Relationship between Anxiety and Problematic Smartphone Use in First-Year Junior High School Students: Moderated Mediation Effects of Physical Activity and School Adjustment
Abstract
:1. Introduction
1.1. Anxiety and Problematic Smartphone Use
1.2. School Adjustment as a Mediator
1.3. Physical Activity as a Moderator
1.4. Present Study
2. Method
2.1. Participants
2.2. Measures
2.2.1. Physical Activity Rating Scale
2.2.2. Smartphone Addiction Scale
2.2.3. Depression Anxiety Stress Short Version Scale
2.2.4. School Adjustment Scale
2.3. Data Analysis
3. Result
3.1. Preliminary Analyses
3.2. Mediation Analyses
3.3. Moderated Mediation Analyses
4. Discussion
4.1. Relationship between Anxiety and Problematic Smartphone Use
4.2. Mediating Effect of School Adjustment on the Relationship between Anxiety and Problematic Smartphone Use
4.3. Moderating Effect of Physical Activity on the Relationship between Anxiety and School Adjustment
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- CNNIC. The 52nd Statistical Report on China’s Internet Development; CNNIC: Beijing, China, 2023. [Google Scholar]
- Kuss, D.J.; Harkin, L.; Kanjo, E.; Billieux, J.J. Problematic smartphone use: Investigating contemporary experi-ences using a convergent design. Int. J. Environ. Res. Public Health 2018, 15, 142. [Google Scholar] [CrossRef] [PubMed]
- Horwood, S.; Anglim, J. Personality and problematic smartphone use: A facet-level analysis using the Five Factor Model and HEXACO frameworks. Comput. Hum. Behav. 2018, 85, 349–359. [Google Scholar] [CrossRef]
- Lapointe, L.; Boudreau-Pinsonneault, C.; Vaghefi, I. Is smartphone usage truly smart? A qualitative investigation of IT addictive behaviors. In Proceedings of the 2013 46th Hawaii International Conference on System Sciences, Wailea, HI, USA, 7–10 January 2013; IEEE: Piscataway, NJ, USA, 2013; pp. 1063–1072. [Google Scholar]
- Turel, O.; Serenko, A.; Bontis, N.J.A.P. Blackberry addiction: Symptoms and outcomes. In Proceedings of the AMCIS 2008 Proceedings, Toronto, ON, Canada, 14–17 August 2008; p. 73. [Google Scholar]
- Soror, A.A.; Steelman, Z.R.; Limayem, M. Discipline yourself before life disciplines you: Deficient self-regulation and mobile phone unregulated use. In Proceedings of the 2012 45th Hawaii International Conference on System Sciences, Maui, HI, USA, 4–7 January 2012; IEEE: Piscataway, NJ, USA, 2012; pp. 849–858. [Google Scholar]
- Aktürk, Ü.; Budak, F.; Gültekin, A.; Özdemir, A. Comparison of smartphone addiction and loneliness in high school and university students. Perspect. Psychiatr. Care 2018, 54, 564–570. [Google Scholar] [CrossRef]
- Wang, P.; Liu, S.; Zhao, M.; Yang, X.; Zhang, G.; Chu, X.; Wang, X.; Zeng, P.; Lei, L. How is problematic smartphone use related to adolescent depression? A moderated mediation analysis. Child. Youth Serv. Rev. 2019, 104, 104384. [Google Scholar] [CrossRef]
- Alhassan, A.A.; Alqadhib, E.M.; Taha, N.W.; Alahmari, R.A.; Salam, M.; Almutairi, A.F. The relationship between addiction to smartphone usage and depression among adults: A cross sectional study. BMC Psychiatry 2018, 18, 148. [Google Scholar] [CrossRef]
- Cho, H.; Kim, D.J.; Park, J.W. Stress and adult smartphone addiction: Mediation by self-control, neuroticism, and extraversion. Stress Health 2017, 33, 624–630. [Google Scholar] [CrossRef] [PubMed]
