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Gender differences in associations between parental problem drinking and early adolescents’ Internet addiction Mi Heui Jang and Eun Sun Ji

Mi Heui Jang, PhD, RN, is a Postdoctoral Fellow, College of Nursing, University of Illinois, Chicago, Illinois, USA; and Eun Sun Ji*, PhD, RN, is an Assistant

Professor, Department of Nursing , Konkuk University, Seoul, Korea

Search terms Addiction, alcohol, early adolescent, Internet,

parent.

Author contact [email protected], with a copy to the Editor:

[email protected]

Acknowledgements The authors thank Dr. Chang Gi Park for his

statistical consultation and Gloria Kim for her

editing comments with this article.

Disclosure: The authors report no actual or

potential conflicts of interest.

First Received January 5, 2012; Revision

received April 4, 2012; Accepted for publication

June 5, 2012.

doi: 10.1111/j.1744-6155.2012.00344.x

Abstract

Purpose. The purpose was to examine gender differences between paren- tal problem drinking (PPD) and early adolescents’ Internet addiction (IA). Design and Methods. This was a cross-sectional, correlational design with 519 (266 boys and 253 girls) early adolescents. Results. PPD had a significant direct effect on IA in boys but not in girls. Significant indirect effects of PPD on IA were evidenced via anxiety- depression and aggression for boys and via family function and aggression for girls. Practice Implications. Findings suggest that tailored interventions for the prevention of IA should consider gender.

Parental problem drinking (PPD) is a well- established risk factor for behavioral, emotional, and social problems in children (Kelly et al., 2010; West & Prinz, 1987). PPD has been closely linked to physi- cal, psychological, social, legal, economic, and spiri- tual problems in individual life and family and other interpersonal relationships (Daley & Marlatt, 1997). A study from the United States showed that 12.5% of adults were alcohol dependent and 17.8% of adults were abusing alcohol, according to the defini- tions in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision), at some time in their life (Hasin, Stinson, Ogburn, & Grant, 2007). Eleven percent of U.S. children live with at least one parent who abuses or is dependent on alcohol or other substances (Kelly et al., 2010). In Korea, it was found that 75% of the adult population consumed alcohol, 10.5% of the adult male population had alcohol dependence, and 42.7% of the adult popula-

tion had problem drinking (Korean Alcohol Research Foundation, 2009). Exposure to an alcohol-dependent parent was found in 30% of Korean children (Kim, 2005). The findings in several Korean studies have shown that adolescents who experience PPD have higher problem behaviors and mental health problems compared with norma- tive control groups (Hyun, Nam, & Kim, 2008; Lee, Kweon, & Choi, 2003; Park, 2006). Also, in line with those Korean findings, it has been documented that children of alcoholics have more externalizing behavioral problems (conduct disorders, hyperactiv- ity, impulsivity, and aggression) and internalizing problems (depression, anxiety, and low self-esteem; Christensen & Bilenberg, 2000; Eiden, Molnar, Colder, Edwards, & Leonard, 2009). Therefore, at-risk children who are exposed to PPD need to prevent adverse outcomes and promote their mental health.

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Journal for Specialists in Pediatric Nursing

According to problem behavior theory, parental alcohol problems particularly have been identified as a substantial risk factor that leads to adolescents’ behavioral problems (Jessor, 1991). More recently, some researchers reported that PPD was associated with adolescents’ Internet addiction (IA; Kim, Chae, Rhim, & Shin, 2004; Ko et al., 2008; Yen, Yen, Chen, Chen, & Ko, 2007). That is, these researchers sug- gested that parents’ problematic alcohol use pre- dicted adolescents’ IA (Kim et al., 2004; Ko et al., 2008; Yen et al., 2007). Although studies have often focused on the bivariate associations between two conditions, few have examined the underlying mechanisms. Therefore, more research is needed to identify the relationship between PPD and adoles- cents’ IA.

In South Korea, IA has become one of the most serious public health issues in the last decade. IA refers to “excessive or poorly controlled preoccupa- tions, urges or behaviors regarding Internet access that lead to impairment of daily life” (National Infor- mation Society Agency [NIA], 2011). Particularly, 12.4% of adolescents exhibited symptoms of IA in 2010, which was twice as high as the adults’ IA rate (5.8%; NIA, 2011). Especially, the IA rate of early adolescents ages 10–12 in elementary schools in Korea has increased by 13.7%, which is 3% higher than last year (NIA, 2011). This increase in rate is greater than it is in any other adolescent age group. Therefore, there needs to be more focus and interest on IA prevention for early adolescents. In recent years, researchers have demonstrated relationships between IA and individual, familial, and environ- mental factors (Ko, Yen, Yen, Lin, & Yang, 2007). Adolescents’ IA has been found to be associated with self-esteem, family function, depression, anxiety, and aggression (Park, 2009; Park, Kim, Lee, & Kim, 2009). Adolescents’ self-esteem was negatively asso- ciated with their IA (Ko et al., 2007; Park et al., 2009). Also, family factors, including poor family function and ineffective parenting, were reported to be major risk factors for adolescents’ IA (Ko et al., 2007; Park, Kim, & Cho, 2008). Adolescents’ IA was found to be associated with various psychiatric prob- lems, such as depressive disorder, anxiety disorder, and aggressive behaviors (Fu, Chan, Wong, & Yip, 2010; Ha et al., 2007; Kim et al., 2006). Based on these reviewed studies and conceptual reasoning to be explained later, we conceptualized that adoles- cents’ “psychosocial resources,” such as self-esteem, family function, anxiety-depression, and aggression, might have been mediators for the relationship between PPD and adolescents’ IA.

