Longitudinal relationship from school burnout to short video addiction in adolescents: the mediating role of psychological distress

Abstract

Background

This study investigated the longitudinal relationship from school burnout to short video addiction among middle school students, considering the potential mediating role of psychological distress.

Methods

Utilizing a two-wave longitudinal survey with a 12-month interval, the research involved 398 middle school students from three schools in Wuhan, China. Participants completed the School Burnout Inventory, the Depression, Anxiety, and Stress Scales-21 (DASS-21), and the Short Video Overuse Behavior Scale.

Results

Cross-lagged panel analysis revealed that school burnout at T1 significantly predicted short video addiction at T2, while the reverse path was non-significant. Furthermore, psychological distress significantly mediated the path from school burnout to short video addiction, though not vice versa.

Conclusions

School burnout serves as a longitudinal antecedent of short video addiction in adolescents. Psychological distress mediates the effect of school burnout on short video addiction, but no significant reverse effect was found. These findings enhance the current understanding of how academic disengagement relates to problematic short video use and provide practical insights for the prevention and intervention of short video addiction among middle school students.

Introduction

According to The 55th Statistical Report on China’s Internet Development, as of December 2024, the number of online video users in China reached 1.07 billion, with short-video users comprising 1.04 billion, or 93.8% of all internet users. In recent years, both the scale and penetration rate of short-video usage have consistently risen. From December 2018 to December 2023, the number of short-video users increased from 648 million to 1.053 billion, with the usage rate climbing from 78.2% to 96.4%, both hitting historic highs. Adolescents have emerged as the largest user demographic, with 54.1% of adolescent internet users regularly watching short videos. This trend has made short videos a fundamental part of their digital experiences, significantly influencing their cognitive, emotional, personality, and behavioral development. For adolescents, utilizing short-video platforms for information gathering, social interaction, and entertainment has become routine. The integration of audio and visual elements, combined with the diverse and easily accessible content, makes short videos more effective than traditional social media in capturing adolescents’ attention and eliciting stronger emotional responses [1].

The increasing prevalence of short-video usage has led to growing concern regarding short video addiction among adolescents [2]. Prior research has introduced the broader concept of “internet addiction” [3] and highlighted the necessity of distinguishing its various subtypes, including mobile phone addiction, social media addiction, and online gaming addiction [4]. Nevertheless, much of the existing literature has concentrated on the broader category of “social media addiction” rather than specifically addressing “short video addiction” [5]. As a significant form of problematic internet use, short video addiction is encompassed within the larger framework of internet addiction [6]. It is characterized by the uncontrolled and excessive use of short-video applications, which leads to behavioral dysregulation and attentional impairments, adversely affecting interpersonal relationships, learning, and occupational adaptation [7]. Research has demonstrated that short video addiction negatively impacts adolescents’ physical and mental health [8, 9], resulting in cognitive decline, emotional disturbances, and functional impairments [6, 9–11].

Despite the growing interest in short video addiction in recent years, the underlying psychological mechanisms remain largely unexplored [12, 13]. Current research on problematic short video use tends to follow two distinct trends [14]. One trend focuses on the antecedents and influencing factors of short video addiction, extending the Interaction of Person–Affect–Cognition–Execution (I-PACE) model [15] to this area [13, 16]. This line of inquiry examines how individual characteristics such as personality traits and motivations, along with affective and cognitive responses and executive functions, interact to contribute to the development of addiction. The other trend emphasizes the consequences of short video addiction, investigating its psychological and behavioral outcomes, including general mental health issues, feelings of regret, fatigue, and fear of missing out [17–19]. One possible reason for these different results is that most existing studies have utilized cross-sectional designs, which do not allow for the determination of the directionality of the associations between short video addiction and other variables. As a result, it remains unclear whether mental health problems are a consequence or a precursor of short video addiction. Furthermore, while researchers generally acknowledge the adverse effects of short video addiction on both physical and psychological health, there is a notable lack of research examining its impact on adolescents’ academic development [1].

In this context, the present study employed a two-wave longitudinal survey to explore the longitudinal relationship from school burnout(a key indicator of academic development) to short video addiction among adolescents, as well as the potential mediating role of psychological distress, commonly defined as encompassing depression, anxiety, and stress.

