A Screening Instrument for Screen Addiction – the CAGE-SA
Professor Ben Green,
PhD, FRCPSych, MB, ChB,
Director, Institute of Medicine,
University Centre Shrewsbury
The author outlines the concept of screen addiction with features such as similar features – increasing amounts of time spent online, anxiety on withdrawal from the screen, damage to relationships through isolation or irritability with others, physical damage through a sedentary lifestyle – e.g. thrombosis from prolonged gaming, reduced repertoire of behaviour to focus on screen activity or a virtual world rather than reality. The author outlines the development of a screening instrument based on the CAGE for alcoholism to enable screening for screen addiction in clinical conversations with adolescents and adults. The CAGE-SA is presented together with plans for research to establish its psychometric properties.
Addiction usually implies some pathological attachment to a substance or activity which involves exclusivity, untoward consequences for the individual and society e.g. psychological or physical consequences, tolerance or habituation, and withdrawal effects. Alcohol dependency is a classic addiction, with suffers having a restricted pattern of behaviour, a preoccupation with obtaining alcohol and consequences for their work, psychological or physical damage to their relatives/friends, tolerance and increasing consumption, physical adverse effects such as liver damage, and withdrawal symptoms on cessation.
Screen addiction exhibits similar features – e.g. tolerance exhibited by increasing amounts of time spent online, anxiety on withdrawal from the screen, damage to relationships through isolation or irritability with others, physical damage through a sedentary lifestyle – e.g. thrombosis from prolonged gaming, reduced repertoire of behaviour to focus on screen activity or a virtual world rather than reality. Such features have been described by various researchers (Lemmens, Valkenburg, & Peter, 2011) and proposed as features of Internet gaming disorder (IGD) in Section 3 of the DSM–5 (American Psychiatric Association [APA], 2013).
The concept of screen addiction would though encompass more than just gaming and also include fascination with social media and other screen based activities.
Screen media addiction has been described in association with devices as various as tablets, television, video games, computers, laptops, mobile phones, and handheld video game devices (Domoff et al, 2017). New permutations and innovations of such devices are likely to proliferate further in future years.
Instruments to measure such addiction e.g. Problematic Media Use Measure (PMUM) exist (Domoff et al, 2017). The PMUM is designed for parents of children however and is lengthy, at 27 items. The Internet Gaming Disorder Scale (IGDS) involves versions ranging from 9-27 items (Lemmens, Valkenburg, & Gentil, 2015).
The author sought to develop a more concise screening instrument that might be used in clinical conversations with adolescents and adults prior to the use of longer questionnaires.
The CAGE was settled on as an ideal model for such an instrument as it is extremely quick and simple to use, and easily remembered. It has considerable work on its reliability and validity and would serve well as a model and the author acknowledges the underlying model.
The CAGE was developed by Dr Ewing in, or around, 1970 in North Carolina (Ewing, 1984) and has been widely used around the world since (Williams, 2014).
This version for screen addiction (SA) is termed the CAGE-SA.
For the purposes of the CAGE-SA screens are intended to mean viewers for Internet applications such as social media, games, programs, apps or other media. Screens would include devices that access the Internet such as smartphones, laptops, tablets, desktop computers.
Addiction is intended to mean a compulsive engagement in rewarding stimuli, despite adverse consequences, and involving features such as dependence, tolerance and withdrawal effects.
The CAGE-SA Instrument
1. Have you ever felt the need to Cut down on your Screen use?
2. Have you ever felt Annoyed by criticism of the time you spend on a Screen?
3. Have you ever felt Guilty about your use of a Screen?
4. Have you ever felt the need to Engage with a Screen just after you wake up? (Eye opener)
Two "yes" responses indicate that the possibility of screen addiction should be investigated further.
Item 1 would investigate whether the individual has insight or awareness of the extent of their screen use in terms of duration. Although screen time may be prolonged an individual may not rate this need to ‘cut down’ if they lack appropriate insight, hence the need for the next item.
Item 2 might signal other people have noticed the addiction, confronted the sufferer and their response reflecting threat to their chosen activity may be one of irritability or anger.
In item 3 guilt refers to guilt over time expended or consequences of screen use, such as impaired relationships. It may signal some insight into the adverse consequent of addiction upon others and associated remorse.
In item 4 ‘engage with’ could be substituted with ‘look at’ or ‘use’ if the interviewee requests clarification. The purpose of the item is to demonstrate a limited repertoire of behaviour, an urgency or compulsion to resume screen use on waking and possibly to avoid withdrawal symptoms of cessation e.g. anxiety]
Plans for future development
The CAGE-SA requires study in psychometric analyses of its performance to determine demographic norms for different ages, genders and populations, its reliability and validity in different populations, and its performance in determining addiction in comorbid conditions such as various psychiatric disorders including alcohol dependence, drug misuse, PTSD, anxiety disorders and depression.
Discussion and Conclusion
The CAGE-SA is described in terms of its content and aims to identify potential cases of screen addiction and to aid in the prevention of increasing dependence, psychological and physical damage, and comorbid psychiatric disorders and to signpost a path to identification of a new addition in society and its treatment.
American Psychiatric Association (APA). (2013).
Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Berinsky, A. J., Huber, G. A., & Lenz, G. S.
Domoff, Sarah E. (2017) Development and Validation of the Problematic Media Use Measure: A Parent Report Measure of Screen Media “Addiction” in Children
Psychology of popular media culture. http://dx.doi.org/10.1037/ppm0000163
Ewing J A. (1984) Detecting Alcoholism: The CAGE Questionnaire
JAMA. 1984;252(14):1905-1907. doi:10.1001/jama.1984.03350140051025
Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2011). Psychosocial causes and consequences of pathologi- cal gaming. Computers in Human Behavior, 27, 144–152. http://dx.doi.org/10.1016/j.chb.2010.07 .015
Lemmens, J. S., Valkenburg, P. M., & Gentile, D. A. (2015). The internet gaming disorder scale. Psychological Assessment, 27, 567–582. http://dx.doi .org/10.1037/pas0000062
Williams, N. (2014) The CAGE questionnaire. Occupational Medicine, Volume 64, Issue 6, 1 September 2014, 473-474, https://doi.org/10.1093/occmed/kqu058
The CAGE for screen addiction is based upon the CAGE screen for alcoholism developed in the twentieth century by Dr Ewing at the North Carolina Memorial Hospital.
Vesion 1.0 Published November 22nd 2017
© Copyright Ben Green 2017 onwards