Existing studies on PPD and IA suffer from several methodological problems. First, despite the gender difference in the prevalence rates and cor- relates of the predictors and IA across studies (Kim, Ha, Lee, Cho, & Song, 2005; Kim et al., 2008; Ohannessian, 2009) and in the influence on children of PPD (Christensen & Bilenberg, 2000), most studies did not examine gender differences. Thus, the results did not provide substantial infor- mation for the prevention of and intervention for IA, and influence on children of PPD. Second, many studies on the association between adoles- cents’ IA and those risk factors addressed only direct or bivariate relationships. Because these pre- vious studies limit a grasp of the whole picture of the relationships and make it difficult to identify high-risk groups (Lee, Choi, Kim, Park, & Shin, 2009), it is necessary to investigate the gender dif- ferences in pathways that may better explain the relationship between PPD and IA among early ado- lescents. With present research, researchers and nurses might provide important evidence for iden- tifying more appropriate targets for prevention and intervention efforts aimed at children who are at risk of IA. A major goal of this study was to examine gender differences in the relationship between PPD and IA among early adolescents. Spe- cific aims were to identify the gender differences in direct, indirect, and total influence of PPD on IA and to determine the gender differences in relative magnitudes of specific mediating effects of self- esteem, family function, anxiety-depression, and aggression.

CONCEPTUAL FRAMEWORK

Two conceptual approaches to health problems, problem behavior theory (Jessor, 1991) and dynamic diathesis–stress model (Windle, 1997), guided think- ing about mediation processes in this study. Recently, some researchers reported that IA may be one form of problem behaviors such as substance abuse, smoking, and alcohol use among adolescents (Ko et al., 2008; Yen et al., 2008). Problem behavior theory posits that behavioral problems among ado- lescents share the same psychosocial and environ- mental proneness (Jessor, 1991). Problem behavior theory also proposes that PPD leads to adolescents’ developmental, emotional, and behavioral prob- lems. In the light of these considerations, we hypoth- esized that IA would be associated with PPD. Also, according to Windle’s (1997) dynamic diathesis– stress model of developmental psychopathology as

M. H. Jang and E. S. Ji Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction

applied to children of alcoholics, family history of alcohol abuse or dependency influence risk factors such as difficult temperament, aggression, and parenting deficits, might lead to the development of psychological or other health problems. In this model, problem behavior and/or adjustment are the results of the interaction between characteristics of the individual and environmental stressors. In line with this conceptual reasoning, we hypothesized that children experiencing PPD might develop behavioral problems like IA. Hence, it is imperative to examine modifiable variables that might have mediating roles on the relationship between PPD and early adolescents’ IA.

The hypothesized multiple-mediation model, which was developed based on problem behavior theory, the dynamic diathesis–stress model, and previous findings on IA and PPD, is presented in Figure 1. Based on these reviewed studies, we conceptualized that the effect of PPD on IA was transferred through adolescents’ “psychosocial re- sources,” such as self-esteem and family function, as well as anxiety-depression and aggression. The figure could establish reciprocal relationships between the variables.

METHODS

Design

A cross-sectional comparative descriptive design was used in this study. A self-administered questionnaire was used to collect data from the sample.

Sample and procedure

The research proposal was approved by the ethics committee at Daewon University College. The par- ticipants were early adolescents ages 11–12 years (fifth to sixth grade) who were attending elemen- tary school in J City, South Korea. A researcher con- tacted school nurses of the selected schools to discuss the study’s purpose, significance, and procedure. The researcher presented this proposal to each prin- cipal, vice principal, and parents’ representatives. After receiving consent from each school’s principal, information and passive consent letters asking for the children’s cooperation were sent to all parents. The investigators visited the students during school health classes from June to July 2009. The purpose and procedure of this study were explained by the investigators to the students in class, emphasizing

parental problem drinking

Controls (grade, etc.)