Longitudinal relationship between school burnout and short video addiction in adolescents

School burnout refers to a psychological maladjustment among students brought on by high academic demands. It is characterized by emotional exhaustion, feelings of low academic efficacy, teacher-student alienation, and physical fatigue [20]. This phenomenon can significantly impair adolescents’ academic performance and achievements, and may even lead to health issues or school dropout [21, 22]. Research indicates that approximately 54.9% of Chinese secondary school students report experiencing school burnout [23] and that it positively predicts internet addiction among adolescents [24].

According to the compensatory internet use theory, individuals may turn to the internet to fulfill unmet needs or cope with negative experiences and mental health challenges [25]. In line with this, escapism theory suggests that a primary motivation for excessive internet use is the desire to avoid confronting reality [26]. Given that school burnout is associated with negative emotions (such as depression and anxiety) and cognitions (like low self-efficacy) [17, 27] that obstruct the fulfillment of basic psychological needs, adolescents may excessively engage with short videos as a means of escaping academic stress and compensating for unmet needs in their daily lives [28]. This implies that school burnout may serve as a positive predictor of short video addiction.

Conversely, addiction to short videos may negatively impact adolescents’ psychological functioning, potentially contributing to the onset of school burnout. The job demands–resources model [29] posits that burnout occurs when demands surpass available resources. Adolescents who are addicted to short videos may allocate significant cognitive resources to excessive viewing, which can deplete their attention for demanding academic tasks, ultimately resulting in fatigue and distraction [30]. Compared to academic work, short videos provide more engaging content and immediate positive reinforcement. As adolescents become more drawn to short videos, they may discover academic tasks increasingly difficult, which could lead to burnout. From a self-control perspective, adolescents often confront a dilemma between long-term objectives (e.g., academic success) and short-term rewards (e.g., short videos); achieving long-term goals necessitates self-control [14]. However, loss of control is a defining characteristic of addiction [31]. Consequently, short video addiction may result in a breakdown of self-control, leading to negative consequences such as school burnout and possibly exacerbating the addictive behavior, thereby creating a vicious cycle [25, 32, 33]. Thus, a longitudinal relationship between short video addiction and school burnout is plausible, although it warrants further investigation.

Mediating role of psychological distress

Psychological distress serves as a broad, dimensional indicator of mental health, typically describing the negative emotions and subjective discomfort that individuals experience over a specific period [34, 35]. In this study, psychological distress is defined as a composite negative emotional state that includes depression, anxiety, and stress [36]. While depression and anxiety possess distinct symptom profiles, they also share overlapping features: depression is marked by anhedonia and negative affect, whereas anxiety is characterized by physiological hyperarousal; both conditions involve pervasive feelings of suppression [37]. Stress is commonly viewed as a state of tension and strain arising from external demands and internal imbalances, and it is often considered a contributing factor to anxiety, depression, and other negative emotional states [38]. Collectively, these three dimensions offer a comprehensive understanding of the negative experiences and outcomes that adolescents may encounter.

Burnout experienced during the learning process can significantly impact adolescents’ personal lives, potentially leading to depressive symptoms [39–41]. Students suffering from burnout may display negative emotional traits such as aversion and depression, alongside behavioral patterns like a lack of initiative, and cognitive characteristics that include low self-efficacy and low self-esteem [17]. To cope with the stress associated with burnout, adolescents may resort to maladaptive behaviors, with the consumption of short videos emerging as a common strategy for temporarily escaping stress and negative situations. However, an overreliance on this coping mechanism heightens the risk of developing addiction [42]. Consequently, psychological distress may serve as a mediator in the relationship between school burnout and short video addiction.

Adolescents who are addicted to short videos may experience increased psychological distress. Research has consistently demonstrated the predictive relationship between general internet addiction or specific forms, such as social media addiction, and psychological distress [43–48]. Recent studies indicate that short video addiction and depression exhibit overlapping core symptoms and exhibit comorbidity within symptom networks [33]. This form of addiction may lead to dysfunctional outcomes, thereby contributing to psychological distress [49]. Furthermore, symptoms associated with psychological distress, such as anxiety and depression, are significant risk factors for school burnout [46, 50]. When confronted with psychological distress, adolescents might dedicate their limited resources to emotion regulation, which can leave them with fewer resources for academically demanding tasks [51]. The disparity between academic demands and inadequate academic resources heightens the risk of burnout [22]. While the pathway from short video addiction to school burnout via psychological distress is theoretically plausible (e.g., displacement hypothesis, emotion regulation failure), the empirical evidence for this temporal ordering is less consistent than that for the burnout-to-addiction pathway. Therefore, we treat the reverse mediation as exploratory.

