclass Correlation Coefficient (ICC) was considered to account for the correlation across time points within participants. Initially, the total sample was calculated to be 66. To address potential sample attrition and ensure adequate power for the study, 14 additional participants beyond the estimated number will be included, resulting in a final sample size of 80 individuals.

Participants, Recruitment, and Randomization Procedures

The participants will include adolescents who are involved in IA and simultaneously suffer from symptoms of anxiety and depression. Inclusion criteria: (a) male or female middle school student, (b) age between 12 to 15 years old, (c) diagnose with IA by IAT, (d) commitment to attending both face-to-face and group sessions, (e) moderate to severe state and trait anxiety score ( ≥ 47, according to [89, 90]), or clinically significant depression (RADS cut-off score ≥  77, according to [91]). Exclusion criteria: (a) active psychotic symptoms or suiciadality, (b) significant alcohol or drug use, (c) does not speak Persian, (d) receiving concurrent psychotherapy. Recruitment of participants will be conducted through the dissemination of notices in schools and on each school’s online social media platforms in Telegram and Shad. After establishing communication with potential participants, the research team will extend invitations to engage in the preliminary screening process that includes IAT. Simple randomization method will be used to assign participants to groups. Participants who meet the inclusion criteria will be assigned to the MBCT or LST group using the software (https://www.randomizer.org/) with a ratio of 1:1. The randomization and allocation process will be done by a research group member who will not participate in any of the evaluation and treatment stages (Fig 1).

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Fig 1. The schedule of enrolment, interventions, and assessments.

Note: MBCT-C: Mindfulness-based Cognitive Therapy for Children; LST: Life Skills Training; IAT: Internet Addiction Test; MAAS-A: Mindful Attention Awareness Scale-Adolescents; RADS: Reynolds Adolescent Depression Scale; STAI-C: State-Trait Anxiety Inventory for Children; MPSQ: Mindfulness Program Satisfaction Questioner; MBCT-C-AS: MBCT-C Adherence Scale.

https://doi.org/10.1371/journal.pone.0317824.g001

Procedures

Through the dissemination of announcements in schools of Hamadan province, Iran, male and female students of the (aged 12-15) high school who use the internet will be invited to contact the research team to participate in an intervention study about internet use. Individuals who report symptoms of IA will be screened for eligibility. They will be asked to complete the IAT. Individuals identified as severe internet users, as determined by the cut-off point (total score ≥  50, [92]) set in the questionnaire will be selected to take part in the study. Those meeting the IA criteria will undergo assessment to verify their eligibility, taking into consideration both inclusion and exclusion criteria. Everyone involved will receive information about this investigation and will be asked to provide consent and assent, after being deemed eligible to participate. Participants in the intervention group will engage in MBCT-C sessions on a weekly basis for 12 weeks, commencing within two weeks following the baseline screening. Each MBCT-C session will last for 90 minutes. Participants in the ACG will engage in weekly life skills group sessions for 12 weeks. Each LST session will last for 90 minutes. All participants will complete T2 assessments within two weeks after the interventions and T3 assessments three months later.

Mindfulness-based cognitive therapy for children (MBCT-C)

