Participants
This study was a cross-sectional, conducted between January and May 2019. Three private schools were chosen conveniently for this study. Students were randomly chosen from the list given by the school administration. All participants between the age of 9 and 13 years of age were eligible to participate. The students’ parents are those who answered the questionnaire. Prior to participation, parents were briefed on the study objectives and methodology, and were assured of the anonymity of their participation. Parents had the right to accept or refuse participation in the study, with no financial compensation provided in return.
Sample size calculation
The Epi info program [Centers for Disease Control and Prevention (CDC), Epi Info™] was employed for the calculation of the required sample size for our study, with a prevalence of internet gaming disorder of 9.2% among 524 Lebanese high school students from a study done by Hawi et al. [14], with an acceptable margin of error of 5% and design effect of 2. The youth population is estimated to be 585,000 according to the UNDP statistics in Lebanon; the result showed that the biggest required sample size is 256 participants.
Procedure
The questionnaire was distributed to each student in the classroom to be taken home. Parents filled it within 25 min approximately. The completed questionnaires were collected back and sent for data entry. During the data collection process, the anonymity of the participants was guaranteed.
Questionnaire
The self-administered questionnaire used was in Arabic, the native language of Lebanon. The first part assessed the sociodemographic details of the participants (i.e. age, gender, grade, and father and mother education level). The second part of the questionnaire included the following scales:
Game Addiction Scale for Children (GASC)
The 21-item Gaming Addiction Scale (GASC) is an instrument based on DSM criteria to assess gaming addiction. The seven items in the GAS are rated using a five-point Likert scale ranging from 1 (never) to 5 (very often). A higher score on the GAS indicates more problematic use of online gaming. The scale measures 7 criteria of computer addiction: salience, tolerance, mood modification, withdrawal, relapse, conflict and problems [18]. In this study, the Cronbach alpha values for the GAS was 0.948.
Children’s Memory Questionnaire (CMQ)
The CMQ is a 36-item questionnaire designed to assess parents’ perceptions of their children’s memory. The CMQ requires parents to assess their child’s memory based on five possible options: 1 = never or almost never happens; 2 = happens less than once a week; 3 = happens once or twice in a week; 4 = happens about once a day; and 5 = happens more than once a day [19]. Three subscales derived from the total scale representing the episodic memory, visual memory and working memory and attention. The higher the scores, the greater the impairment in the cognition domain [19]. In this study, the Cronbach alpha values for the episodic memory subscale was 0.888, for the visual memory was 0.770 and for the working memory was 0.845.
Clinical attention problems scale
The scale measures the frequency of activity and attention by asking the parent and teacher to respond to a series of 12 statements and their applicability to their child in the morning and afternoon. Response options range from “not true” (0), “somewhat or sometimes true” (1), “very often” or often true (2). The higher the scores, the greater the attention problems exist [20]. In this study, the Cronbach alpha values for the clinical attention problem in the morning and in the afternoon were 0.844 and 0.839 respectively.
Learning, Executive and Attention Functioning (LEAF) Scale
The LEAF is a 55 item self-report questionnaire that assesses executive functions, related neurocognitive functions, and academic skills in children and adults. The LEAF evaluates a broad set of core cognitive abilities as well as related cognitive learning and academic abilities. Cognitive areas assessed by the LEAF include attention, processing speed (including visual-spatial organization skills), and sustained sequential processing to achieve goals (e.g., planning and executing goal-directed behavior), working memory, and novel problem-solving. Also, LEAF includes comprehension and concept formation, declarative/factual memory, and academic functioning. The LEAF contains Academic subscales assessing reading, writing, and math fluency and abilities. LEAF items are grouped by subscale, and all subscales have the same number of items.
The subscales of the LEAF are: (1) comprehension and conceptual learning (tracking and understanding information), (2) factual memory (memorization and retention of facts); (3) attention (sustained focus); (4) processing speed (speed of completing cognitive and behavioral tasks that involve a component of focus and concentration); (5) visual-spatial organization (organization and visual-constructive skills); (6) sustained sequential processing (planning and sustaining effort in order to follow and complete multistep directions and sequences); (7) working memory (remembering and processing multiple things at the same time); and (8) novel problem solving (initiating effort toward processing new or unfamiliar information). (9) Mathematics skills (math calculation difficulty); (10) basic reading skills (reading/phonics difficulty); and (11) written expression skills (limited/impoverished or slow/effortful written expression). Individual items are rated on a 0–3 scale, and a raw subscale score for each of the 11 content areas is created by summing the 5 constituent items, such that higher scores indicate more cognitive problems [21]. In this study, the Cronbach alpha values for the subscales was: comprehension and conceptual learning = 0.961; factual memory = 0.792; attention = 0.901; processing speed = 0.866; visual-spatial organization = 0.729; sustained sequential processing = 0.768; working memory = 0.816; novel problem solving = 0.811; mathematics skills = 0.871; basic reading skills = 0.923 and written expression skills = 0.905.
Translation procedure
The forward translation was done by one translator. An expert committee formed by healthcare professionals and a language professional verified the Arabic translated version. A backward translation was then performed by a second translator, unaware of the initial English version. The back-translated English questionnaire was subsequently compared to the original English one, by the expert committee. Discrepancies related to inadequate expressions and concepts, confusing in meaning and slightly off in meaning during the reconciliation of the back translated questionnaire with the original source were resolved by consensus.
Statistical analysis
SPSS software version 23 was used to conduct data analysis. Cronbach’s alpha values were recorded for reliability analysis for all the scales. A descriptive analysis was done using the counts and percentages for categorical variables and mean and standard deviation for continuous measures. A multivariate analysis of covariance (MANCOVA) was carried out to compare multiple measures (each scale was taken as a dependent variable) taking the GAS as the major independent variable, controlling for potential confounding variables: age, gender, family monthly income, and mother and father education level. A p-value less than 0.05 was considered significant.