Internet addiction

Family function

a1m

a2m

a3m

a4m

b1m

b2m

C´m b3m

b4m

a1f

a2f

a3f

a4f

b1f

b2f

C´f b3f

b4f

Anxiety- depression

Aggression

Self- esteem

Controls (grade, etc.)

Internet addiction

Family function

Anxiety- depression

Aggression

Self- esteem

Parental problem drinking

Figure 1 Conceptual Model of the Study and Analytic Diagram for the Multiple-Mediation Model Proposed by Gender. Note: The “a” coefficients represent the effects of parental problem drinking on the mediators. The “b” coefficients represent the effects of the mediators

on Internet addiction partialling out the effect of parental problem drinking. The “c” is the total effect of parental problem drinking on Internet addiction.

The “c′ ” is the direct effect of parental problem drinking on Internet addiction. The specific indirect effects are represented by a1b1 (self-esteem), a2b2 (family function), a3b3 (anxiety-depression), and a4b4 (aggression). The total indirect effect is the sum of all the specific indirect effects. The “m” is male (the

left side); the “f” is female (the right side).

Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction M. H. Jang and E. S. Ji

respect for their privacy and encouraging them to participate. Written, informed consents signed by parents were obtained from the students before- hand, and the participants were then invited to com- plete the research questionnaires anonymously. Completion of the questionnaire took approxi- mately 30 min. The effective sample size for per- forming multiple-mediation analysis in the present study included 24 of the estimated parameters, esti- mated minimum 120 to maximum 240, based on Bentler and Chou (1987), who recommended 5–10 participants per estimated parameter. According to their recommendation, a total of 519 participants were chosen for analysis.

Measurements

Demographic variables. The questionnaire in- cluded demographic questions including grade, reli- gion, sibling, school performance, and information about the parent, including education, occupation, economic status, and divorce.

PPD. PPD was measured using the Korean Version of the Children of Alcoholics Screening Test (CAST-K; Kim, Chang, & Kim, 1995), which was originally developed by Jones (1983). The CAST (Pilat & Jones, 1985) is a 30-item questionnaire using a “yes” (score of 1) or “no” (score of 0) format, in which an individual describes feelings, behavior, and experiences related to a parent’s alcohol use subscales. The agreement of parents’ alcoholic prob- lems scores between the self-report and children is 98% on the CAST (Hall & Webster, 2002). CAST-K has shown good internal consistency (Cronbach’s a = .86–.94) and good test–retest reliability (r = .83) previously (Kim et al., 1995). The internal consis- tency, as assessed by the Kuder-Richardson formula 20 a coefficient, was .92 in the present study.

IA. The instrument used to assess the possibility of IA was the 40-item Korean version of the IA self- reported scale developed by the NIA (2002). This scale is a standardized instrument and widely used to screen for Internet addicts and potential risk users among Korean adolescents (Seo, Kang, & Yom, 2009). The scale consisted of seven dimensions of Internet-related problems: (a) disturbance of adaptive functions (nine items); (b) disturbance of reality testing (three items); (c) addictive autonomic thoughts (six items); (d) withdrawal (six items); (e) virtual interpersonal relationships (five items);

(f) deviant behavior (six items); and (g) tolerance (five items; Seo et al., 2009). The items are rated on a 4-point Likert scale (1 = not at all, 4 = always). Item ratings were summed to yield a total score that ranged from 40 to 160; higher scores indicated a higher possibility of IA. The Korean version of the IA self-test scale had an excellent internal consistency reliability previously (Cronbach’s a = .96; Kim, Kim, Park, & Lee, 2002) and in the present study (Cronbach’s a = .91).

Self-esteem. Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965), which was translated into Korean by Jon (1974). The RSES assesses global attitudes toward the self (i.e., the sense of self-worth and self- acceptance). This 10-item scale used a 4-point Likert scale format (1 = strongly disagree, 4 = strongly agree). Item ratings were summed to yield a total score that ranges from 10 to 40; higher scores indicated higher self-esteem. The RSES scale has demonstrated excellent reliability (Cronbach’s a = .89) in previous studies (Jon, 1974) and in the present study (Cronbach’s a = .81).

Family function. Family function was measured using the Family Adaptability and Cohesion Evalua- tion Scale (FACES III). FACES III was originally developed by Olson, Portner, and Lavee (1985) and then modified by Kim (1990) for use in Korea. The FACES III is a 20-item self-reported scale that mea- sures family systems with respect to the levels of current and ideal cohesion and adaptability (Olson, 1991). Each item was rated on a 5-point Likert scale (1 = almost never, 5 = almost always). Item ratings were summed to yield a total score that ranges from 20 to 100. The higher scores were considered to indicate better family function. FACES III has demonstrated good reliability (Cronbach’s a = .80) in previous studies (Kim, 1990) and in the present study (Cron- bach’s a = .88). Culture-specific content validity coefficients for FACES III were in the range of .57– .61 for item-domain correlations and .30–.38 for interdomain correlations (all p < .01; Kim & Park, 2002).

