CYBERPSYCHOLOGY & BEHAVIOR

Volume 11, Number 5, 2008

© Mary Ann Liebert, Inc.
DOI: 10.1089/cpb.2007.0199

The Association between Internet Addiction

and Problematic Alcohol Use in Adolescents:
The Problem Behavior Model

Chih–Hung Ko, M.D.,1,2 Ju-Yu Yen, M.D.,1,2,3 Cheng–Fang Yen, M.D., Ph.D.,1,4
Cheng–Sheng Chen, M.D.,1,2,4 Chih–Chi Weng, M.Sc.,1 and Cheng–Chung Chen, M.D., Ph.D.1,4,5

Abstract

This study aimed to a) evaluate the association between Internet addiction and problematic alcohol use; b)
based on problem behavior theory, explore whether Internet addiction, as well as problematic alcohol use, cor-
related with the psychosocial proneness of problem behaviors among adolescents. A total of 2,114 high school
students (1,204 male and 910 female) were recruited to complete the questionnaire assessing Internet addiction,
problematic alcohol use, and associated psychosocial variables. The result revealed that Internet addiction was
associated with problematic alcohol use. Besides, the psychosocial proneness of problem behaviors is associ-
ated with Internet addiction as well as problematic alcohol use in adolescents. These results suggest Internet
addiction might be included in the organization of problem behavior theory, and it is suggested that preven-
tion and intervention can best be carried out when grouped with other problem behaviors.

Introduction of adolescents which have the same psychosocial proneness,

T HE INTERNET HAS BECOME AN IMPORTANT INFORMATION and
entertainment source for adolescents.1 However, addic-
tion to the Internet has a negative impact to adolescents,
which includes problems with daily routine, school perfor-
mance, and family relationship.2 This phenomenon has been
described as “Internet addiction” by Young,3 and labeled as
one kind of behavior addiction.4 Previous reports found that
19.8% of adolescents had Internet addiction.5 This demon-
strated Internet addiction was an important issue for ado-
lescent health; however, it has not been completely under-
stood. Holden has mentioned that behavior addiction may
share the same underlying mechanism with substance ad-
diction.4 Thus, to test the similarity between Internet addic-
tion and other substance addiction among adolescents would
benefit the understanding of Internet addiction.
Problematic alcohol use is one kind of substance addiction
which also leads to negative impact for adolescents. It is also
a typical problem behavior as defined by problem-behavior
theory.6 According to this theory, alcohol, smoking, and il-
licit substance use, have been grouped as problem behaviors
including social environment, perceived environment, per-
sonality, and behavior.7 These behavior problems usually co-
exist as a life style and result in negative outcomes. Thus, it
has been suggested that intervention programs directed at
the organization of problem behaviors may be more appro-
priate than those which focus on specific behaviors alone.7
Internet addiction is a newly emerged behavioral problem
of adolescents which was reported after problem behavior
theory was proposed. In our clinical experience, adolescents
with the above problem behavior usually also spent much
time on online behavior at home or at a cyber cafe. Whether
Internet addiction is a new problem behavior defined by
problem behavior theory was an important issue in reveal-
ing the mechanism of Internet addiction and to determine
whether Internet addiction should be grouped with other
problem behaviors for intervention.
If the behavior and substance addiction share the same
mechanism, having an addiction may lower the threshold to
develop another.4 Besides, comorbidity of two disorders may
indicate the causal relationship or common etiology shared
by them.8 Thus, evaluating the comorbidity and comparing

1Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan.

2GraduateInstitute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
3Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan.
4Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
5Kaohsiung Kai-Suan Psychiatric Hospital, Kaohsiung City, Taiwan.

