EVALUATION OF AN INTERNET ADDICTION TREATMENT
PROGRAM FOR CHDIESE ADOLESCENTS IN HONG KONG
Daniel T. L. Shek, Vera M. Y. Tang, and C. Y. Lo
This paper described an indigenous multi-level counseling progreun designed
for young people with Internet addiction problems based on the responses of
59 clients. Regarding objective outcome evaluation, pretest and posttest data
generally showed that the Internet addiction problems of the participants de-
creased after joining the program and there were some slight positive changes
in the parenting attributes. For the subjective outcome evaluation findings,
participants generally perceived that the program was helpful. Findings based
on these two evaluation strategies suggest this multi-level indigenous counsel-
ing program has promise for helping young people with Internet addiction
Despite the high speed of information flow and potential educational
value of the Internet, several of its attributes may foster addictive
behavior. These include easy access 24 hours a day, anonymity, provi-
sion for free, diversified, and an unlimited numher of social networks
without geographical boundaries, greater control over one's self-pre-
sentation, and provision of numerous opportunities to fulfill the need
for belongingness as well as escape from emotional difficulties, prob-
lematic situations, and personal hardships (Bayraktar & Gun, 2007;
Young, 1999a). Young (1999h) pointed out that Internet addiction ad-
versely affected physical health, family life, and academic perfor-
mance. Research studies in the Western (e.g., Kaltiala-Heino,
Lintonen & Rimpelä, 2004; Johansson & Götestam, 2004) and Asian
contexts (e.g., Kim et al., 2006; Ko et al., 2007; Shek, Tang, & Lo, in
press) suggest that the risk of Internet addiction among young people
The Youngster Internet Addiction Prevention and Counseling Service under-
taken by the Jockey Club Wah Ming Lutheran Integrated Service Centre,
Hong Kong Lutheran Social Service, LC-HKS was funded by the Community
Chest of Hong Kong. Preparation for this paper was financially supported by
the. Wofoo Foundation Limited.
Requests for reprints should be sent to Daniel T. L. Shek, Social Welfare
Practice and Research Centre, Department of Social Work, The Chinese Uni-
versity of Hong Kong, Shatin, Hong Kong (e-mail address: danielshek®
ADOLESCENCE, Vol. 44, No. 174, Summer 2009
Libra Publishers, Inc., 3089C Clairemont Dr., PMB 383, San Diego, CA 92117
In response to the increasing risk of Internet addiction and its nega-
tive eonsequenees, there is a need to explore intervention models. Un-
fortunately, a survey of the literature shows that there are only a few
treatment programs for Internet addietion, sueh as group therapy with
a combination of Readiness to Change (RtC), Cognitive Behavioral
Therapy (CBT), and Motivational Interviewing (MI) interventions (Or-
zack et al., 2006), as well as Reality therapy group counsehng programs
(Kim, 2007). Some of the programs were developed to help chents with
specific addictions, such as Internet-addicted sexual behavior, but the
protocols of those programs were not presented in detail. In addition,
the effectiveness of those programs is not altogether elear.
Since the effective intervention models for Internet addiction prob-
lems in Chinese culture are almost non-existent, an indigenous multi-
level counseling program was designed to provide services for young
people who displayed Internet addictive behavior in Hong Kong. This
program was part of a project entitled "Youngster Internet Addiction
Prevention and Counseling Sendee" funded by the Community Chest
of Hong Kong, whieh was launched by the Jockey Club Wah Ming
Lutheran Integrated Service Centre, Hong Kong Lutheran Social Ser-
vice, Lutheran Chureh-Hong Kong Synod (LC-HKS).
Based on a thorough review of the literature on intervention strate-
gies and teehniques used in the fields of substanee abuse, family eoun-
seling, and peer support groups (e.g.. Gross, 1996; Kurtz, 2001;
Miller & RoUnick, 1991; Otto, 1999; Washton, 2001), a multi-level in-
tervention model with the following features was developed:
1. Emphasis on controlled and healthy use of the Internet: Instead
of proposing complete abstinenee of Internet use, it is argued
that Internet use is intrinsieally neutral. As sueh, eontroUed and
healthy use was regarded as the desired outcome.