Anxiety-depression. Anxiety-depression was ass- essed using the 14-item anxiety/depression subscale of the Korean version of the Child Behavior Checklist (K-CBCL; Oh, Lee, Hong, & Ha, 1997). The CBCL (Achenbach, 1991) is a widely used measure of chil- dren’s behavioral/emotional problems, with well- established psychometric properties (Eiden et al.,

M. H. Jang and E. S. Ji Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction

2009). The items on the anxiety/depression subscale of the CBCL as a cohesive set reflects the complexity of affective problems among children and adolescents (Wadsworth, Hudziak, Health, & Achenbach, 2001). Items are rated on a 3-point Likert scale (0 = not true, 1 = somewhat or sometimes true, 2 = very or often true). Item scores are summed to yield a total score that ranges from 0 to 28; higher scores indicate higher anxiety- depression. The scale showed satisfactory reliabilities (Cronbach’s a = .80) in a previous K-CBCL study (Oh et al., 1997) and in the present study (Cronbach’s a = .89). The culture-specific study for the K-CBCL showed good discriminant validity (all p < .001) and good criterion-related validity (r = .28–.97; Oh, Ha, Lee, & Hong, 2007).

Aggression. Aggression was measured using the 20-item externalizing behavior subscale of the K-CBCL (Oh et al., 1997). Research indicates the CBCL is highly valid in diagnosing serious external- izing behavior problems in children (Hudziak, Cope- land, Stanger, & Wandsworth, 2004). Item ratings were summed to yield a total score that ranges from 0 to 40; higher scores indicated higher aggression. The scale showed satisfactory reliabilities (Cron- bach’s a = .86) in a previous K-CBCL study (Oh et al., 1997) and in the present study (Cronbach’s a = .90).

Data analysis

Data were analyzed using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) and Indirect SPSS macros for multiple-mediation (Preacher & Hayes, 2008). The difference in demographic and study variables between boys and girls was analyzed by using descriptive analysis, Pearson’s chi-square test, and unpaired t-tests. Pearson’s r correlations were esti- mated to explore the relationships among major study variables. Gender differences on bivariate cor- relation coefficients were tested by Fisher’s z statis- tics. Also, gender differences in covariance of all study variables were tested utilizing a multiple group analysis of the AMOS 19 program.

To test the multiple-mediation hypotheses, multiple-mediation analysis was recommended over the Sobel test (MacKinnon, Lockwood, & Williams, 2004; Preacher & Hayes, 2008). Multiple-mediation analysis can test if an overall mediation effect existed and determine the variable-specific effect, control- ling for other mediators and covariates (Preacher & Hayes, 2008). For this study, a multiple-mediation analysis procedure was used to determine whether

significant relationships between PPD and IA were mediated by changes in the four mediating factors, and whether a significant relationship existed between PPD and IA after controlling for mediator effects in boys and girls separately. All demographic variables for this study were controlled in multiple- mediation analyses. In the present study, bootstrap- ping for the testing of the multiple-mediation model was conducted (Preacher & Hayes, 2008; Shrout & Bolger, 2002). An indirect effect was considered to be significant if its 95% bootstrap confidence intervals (CI) from 5,000 bootstrap samples did not include zero (Shrout & Bolger, 2002).

RESULTS

General characteristics of the participants and gender differences in the level of major study variables

There were 266 (51.3%) boys and 253 (48.7%) girls in the sample, ranging in age from 11 to 12 years. Among the participants, 57.9% of the boys were sixth graders and 53.8% of the girls were sixth graders. Almost all of the students (90.6%) had at least one sibling. More than half of their parents were above-college graduates, and 72.4% of the stu- dents reported that their economic status was mod- erate. Of the students, 3.5% were from divorced families.

Table 1 shows mean and standard deviations of the major study variables for boys and girls sepa- rately. The level of IA differed significantly between boys and girls. Boys scored significantly higher than girls in the level of IA (M = 57.07, SD = 14.58 vs. M = 49.54, SD =12.49, t = 6.33, p < .001). There was a significant gender difference between the general user and IA groups (c2 = 17.54, p < .001). There were no significant gender differences in PPD, family function, anxiety-depression, and aggression, while self-esteem scores of the girls were significantly higher than those of the boys (M = 28.32, SD = 5.11 vs. M = 27.03, SD = 4.31, t = -3.09, p = .002).