The twelve-week MBCT-C program was published by Semple and Lee in 2011 [93]. It was specifically developed to cater to individuals between the ages of 8 and 18 who are diagnosed with various anxiety disorders, including generalized anxiety disorder, separation anxiety disorder, specific phobia, and social phobia. This program, which is adapted from the traditional MBCT program, uses a variety of meditations and mindfulness techniques to address and overcome the emotional challenges of children and adolescents. The main objectives are to enhance cognitive, emotional, and somatic awareness. Therapy sessions begin with an introduction to mindfulness, then continue with the cultivation of mindful activities for each of the senses, and end with the integration of the lessons. The initial phase of the MBCT-C (sessions 1 to 3) is centered on establishing a foundation for mindfulness, exploring the participants’ expectations of the interventions, looking at the fundamental principles and significant factors of the sessions, and discussing strategies for overcoming obstacles to practicing and completing assignments. In addition, these sessions provide instruction on breath and body mindfulness meditations to participants. During the middle stage (sessions 4 to 10), children and adolescents acquire knowledge regarding the interplay between their cognitive processes, emotional experiences, and bodily sensations, and how these factors can influence the intensity of their emotions. Participants can cultivate greater mindfulness by engaging in activities designed to increase mindfulness in each of the five senses. By increasing awareness of judgmental thoughts and engaging in intentional observation of present-moment experiences, individuals may discern alternative courses of action that are and make more skillful choices. During sessions 11 and 12, participants receive guidance in integrating mindfulness practices into their daily routines. Given the potential challenges associated with sustaining mindfulness practice, self-written correspondence will be mailed to each participant three months after the conclusion of the program, which is intended to foster the continuation of daily practice. In each session, program materials, including session summaries, homework sheets, and poems or stories related to that session are provided to the participants (Table 2).

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Table 2. Sessions, contents, and assignments from the MBCT-C treatment guide [Semple and Lee, 93].

https://doi.org/10.1371/journal.pone.0317824.t002

Semple and Lee [69] proposed that specific cognitive abilities are crucial for grasping and effectively implementing mindfulness. They theorized these abilities to include orienting attention to others’ experiences, understanding multiple perspectives, discerning temporal dimensions, and making causal inferences. Subsequently, they devised an intervention tailored for children over 11 years old, transitioning into the formal operational stage. For adolescents aged 12-15, MBCT-C will be utilized with adjustments to ensure age-appropriate language and discussions tailored to topics relevant to early teens, such as motivations for practice.

MBCT-C group sessions will be conducted by a doctoral candidate in psychology and a group facilitator with a master’s degree in psychology. The main therapist has repeatedly practiced the MBCT protocol in clinics and counseling centers for children and adolescents under clinical supervision for two years. The group facilitator was a psychologist with experience and training in the field of group interventions, who was trained under the supervision of the study with the framework of this protocol. Considering that the programs implemented in all sessions will be recorded step by step and in detail by the group facilitator, the supervisor of this study will examine the adherence to the protocol using the MBCT-C Adherence Scale (MBCT-C-AS) in each session and provide the therapist with feedback.

Life skills training (LST)

The core set of life skills [94] will be presented in twelve weekly sessions (90 minutes) to provide adolescents with the essential skills required to flourish during their life. The program teaches a range of skills, including self-awareness, interpersonal communication, empathy, coping stress, problem solving, decision making, emotional management, critical thinking, and creative thinking. A trained therapist facilitates sessions in which individuals can acquire life skills and foster personal development. The engaging and collaborative quality of this program is one of its primary strengths. The program includes practice components, such as interactive dialogues, role-playing scenarios, and other activities, which facilitates the acquisition of practical skills that are applicable to daily life. LST was created to address the requirements of adolescents. The therapist acknowledges the difficulties encountered by participants and tailors the interventions accordingly. Adolescents have the capacity to enhance their opportunities for achievement in several domains of life by active engagement in this program (Table 3).

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Table 3. Introducing the sessions, main contents, and assignments of life-skills training [Esmaeilinasab and et al, 94].

https://doi.org/10.1371/journal.pone.0317824.t003

LST group sessions are also run by the same therapist and facilitator who will conduct MBCT-C. The process of evaluating the therapists’ commitment to the protocol is also reviewed by the group supervisor on a session-by-session basis.

Demographics

Demographic data will be collected using self-report questionnaires for each adolescent and their parents. Participant age, gender, and educational attainment, ethnicity, religion, parental education level and family income will be collected at T1.