571
572
associated factors between Internet addiction and problem-
atic alcohol use may shed light on the inherent psy-
chopathology of Internet addiction.
According to problem behavior theory,9 personality that
determines risk-taking propensity was a proximal proneness
for problem alcohol use. According to Gray’s Reinforcement
Sensitivity Theory, the behavior inhibition system (BIS) re-
sponds to punishment, and results in behavior withdrawal
and arousal, and the behavior activation system (BAS) re-
sponds to reward and results in behavior approach and
arousal.10 High BAS-sensitive persons are more prone to en-
gage in approach behavior for stimuli with reward,10 such
as alcohol use.11 Besides, lower self esteem, attitudinal tol-
erance of deviance, lower life satisfaction, poor family func-
tion, peer influence, and family history of alcoholism have
been reported to be associated with problem alcohol use of
adolescents based on problem behavior theory.7,9,12 Thus,
whether these proved associated factors of alcohol use also
correlate with Internet addiction should be evaluated, to test
our hypothesis.
The association between psychosocial proneness and In-
ternet addiction has been reported in previous reports.
Lower self-esteem and life satisfaction was reported to be as-
sociated with Internet addiction among adolescents.13 How-
ever; it was not compared directly to alcohol use in the same
data. The tridimensional personality of Internet addiction
has been directly compared with adolescents with substance
exposure. It demonstrated that high novelty-seeking and
lower reward dependence were shared personality traits of
Internet addiction and substance exposure.14 However, sub-
stance exposure was assessed by dichotomous questions but
not a developed scale.
Thus, this study aimed to: a) evaluate the association be-
tween Internet addiction and problematic alcohol use; b)
based on problem behavior theory, explore whether Internet
addiction correlates with the psychosocial proneness of
problem behaviors as well as problematic alcohol use among
adolescents.
Material and Method
Three senior high schools and seven vocational high
schools in southern Taiwan were randomly selected in this
study. Two classes were randomly selected from each grade.
In the selected classes, an informed consent form was pro-
vided to each student. Then, participants who signed the
form were invited to complete the questionnaires anony-
mously. A total of 2,114 students (1,204 male and 910 female)
were recruited, and their mean age was 16.26 years (SD 
0.99, range 15 to 23 years). Additionally, this study had been
approved by the Institutional Review Board (IRB) of Kaoh-
siung Medical University Hospital.
Measurement
Chen Internet Addiction Scale (CIAS). The CIAS consists
of 26 items, scored on a four-point Likert scale and ranged
from 26 to 104. Higher CIAS scores indicated increased
severity of Internet addiction. The internal reliability of the
instrument and its sub-scales ranged from 0.79 to 0.93.15 Ac-
cording to the diagnostic criteria of Internet addiction,16 the
63/64 cut off point of CIAS has highest diagnostic accuracy
(87.6%), accepted sensitivity (67.8%), and specificity (92.6%).5
KO ET AL.
Accordingly, those with CIAS scores of 64 or more were clas-
sified as the “Internet addiction” group.
The CRAFFT substance abuse screening test (CRAFFT).
This self-reported dichotomy questionnaire was developed
to assess the problematic substance and drug use in adoles-
cents.17 Previous reports had modified the items to query al-
cohol only, rather than “alcohol or drug use” as in the orig-
inal measure, and had demonstrated that a cutoff score of 2
of CRAFFT could identify adolescents with a Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (DSM-IV)
alcohol use disorder or a problematic alcohol use.18 In this
study, we modified the CRAFFT as per the previous report,
and classified the adolescents with a score of CRAFFT 2
and self-reported current regular alcohol use as the “prob-
lematic alcohol use” group.
Behavior inhibition system and behavior approach system
scale (BIS/BAS scale). The BIS/BAS scales were designed to
assess individual differences in the sensitivity of the two mo-
tivational systems proposed by Gray.19 The BIS Scale mea-
sures the degree to which respondents expect to feel anxiety
when confronted with cues for punishment. The BAS Scale in-
cluded subscales of reward responsiveness, drive, and fun
seeking. The Cronbach’s alphas of the four subscales were
0.66–0.76.10 The scale was utilized to assess the personality
which determines risk-taking propensity in this study.
Questionnaire for attitude toward alcohol. A total of thir-
teen 5-point items in the scale were selected from undupli-
cated scale of Yang and Huang. Only item 2 describes the
negative effect of alcohol: wasting money. The other items
described positive effects of alcohol which were important
for social activities, boosting one’s bravery, more accepted
by others, benefit of social activities, cool, and mature. Items
8, 9, and 12 described father, mother, and best friend’s atti-
tude to participant’s alcohol use. Items 10, 11, and 13 de-
scribed that participant’s attitude toward father, mother, and
best friend’s alcohol use. Higher scores indicate that the sub-
jects had an attitude of rejecting alcohol. The score had been
reported to be negatively associated with substance use dis-
order among adolescents.20 Cronbach’s alpha in the pre-
senting study was 0.90.
Self-esteem, perceived family function, and life satisfac-
tion were assessed by Rosenberg Self-Esteem Scale (RSES),21
Family APARG Index (APGAR), 22 and Brief Multidimen-
sional Students’ Life Satisfaction Scale (BMSLSS),23 respec-
tively. Higher scores in the three measures indicated higher
levels of self-esteem, better family function, and greater sat-
isfaction with life. Besides, peer factors, including friends
with alcohol use, or deviant behavior, family relationship,
including parent–adolescent conflict and intra- parental con-
flict, and family regular alcohol use were also questioned.
Statistical analysis
Participants completing the CIAS and CRAFFT were en-
rolled in the final analysis. The participants were classified
as Internet addiction or problematic alcohol use groups ac-
cording to the CIAS and CRAFFT scores, respectively. The
associations between Internet addiction and problematic al-
cohol use were analyzed by Chi-square analysis. Then the
INTERNET ADDICTION AND PROBLEMATIC ALCOHOL USE 573

