Abstract
Background:
Internet addiction (IA) and gaming disorder (IGD) are emerging public health concerns among youth. Sluggish cognitive tempo (SCT)/cognitive disengagement syndrome has been linked with risky online behaviors, but the literature on medical students is limited.
Aim:
To determine associations between SCT, IA, and IGD in Indian medical undergraduates.
Materials and Methods:
The study included 303 medical students (ages: 18–24, 66% male). The Sociodemographic Information Form, Barkley SCT Scale, Young Internet Addiction Test-Short Form, and The Digital Game Addiction Scale were utilized to collect data. Contingency Table analyses, Mann–Whitey U-test, Chi-square test, and correlation analyses were used for analysis.
Results:
The prevalence of IA and IGD was 101 (33.3%) and 61 (20%), respectively. Students with IA or IGD had significantly higher SCT, daydreaming, and sluggishness scores (P < 0.01). SCT, daydreaming, and sluggishness showed significant positive correlations with IA and IGD severity (P < 0.01).
Conclusion:
Greater SCT symptoms demonstrated significant associations with increased risk of IA and IGD among medical students. Screening for SCT alongside IA and IGD may enable targeted interventions to promote healthy Internet use.
Keywords: Internet addiction, internet gaming disorder, medical student, sluggish cognitive tempo
The Internet has become deeply embedded in modern society, providing unlimited access to information, communication, entertainment, and more. However, unrestrained use can give rise to problematic behaviors like Internet addiction (IA) and Internet gaming disorder (IGD).[1] IA is characterized by dysregulated use of the Internet, leading to impairment in daily functioning.[2] IGD or gaming addiction specifically involves an obsessive, dysfunctional pre-occupation with online games that interferes with other life activities.[3] These behavioral addictions are an emerging public health concern, especially among adolescents and young adults who are “digital natives”.
Multiple studies worldwide have reported high rates of IA ranging from 1% to 36% among youth.[4,5] In India, the prevalence has been estimated to be 18% to 35% among college students.[6] Risk factors identified for IA include underlying mental health conditions like depression, attention-deficit/hyperactivity disorder (ADHD), and addictive personalities.[7] IGD prevalence has been reported between 2% and 10% among adolescents globally.[8] Psycho-social factors like loneliness, shyness, stress, and low self-esteem have been linked to IGD vulnerability.[9] However, there remain research gaps on pathological Internet and gaming use among medical students. Key reasons why medical students were chosen as the study population for examining associations between sluggish cognitive tempo (SCT), Internet addiction (IA), and Internet gaming disorder (IGD): High prevalence of Internet/technology use: Medical students have extensive access to the Internet and online resources as part of their education and training. This puts them at potentially higher risk for problematic Internet behaviors like IA and IGD if not used judiciously. Academic pressures: The intense academic pressures and curriculum demands on medical students can make them vulnerable to using the Internet as an unhealthy coping mechanism or escape, especially for those with underlying conditions like SCT. Limited literature: Most research on SCT, IA, and IGD has focused on children, adolescents, or the general population. There are limited data specific to medical students despite their academic importance, representing a unique demographic: Medical students represent a relatively homogeneous demographic group in terms of age, education, lifestyle, and stress. This reduces potential confounding factors when examining associations between SCT, IA, and IGD.
SCT/cognitive disengagement syndrome is a cluster of symptoms involving excessive daydreaming, mental confusion, apathy, and drowsiness manifesting since childhood. It has conceptual overlaps with ADHD inattention but appears to be a distinct clinical construct.[10] Preliminary studies have indicated positive associations of SCT symptoms with IA and IGD.[11,12] Under-stimulated SCT profiles may lead to the overuse of reward-based Internet activities like gaming for stimulation.[12] However, literature elucidating SCT-IGD relationships is limited, especially within non-Western contexts.
With expanding Internet penetration, technological addictions pose a growing threat to the productivity, learning, development, and well-being of medical students. SCT is also common in this group. Hence, the present study aimed to determine the associations between SCT, IA, and IGD among medical undergraduates in an Indian setting. Elucidating connections between SCT and risky online behaviors can enable targeted interventions to promote healthy Internet use among students.
MATERIALS AND METHODS
Study design and setting
This was a questionnaire-based cross-sectional study conducted at a medical college in Gujarat between January 2023 and June 2023.
Participants
Participants were undergraduate medical students aged 18–24 years. Students with a prior history of psychiatric illness were excluded.
Sample size and sampling
The sample size was calculated as 264 based on an expected IA prevalence of 18%[13] and a precision of 5%. Accounting for non-response, 303 students were recruited by simple random sampling from the college roster.