While previous studies have partially explored the connection between problematic internet use and adolescent mental health, the relationship and underlying mechanisms linking short video addiction—an emerging form of internet addiction—with school burnout remain insufficiently examined. Building on existing research, this study aims to investigate the relationship from school burnout to short video addiction among adolescents, along with the potential mediating role of psychological distress. The following hypotheses are proposed:

• H1: School burnout at T1 will positively predict short video addiction at T2.

• H2: Psychological distress will mediate the relationship from school burnout to short video addiction.

Methods

Participants

A convenience sampling method was employed to recruit participants from three secondary schools in Wuhan, Hubei Province, China. A two-wave longitudinal survey was utilized, with a 12-month interval between measurements. The first survey (T1) was conducted in December 2023. The second survey (T2) was conducted in December 2024, with valid responses from 398 participants. Among them, 180 were male (45.2%), 206 were female (51.8%), while 12 participants did not disclose their gender. The average age of the participants was 14.45 years (SD = 1.70), ranging from 12 to 17 years.

Measures

School burnout

Student burnout was assessed using the School Burnout Inventory [52]. The scale consists of 9 items rated on a 6-point Likert scale (1 = “Strongly Disagree” to 6 = “Strongly Agree”), where higher scores signify increased levels of school burnout. The Cronbach’s α was 0.89 at T1 and 0.90 at T2 in this study.

Psychological distress

Psychological distress was assessed with the Depression, Anxiety, and Stress Scales − 21 [36, 53]. The scale contains 21 items across three subscales: depression, anxiety, and stress. Each item is rated on a 4-point Likert scale (0 = “Did not apply to me at all” to 3 = “Applied to me most of the time”), with higher scores reflecting greater psychological distress. The Cronbach’s α was 0.95 at T1 and 0.96 at T2 in this study.

Short video addiction

Short video addiction was assessed using the Chinese version of the Short Video Overuse Behavior Scale [12]. The scale consists of 6 items rated on a 7-point Likert scale (1 = “Not at all true of me” to 7 = “Very true of me”), with higher scores indicating higher levels of short video addiction. The Cronbach’s α was 0.85 at both T1 and T2 in this study.

Data analysis

Descriptive statistics, correlation analyses, and common method bias tests were performed using SPSS 27.0. Cross-lagged models were created using Mplus 8.0 to explore longitudinal relationships among variables, alongside testing for mediation effects within the same software. It should be noted that the cross-lagged panel models with three observed variables at two time points are just-identified (saturated) with zero degrees of freedom. Consequently, conventional fit indices (e.g., CFI, TLI, RMSEA, SRMR) are uninformative and therefore not reported.

Results

Common method bias testing

To assess the potential impact of common method bias, Harman’s single-factor test was conducted [54]. The results indicated that six factors with eigenvalues greater than 1 were extracted at both T1 and T2. At T1, the first factor accounted for 13.72% of the total variance, and at T2, it accounted for 14.48%. As the proportion of variance explained by the first factor was below the critical threshold of 40% at both time points, this indicates that there is no significant common method bias in this study.

Descriptive statistics and correlation analysis

As shown in Table 1, school burnout, psychological distress, and short video addiction were significantly and positively correlated with each other. These correlations were observed within the same time point (T1 or T2) as well as across time points (T1 and T2), indicating temporal stability. All variables also showed significant positive correlations between T1 and T2.

Table 1.