Gender differences in correlations among the study variables

The correlations among the study variables are pre- sented in Table 1. For boys, IA was positively corre- lated with PPD and aggression, while it was negatively correlated with self-esteem; however, there was no significant correlation between family function and IA. PPD was significantly correlated

Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction M. H. Jang and E. S. Ji

with anxiety-depression, aggression, and IA; however, there was no significant correlation between self-esteem and family function. In con- trast, for girls, there were significant correlations among all the variables. IA showed the strongest cor- relation with aggression for both boys and girls. Girls scored higher on aggression compared with boys, but there was no gender difference on the correla- tion coefficient between aggression and IA (Fisher’s z = -.29, p = .385). Moreover, there were no gender differences on each bivariate correlation coefficient between PPD, self-esteem, anxiety-depression, and IA (Fisher’s z = .12, p = .072, Fisher’s z = 1.46, p = .072, Fisher’s z = .67, p = .251, respectively). Because this bivariate correlation could not consider the other associated variables, the simple comparison of bivariate correlation coefficients could not represent the true gender difference. In contrast, the compari- son of structural covariance of all study variables between boys and girls showed a significant differ- ence (c2 = 78.943, df = 21, p < .001).

Direct and indirect effects of PPD on IA in boys and girls

Results of multiple-mediation analysis for boys and girls are displayed in Table 2, and the multiple- mediation models are illustrated in Figures 2 and 3. For boys, PPD had a positive effect on anxiety- depression (b = .18, p = .006) and aggression (b = .11, p = .010), while it had no significant effect on anxiety-depression (b = -.01, p = .883) and family function (b = -.13, p = .404). In contrast, for girls, PPD had a significant direct effect with all mediators; PPD had a negative effect on self-esteem (b = -.31, p < .001) and family function (b = -.67, p < .001), and a positive effect on anxiety-depression (b = .53, p < .001) and aggression (b = .27, p < .001). The

magnitude of effect on mediating variables of PPD for girls showed higher effects than that of boys. For boys, in the test of the direct effects of the mediators on IA in this model, anxiety-depression (b = .66, p < .001) and aggression (b = .57, p = .036) significantly predicted IA, while for girls, family function (b = -.12, p = .025) and aggression (b = 1.25, p < .001) significantly predicted IA. In particular, aggression for girls was two times higher than in boys.

Table 2 also shows that the total effect of PPD on IA was significant for both boys (b = .74, p < .001) and girls (b = .69, p < .001). For boys, the effect on IA attributed to PPD was reduced from .74 (total effect of PPD) to .57 (remaining significant direct effect, p < .001) when the four mediators were included in the model. While for girls, the effect on IA attributed to PPD was reduced from .69 (total effect of PPD) to .25 (remaining no significant direct effect, p = .130) when the four mediators were included in the model. In other words, the remaining direct effects on IA of PPD showed only a significant effect in boys; the effect in boys was more than two times as much as in girls. Overall, the multiple-mediation model explained 30.0% for boys and 39.0% for girls of the variance in IA (F = 8.56, p < .001; F = 11.80, p = .001, respectively).

Also, PPD was found to have a significant indirect effect (mediation effect) on IA for both boys (b = .17, 95% CIs [.04, .34]) and girls (b = .44, 95% CIs [.23, .76]). The total indirect effect in girls was greater than twice as much as in boys. Significant indirect effects of PPD on IA was evidenced via anxiety- depression (b = .12, 95% CIs [.04, .27]) and aggres- sion (b = .06, 95% CIs [.00, .18]) for boys and via family function (b = .08, 95% CIs [.01, .23]) and aggression (b = .34, 95% CIs [.14, .76]) for girls. In other words, IA was substantially mediated by anxiety-depression (i.e., .12 out of .17) for boys and

Table 1. Correlations, Means, and Standard Deviations for Scores on the Study Variables

Variable 1 2 3 4 5 6 M SD

1. PPD — -.04 -.10 .20* .25** .28** 3.24 5.12 2. SE -.34** — .30** -.35** -.18* -.20* 27.03 4.31 3. FF -.28** .52** — -.08 -.02 -.05 56.18 13.25 4. AD .40** -.56** -.34** — .72** .42** 6.24 5.49 5. AG .32** -.45** -.22** .74** — .45** 9.72 7.25 6. IA .27** -.32** -.27** .37** .47** — 57.05 14.58 M 3.00 28.32 58.43 6.86 10.44 49.54 — —

SD 4.23 5.11 13.64 6.47 7.84 12.49 — —

Note: *p < .01, **p < .001. Correlations above the diagonal are for boys (n = 266); those below the diagonal are for girls (n = 253). Means and standard deviations in the vertical columns are for boys; those in the horizontal rows are for girls. PPD, parental problem drinking; SE, self-esteem;

FF, family function; AD, anxiety-depression; AG, aggression; IA, internet addiction; M, mean;

SD, standard deviation.

M. H. Jang and E. S. Ji Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction

by aggression (i.e., .34 out of .44) for girls. Since bootstrap CIs (95% ) did not include zero, the effect was significantly different from zero.