Study instruments
The data collection for this study was meticulously conducted through a comprehensive set of tools, encompassing a socio-demographic questionnaire and three well-established scales. The Barkley Sluggish Cognitive Tempo Scale[10] was utilized to gauge SCT, providing a validated and standardized measure for this dimension. The Young’s Internet Addiction Test Short Form[2] served as a validated instrument to assess IA, while the Digital Game Addiction Scale[3] was employed to measure IGD. All three scales are recognized in the field and have undergone validation processes, ensuring the reliability of the data collected.[2,3,10]
Data collection
The self-administered questionnaires were distributed to consenting participants. Respondents completed the survey anonymously during free time in the classroom. The purpose and protocol were explained, and investigators were present to clarify any doubts.
Statistical analysis
Data were analyzed using SPSS v22.0. Descriptive statistics were calculated. Bivariate comparisons between high- and low-risk IA/IGD groups were performed using Chi-square tests for proportion and Mann–Whitney U-test for mean. Correlation analysis was conducted to determine SCT-IA/IGD relationships. P < 0.05 was considered statistically significant.
Ethical considerations
Institutional ethics committee approval and informed consent from all participants were obtained. Anonymity and confidentiality were ensured. Students could voluntarily withdraw from the study at any time (REF No. 110/02/2023). Students who were screened positive for addictive online behaviors were referred for appropriate counseling and treatment, especially given their academic pressures.
RESULTS
The study examines the associations between SCT, IA, and IGD among medical students:
Table 1 shows the socio-demographic characteristics of the 303 medical students included in the study. The mean age was 20 years. 67% were males, and 33% were females. 33.3% were from each of the first, second, and third years of study. 40.5% were at risk for SCT. 33.3% had IA, and 20% had IGD.
Table 1.
Socio-demographic characteristics of the participants, n=303
| Variables | Frequency | Percentage |
|---|---|---|
| Age | ||
| <20 | 207 | 68 |
| ≥20 | 96 | 32 |
| Gender | ||
| Males | 202 | 67 |
| Females | 101 | 33 |
| Year of studying | ||
| 1st year | 101 | 33.3 |
| 2nd year | 101 | 33.3 |
| 3rd year | 101 | 33.3 |
| ↑ risk of SCT | 123 | 40.5 |
| IA present | 101 | 33.3 |
| IGD present | 61 | 20 |
Table 2 shows the association between IA and other factors. Students with IA had significantly higher overall SCT scores (P < 0.001), daydreaming scores (P < 0.001), and sluggishness scores (P < 0.001) compared to students without IA. No significant association was seen between IA and gender or age.
Table 2.
Association between IA and other factors in the study participants
| Variables | IA present | IA not present | P |
|---|---|---|---|
| Overall SCT scores | 6.49±4.93 | 4.37±4.49 | <0.001** |
| Daydreaming | 9.76±6.64 | 6.64±6.0 | <0.001** |
| Sluggish | 5.71±3.78 | 3.78±3 | <0.001** |
| Gender | |||
| Male | 70 | 132 | Chi-square-0.475, P=0.491 |
| Female | 31 | 70 | |
| Age | |||
| <20 | 63 | 144 | Chi-square -2.47 P=-0.116 |
| <20 | 38 | 58 | |
P<0.05*, significant; P<0.001**, highly significant
Table 3 shows the association between IGD and other factors. Students with IGD had significantly higher SCT scores (P = 0.004), daydreaming scores (P < 0.001), sluggishness scores (P = 0.004), and IA scores (P = 0.022) compared to students without IGD. No significant association was seen between IGD and gender or age.
Table 3.
Association between IGD and other factors in the study participants
| Variables | IGD present | IGD not present | P |
|---|---|---|---|
| Overall SCT scores | 6.59±5.01 | 4.69±4.60 | 0.004* |
| Daydreaming | 15.9±10 | 8.50±9 | <0.001** |
| Sluggish | 9.11±4 | 7.38±3.63 | 0.004* |
| IA scores | 5.21±3.29 | 4.22±3.09 | 0.022* |
| Gender | |||
| Male | 41 | 161 | Chi-square -0.010, P=0.919 |
| Female | 20 | 81 | |
| Age | |||
| <20 | 40 | 167 | Chi-square -2.66, P=-0.606 |
| ≥20 | 21 | 75 | |
P<0.05*, significant; P<0.001**, highly significant
The correlation heat map visually depicts the correlations between IGD, IA, SCT, daydreaming, and sluggishness. Stronger correlations are shown in darker colors [Figure 1].
Figure 1.