Means, standard deviations, and correlation coefficients among study variables (N = 398)

	1	2	3	4	5	6
T1 School Burnout	1
T1 Psychological Distress	0.64***	1
T1 Short Video Addiction	0.38***	0.29***	1
T2 School Burnout	0.36***	0.26***	0.20***	1
T2 Psychological Distress	0.33***	0.41***	0.18***	0.62***	1
T2 Short Video Addiction	0.28***	0.18***	0.40***	0.46***	0.29***	1
M	3.28	0.78	2.19	3.43	0.84	2.31
SD	1.12	0.67	0.87	1.09	0.69	0.88

Notes: *** p < 0.001

Longitudinal relationship from school burnout to short video addiction

A cross-lagged panel model was constructed with school burnout and short video addiction at T1 as predictor variables, and the corresponding constructs at T2 as outcome variables (Fig. 1). The results showed that T1 school burnout significantly predicted both T2 school burnout (β = 0.33, p < 0.001) and T2 short video addiction (β = 0.15, p < 0.01). Additionally, T1 short video addiction significantly predicted T2 short video addiction (β = 0.34, p < 0.001). However, the cross-lagged path from T1 short video addiction to T2 school burnout was non-significant (β = 0.07, p > 0.05).

Fig. 1.

Cross-lagged model of school burnout and short video addiction

Mediation role of psychological distress

A cross-lagged model was implemented to investigate the mediating role of psychological distress. In this model, T1 school burnout and T1 short video addiction were posited as predictor variables, T1 and T2 psychological distress served as mediators, and T2 school burnout and T2 short video addiction represented the outcome variables (Fig. 2). The model indicated that T1 school burnout significantly predicted T2 school burnout (β = 0.25, p < 0.001) and T1 psychological distress (β = 0.62, p < 0.001). T1 short video addiction significantly predicted T2 short video addiction (β = 0.33, p < 0.001). T1 psychological distress significantly predicted T2 psychological distress (β = 0.34, p < 0.001). Moreover, T2 psychological distress significantly predicted both T2 school burnout (β = 0.59, p < 0.001) and T2 short video addiction (β = 0.22, p < 0.001).

Fig. 2.

Cross-lagged model of school burnout, psychological distress, and short video addiction

To investigate the indirect effects, a bootstrap procedure with 5,000 resamples was conducted. The 95% confidence intervals (CIs) were utilized to assess the significance of the mediation effects; a mediation effect was deemed significant if the CI did not include zero. As illustrated in Table 2, psychological distress at T1 and T2 jointly mediated the relationship from T1 school burnout to T2 short video addiction. However, no significant mediation was found in the reverse direction, from T1 short video addiction to T2 school burnout.

Table 2.

Mediation analysis results

Path	Indirect Effect	Indirect to Total Effect	95% CI
			LL	UL
T1SB→T1PD→T2PD→T2SVA	0.05	30.67%	0.02	0.09
T1SVA→T1PD→T2PD→T2SB	0.01	13.70%	-0.01	0.03

Discussion

The current study explored the longitudinal relationship from school burnout to short video addiction in adolescents, along with the potential mediating role of psychological distress. Utilizing a two-wave longitudinal survey with a one-year interval, involving 398 adolescents, the results highlight the intricate interplay among these constructs and the mechanisms underlying them. The discussion that follows synthesizes these findings with the existing literature.

Longitudinal relationship between short video addiction and school burnout in adolescents

Our findings indicated a positive correlation between short video addiction and school burnout at the same point in time. Longitudinally, school burnout measured at T1 significantly predicted short video addiction at T2, while T1 short video addiction did not significantly predict school burnout at T2. According to the Conservation of Resources (COR) theory [55], individuals have a tendency to acquire, maintain, and protect their resources, and the depletion of these resources can lead to various negative psychological and behavioral outcomes. Additionally, self-control is regarded as a finite resource. Much like other forms of addiction, short video addiction is often viewed as a result of self-control failure [16, 56, 57]. Adolescents may experience a self-control dilemma, having to choose between the appealing, effortless use of short videos and the challenging, monotonous, and demanding nature of academic study [14]. Opting for study over short video consumption requires significant self-control. When self-control is compromised, adolescents are more inclined to indulge in short video use, potentially leading to addiction due to their inability to resist related temptations. This aligns with previous evidence suggesting that a primary motivation for short video consumption is to escape academic stress [19].

Conversely, short video addiction may undermine adolescents’ self-control [58]. During adolescence—a critical period of cognitive development—the continuous engagement of cognitive resources with short video content and personalized algorithmic recommendations can change how adolescents acquire and process complex information [59, 60] and even affect their neural activity patterns [19]. Specifically, the use of short videos may cultivate a preference for immediate gratification at the expense of long-term objectives (e.g., academic tasks), with the ability to delay gratification being a vital aspect of self-regulation [61, 62]. Moreover, the wealth of personalized content and audiovisual stimulation offered by short video platforms can impose a significant burden on working memory, potentially leading to cognitive overload [17, 18]. This cognitive overload may impair functions such as working memory and attentional control, ultimately hindering academic performance and contributing to feelings of school burnout. Successful completion of complex, higher-level academic tasks requires ample self-control resources. From the perspective of the Job Demands–Resources model [29], when self-control resources are excessively consumed due to short video addiction, the ensuing burnout in the learning process may signify a depletion of these essential resources.