Primary Outcome Measure

Mindful Attention Awareness Scale- Adolescents (MAAS-A) is a 14-item unidimensional scale that was developed to measure the characteristics of mindfulness [95]. Responding to each item is based on a 6-point Likert scale ranging from 1 (almost always) to 6 (almost never). The MAAS-A total score is equal to the average of the item scoreswith higher scores indicating higher levels of mindfulness. The Internal consistency of the original version of the MAAS-A among children has been good (α =  .82) [96]. Likewise, its internal consistency has been reportedgood in the Iranian population (Cronbach’s alpha = .73) [97].

Secondary Outcome Measures

Internet Addiction Test (IAT) is a self-report instrument that assesses the severity of addiction to the internet [98]. The current version of the IAT includes 20 items that are evaluated by a Likert-type scale from 0 (not applicable) to 5 (always). The measures a variety of behaviors pertaining to internet usage (e.g., excessive loss of control over internet use, preoccupation with the internet, and adverse consequences related to internet use). Scores range between 0 and 100. Scores between 0 and 39 are classified as normal, scores between 41 and 69 are considered risk, and scores between 71 and 100 are indicative of IA. A meta-analysis indicated that the IAT exhibits a high level of internal consistency, with a coefficient of.90 observed among college students and.93 among high school students [99]. Furthermore, the reliability of this tool has been assessed in an Iranian sample, with internal consistency (Cronbach’s alpha) of.92 [100].

State-Trait Anxiety Inventory for Children (STAI-C) was initially developed for adults [101] and subsequently modified and standardized for individuals between the ages of 8 and 18 [102]. The questionnaire includes 40 items, with two components (state anxiety and trait anxiety) that have 20 items each. The state anxiety section evaluates how individuals feel in the present moment; while the trait anxiety section evaluates how individuals felt in general. A 4-point Likert scale (State: from 1 = not at all to 4 = very much so; Trait: 1 = almost never to 4 = almost always) is used to score STAI-C. Higher scores represent higher levels of anxiety. Investigation the literature indicates that there is no specific cut-off point for this tool, however, scores of 47 to 61 are common in anxiety disorders. In the present study, the score of 47 will be considered as the clinical cut-off point. The Cronbach’s alpha of the STAI-C was reported to be good for state anxiety (.86 for males and.87 for females) and trait anxiety (.78 for males and.81 for females) [103]. The test-retest reliability of STAI-C has been reported to be acceptable (give the actual coefficient number) [102].

Reynolds Adolescent Depression Scale (RADS) evaluates the severity of symptoms associated with depression among adolescents [104]. This scale consists of 30 items that assess depressive symptoms across four dimensions: negative self-evaluation (8 items), dysphoric mood (8 items), anhedonia/negative affect (7 items), and somatic complaints (7 items). In the present study, the cutoff score of 77, which was previously suggested [91], will be used as one of the criteria for entering the study participants. The RADS has demonstrated high internal consistency during the primary evaluation (Cronbach’s alpha = .91) and strong reliability (test-retest, intraclass correlation coefficient = .87). A significant positive correlation (.76, p < .001) was also reported between the RADS and the Hamilton Depression Rating Scale (HDRS) during the retest, indicating satisfactory criterion validity for this assessment tool [105]. An examination of the psychometric characteristics with Iranian adolescents showed good internal consistency for each of the subscales. Cronbach’s alphas were reported as.75,.90,.75,.80, and.85, respectively [106].

Mindfulness Program Satisfaction Questioner (MPSQ) is adapted from the 8-item Client Satisfaction Questionnaire [CSQ; Attkisson & Zwick, (1982); 107]. In this questionnaire, 8 items scored using a 4-point Likert scale are used to evaluate the level of satisfaction of the participants with MBCT-C. MPSQ scoring method is direct (including 5, 4, 2 and 8) and reverse (including 1, 3, 6 and 7). Participants who score higher have a higher level of satisfaction with MBCT-C.