- Li, L.; Lin, T.T.C. Smartphones at work: A qualitative exploration of psychological antecedents and impacts of work-related smartphone dependency. Int. J. Qual. Methods 2019, 18. [Google Scholar] [CrossRef]
- Busch, P.A.; McCarthy, S. Antecedents and consequences of problematic smartphone use: A systematic literature review of an emerging research area. Comput. Hum. Behav. 2020, 114, 106414. [Google Scholar] [CrossRef]
- Xie, A.; Yang, Y. Relationship between Adult Attachment and School Adjustment of College Freshmen. Chin. J. Clin. Psychol. 2015, 23, 339–342. [Google Scholar] [CrossRef]
- Li, D.H. A Study on Stress and Adaptation of Secondary School Students during School Transition and Their Coping Resources. Ph.D. Thesis, Beijing Normal University, Beijing, China, 2004. [Google Scholar]
- Troy, A.S.; Mauss, I.B. lifespan mhCat: Resilience in the face of stress: Emotion regulation as a protective factor. Resil. Ment. Health 2011, 1, 30–44. [Google Scholar] [CrossRef]
- Minami, M.; Asakawa, K.; Akimitsu, K.; Nishimura, A. School adjustment and anticipatory anxiety about the transition from elementary school to junior high school: A school psychology study. Jpn. J. Educ. Psychol. 2011, 59, 144–154. [Google Scholar] [CrossRef]
- Elhai, J.D.; Levine, J.C.; Dvorak, R.D.; Hall, B.J. Non-social features of smartphone use are most related to depression, anxiety and problematic smartphone use. Comput. Hum. Behav. 2017, 69, 75–82. [Google Scholar] [CrossRef]
- Kim, S.-E.; Kim, J.-W.; Jee, Y.-S. Relationship between smartphone addiction and physical activity in Chinese international students in Korea. J. Behav. Addict. 2015, 4, 200–205. [Google Scholar] [CrossRef] [PubMed]
- Beranuy, M.; Oberst, U.; Carbonell, X.; Chamarro, A. Problematic Internet and mobile phone use and clinical symptoms in college students: The role of emotional intelligence. Comput. Hum. Behav. 2009, 25, 1182–1187. [Google Scholar] [CrossRef]
- Elhai, J.D.; Dvorak, R.D.; Levine, J.C.; Hall, B.J. Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology. J. Affect. Disord. 2017, 207, 251–259. [Google Scholar] [CrossRef] [PubMed]
- Kardefelt-Winther, D. A conceptual and methodological critique of internet addiction research: Towards a model of compensatory internet use. Comput. Hum. Behav. 2014, 31, 351–354. [Google Scholar] [CrossRef]
- Elhai, J.D.; Tiamiyu, M.; Weeks, J. Depression and social anxiety in relation to problematic smartphone use. Internet Res. 2018, 28, 315–332. [Google Scholar] [CrossRef]
- Zhitomirsky-Geffet, M.; Blau, M. Cross-generational analysis of predictive factors of addictive behavior in smartphone usage. Comput. Hum. Behav. 2016, 64, 682–693. [Google Scholar] [CrossRef]
- Vahedi, Z.; Saiphoo, A. The association between smartphone use, stress, and anxiety: A meta-analytic review. Stress Health J. Int. Soc. Investig. Stress 2018, 34, 347–358. [Google Scholar] [CrossRef]
- Brand, M.; Young, K.S.; Laier, C.; Wölfling, K.; Potenza, M.N. Integrating psychological and neurobiological considerations regarding the development and maintenance of specific Internet-use disorders: An Interaction of Person-Affect-Cognition-Execution (I-PACE) model. Neurosci. Biobehav. Rev. 2016, 71, 252–266. [Google Scholar] [CrossRef]
- Heo, Y.; Lee, K. Smartphone addiction and school life adjustment among high school students: The mediating effect of self-control. J. Psychosoc. Nurs. Ment. Health Serv. 2018, 56, 28–36. [Google Scholar] [CrossRef] [PubMed]
