Internet Gaming Disorder in adolescence: investigating profiles and associated risk factors

Gaming is a popular and fast-growing leisure activity worldwide with the estimated number of gamers in 2020 being around 2.7 billion individuals [1]. Given how pervasive gaming is, particularly among younger individuals, concerns have emerged regarding disordered gaming behaviors, leading the American Psychiatric Association (APA) to include ‘Internet Gaming Disorder’ (IGD) within Section III of the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a tentative disorder requiring further research [2].

More recently, the World Health Organization (WHO) has decided to officially include ‘Gaming Disorder’ (GD) as a mental health condition within the latest (eleventh) revision of the International Classification of Diseases (ICD-11) [3, 4]. Table 1 illustrates the current conceptual approach to disordered gaming within the APA and WHO diagnostic framework.

Previous research has reported significant variation in prevalence rates of disordered gaming across a wide range of studies. Griffiths et al. [5] found prevalence rates ranging from 0.2 to 34% and reported that disparities may be due to different sample sizes, distinct age range, sampling characteristics (general population vs. gamers only), type of gaming activity assessed, and psychometric test used to assess disordered gaming [6]. However, in representative samples of children and adolescents, previous findings reported that about 2% are likely to be affected by IGD [7], with a similar prevalence rate of 2.5% being found among Slovenian adolescents [8].

Most of the epidemiological findings have reported higher IGD prevalence rates among males in comparison to females [9–16]. Furthermore, in children and adolescent samples, IGD may be observed up to five times more often among males than females [7, 9, 14].

Disordered gaming has also been linked to several negative health-related outcomes and psychosocial detriments, such as increased stress, increased obesity, decreased job performance and/or job loss, decreased academic achievement, sleep abnormalities, relationship problems, depression, lower psychosocial wellbeing, and anxiety [7] alongside other similar addictive disorders involving excessive technology use [17]. Additionally, Severo et al. [18] recently found that increased depressive symptoms, poor sleeping, male gender, greater time spent gaming, and total free-time spent gaming are key IGD risk factors. In addition, other adolescent studies reported increased time spent gaming among disordered gamers [19], a phenomenon that is arguably reflected within the IGD definition itself through the operationalization of tolerance symptoms in IGD (i.e., “tolerance—the need to spend increasing amounts of time engaged gaming”) [2].

Recent longitudinal research carried out by Teng et al. [10] has examined the links between psychosocial wellbeing and IGD among older aged adolescents and emerging adults. The results of this study suggested that IGD is a maladaptive response leading to poorer psychosocial wellbeing, further showing that IGD is negatively associated with self-esteem and social support at the longitudinal level [10]. Similarly, the Slovenian representative study Health Behavior in School-Aged Children (HBSC) conducted in 2018 (among 11-, 13-, 15- and 17-year-old adolescents, N = 7449) reported higher odds for IGD among male adolescents (OR = 4.5), experiencing greater difficulties to communicate with their fathers (OR = 1.4), presenting with multiple health complaints more than once a week (OR = 1.8), engaging in bullying (OR = 2.3) or being bullied (OR = 1.3), feeling pressured with school work (OR = 1.4), and reporting feeling less supported by their friends (OR = 1.2) [14].

In relation to personality traits and other health-related factors, IGD has been shown to have associations with aggression and hostility, neuroticism, loneliness and introversion, avoidant and schizoid interpersonal tendencies, boredom inclination, social inhibition, sensation-seeking, diminished self-control and narcissistic personality traits, lower agreeableness, greater state and trait anxiety levels, lower self-esteem and emotional intelligence [20]. Moreover, loss of control is featured in the definition of IGD (“Unsuccessful attempts to control the participation in internet games”) [2] and has been systematically reported by other IGD studies [7, 21–24]. Relatedly, de Hesselle and colleagues have recently shown that lower levels of extraversion, agreeableness, and conscientiousness predict increased gaming time, with male gamers being more likely to spend greater time playing video games compared to female gamers [25].