MBCT-C Adherence Scale (MBCT-C-AS) is a 20-component scale developed by Semple and Sears [108]. This scale assesses the quality and extent of the therapist’s adherence to the MBCT-C protocol, including training, assignments, participation, activities, coping strategies, homework, etc. The scale is scored on a 3-point scale: 0 (not at all), 1 (slightly- inconsistent), and 2 (clearly- consistent). Higher scores on this scale indicate greater therapist adherence to the MBCT-C protocol. This scale has not yet been officially published.

Ethical Considerations

The methodological framework of this research was designed based on principles and standards determined in the Declaration of Helsinki in 1964 [109] and its subsequent revision in 2008 [110]. All participants will be informed that this study will protect their rights, including the confidentiality of identifiable information. Participation in this study is voluntary and participants have the freedom to withdraw at any stage. Participants will each sign assent forms, and their parents will sign informed consent forms. This study has been registered in the IRCT database and has received the approval of the local ethics committee of Islamic Azad University, North Tehran branch (ethical number: IR.IAU.TNB.REC.1402.040). After the proposal was registered in the Clinical Trials Registration Center of Iran, this study protocol underwent modifications to enhance its comprehensiveness. Specifically, two instruments were incorporated: the MAAS-A and MPSQ.

Moreover, necessary measures have been taken to report protocol changes and monitor and report any unexpected adverse responses. For example, in case of changes in the duration and manner of implementation of the protocol, the changes will be communicated to the study director, the university ethics committee, and the IRCT and subsequently reported there.

Inclusivity in Global Research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 File).

Statistical Strategy

There will be three stages of data analysis: an evaluation of the consistency of the data, descriptive and visual analysis, and inferential analysis. Inclusion or exclusion of outliers will be determined by assessing the means and a 5% trimmed mean. If these values lack statistical significance and exert no impact on the primary findings of the study, the analyses will incorporate the entirety of the data. The utilization of chi-square and independent t-tests will be anticipated for the purpose of analyzing the demographic differences at the initial stage and validating the successful randomization of participants to groups. Should there be missing data, such as when participants missed more than three intervention sessions or dropped out before the follow-up assessment, an intent-to-treat analysis (ITT) will be conducted to assess the potential impact of these missing data on the study findings. Multiple imputation will be used as the primary approach for handling missing values, as it provides a less biased estimation by accounting for the uncertainty around missing data points. Should missing data constitute less than 5% of the overall data, multiple imputation will be applied to maintain the integrity of the analyses.

A mixed regression model will be employed to concurrently assess the fixed and random effects, aiming to measure the differences in the two groups between T1, T2, and T3. Prior to conducting the analyses, the adequacy of the data will be assessed by evaluating its adherence to underlying assumptions, including linearity, normality, homoscedasticity, independence of errors, multicollinearity, and random effects Demographic variables, including age, gender, and baseline internet addiction levels, will be controlled for in the mixed regression model. These variables were selected based on prior research demonstrating their potential influence on mindfulness and psychological outcomes in adolescents [111].All analyses will use a significance level (alpha) of less than.05. Cohen’s d will be used specifically to assess effect sizes for group differences in means, particularly in t-tests and ANOVA comparisons across time points. Effect sizes will be assessed using Cohen’s d, where d approximately equals.20 for a small effect, where it approximately equals 0.50 for a medium effect, and d greater than.80 for a large effect [112]. STATA 18 will be used for statistical analysis. In addition to ITT, a Per-Protocol (PP) analysis will be conducted to examine the treatment effect among participants who fully adhered to the intervention protocol. This approach will provide a more comprehensive understanding of the treatment’s efficacy by assessing outcomes under both ideal and real-world conditions. Finally, LOCF will be applied only as a secondary sensitivity analysis to assess the robustness of the results, ensuring that the primary findings remain consistent under different methods of handling missing data [113].

The findings of this study will be presented using the guidelines outlined in the Consolidated Standards of Reporting Trials (CONSORT) 2010 statements [114] and the Standard Protocol Item: Recommendations for Interventional Trials (SPIRIT) guidelines [115].