In this longitudinal study, it is noteworthy that T1 short video addiction did not significantly predict T2 school burnout. One possible explanation for this finding is that school burnout may serve as a more severe and typical indicator of negative psychosocial development compared to short video addiction. Previous research has raised questions about the consistent negative impact of short video addiction on adolescents’ academic success [11, 58]. As previously mentioned, short video platforms offer diverse content that could potentially foster self-control and enhance competitive skills [59]. The extent to which students’ learning can benefit from such media platforms remains a subject of ongoing debate [60]. While these post-hoc explanations remain speculative, a more conservative interpretation—grounded in the limitations of our two-wave design—is that the non-significant path from T1 short video addiction to T2 school burnout suggests that, within the one-year interval examined, short video addiction did not exert a measurable longitudinal effect on school burnout. This null finding may reflect the 12-month interval being too long to capture acute effects, the presence of unmeasured protective factors, or the possibility that school burnout is a more stable and severe indicator of maladjustment than short video addiction in this developmental period. Future research with more frequent measurement occasions (e.g., intensive longitudinal designs) is needed to clarify the short-term dynamics of this association.

Mediating role of psychological distress

The findings indicate that psychological distress serves as a mediator in the relationship from school burnout to short video addiction, but not vice versa. Supporting previous research, negative emotional states—such as depression, anxiety, and stress—are frequently associated with short video addiction [11, 33, 62–63] In many instances, pre-existing negative emotional states are strong predictors of later short video addiction [64, 65]. According to the Opponent Process Theory (OPT), psychological distress compels individuals to seek pleasure, and the content available on short video platforms provides an effective means for escaping negative emotions and pursuing gratification [66]. As previously noted, school burnout is a significant source of negative emotions among adolescents [17], which can create a compelling drive to overconsume short videos. While the pleasure and immediate gratification derived from short video use may initially foster positive emotions, this connection tends to weaken over time. Once the pleasure diminishes, adolescents may revert to experiencing negative emotions, which in turn reinforces excessive usage, ultimately establishing a cycle of addiction—precisely the process elucidated by OPT.

Negative emotions and psychological distress not only serve as risk factors for short video addiction [33, 65, 67] but also represent detrimental outcomes of that addiction, potentially contributing to school burnout. The displacement hypothesis suggests that time spent on short videos displaces time for real-life activities, hindering social adaptation and leading to emotional problems [68, 69]. From an emotion regulation standpoint, using short videos is a common strategy to cope with negative emotions; however, it fails to address the underlying causes of psychological distress. In fact, such usage may strengthen dependence on short video platforms and worsen emotional issues over time [70]. Supporting the concept of Opponent Process Theory(OPT), the dual-process theory of addiction elucidates the connection between short video addiction and negative emotions [63]. As excessive use persists, the initial motives rooted in emotional regulation gradually evolve into cue-induced and habitual behaviors. This shift transforms compensatory short video usage from an intentional emotional regulation strategy into an unconscious, automated operant conditioning process. This aligns with the process perspective of the I-PACE model, highlighting that addiction develops through the interplay of cognitive and affective responses along with reinforcement mechanisms [15]. Once the use of short videos becomes automatic, individuals may find themselves more deeply addicted and facing greater negative consequences [13]. Furthermore, as emotional regulation ceases to be the primary motive, short video platforms may lose their effectiveness in alleviating negative emotions. Short video addiction can lead adolescents to focus on virtual interactions and experiences, often at the expense of real-life communication, which can damage interpersonal relationships and diminish social support. This cycle further intensifies negative emotions and psychological distress [70].

Previous studies have confirmed that short video addiction can impact various academic-related factors, such as learning motivation, achievement motivation, and academic procrastination [6, 71, 72], particularly in terms of motivation and performance. However, the current study did not identify a mediating effect of psychological distress between short video addiction and school burnout [73]. This finding suggests that the relationship between short video addiction and school burnout—a construct that includes both cognitive and emotional components—may involve more complex mechanisms.