association between family regular alcohol use, family rela-
tionship, peer factors, and Internet addiction, as well as prob-
lematic alcohol use was evaluated by Chi-square analysis.
Also, the association between personality, family function,
self-esteem, life satisfaction, and attitude toward alcohol and
Internet addiction, as well as problematic alcohol use were
evaluated by t-test. All statistical analyses were performed
using the SPSS computer package program. A p-value less
than 0.05 was considered significant.
Results
The data of 1,998 (94.5%) participants (1,134 boys and 864
girls) were entered into the final statistical analysis. There
was no difference in gender between adolescents enrolled
and excluded (X2  0.57, p  0.45). The mean age was
16.26  0.99 (range: 15–23 years). There were 784 (39.2%), 636
(31.8%), and 578 (28.9%) students from grades 10, 11, and 12,
respectively. Within them, 366 (18.3%) and 270 (13.5%) were
classified as Internet addiction and problematic alcohol use
groups, respectively.
In Table 1, chi-square analysis revealed that Internet ad-
diction was associated with problematic alcohol use. Besides,
both adolescents with Internet addiction (Table 1) and prob-
lematic alcohol use (Table 2) were more likely to be male,
and have higher levels of parent–adolescent conflicts, more
intra-parental conflicts, more friends with deviant behaviors,
more friends using alcohol, and more family regular alcohol
use.
Table 3 reveals that adolescents with either Internet ad-
diction or problematic alcohol use had higher scores on the
BAS drive and BAS fun seeking, and lower scores on RESE,
APGAR, BMSLSS, and questionnaire for attitude toward al-
cohol. Only adolescents with problematic alcohol use had
lower scores on the BIS scale.
Discussion
Internet addiction has been reported to be associated with
substance exposure among adolescents.14 The presenting in-
vestigation among high school students revealed that Inter-
net addiction is associated with problematic alcohol use.
In this presenting study, possessing the following psy-
chosocial factors: being male, having friends with deviant
behavior or alcohol use, having high parental–adolescent or
intra-parental conflict, having family regular alcohol use or
lower family function, having lower self-esteem or lower life
satisfaction, and positive attitude toward alcohol were all as-
sociated with problematic alcohol use. This result corre-
sponded to problem behavior theory. In addition, these psy-
chosocial factors which were defined in problem behavior
theory were also associated with Internet addiction. These
results suggest Internet addiction shares the same psy-
chosocial proneness with problematic alcohol use.
Based on problem behavior theory, the problem behaviors
were inter-related. These behaviors reflect an adolescent’s
way of being in the world. The psychosocial proneness in-
cluding social environment, perceived environment, per-
sonality system, and behaviors could develop the psychoso-
cial framework to develop problem behavior. In this study,
a) personality system: including personality, lower self-es-
teem, and attitude toward alcohol, b) perceived environ-
ment: including family support, intra-family conflict, and life
satisfaction; c) social environment: including family regular
alcohol use, friend alcohol use, and friend deviant behaviors
were proved again to be associated with adolescent prob-