- Lee, J.; Cho, B. Effects of self-control and school adjustment on smartphone addiction among elementary school students. Int. J. Contents 2015, 11, 1–6. [Google Scholar] [CrossRef]
- Jang, S.-H.; Cho, K.-D. Effects of depression scale, interaction anxiety and school adjustment on cellular phone addiction of teenagers. J. Korea Contents Assoc. 2010, 10, 285–293. [Google Scholar] [CrossRef]
- Choe, C.; Yu, S. The reciprocal relationship between mobile phone dependence and school adaptation in Korean adolescents: Autoregressive cross-lagged modeling. Acta Psychol. 2022, 228, 103628. [Google Scholar] [CrossRef]
- Jiang, S.; Ren, Q.; Jiang, C.; Wang, L. Academic stress and depression of Chinese adolescents in junior high schools: Moderated mediation model of school burnout and self-esteem. J. Affect. Disord. 2021, 295, 384–389. [Google Scholar] [CrossRef]
- Liu, Y.; Long, J.; Billieux, J.; Qi, C.; He, H.; Chen, S.; Wu, Q.; Xiong, Y.; Liu, T. Problematic smartphone use and its relation with anxiety and depression: A survey in a large sample of undergraduates. China Med. Abstr. (Intern. Med.) 2017, 50, 270–275. [Google Scholar]
- Eoh, Y.; Lee, E.; Park, S.H. The relationship between children’s school adaptation, academic achievement, happiness, and problematic smartphone usage: A multiple informant moderated mediating model. Appl. Res. Qual. Life 2022, 17, 3579–3593. [Google Scholar] [CrossRef]
- Caspersen, C.J.; Powell, K.E.; Christenson, G.M. Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Rep. 1985, 100, 126–131. [Google Scholar]
- Yan, J.; Tao Bl Shi, L.; Lou, H.; Li, H.Y.; Liu, M. The relationship between extracurricular physical activity and school adaptation among adolescents: A chain mediation model and gender differences. Chin. Sports Sci. Technol. 2020, 56, 11–18. [Google Scholar] [CrossRef]
- Yang, G.; Li, Y.; Liu, S.; Liu, C.; Jia, C.; Wang, S. Physical activity influences the mobile phone addiction among Chinese undergraduates: The moderating effect of exercise type. J. Behav. Addict. 2021, 10, 799–810. [Google Scholar] [CrossRef]
- Shi, M.; Zhai, X.; Li, S.; Shi, Y.; Fan, X. The relationship between physical activity, mobile phone addiction, and irrational procrastination in Chinese college students. Int. J. Environ. Res. Public Health 2021, 18, 5325. [Google Scholar] [CrossRef]
- Penglee, N.; Christiana, R.W.; Battista, R.A.; Rosenberg, E. Smartphone use and physical activity among college students in health science-related majors in the United States and Thailand. Int. J. Environ. Res. Public Health 2019, 16, 1315. [Google Scholar] [CrossRef]
- Yang G, Li Y, Liu H, Wang SJJoPE: Analysis of the relationship between physical exercise and cellphone dependence of university students in Guangzhou. J. Phys. Educ. 2020, 27, 117–125. [CrossRef]
- Yang, G.; Tan, G.-X.; Li, Y.-X.; Liu, H.-Y.; Wang, S.-T. Physical exercise decreases the mobile phone dependence of university students in China: The mediating role of self-control. Int. J. Environ. Res. Public Health 2019, 16, 4098. [Google Scholar] [CrossRef]
- Zhong, W.; Wang, Y.; Zhang, G. The impact of physical activity on college students’ mobile phone dependence: The mediating role of self-control. Int. J. Ment. Health Addict. 2020, 19, 2144–2159. [Google Scholar] [CrossRef]