DISCUSSION

The proposed multiple-mediation models for early adolescent boys and girls were partially supported by the results of this study. The findings from this study showed the gender differences in the mechanism of how PPD had significant effects on IA after control- ling for the covariants such as grade, religion, sibling,

parent’s education and occupation, school perfor- mance, economic status, and parents’ divorce.

For boys, PPD had significant direct, indirect, and total effects on IA. Importantly, the findings on the significant direct effect of PPD on boys’ IA, in con- trast to that of girls, showed that it accounted for a substantial percentage (approximately 77%). The result suggests that PPD is a strong predictor for boys’ IA, even after controlling for four mediating factors. That is, early adolescent boys with PPD are more likely to experience IA. Similar findings have been reported by other researchers (Kim et al., 2004; Ko

Table 2. Multiple-Mediation Estimates for IA by Gender, Controlling for Demographic CharacteristicsVariable

Boys (n = 266) Girls (n = 253)

b t p b t p

Effects of PPD on mediators

Self-esteem -.01 -.14 .883 -.31 -4.71 < .001 Family function -.13 -.84 .404 -.67 -3.44 < .001 Anxiety-depression .18 2.75 .006 .53 5.93 < .001 Aggression .11 2.59 .010 .27 4.64 < .001

Effects of mediators on IA

Self-esteem -.18 -.88 .379 -.24 -1.40 .160 Family function .03 .55 .582 -.12 -2.24 .025 Anxiety-depression .66 3.74 < .001 -.10 -.73 .461 Aggression .57 2.11 .036 1.25 6.17 < .001

Total effect of PPD on IA

PPD .74 4.58 < .001 .69 4.09 < .001 Remaining direct effect of

PPD on IA

PPD .57 3.67 < .001 .25 1.51 .130 Partial effects of control

variables on IA

Grade 7.34 4.64 < .001 4.87 3.75 < .001 Religion -.54 -.88 .380 -.29 -.57 .568 Sibling -1.41 -.60 .546 5.11 1.94 .052 Father’s education 4.15 2.37 .018 1.60 1.06 .288

Mother’s education -2.36 -1.34 .178 -2.43 -1.67 .095 Father’s occupation 1.01 .79 .428 -1.27 -1.21 .225 Mother’s occupation .09 .11 .908 -.90 -1.28 .200 School performance 1.39 1.06 .290 -1.73 -1.25 .209 Economic status .42 .25 .800 .98 .68 .496

Parents’ divorce -4.84 -1.07 .283 12.93 4.35 < .001

95% CIs

p b

95% CIs

pLL UL LL UL

Indirect effects of PPD on IA

via mediators (bootstrap

results)

Total indirect effects .17 .04 .34 .010 .44 .23 .76 .010

Self-esteem -.00 -.04 .02 n.s .07 -.04 .23 n.s Family function -.01 -.06 .01 n.s .08 .01 .23 .010 Anxiety-depression .12 .04 .27 .010 -.06 -.33 .10 n.s Aggression .06 .00a .18 .010 .34 .14 .76 .010

Note: aThe lower CI is not exactly zero. The next lowest number after .00 is 3. PPD, parental

problem drinking; IA, Internet addiction; CI, confidence interval; LL, lower limit; UL, upper

limit; n.s, not statistically significant.

Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction M. H. Jang and E. S. Ji

et al., 2008; Yen et al., 2007) who found a positive association between parental alcohol problems and adolescents’ IA. However, these researchers did not provide any real insights into the gender differences, nor did they provide a precise explanation about adolescents’ IA in relation to PPD.

Our findings may be explained by Sher’s (1991) deviance proneness model. This model relates to the pathway of risk for the development of substance abuse among children of alcoholics (Sher, 1991). Although this pathway was originally proposed to explain the development of alcohol disorders among children of alcoholics, this could also be extended to other negative outcomes (Rice, Dandreaux, Handley, & Chassin, 2006) such as IA. The deviance proneness pathway theorizes that parental sub- stance abuse leads to poor parenting, family conflict, difficult child temperament, and cognitive dysfunc- tion, and that it puts the children of alcoholics at increased risk for substance abuse (Sher, 1991). One

component of the deviance proneness model is that poor parenting leads to behavior problems in children. Therefore, decreased parental monitoring of the child’s behavior, inconsistent discipline, and low levels of social support from parents with alcohol problems may also lead to increased risks for early adolescent boys’ IA. Another compo- nent of the deviance proneness model is difficult temperament or personality (Sher, 1991). The tem- perament or personality traits that are associated with adolescents’ IA, like substance use, include high novelty seeking, low self-directedness, high self-transcendence, and an inability to delay gratifi- cation (Ha et al., 2007; Wills, Windle, & Cleary, 1998). Those explanations based on the deviance proneness pathway model by Sher (1991) are in line with the conceptual reasoning that family history of alcoholism influences health problems of the children via risk factors such as parenting deficit and difficult temperament presented in the