Implications and limitations

This study presents several limitations. First, the two-wave longitudinal design, while providing temporal separation superior to cross-sectional research, imposes inherent constraints on causal and mediational interpretation. The 12-month interval may be too coarse to capture acute or short-term transactional dynamics, and cross-lagged mediation based on only two time points cannot fully exclude third-variable explanations or establish definitive temporal precedence of the mediator over the outcome. These collective constraints mean that the observed temporal sequencing should be interpreted as preliminary evidence rather than conclusive causal demonstration. Second, all measures relied on self-report questionnaires, which carry well-documented risks of social desirability bias and recall inaccuracy, particularly for estimating short-video usage duration [74]. Although Harman’s single-factor test was conducted, it is recognized as an insufficient remedy for common method variance in longitudinal self-report designs; nevertheless, the temporal separation of the two assessments serves as a procedural control that attenuates single-source bias. Additionally, aggregating depression, anxiety, and stress into a single psychological distress composite follows the DASS-21 developers’ dimensional conceptualization and prevailing practice in adolescent internet-addiction research, yet this approach may obscure differential pathways, and the very high internal consistency estimates (α = 0.95–0.96) could signal item redundancy rather than broad construct coverage. Future studies would benefit from multi-method assessment (e.g., behavioral logging, clinician-rated measures) and from modeling the three emotional dimensions separately. Third, the findings are bounded by sampling and omitted-variable constraints. The convenience sample was drawn from a single city, limiting generalizability to broader adolescent populations. Moreover, potentially influential control variables—such as the objective intensity and frequency of short-video use, demographic covariates(e.g., gender, age)—were not included, which may affect the robustness of the estimated associations. Although the sample is relatively homogeneous in age, reducing some demographic confounding, future research should employ larger, multi-site samples with diverse sociodemographic backgrounds and incorporate objective behavioral and academic controls to clarify the interplay among these constructs.

Despite these limitations, the present study makes several meaningful contributions. First, it broadens previous research on internet addiction, social media addiction, and online gaming addiction by focusing on the context of short video usage. Understanding the psychological mechanisms behind short video addiction can provide a solid theoretical basis for developing intervention programs. Second, through the construction of a cross-lagged panel model, this study examined the interactions between school burnout, psychological distress, and short video addiction, enriching theoretical discussions on the relationship between problematic internet use and psychosocial adaptation. Lastly, the findings offer valuable insights into the mindful consumption of short videos. Users should recognize that school burnout and negative emotions, such as psychological distress, may drive excessive short video usage; however, relying on such use as a strategy for emotional regulation is not sustainable and may lead to more severe adverse outcomes. This study highlights the significant role of psychological distress in the development of both school burnout and short video addiction, providing an explanatory framework for their association. Future research should investigate the psychosocial processes connecting various forms of negative emotions or psychological distress with short video addiction and other problematic internet behaviors, thus informing strategies to enhance adolescents’ digital adaptation in the contemporary era.

Conclusions

1. School burnout at T1 significantly predicted short video addiction at T2, whereas the reverse prediction was not statistically significant.

2. Psychological distress mediates the relationship from school burnout to short video addiction but not from short video addiction to school burnout.

Abbreviations

T1

Time 1

T2

Time 2

SBI

School Burnout Inventory

DASS-21

Depression, Anxiety, and Stress Scales-21

SB

School Burnout

PD

Psychological Distress

SVA

Short Video Addiction

Authors' contributions

Study design: Wenjing Sun, Yilin Zhang. Data collection and analysis: Ruiyu Ge, Yifan Liu, Yilin Zhang. Manuscript writing: Wenjing Sun. Manuscript editing: Yilin Zhang. Supervision: Yilin Zhang.

Funding

This work was supported by Planning Project of Zhejiang Provincial Philosophy and Social Science, 2023 (Grant No. 23GXSZ059YB).

Data availability

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All human experiments in this study comply with the ethical guidelines of the Declaration of Helsinki and have been approved by the Human Research Ethics Review Committee of Central China Normal University. The approval number for this study is CCNU-IRB-202403052 A. Informed consent was obtained from parents or legal guardians of all participants who were minors (aged 12–17 years).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.