Other studies reported important parental influence in IGD development, such as poor parental competence and supervision, inconsistent parental behavior and poor parental care [7]. Jeong et al. reported that conflict between parents resulted in greater IGD symptom-severity in children after 1 year [26]. A systematic review of family factors in adolescent IGD [27] reported four important factors: parent–child relationship, parent status (e.g., mental health, socioeconomic status), family environment (e.g., number of people living in a household) and parental influence on gaming (e.g., attitudes toward gaming, parental supervision). Parent-child relationships remain as a critical topic of several studies, which associate poorer quality relationships with increased severity of IGD [27].

Video games are one of the most popular leisure activities of children and adolescents worldwide, with dysregulated gaming being able to lead to addiction-like symptoms. A systematic literature review on IGD by Paulus et al. showed that IGD may be observed up to five times more often among male children than female children [7], and the present study showed that male gender was an important predictor of disordered gaming, a finding that was reported across several past studies [9–16, 19].

Moreover, free-time activities of ‘high risk gamers’ were mostly related to screen time activities than non-screen time activities when compared to ‘low risk gamers’ and ‘non-gamers’. Specifically, ‘high risk gamers’ were found to play more video games, watch more TV, and engage more in social media. Nevertheless, the majority of adolescents in that particular age had healthier habits of spending their free-time as they more frequently spent time with their friends and engaged more in sports activities than played video games. Surprisingly, the present study showed no statistically significant differences in regards to free-time sports activities between ‘high risk gamers’ and the two other groups of participants (‘low risk gamers’ and ‘non-gamers’) even though previous research has suggested that IGD is associated with obesity [20] and overweight in young adult females [39]. This study also found that time spent gaming was sigificantly greater for ‘high risk gamers’ both on weekdays and weekends in comparison to ‘low risk gamers’. Time spent gaming is an important predictor of IGD that is frequently reported in similar studies [19], as well as being reflected in the APA framework for IGD [2] via tolerance (i.e., the need to spend increasing amounts of time engaged in gaming).

There are several internal and external factors related to development of IGD [7], including self-control (internal) and parental influences (external), which were assessed in the present study. More specifically, we found that ‘high risk gamers’ presented with significantly lower levels self-control when compared to ‘low risk gamers’ and ‘non-gamers’. Several studies reported lower levels of self-control among heavy gamers [21–24] in addition to increased impulsivity [40–42].

Although self-control is an important aspect of the diagnostic criteria of IGD developed by the APA, a study by Pontes et al. [43] suggested that different IGD criteria may carry different diagnostic weight. Accordingly, ‘withdrawal’ (criterion 2) and ‘loss of control’ (criterion 4) have been reported as key factors in the etiology of IGD as together they may increase the likelihood of IGD by 77.77% [43]. However, answering ‘very often’ in the IGDS9-SF in relation to ‘withdrawal’, ‘loss of control’ and ‘negative consequences’ (criterion 9), may increase the likelihood of IGD by 26.66% [43]. Moreover, King et al. reported loss of control as one of the core symptoms of disordered gaming, together with withdrawal and conflict, and other symptoms being considered peripheral (i.e., not essential for the diagnosis of IGD) [44]. Self-control emerged as a statistically significant predictor for ‘high risk gamers’ also in our study.

There are additional external factors contributing to the development of IGD, such as parental influence and parental factors related to poor parental competence and supervision, inconsistent parental behavior, and poor parental care [7]. In our study we did not find important differences in terms of parent-child relationship between ‘high-risk gamers’ and the other two groups of participants, apart from the fact that ‘low risk gamers’ reported better understanding in the context of their parental relationships than ‘high risk gamers’.

Previous studies have also shown that conflict between children and their parents leads to higher levels of IGD after 1 year [26]. Similarly, disordered gaming symptoms have been found to be higher among adolescents presenting with lower commitment to family social activities, whereas important prevention strategies may focus on strong parent-child relationships [19]. A study among Korean adolescents [45] revealed that while father-child communication reduced risk of IGD, mother-child relationship did not, which may imply that fathers should make additional efforts in order to improve open and positive communication skills with their children [26, 45].