Shows the Correlation hHeatmap
The correlation matrix quantifies that IGD had significant positive correlations with IA, SCT, daydreaming, and sluggishness (P < 0.01 or P < 0.001). IA also had significant positive correlations with SCT, daydreaming, and sluggishness (P < 0.001). SCT, daydreaming, and sluggishness were positively correlated with each other (P < 0.001) [Table 4].
Table 4.
Correlation matrix between IGD, IA, and SCT
| IGD | IA | SCT | Daydreaming | Sluggishness | |||||
|---|---|---|---|---|---|---|---|---|---|
| IGD | Pearson’s r | — | |||||||
| df | — | ||||||||
| P | — | ||||||||
| IA | Pearson’s r | 0.510 | *** | — | |||||
| df | 301 | — | |||||||
| P | <0.001 | — | |||||||
| SCT | Pearson’s r | 0.178 | ** | 0.274 | *** | — | |||
| df | 301 | 301 | — | ||||||
| P | 0.002 | <0.001 | — | ||||||
| Daydreaming | Pearson’s r | 0.194 | ** | 0.318 | *** | 0.298 | *** | — | |
| df | 260 | 260 | 260 | — | |||||
| P | 0.002 | <0.001 | <0.001 | — | |||||
| Sluggishness | Pearson’s r | 0.240 | *** | 0.329 | *** | 0.306 | *** | 0.644 | *** |
| df | 301 | 301 | 301 | 260 | |||||
| P | <0.001 | <0.001 | <0.001 | <0.001 | |||||
Note. *P<0.05, **P<0.01, ***P<0.001
In summary, the study found that SCT symptoms, daydreaming, and sluggishness were positively associated with increased risk of Internet addiction and gaming disorder among medical students.
DISCUSSION
This study aimed to assess the associations between SCT, IA, and IGD among 303 medical students. Our findings align with prior research indicating significant relationships between SCT symptoms and risky Internet use behaviors.
In the current study, 33% of students were classified as having IA and 20% had IGD based on validated scale cut-offs. These prevalence rates are comparable to estimates among medical students in prior Asian studies which have reported IA rates between 11 and 36%.[14,15] Students with IA or IGD demonstrated significantly higher scores for overall SCT severity, daydreaming, and sluggishness in bivariate analysis. This builds on cross-sectional studies which showed positive associations between SCT symptoms and IA risk.[11,16]
The present study correlation analysis provides further evidence for inter-relationships between SCT, IA, and IGD. Significant moderate positive correlations were seen between daydreaming and sluggishness with IA severity. Similarly, an earlier study also found sluggishness to have the strongest correlation with IA out of SCT symptom domains.[11] It has been proposed that those with elevated SCT may use the Internet excessively to escape boredom or stimulate underactive minds.[11,16]
Interestingly, no significant gender or age differences were found between high- and low-risk IA/IGD groups unlike some past research. This suggests SCT may be a more salient risk factor during IA/IGD screening. Overall, our study provides novel data supporting SCT-IA/IGD associations within an Indian medical education context. Evaluating SCT alongside investigating IA/IGD in students could aid in early identification and management.[17]
Limitations
Several limitations are acknowledged. The cross-sectional design impedes the establishment of causal relationships between SCT, IA, and IGD. Reliance on self-reported data introduces the potential for recall bias, and the single-center nature of the study may restrict the generalizability of findings. Notably, the study did not evaluate co-morbid mental health conditions like depression, which are known to be linked to IA/IGD risk. Moreover, the omission of an assessment of suicidal ideation among students with addictive online behaviors is a notable gap, and also, the lack of intervention is a major limitation of the study. We recommended that future studies in this area ensure proper referrals and access to support services for students with concerning test scores, and also, longitudinal studies are recommended to establish temporal sequencing between SCT, IA, and IGD. Future research should also incorporate assessments of co-morbid mental health conditions, including depression and suicidal ideation. Additionally, the role of psycho-social factors, such as stress, should be studied in conjunction with SCT-IA/IGD links. Implementing interventions targeting SCT is proposed as a proactive measure to reduce addictive online behaviors among the studied population.
CONCLUSION
This study found significant positive associations between SCT symptoms, specifically daydreaming and sluggishness, with increased risk of IA and IGD among medical students. No significant demographic correlations were observed. Routine screening for SCT alongside IA and IGD could enable early identification and management in this high-risk population. Longitudinal research is needed to elucidate causal pathways between SCT, IA, and IGD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We acknowledge and are grateful to all the patients who contributed to the collection of data for this study. We are also thankful to Dr. Nandini Desai (Dean and Chairman of MDRU and Dr. Dipesh V Parmar (Professor and Head, Department of Community Medicine) of our institute – Shri M P Shah Government Medical College, Jamnagar, India.
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