2. Understanding the change process in adolescerits with Internet
addiction behavior: In the change model (Proehaska & DiClem-
ente, 1984, 1986), there are several stages in the process of
change, including pre-contemplation, contemplation, determina-
tion, action, maintenance, and relapse. This model was used in
the present context in order to understand the needs of adoles-
cents with Internet addietion problems and of their family mem-
bers. In the intervention model, counseling tasks in relation to
these different stages of change were devised.
3. Utilization of motivational interviewing model: Motivational in-
terviewing is a directive, client-centered counseling style for elic-
iting behavior change by helping clients explore and resolve
ambivalence (RoUnich & Miller, 1995). It assumes that the re-
sponsibility and capability for change are within the client.
4. Adoption ofa family perspective: Internet addiction often occurs
in the family context which results in serious conflicts between
the adolescents and their parents. Since there are family theories
and research suggesting that etiological family factors as well as
therapeutic factors underlying addiction problems, family-based
counseling is considered important in this pilot project. The sys-
temic view, which is the foundation of different family therapies,
was employed as the theoretical backdrop of family-based coun-
seling utilized in this project.
5. Multi-level counseling model: Since a multi-level counseling
model is effective in helping people with addictive behavior, an
intervention model incorporating an individual counseling com-
ponent, a family counseling component, and a peer support com-
ponent was developed. The techniques intrinsic to the individual-
based (Miller, 1995; Treasure, 2004) and family-based (Hanna &
Brown, 1995) counseling models are briefly introduced in Table 1.
6. Utilization of case work and group work: Since peer relations are
very important in adolescent development, a peer support group
approach was used as a supplement to the casework approach.
With the use of group djmamics, mutual support, and modeling
opportunities, group members can learn from each other.
A detailed description of the features of the intervention model and
the intervention process can be seen in Shek, Tang, and Working
Group of @er.com (2008). To evaluate the effectiveness of this multi-
level counseling model, different strategies including objective outcome
evaluation, subjective outcome evaluation, and qualitative evaluation
were adopted. In this paper, evaluation findings based on objective and
subjective outcome evaluations are presented.
Participants and Procedures
A total of 59 participants joined the counseling program, (generally
speaking, those who were identified as Internet addicts by one of the
assessment tools as described below were eligible for the service. How-
ever, one participant did not meet the above assessment criteria. Since
he almost met the diagnostic criteria ofthe Chinese Internet Addiction
Table 1 : Summary of individual-based counseling and
family-based counseling techniques
Elicitation of self-motiyational statements.
Handling resistance of changing Internet addictive behavior
Discussion of good things and less good things about current
Discussion of pros and cons of changing Internet addictive
behavior in future.
Values exploration and identification of the discrepancies
between values and current\online behavior
• Identification and discussion ofthe stages of change.
• Application of OARS (Open-end questions. Affirmations,
Reflective listening, and Summarization).
Feedback on online behavior through objective assessment on
Construction of personal inventory of activities stopped
engaging after addicted to Internet and the impacts.
Construction of behavioral contract for Internet use.
Development of career plan.
Refi'aming the symptoms of internet addiction.
Dealing with unbalanced family power structure.
Resolution of conflicts and facilitation of congruent
Identification and discussion ofthe stages of change.
(Young's 10-item) Scale (i.e., he responded "Yes" to 3 of the questions)
and his family members desperately wanted him to be helped, service
Of the program participants 58 were male and 1 was female. Most
of them were in early adolescence (aged 11 to 15; N = 29) and late
adolescence (aged 16 to 18; N = 27), while 3 participants were over
18. The educational background of the participants was: primary edu-
cation (N = 7); Secondary 1 to Secondary 3 (iV = 33), Secondary 4 to
Secondary 5(N = 18); Secondary 6 and above (N = 1). Different sources
of referral for the participants were identified, including school social
workers (N = 27), parents (N = 22), teachers (N = 5), non-school social
workers (N = 4), and sibling (N = 1).