TABLE 1. THE ASSOCIATION BETWEEN INTERNET ADDICTION AND CATEGORY PSYCHOSOCIAL FACTORS

Internet addiction

Yes No
Variables (Mission value) Number (%) Number 2

Gender (0)
Male 261 (23.0) 873 38.68***
Female 105 (12.2) 759
Family regular alcohol use (29)
Yes 95 (23.7) 306 10.49**
No 262 (16.7) 1306
Parental-adolescent conflict (14)
Usual 69 (32.4) 144 31.73***
Unusual 294 (16.6) 1477
Inter-parental conflict (16)
Usual 51 (27.4) 135 11.37**
Unusual 312 (17.4) 1484
Friends alcohol use (1)
Yes 231 (23.7) 745 37.14***
No 134 (13.1) 887
Friends with deviant behavior (1)
Yes 187 (24.9) 564 34.74***
No 179 (14.4) 1067
Problematic alcohol use
Yes 92 (34.1) 178 51.80***
No 274 (15.9) 1454

**p  0.01; ***p  0.001.

574 KO ET AL.

TABLE 2. THE ASSOCIATION BETWEEN PROBLEMATIC ALCOHOL USE AND

INTERNET BEHAVIOR AND CATEGORY PSYCHOSOCIAL FACTORS

Problematic alcohol use

Yes No
Variables (Mission value) Number (%) Number 2

Gender (0)
Male 180 (15.9) 954 12.49***
Female 90 (10.4) 774
Family regular alcohol use (29)
Yes 104 (25.9) 297 67.30***
No 161 (10.3) 1407
Parental-adolescent conflict (14)
Usual 54 (25.4) 159 28.99***
Unusual 213 (12.0) 1558
Inter-parental conflict (16)
Usual 35 (18.8) 151 5.03*
Unusual 232 (12.9) 1564
Friends alcohol use (1)
Yes 238 (24.4) 738 192.73***
No 32 (3.1) 989
Friends with deviant behavior (1)
Yes 184 (24.5) 567 124.12***
No 86 (6.9) 1160

*p  0.05; ***p  0.001.

lematic alcohol use. It demonstrated that adolescents with
problem behavior had lower resources and perceived lim-
ited life chances. Thus, problematic alcohol use may serve as
a coping mechanism for dealing with stress, frustration, in-
adequacy, and failure—or the anticipation of failure. It also
functions to express solidarity with peers to demonstrate
identification with the youth culture.11
Our results also demonstrate the psychosocial proneness
was also associated with Internet addiction and it was asso-
ciated with problematic alcohol use. Since Internet is cheap
in Taiwan, it could provide adolescents with a value-poor
resource to get information and friendship with others. Sev-
eral characteristics of Internet use could explain its function
on adolescents with problem behaviors. First, the anonymity
and fluidity of identity of the Internet 24 relieves adolescents
of their original identity with anticipation of limited future.
Second, the pleasure of control online could help cope with
the helplessness in real life. Third, role playing games online
could provide a chance to get success and increase one’s level
in the virtual world with clear rules. Virtual success may be
utilized to cope with lower self-esteem and poor life satis-
faction in the real world. Fourth, the design of online gam-
ing and chat rooms make it easy to get friends online. The
support from the Internet could provide compensation for
their real-life poor support resources. Fifth, the Internet pro-
vides an environment free from traditional culture. In it, their

TABLE 3. THE ASSOCIATION BETWEEN CONTINUOUS VARIABLES AND INTERNET ADDICTION AND PROBLEMATIC ALCOHOL USE

Internet addiction Problematic alcohol use

Yes No Yes No
(N  366) (N  1632) (N  270) (N  1728)
Mean  SD Mean  SD T Mean  SD Mean  SD T

Age 16.40  0.97 16.23  1.00 2.91** 16.44  1.12 16.23  0.97 2.92**
BIS 20.89  2.89 20.71  2.88 1.09 20.13  2.93 20.84  2.87 3.75***
BAS reward 17.03  2.53 16.89  2.35 0.96 16.80  2.62 16.94  2.35 0.90
BAS drive 12.30  2.38 11.92  2.19 2.84** 12.30  2.42 11.94  2.20 2.35*
BAS fun seeking 11.90  2.26 10.73  2.24 9.02*** 11.93  2.32 10.79  2.24 7.71***
APGAR 12.15  3.39 13.46  3.51 6.43*** 12.12  3.70 13.39  3.47 5.51***
Negative attitude 48.91  10.95 51.99  10.89 3.32** 44.09  9.34 53.20  10.58 10.48***
toward alcohol
BMSLSS 26.28  6.95 28.77  6.10 6.84*** 26.45  6.95 28.61  6.18 5.20***
RSES 25.51  5.63 27.71  4.93 6.94*** 26.30  5.05 27.49  5.13 3.53***

