J Adolesc Health. 2019 Jan;64(1):5-7. doi: 10.1016/j.jadohealth.2018.10.010.
King DL1, Potenza MN2.
PMID:30579437
DOI:10.1016/j.jadohealth.2018.10.010
Adolescents are among the most avid consumers of online digital entertainment, particularly video games and related online activities (e.g., live streaming, eSports broadcasts). Global research data indicate that most adolescents report past-year gaming usage across a range of devices, including personal computers, laptops, consoles, and, increasingly as the technology has become more sophisticated, smartphones [1, 2, 3]. Internationally, average gaming usage among adolescents has increased over the last three decades, particularly among males. The Generation M2 study in the United States, for example, reported that average daily gaming usage among individuals, aged 8–18 years, increased from 24 to 73 minutes between 2004 and 2009 [4]. Recent Australian data indicate that males aged 15–24 years play games for an average of 155 min/day [5] and that 4.1% of males aged 11–17 years play games for 9 hours or more on an average weekday [6]. For many children and adolescents, gaming can transition rapidly from a hobby to a routine that is difficult to self-regulate, reduce, or go without, even temporarily. The rising popularity and misuse of video games among adolescents may be attributed to the notion that there may be no other more accessible leisure product that provides a low-effort/low-cost experience of action and excitement, progress and achievement, social connection, and self-expression.
While many young people play games in moderation, gaming is not always “fun” or a harmless diversion. Decades of research have shown that some adolescents who engage in persistent gaming behavior, voluntarily or otherwise, can experience mild to serious negative effects on psychological wellbeing [1, 7, 8]. In extreme cases, players may feel unable to control or stop their gaming without external influence or intervention. Excessive gaming behavior may have significant negative consequences, particularly when sustained over a long period of time (e.g., more than 12 months), including school dropout, family conflict, poor mental health, and social isolation. Recognizing these phenomena and the need to classify health risks to develop public health responses, the World Health Organization (WHO) [9] has included “Hazardous gaming” (QE22) and ”Gaming disorder” (6C51) in its latest revision of the International Classification of Diseases (ICD-11).
Some commentators have opined that the ICD-11 gaming classifications were developed by the WHO in response to ”political pressure” exerted by some Asian countries [10]. While this view has been at times perpetuated in the media, and those scholars who express opposing views on ICD-11 gaming disorder receive publicity from the global gaming industry [11], the argument that ”gaming disorder” was developed in response to political pressure is untrue [10]. As reported by Saunders et al. [12] and Rumpf et al. [13] (i.e., two papers prepared by groups of researchers and clinicians who attended the WHO meetings and contributed to the ICD-11 development), the ICD-11 classifications were developed by a consultative process over several years which involved critical evaluation of scientific and clinical evidence. The WHO expert meetings—involving 66 experts from 25 countries and held in Tokyo, Japan (2014), Seoul, South Korea (2015), Hong Kong, China (2016), and Istanbul, Turkey (2017)—provided the rationale and justification for the recommendation to include gaming disorder in the ICD-11 [9]. The support for gaming disorder was based on the evidence provided by experts from psychiatry, clinical psychology, internal medicine, family practice, child study, epidemiology, neurobiology, public health, and other domains [14].
With the formal recognition of gaming disorder, it is hoped that further important work on this topic will be more readily supported, including more funding for epidemiological, neurobiological, and intervention-based research, to ultimately serve the needs of individuals who require assistance for gaming-related problems [15, 16]. The critical discussion of gaming-related classifications will continue within the field of behavioral addictions and in other areas of study, as well as in the context of further WHO meetings. Since the inception of the WHO meetings in 2014 (which were conceived with the scope to consider ”the public health implications of excessive use of the Internet, computers, smartphones, and similar devices” and not solely video-gaming), the meeting agendas have facilitated discussion of research findings and wider developments (e.g., industry innovations, policy matters, and service delivery) to inform new understandings and considerations of relevance to the ICD-11 [17, 18]. One such topic for further consideration, for example, is the convergence of gaming and gambling activities [19, 20], which is a broad phenomenon encompassing a range of gaming-gambling cross-over products (e.g., ”skin gambling” and betting on eSports matches) and promotions (e.g., live streaming promotions for skin gambling) that may appeal in particular to adolescents [21]. Convergence also includes the monetization of certain types of random in-game content (e.g., ”loot boxes”) [22, 23] which have recently determined to be illegal gambling in several jurisdictions (Belgium, and the Netherlands). Cross-overs between gaming and other potentially addictive behaviors (e.g., online pornography viewing) should also be noted [24], particularly given the prevalence of pornography viewing (including among adolescents), problematic pornography use, and the inclusion of compulsive sexual behavior disorder (6C72) in ICD-11 [25].
Health conditions related to digital technology-based behaviors, such as online gaming, are likely to change over time as these activities have new player demands and offer new experiences for users. Given that online games often intersect with other activities in a shared online ecosystem (e.g., gaming while watching gaming-related news, social media, podcasts, live streaming, and eSports), there is a need to ensure that clinical descriptions, screening, and interventions remain consistent with the activities that are commonly performed and may cause problems for users. While it may have become socially accepted that adolescents will tend to lead ”always-online” digital lifestyles, there is sufficient evidence to support the notion that harmful usage of video-games and other electronic media does occur, and that gaming in particular may manifest as an addictive disorder, especially among adolescents. These evidences should not be disregarded to perpetuate the view that all digital media usage, without exception, enhances people’s lives. Appropriate interventions are needed in policy, prevention, and treatment domains across jurisdictions in order to protect the public health, especially with respect to ensuring safe and healthy development from childhood, through adolescence and into adulthood.
Funding Sources
This work received financial support from a Discovery Early Career Researcher Award (DECRA) DE170101198 funded by the Australian Research Council (ARC). M.N.P. was supported by a Center of Excellence grant in Gambling Research from the National Center for Responsible Gaming, the Connecticut Council on Problem Gambling and the Connecticut Department of Mental Health and Addiction Services.
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