Pretest and posttest scores based on different assessment tools were
collected from 22 of the 59 participants, whereas subjective outcome
evaluation data were collected from 27 participants. The factors con-
tributing to the final sample size are presented in Table 2.
A one-group pretest-posttest design involving pretest and posttest
assessment data collected from the participants was adopted to deter-
mine changes in the participants. At the pretest and posttest sessions,
participants were asked to complete a self-administered questionnaire
that included different measures of Internet addiction behavior, beliefs
and behavior related to Internet usage, perceived parenting, family
functioning, and psychological well-being. At posttest, participants re-
sponded to a subjective outcome evaluation tool.
Objective Outcome Assessment
Assessment of Internet addiction behavior. To obtain a comprehen-
sive assessment of Internet addiction, four measures were used. Three
versions of Young's assessment tools were used (Shek, Tang, & Lo,
in press). These included the 10-item, 8-item and 7-item measures
(Griffiths, 1998; Suler, 2004; Young, 1999b). In addition, the assess-
ment scale based on Goldberg's framework (Suler, 1998) was employed.
For Young's 10-item scale (CIA-YounglO), a respondent who answers
"Yes" to four or more of the questions is defined as "Internet depen-
dent." For Yoiing's 8-item scale (CIA-Young8) one who answers "Yes"
to five or more of the questions and does not present with manic symp-
toms is defined as "Internet dependent." For Young's 7-item scale (CIA-
Young7), one who meets three or more criteria is defined as "Internet
dependent." Finally, for the Chinese Internet Addiction Scaie'(CIÄ^
Goldberg), one who meets three or more criteria is defined as having
"Internet Addiction Disorder."
Table 2: Reasons for unsuccessful collection of data from the
participants involving in the two evaluation strategies
Total number of cases in the Program: N=59
Cases with pretest data and posttest data: N=22
Cases with subjective outcome evaluation data: N=27
Reasons for unsuccessful
collection of pretest and
posttest data from the cases
Reasons foi^ unsuccessful
collection of subjective
outcome evaluation data
from the cases
Newly intake cases
Unwilling to fill in questionnaires
Unwilling to fill in
Unable to make arrangement before deadline
Unable to make
No questionnaire is filled
Assessment of beliefs and behavior of using Internet. To understand
the beliefs (e.g., benefits to self, harms of addiction), and behavior
(e.g., interpersonal encounters, Internet as a form of coping) of using
Internet among the participants, 34 items were designed hy the first
and second authors, with 13 items modeled after those assessing the
beliefs and behavior of cough medicine ahuse among adolescents used
in the study hy Shek and Lam (2006), and 21 items were modified in
several available measures. These ineiuded 7 items from the Computer
Use Survey (Pratarelli, Browne, & Johnson, 1999), 6 items from the
Online Cognition Seale (OCS) (Davis, Flett, & Besser, 2002), 6 items
from the Internet Addietion-Related Pereeptions and Attitudes Seale
(Xie & Yang, n.d.), and 2 items from the IAD-Related Experienee Scale
j^sessment of use of Internet. Based on a review of the literature in
both Western and Chinese eommunities (Egger & Rauterberg, 1996;
Pratarelli, Browne, & Johnson, 1999; Commission on Youth, 2001), 14
items were developed by the first and second authors to xmderstand
the frequency of using the Internet and the activities engaged in (e.g.,
playing on-line games, downloading software, meeting new friends) in
the last twelve months among the respondents. In addition, two self-
assessed Internet addiction/dependence questions were developed: "Do
you consider yourself to be addicted to the Internet?" and "Do you
consider that you excessively use or are dependent on the Internet to
satisfy different kinds of need?" Responses were on a 5-point scale (1
= definitely not to 5 = absolutely yes).
Assessment of perceived parental monitoring and demandingness.
Parental monitoring and demandingness were assessed by 6 items.
These were modeled after those of monitoring (Shek, 2006) and de-
mandingness (Shek, 2007a, 2007b) used in previous studies.
Assessment of perceived family functioning. The 33-item Chinese
Family Assessment Instrument (C-FAI) was developed by Shek (2002)
to measure family functioning in Chinese populations.