APGAR, Family APARG Index; BMSLSS, Brief Multidimensional Students’ Life Satisfaction Scale; RSES, Rosenberg Self-Esteem Scale.
*p  0.05; **p  0.01; ***p  0.001.
INTERNET ADDICTION AND PROBLEMATIC ALCOHOL USE
problem behaviors may be recognized, rationalized, and mu-
tually encouraged by others. Last, the lack of monitoring in
the Internet provides them with a subjective sense of auton-
omy and maturity.
These functions were similar to the function of problem-
atic alcohol use described in problem behavior theory. Thus,
our result may suggest the framework explaining behavior
problems could also be applied to Internet addiction in ado-
lescents. This result also supports the hypothesis that Inter-
net addiction could be included in organization of problem
behaviors. Thus, adolescents with problematic alcohol use or
Internet addiction should be evaluated for comorbidity of
each other. Besides, Internet addiction should be prevented
and intervened with and grouped with other problem be-
haviors based on problem behavior theory.
Comorbidity of two disorders may indicate the causal re-
lationship or common etiology shared by them.8 Personality
had been believed to be predisposing factor for substance
dependence. The study demonstrated that BAS drive and
BAS fun seeking were shared associated factors of Internet
addiction and problematic alcohol use. BAS fun seeking, sim-
ilar to sensation seeking, demonstrated the approach be-
havior to rewarded cues with high sensitivity.10 It has been
reported to predict substance use and alcohol misuse.25 Since
Internet activities, especially online gaming, provide a highly
varied virtual environment satisfying sensation seeking
needs, adolescents with high sensation seeking who seek out
and impulsively engage in online behavior would be at risk
of having Internet addiction. Besides, the BAS score, espe-
cially for drive and fun seeking, has been reported to be as-
sociated with dopamine function.26 The shared personality
between Internet addiction and problematic alcohol use in
adolescents may reflect the shared predisposed underlying
dopamine dysfunction, the common underlying mechanism
for substance abuse and addiction.27 However, only the ado-
lescents with problematic alcohol use had lower behavior in-
hibition. Since alcohol was perceived as more hazard be-
havior than Internet use, the adolescents who worry about
the punishment of behavior were less likely to choice the al-
cohol use to satisfy their need of fun seeking. On other hand,
the Internet use was a more accepted behavior, the result
might suggest the worry about punishment of behavior did
not prevent the Internet use among adolescents.
This study has several limitations that should be considered
when interpreting its findings. First, a higher proportion of vo-
cational high school students are included than in the general
population. Second, all our investigations relied on self-re-
ported data from adolescents. Third, social restrictions on al-
cohol use may predispose adolescents from admitting alcohol
use, even in anonymous questionnaires. Fourth, the cross-sec-
tional research design of the present study could not confirm
causal relationships between the associated factors and Inter-
net addiction and problematic alcohol use.
In conclusion, this presenting study demonstrated that the
psychosocial proneness of problems behaviors, including a)
personality system: including personality, lower self-esteem,
and attitude toward alcohol, b) perceived environment: fam-
ily support, intra-family conflict, and life satisfaction; c) so-
cial environment: family regular alcohol use, friend alcohol
use, and friend deviant behaviors are associated with Inter-
net addiction as well as problematic alcohol use in adoles-
cents. It may suggest that Internet addiction could be in-
575
cluded in organization of problem behavior theory. Thus, In-
ternet addiction should be intervened and prevented when
grouped with other problem behaviors.
Acknowledgments
This study was supported by a grant from Department of
Health, Executive Yuan, ROC (DOH95-TD-M-113-039).
Disclosure Statement
The authors have no conflict of interest.
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Address reprint requests to:
Dr. Cheng–Chung Chen
Department of Psychiatry
Kaohsiung Medical University Hospital
100 Tzyou 1st Road
Kaohsiung City
Taiwan 807
E-mail: ccchen@mail.khja.org.tw