- Taylor-Covill, G.A. The Role of Energetic Resources on Perception and Physical Activity Choices. Ph.D. Thesis, University of Birmingham, Birmingham, UK, 2013. [Google Scholar]
- Gaudlitz, K.; Lindenberger, B.L.V.; Strhle, A. Physical Activity and Anxiety: Lifestyle Medicine, 2nd ed.; CRC Press: Boca Raton, FL, USA, 2013; ISBN 978-1-4398-4542-4. [Google Scholar] [CrossRef]
- De Moor, M.; Beem, A.; Stubbe, J.; Boomsma, D.; De Geus, E. Regular exercise, anxiety, depression and personality: A population-based study. Prev. Med. 2006, 42, 273–279. [Google Scholar] [CrossRef] [PubMed]
- Nakagawa, T.; Koan, I.; Chen, C.; Matsubara, T.; Hagiwara, K.; Lei, H.; Hirotsu, M.; Yamagata, H.; Nakagawa, S. Regular Moderate- to Vigorous-Intensity Physical Activity Rather Than Walking Is Associated with Enhanced Cognitive Functions and Mental Health in Young Adults. Int. J. Environ. Res. Public Health 2020, 17, 614. [Google Scholar] [CrossRef]
- Tali, E.; Potharst, E.S.; de Bruin, E.I.; Utens, E.M.W.J. Self-Compassion and Anxiety in Adolescents with and without Anxiety Disorder. Children 2023, 10, 1181. [Google Scholar] [CrossRef]
- Elhai, J.D.; Levine, J.C.; Dvorak, R.D.; Hall, B.J. Fear of missing out, need for touch, anxiety and depression are related to problematic smartphone use. Comput. Hum. Behav. 2016, 63, 509–516. [Google Scholar] [CrossRef]
- Kim, J.; Seo, M.; David, P. Alleviating depression only to become problematic mobile phone users: Can face-to-face communication be the antidote? Comput. Hum. Behav. 2015, 51, 440–447. [Google Scholar] [CrossRef]
- Ooi, L.L.; Nocita, G.; Coplan, R.J.; Zhu, J.; Rose-Krasnor, L. Beyond bashful: Examining links between social anxiety and young children’s socio-emotional and school adjustment. Early. Child. Res. Q 2017, 41, 74–83. [Google Scholar] [CrossRef]
- Xie, J.Q.; Zimmerman, M.A.; Rost, D.H.; Yin, X.Q.; Wang, J.L. Stressful life events and problematic smartphone usage among Chinese boarding-school adolescents: A moderated mediation model of peer support and depressive symptoms. Addict. Res. Theory 2020, 28, 493–500. [Google Scholar] [CrossRef]
- Cho, G.S.; Choi, Y.J. The Relationship between Ego-Resilience, Mattering and School Life Adjustments of Elementary Students Participating in Physical Activity after School. J. Digital. Converg. 2016, 14, 477–487. [Google Scholar] [CrossRef]
- Liang, D.Q. Stress levels of college students and their relationship with physical activity. Chin. J. Ment. Health 1994, 1, 5–6. [Google Scholar]
- Kwon, M.; Kim, D.-J.; Cho, H.; Yang, S. The Smartphone Addiction Scale: Development and Validation of a Short Version for Adolescents. PLoS ONE 2013, 8, e83558. [Google Scholar] [CrossRef] [PubMed]
- Chen, B.; Liu, F.; Ding, S.; Ying, X.; Wang, L.; Wen, Y. Gender differences in factors associated with smartphone addiction: A cross-sectional study among medical college students. BMC Psychiatry 2017, 17, 1–9. [Google Scholar] [CrossRef]
- Lovibond, P.F.; Lovibond, S.H. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav. Res. Ther. 1995, 33, 335–343. [Google Scholar] [CrossRef]
- Wang, K.; Shi, H.-S.; Geng, F.-L.; Zou, L.-Q.; Tan, S.-P.; Wang, Y.; Neumann, D.L.; Shum, D.H.K.; Chan, R.C.K. Cross-cultural validation of the Depression Anxiety Stress Scale–21 in China. Psychol. Assess. 2016, 28, e88–e100. [Google Scholar] [CrossRef]