Measures of psychological well-being. Several measures were used
to assess psychological well-being of the program participants. These
included the Chinese Purpose in Life Questionnaire (Shek, 1999), Chi-
nese Beck Depression Inventory (Shek, 1990), Chinese Hopelessness
Seale (Shek, 1993), and Chinese Rosenberg Self-Esteem Seale (Shek
Subjective Outcome Assessment
In the present study, program participants were invited to determine
the degree of agreement (1 = totally agree to 5 = totally disagree) with
reference to the following items:
• The objectives of the participant have been achieved via coun-
• The counseling service was helpful.
• I have learned how to deal with my own problems through coun-
• Compared with the first time I received counseling, I feel much
• Compared with the first time I received counseling, I am more
able to solve my problems.
Participants were also requested to provide a score within the range
of 0 to 100 (with 50 as the passing mark) to the counseling service.
Finally, participants were asked to indicate whether they would recom-
mend that others use the counseling service and would use the service
again if they had the need.
After establishing a relationship, the client was asked to fill out
the pretest assessment containing the above instruments; after the
program was completed (15 to 19 months, depending on the service
(i.e., individual-based counseling, family-based counseling, group ser-
vice, voluntary service and interest class) needed by each client, the
client was invited to respond to both posttest assessment and subject
outcome assessment. Informed consent was obtained from all partici-
pants. All assessments were provided in a self-administered format.
For those who had problems comprehending the content, the worker
read the questionnaire and explained it to them.
Regarding the objective outcome evaluation, changes in participants
were examined with reference to the pretest and posttest scores (Table
3). Several observations can be highlighted from the analyses: (a) parti-
cipants generally showed a reduction in Internet addiction S3miptoms
as assessed by different measures of addiction; (b) using the composite
scores of beliefs and behavior related to Internet use, there were no
differences between pretest and posttest scores, (c) there were some
differences between pretest and posttest scores on the measures of
perceived parental monitoring and family functioning; and (d) there
were generally no differences between pretest and posttest scores on
the measures of psychological well-being.
Examination ofthe findings based on subjective outcome evaluation
showed that participants generally had positive perceptions ofthe pro-
gram. The major findings presented in Table 4 can be summarized as
follows: (a) all participants agreed that the objectives had been
achieved via counseling; (b) all participants regarded the coimseling
as helpful; (c) a high proportion of the respondents (92.5%) agreed
that they had learned how to deal with their own problems through
counseling; (d) all participants agreed that they felt much better as
Table 3: Pretest and posttest scores on different measures of Internet
t value Wilcoxon
Internet Addiction Symptoms
Sum of Internet addiction
symptoms (22 items)
Beliefs and Behavior of Using Internet
Sum of 34 items
Perceived Parenting and Family Functioning
Maternal knowledge about
Maternal knowledge about
after school activities
Paternal knowledge about
after school activities
Chinese Family Assessment
Chinese Purpose in Life
Chinese Beck Depression
Chinese Hopelessness Scale
Chinese Rosenberg Self-
Esteem Scale (ESTEEM)
** p< .01 (two-tailed)
* ;?<.05 (two-tailed)
a p <.05(one-tailed)
Table 4: Percentages of responses to the items in the subjective
outcome evaluation questionnaire
4 3 2
1. The objectives of the case
have been achieved via
2. The counseling service was
3. I have learned how to deal
with my own problems
4. Compared with the first
time I received counseling,
I felt much better now.
5. Compared with the first
time I received counseling,
I was more able to solve
11.1 40.7 48.1 0.0 0.0
22.2 37.0 33.3 7.4 0.0
14.8 48.1 37.0 0.0 0.0
7.7 46.2 42.3 3.8 0.0
counseling service (0 to
100 with 50 as the passing
given to the
38.57. If my friend has a need, I
will recommend him/her
for the service.
8. If I have the need, I will
use the service again.
Note: 5 =Totally Agree. 4 ^Moderately Agree. 3 =Mildly Agree.