Parental problem drinking

Family function

Internet addiction

Self-esteem

Anxiety- depression

Aggression

Total effect of parental problem

drinking

Mediation path associations

Indirect effects of parental problem

drinking via mediators

Remaining direct effect of parental problem drinking

β = –.01, p = .883 β = –.18, p = .379

β = –.13, p = .404

β = .18, p = .006

β = .03, p = .582

β = .74, p < .001

β = .57, p < .001

β = .57, p = .036

β = .66, p < .001

β = .12, p = .010

β = .06, p = .010 β = .11, p = .010

β = –.01, n.s

β = –.00, n.s

R2Adj. = .30

Figure 2 Multiple-Mediation Bootstrap Analysis of Relationships Between Parental Problem Drinking and Internet Addiction as Mediated by Self-Esteem, Family Function, Anxiety-Depression, and Aggression for Boys.

M. H. Jang and E. S. Ji Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction

dynamic diathesis–stress model by Windle (1997). Previous research has demonstrated the importance of a number of familial factors (e.g., parental social support, consistency of parental discipline) in buffer- ing the risk associated with PPD. But those children at especially high risk (e.g., children with high levels of impulsivity and sensation seeking or high levels of family alcoholism) may not benefit from these familial protective factors (Rice et al., 2006). There- fore, early identification and family intervention for PPD in boys are important for the prevention of IA.

The findings on specific indirect effects showed that only anxiety-depression and aggression variables significantly mediated the associations between PPD and early adolescent boys’ IA. Particularly, boys’ anxiety-depression were revealed as a more important mediator than aggression. Previous research (Licitra-Kleckler & Waas, 1993; Rubin et al., 1992) had demonstrated that depression was related more often to externalizing or antisocial behavior for

boys than for girls. By consideration of the results, we may cautiously suggest that for boys exposed to PPD, overindulgence of the Internet may be explained as a desire to escape into cyberspace as a self-soothing behavior or self-medication in reaction to internal- ized depressive mood (Ha et al., 2007; Mythily, Qiu, & Winslow, 2008).

In contrast to boys, PPD had no significant remaining direct effect on IA for girls after control- ling for four mediating factors. As a possible expla- nation of this finding, PPD had much higher significant negative effects on all psychosocial medi- ating variables than it did in boys. Thus, this may reflect that direct influence of PPD on IA for girls was attenuated to the extent that all mediators’ influ- ence contributed to IA. Another explanation may be offered by Sher’s stress and negative effect path- way proposed in the deviance proneness model. The stress and negative effect pathway suggests that parental substance abuse increases children’s

Parental problem drinking

Family function

Internet addiction

Self-esteem

Anxiety- depression

Aggression

Total effect of parental problem

drinking

Mediation path associations

Indirect effects of parental problem

drinking via mediators

Remaining direct effect of parental problem drinking

β = –.31, p < .001 β = –.24, p = .160

β = –.67, p < .001

β = –.12, p = .025

β = .53, p < .001

β = .69, p < .001

β = .08, p = .010

β = .25, p < .130

β = 1.25, p < .001

β = .10, p = .461

β = .34, p = .010

β = .27, p < .001

β = .07, n.s

β = –.06, n.s

R2Adj. = .39

Figure 3 Multiple-Mediation Bootstrap Analysis of Relationships Between Parental Problem Drinking and Internet Addiction as Mediated by Self-Esteem, Family Function, Anxiety-Depression, and Aggression for Girls.

Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction M. H. Jang and E. S. Ji

exposure to stressful life events such as parental job instability, familial financial difficulty, and parental legal problems (Chassin, Pitts, DeLucia, & Todd, 1999; Sher, 1991). These potentially chronic stres- sors may lead to emotional distress in girls exposed to PPD, and girls may turn to overuse of the Internet. Our findings concerning more negative psychosocial effects of PPD in girls than those of boys were in line with previous reports that daughters were more influenced by living with parents having problem drinking than sons were (Christensen & Bilenberg, 2000; Park, 2006). Also, participants were likely to be affected by family problems; particularly, adoles- cent girls got into more difficulties in the family than boys. The finding is consistent with a prior study (Gore, Aseltine, & Colten, 1993) in which adolescents had more difficulty separating them- selves from the problems of others close to them. For these reasons, significant indirect effect of family function might show only in girls in the present study. Therefore, prevention and intervention for girls’ IA compounded with PPD should address good strategies to cope with girls’ stress and negative affect.