- Cui, N. A Study on the Correlation between School Adjustment and Self-Concept of Junior High School Students. Ph.D. Thesis, Southwestern University, Chongqing, China, 2008. [Google Scholar]
- Jin, B.; Park, N. In-Person Contact Begets Calling and Texting: Interpersonal Motives for Cell Phone Use, Face-to-Face Interaction, and Loneliness. Cyberpsychol. Behav. Soc. Netw. 2010, 13, 611–618. [Google Scholar] [CrossRef]
- Shen, X.; Ran, G.M. The effect of social anxiety on smartphone overuse: The mediating role of loneliness and motivation. Psy-Chological Res. 2018, 11, 570–576. [Google Scholar]
- Whang, L.S.-M.; Lee, S.; Chang, G. Internet over-users’ psychological profiles: A behavior sampling analysis on internet addiction. CyberPsychology Behav. 2003, 6, 143–150. [Google Scholar] [CrossRef]
- Hartanto, A.; Yang, H. Is the smartphone a smart choice? The effect of smartphone separation on executive functions. Comput. Hum. Behav. 2016, 64, 329–336. [Google Scholar] [CrossRef]
- Jang, S.H.; Kim, S.J.; Choi, S.Y.; Lee, J.Y. The effect of self-esteem, school adjustment, mental health on elementary school students cellular phone addiction. J. Child Educ. 2013, 22, 243–256. [Google Scholar]
- Lee, K.N. The effects of children’s perception of communications with mothers and self-control on game addiction. J. Korean Home Econ. Assoc. 2003, 41, 77–91. [Google Scholar]
- Aljomaa, S.S.; Al Qudah, M.F.; Albursan, I.S.; Bakhiet, S.F.; Abduljabbar, A.S. Smartphone addiction among university students in the light of some variables. Comput. Hum. Behav. 2016, 61, 155–164. [Google Scholar] [CrossRef]
- Eisner, M.D.; Blanc, P.D.; Yelin, E.H.; Katz, P.P.; Sanchez, G.; Iribarren, C.; Omachi, T.A. Influence of anxiety on health outcomes in COPD. Thorax 2010, 65, 229–234. [Google Scholar] [CrossRef] [PubMed]
- Pagani, M.; Giovannetti, A.M.; Covelli, V.; Sattin, D.; Raggi, A.; Leonardi, M. Physical and Mental Health, Anxiety and Depressive Symptoms in Caregivers of Patients in Vegetative State and Minimally Conscious State. Clin. Psychol. Psychother. 2013, 21, 420–426. [Google Scholar] [CrossRef] [PubMed]
- Yang, E.H. An exploration of teacher-student and peer relationships and anxiety among junior high school students. Chin. J. Ment. Health 2001, 15, 78–80. [Google Scholar] [CrossRef]
- Rodgers, A.; Dunsmuir, S. A controlled evaluation of the ‘FRIENDS for Life’ emotional resiliency programme on overall anxiety levels, anxiety subtype levels and school adjustment. Child Adolesc. Ment. Health 2013, 20, 13–19. [Google Scholar] [CrossRef]
- Sowislo, J.F.; Orth, U. Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies. Psychol. Bull. 2013, 139, 213–240. [Google Scholar] [CrossRef]
- Teixeira, P.J.; Carraça, E.V.; Markland, D.; Silva, M.N.; Ryan, R.M. Exercise, physical activity, and self-determination theory: A systematic review. Int. J. Behav. Nutr. Phys. Act. 2012, 9, 1–30. [Google Scholar] [CrossRef]
- Marques, A.; Marconcin, P.; Werneck, A.O.; Ferrari, G.; Gouveia, R.; Kliegel, M.; Peralta, M.; Ihle, A. Bidirectional Association between Physical Activity and Dopamine Across Adulthood—A Systematic Review. Brain Sci. 2021, 11, 829. [Google Scholar] [CrossRef]
- Hwang, J. The Effects of Physical Activity and Time Perspective on School Adjustment of High School Students. Korean J. Phys. Educ. 2017, 56, 209–223. [Google Scholar] [CrossRef]