Additionally, the Slovenian HBSC study investigating the role of key IGD predictors among adolescents found higher odds for IGD among those who presented with greater difficulties communicating with their fathers [14]. Furthermore, a study by Koning et al. revealed that parenting practices among disordered adolescent gamers had bidirectional effects, with increased parent-adolescent communications about the internet predicting greater IGD symptoms among males, while greater IGD symptoms predicting more reactive rules among males and females. Displaying IGD symptoms appears to elicit ineffective parental responses, which may further exacerbate disordered gaming [45].

Our study also found that self-reported life satisfaction and mental health state were not statistically different among the three groups of participants even though IGD in adolescence has been reported to be related to several types of health problems, including mental health difficulties [13, 14, 46]. Since the present sample was relatively young, participants may not be experiencing intense and severe mental health problems yet, therefore the findings obtained may be justified on the basis of the samples’ current developmental stage. Mental health disorders are statistically more prevalent among adults, where gaming and internet overuse may be related to coping strategies related to stress, depression, suicidal ideation, and suicide attempts [47].

Present study revealed less IGD predictors than Slovenian HBSC study, although they were both conducted in representative adolescent samples. The 2018 HBSC study used nine IGD variables with yes/no scale of answers, where adolescents were classed as being ‘at risk’ if they had provided 5 or more ‘yes’ answers [14]. The proportion of 'at risk' participants within the HBSC study was therefore higher than in present study, where ‘at risk gamers’ were calculated when 5 or more 4 (‘often’) or 5 (‘very often’) answers to the nine IGDS9-SF items were provided. Another reason for different number of calculated IGD predictor was the broader range of health related variables in the HBSC study whereas our study was limited to few independent variables. Nevertheless, both studies facilitate future preventive initiative based on their findings. Gaming is rapidly growing [1] – since the data were collected in 2015, prevalence rates of IGD may be higher now. We believe this complex phenomenon should be investigated by interdisciplinary teams in future research so that collaborative actions can take place in order to mitigate the burden of disordered gaming among youth.

Potential limitations in the present study may relate to the low number of independent variables within the current survey as time for designing and conducting research was limited and scheduled at the beginning of the project. Due to ethical and financial constraints, the survey was not possible to be extended in order to collect multilevel data, therefore, this may constitute as a potential limitation in the present study. Moreover, the data was collected in 2015 and it is possible that different findings would have been found, especially at the epidemiological level, if the data collection was more recent. Additional potential limitations may be related to the self-report nature of the study and lack of an experimental design capable of generating causal findings. Despite these potential issues, the present study offers novel insights on IGD based on a relatively large national sample from Slovenia.

Disordered gaming may elicit a wide range of health- and relationship-related problems. Younger individuals are particularly drawn to gaming, so helping youth struggling with gaming problems is key since most addictions seem to develop in early adulthood. The pathway to addiction is characterized by a change in emphasis from fun through losing control, to obsession [7], therefore public health measures should target ‘high risk gamers’ in early preventive initiatives.

The present study showed that ‘high risk gamers’ presented with lower levels of self-control. With parental influence being diminished at this age, prevention efforts must be established to target adolescents who may experience excessive gaming or IGD. Several countries do not currently offer treatment to individuals struggling with IGD, with some non-governmental organizations providing help to affected gamers. The recent preliminary recognition of IGD by the APA and official recognition of GD by the WHO fostered additional investigation and research in this field but also treatment efforts in many countries.

The authors would like to thank all participants of this study for partaking in this study. We would also like to thank all involved school for allowing this research to be conducted. Finally, we thank all parents who gave their consent for the participation of their children in the research.

MM designed the study (questionnaire, sample, methodological guidelines for the schools and trained staff), cleaned and analyzed the data and drafted the manuscript. HPM has helped designing the study, provided assistance on the interpretation of the results, and helped in drafting and reviewing the manuscript. Both authors approved the final version of the manuscript.

Field study was supported by Norway Grants (http://eeagrants.org/project-portal/project/SI05-0007↗; under Grant SI05–0007). The funding agency had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article.

The data set used and analyzed during the current study is available from the corresponding author on reasonable request.