Notably, the finding of the significant indirect effect of PPD on girls’ IA showed that it accounted for a substantial percentage (approximately 67%). The results suggest that PPD influences girls’ IA only via aggression and family function. Furthermore, the finding indicated that the strength of the two signifi- cant mediators differed. In particular, aggression was found to be a more salient mediator than family function for early adolescent girls. These findings indicate that aggression plays a critical role in the development of IA in girls exposed to PPD. This finding supports previous studies that show aggres- sion has been identified as an outcome of growing up in an alcoholic family (Barnow, Schuckit, Smith, Preuss, & Danko, 2002; Sher, 1991). Also, this finding was in line with previous studies that showed aggression was associated with IA among adolescents (Kim et al., 2005; Ko, Yen, Liu, Huang, & Yen, 2009). However, our finding provides new information regarding bidirectional impact and con- nections to PPD of IA, previously separately iden- tified risk factors for aggression. Also, aggression appears to peak during early adolescence rather than during later periods of adolescent development (Kirsh, 2003). Therefore, early screening and inter- vention with girls who have higher aggression is important because they are at substantial risk for future IA, as well as subsequent problem behaviors such as substance abuse and delinquency during

adolescence (Farrell, Sullivan, Esposito, Meyer, & Valois, 2005; Kim, 2010).

The characters of girls, which are somewhat less aggressive, particularly less physically aggressive, more ruminate, and more self-focused to their dis- tress than boys, are well known (Nolen-Hoeksema & Girgus, 1994). However, in some Korean adolescent studies, including our present study, girls had signifi- cantly higher aggression and/or anger than boys did (Kim et al., 2005; Lee, Ha, & Oh, 2005; Lee et al., 2009). These gender differences might be due to the greater impact of familial problems on girls (Ohan- nessian, 2009) or a better ability to recognize and articulate the emotional distress caused by parental substance abuse (Gance-Cleveland, Mays, & Steffen, 2008). Also, as Korean girls may tend to have stron- ger expectations from other people to conform to gender-role stereotypes, girls might be more aggres- sive due to suppressing their desires than boys (Lee et al., 2005). Thus, boys and girls may experience and express aggression and/or anger in different ways among Korean adolescents (Lee et al., 2005). Further studies are needed to understand the spe- cific gender-sensitive role of aggression in the devel- opment of early adolescents’ IA compounded with PPD and to develop strategies for dealing with early adolescents’ aggression in the Korean culture and social systems.

Limitations of the study

This study has some limitations that should be con- sidered when interpreting its findings. The cross- sectional design involved concurrent data on PPD, the mediators, and IA. This makes it difficult to draw causal conclusions. Future research may benefit from a longitudinal mediational design that would help establish a causal relationship. Generalizability of the findings is limited because of a convenience sample of Korean early adolescents from a specific geographical area. Further research is required to replicate, confirm, and expand the findings of the present study. Further research is also needed to address the question of whether the current findings can be generalized to early adolescents in other cul- tures or ethnic groups. Relying on self-reported data from adolescents is another limitation. To capture a complete picture of the phenomenon, future research should explore the relationships between the variables using data from various sources (e.g., parent and teacher report). Potential mediat- ing variables to better explain boys’ IA should also be examined in future research.

M. H. Jang and E. S. Ji Gender Differences in Associations Between Parental Problem Drinking and Early Adolescents’ Internet Addiction

How might this information affect nursing practice?

Although further research needs to explore the underlying mechanisms involved in the relation- ship between PPD and early adolescents’ IA, the findings can contribute to the development of inter- vention strategies to minimize or disentangle the ill effects of PPD on IA by gender. Given that our find- ings showed substantial direct effects of PPD on boys’ IA, early screening of children of alcoholics and family-centered interventions for enhancing parental involvement and support of parents with alcohol problems are very important to developing preventative programs for Korean early adolescent boys’ IA. Also, prevention and intervention for IA in early adolescent boys could be most effective when both PPD and anxiety-depression are addressed in tandem. For Korean early adolescent girls, it is imperative to identify and reduce aggression early, which has a key role in the interconnection between PPD and IA. In addition, considering that significant indirect effects of aggression also showed in boys, focusing on aggression of early adolescents with PPD may be a key to establishing effective pre- vention programs for IA. As early adolescents are beginning to engage in health-risk behaviors, such as IA and aggressive behavior, the ideal time for pre- vention activities is the transition from elementary to middle school (Riesch, Anderson, & Krueger, 2006). Therefore, intervention programs should be developed to prevent IA among early adolescents, especially in elementary school settings that are often on the front line for the identification of potentially life-threatening behaviors (Kim et al., 2006). It is important that nursing professionals and school nurses consider PPD as an antecedent to IA in early adolescents. Also, we recommend paying attention to anxiety-depression and/or aggression as a proxy for detecting teens who may be at risk of IA. In sum, nursing professionals and school nurses should take sex differences into consider- ation when developing prevention and interven- tion strategies for early adolescents’ IA. Based on these results, more gender-specific selective pre- vention and interventions for IA can be cost- effective and efficient in Korean early adolescents.

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