2 =Moderately Disagree. 1 =Totally Disagree.
compared with the first time they received counseling; and (e) a high
proportion of the respondents (96.2%) agreed that they were more able
to solve their own problems as compared with the first time they re-
A survey of the literature shows that research studies documenting
the effectiveness of Internet addiction treatment programs are scarce,
particularly in the Chinese culture. As such, a research design involv-
ing objective outcome evaluation based on a pre-experimental design
(one group pretest-posttest design) and subjective outcome evaluation
was adopted in this study to evaluate an indigenously developed multi-
level counseling program. There are several characteristics of this
treatment model, including the emphasis on controlled and healthy
use of the Internet, understanding the change process in adolescents
with Internet addiction behavior, utilization of a motivational inter-
viewing model, adoption of a family perspective, use of a multi-level
counseling model, and of individual and group counseling. It is note-
worthy that this is an intervention model based on an integration of
the research findings, particularly those hased on the field of suh-
Two comments can be made regarding the design of the evaluation
study. First, this is a pioneering study that utilized two strategies in
evaluating an indigenously developed Internet addiction counseling
program. A review of the existing literature shows that this is the first
known scientific study that attempts to rigorously evaluate an Internet
addiction counseling program from different angles in a Chinese con-
text. In view of the lack of evaluation studies in different Chinese
contexts (Shek, Lam, & Tsoi, 2004), this study constitutes a significant
contribution to the academic and professional literature.
Second, collection of objective and suhjective outcome evaluation
data permits triangulation of the data. Borrowing concepts from navi-
gation and military disciplines, Denzin (1978) used the term "triangu-
lation" to argue for the utilization of different types of data hased on
different methodologies to examine the same phenomenon. The basic
belief underljdng the concept of triangulation is that there are biases
in any one type of investigation and such hiases and errors would he
revealed and cancelled out when different methods, data sources, and/
or investigators are involved. In other words, triangulation refers to
the process of seeking convergence of results hased on different meth-
ods, researchers, and settings on the same phenomenon under observa-
tion. Evaluators generally suggest that triangulation is an important
principle that should he utilized to check the quahty of evaluation data
(Shek & Siu, 2006). In this study, triangulation hy different methods
(ohjective and suhjective outcome evaluations) was carried out.
The objective outcome evaluation findings showed that the Internet
addiction symptoms generally decreased after intervention. There
were also some positive changes in parental monitoring in the process.
These changes could be regarded as impressive in view of the small
sample size involved. Nevertheless, although these ehanges provide
some support for the usefulness of the intervention, threats to internal
validity underlying pre-experimental designs should be reeognized. In
addition, it should be noted that there were not much positive change
in beliefs about the Internet, family functioning, and psychological
well-being. These findings may be attributable to the low power of the
statistical tests based on such a small sample.
The subjeetive outeome evaluation findings suggest that partieipants
were satisfied with the program and pereeived it to be helpful in reduc-
ing their Internet addietion symptoms. Subjeetive outcome evaluation
or a client satisfaetion survey is eommonly used to assess pereeived
benefits and degree of satisfaction with different aspects of the pro-
gram. The use of subjective outcome indicators or the client satisfaction
approach in evaluation has a long history in hvmian services in differ-
ent cultures (Shek, Siu, & Lee, 2007). Although there are arguments
against the use of subjeetive outcome assessment, there is evidence
that it correlated with objective outcome measures (Shek, Lee,; Siu, &
Both objective and subjeetive evaluation findings elearly suggest
that the program is effective. Because no known evaluation study of
an Internet addiction counseling program utilizing different evaluation
approaches has been carried out in different Chinese contexts, present
findings eontribute to the limited literature on Internet addietion eoun-
seling. In addition, the present study serves as an example of how
programs in the soeiai services context can be rigorously evaluated.
Nevertheless, there are several limitations of the present study. First,
because there was no control group in the objective outcome evalua-
tion, threats to internal validity and alternative explanations should
be considered. Seeond, for different reasons, not all partieipants joined
the evaluation. As such, sample attrition bias might affect the result.
In addition, it would be desirable if a large sample could be recruited
for the objective outcome evaluation.
Despite these limitations, an integration and triangulation of these
two sources of evaluation data clearly suggest that participants in the
program displayed positive change as far as Internet use and family
processes are concerned. These findings suggest that the program can
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