- Carter, T.; Pascoe, M.; Bastounis, A.; Morres, I.D.; Callaghan, P.; Parker, A.G. The effect of physical activity on anxiety in children and young people: A systematic review and meta-analysis. J. Affect. Disord. 2021, 285, 10–21. [Google Scholar] [CrossRef] [PubMed]
M | SD | 1 | 2 | 3 | 4 | |
---|---|---|---|---|---|---|
1 anxiety | 10.389 | 3.461 | 1 | |||
2 school adjustment | 22.206 | 2.854 | −0.462 ** | 1 | ||
3 problematic smartphone use | 18.133 | 10.229 | 0.392 ** | −0.596 ** | 1 | |
4 physical activity | 27.342 | 22.585 | −0.109 * | 0.244 ** | −0.169 * | 1 |
Predictor | B | SE | t | p | 95% CI |
---|---|---|---|---|---|
gender | 0.403 | 0.242 | 1.662 | 0.097 | [−0.074, 0.879] |
age | −0.1765 | 0.154 | −1.149 | 0.251 | [−0.478, 0.125] |
class | 0.089 | 0.063 | 1.409 | 0.159 | [−0.035, 0.213] |
anxiety | −0.381 | 0.035 | −10.909 | 0.000 | [−0.450, −0.313] |
school adjustment | |||||
R2 | 0.223 | ||||
F | 31.482 *** |
Predictor | B | SE | t | p | 95% CI |
---|---|---|---|---|---|
gender | −1.3350 | 0.779 | −1.713 | 0.087 | [−2.867, 0.197] |
age | −0.646 | 0.493 | −1.311 | 0.191 | [−1.615, 0.323] |
class | 0.087 | 0.202 | 0.429 | 0.668 | [−0.311, 0.485] |
anxiety | 0.475 | 0.126 | 3.759 | 0.000 | [0.227, 0.723] |
school adjustment | −1.883 | 0.153 | −12.321 | 0.000 | [−2.183, −1.582] |
R2 | 0.379 | ||||
F | 53.768 *** |
Predictor | B | SE | t | p | 95% CI |
---|---|---|---|---|---|
gender | 0.570 | 0.238 | 2.400 | 0.017 | [0.103, 1.037] |
age | −0.207 | 0.148 | −1.398 | 0.163 | [−0.498, 0.084] |
class | 0.087 | 0.061 | 1.429 | 0.154 | [−0.033, 0.207] |
anxiety | −0.514 | 0.054 | −9.452 | 0.000 | [−0.621, −0.407] |
physical activity | −0.032 | 0.018 | −1.801 | 0.072 | [−0.066, 0.003] |
anxiety × physical activity | 0.006 | 0.002 | 3.533 | 0.000 | [0.003, 0.009] |
R2 | 0.288 | ||||
F | 29.509 *** |
Predictor | B | SE | t | p | 95% CI |
---|---|---|---|---|---|
gender | −1.629 | 0.733 | −2.224 | 0.027 | [−3.071, −0.189] |
age | −0.646 | 0.493 | −1.311 | 0.1901 | [−1.6151, 0.323] |
class | 0.087 | 0.202 | 0.4297 | 0.668 | [−0.311, 0.485] |
anxiety | 0.475 | 0.126 | 3.759 | 0.000 | [0.227, 0.723] |
school adjustment | −1.883 | 0.153 | −12.321 | 0.000 | [−2.183, −1.582] |
R2 | 0.379 | ||||
F | 53.768 *** |
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Cao, M.; Yang, H.; Chen, D. Relationship between Anxiety and Problematic Smartphone Use in First-Year Junior High School Students: Moderated Mediation Effects of Physical Activity and School Adjustment. Behav. Sci. 2023, 13, 901. https://doi.org/10.3390/bs13110901
Cao M, Yang H, Chen D. Relationship between Anxiety and Problematic Smartphone Use in First-Year Junior High School Students: Moderated Mediation Effects of Physical Activity and School Adjustment. Behavioral Sciences. 2023; 13(11):901. https://doi.org/10.3390/bs13110901
Chicago/Turabian StyleCao, Mei, Haibo Yang, and Duanduan Chen. 2023. "Relationship between Anxiety and Problematic Smartphone Use in First-Year Junior High School Students: Moderated Mediation Effects of Physical Activity and School Adjustment" Behavioral Sciences 13, no. 11: 901. https://doi.org/10.3390/bs13110901
APA StyleCao, M., Yang, H., & Chen, D. (2023). Relationship between Anxiety and Problematic Smartphone Use in First-Year Junior High School Students: Moderated Mediation Effects of Physical Activity and School Adjustment. Behavioral Sciences, 13(11), 901. https://doi.org/10.3390/bs13110901