Bio-psychosocial factors of children and adolescents with internet gaming disorder: a systematic review

Internet gaming disorder (IGD) was recently included as a tentative disorder in the latest (fifth) edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1]. The DSM-5 summarizes IGD as the “persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress,” as indicated by five or more out of nine proposed items (Table 1). Gaming disorder is under consideration for inclusion as a new diagnostic category in the WHO ICD-11 (International Classification of Diseases, 11th revision). Before the DSM-5 classification for IGD, previous studies employed various questionnaires to classify IGD or problematic online game play. However, the criteria used were not completely consistent. The Beard Diagnostic Questionnaire [2] does not assess criterion E of the DSM-5 IGD classification. Similarly, Young’s Internet Addiction Test (IAT) [3] and the Young Diagnostic Questionnaire (YDQ) [4] do not assess criterion F [5]. The Scale for the Assessment of Internet and Computer game Addiction—Gaming Module (AICA-S-gaming) [6] does not include criterion E, G, or I of the DSM-5 classification. Thus, the classification of IGD in the DSM-5 has played an important role in the accumulation of reliable study results for IGD.

According to the latest survey by the Entertainment Software Association (ESA), which gathered data from more than 4000 households in the U.S., 65% of households were home to at least one person who played computer and video games regularly, and 29% of the players were under the age of 18 years [7]. Previous large-scale studies suggest that IGD among minors has become an important public concern in many areas, e.g., Asia [8, 9], Australia [5, 10], and Europe [11‐15]. Minors are known to be particularly susceptible to problematic use of internet gaming [16, 17] because of their immature cognitive control during this period [18‐20]. In addition, one study compared online and offline gamers and indicated that online gamers were more likely to score higher on overuse, interpersonal conflict, and social isolation subscales of the Problematic Online Gaming Questionnaire (POGQ) [21]. Prevention efforts must be established that target adolescents who have their first experiences with addictive substances and behaviors during pubescence [17] because it appears that addictions tend to have precursors that appear during adolescence [22]. Additionally, children and adolescents are particularly expected to exhibit prominent relationships among the family environment, parent-child relationship, academic performance, and IGD symptoms; thus, the pathophysiology of IGD in children and adolescents should be understood from a different perspective to that of adults.

A review of IGD in children and adolescents was published by Kuss et al. [17] in 2012. Since the DSM-5 classification of IGD was published in 2013, the number of articles about IGD has drastically increased. Thus, we reviewed previous studies of IGD in children and adolescents to gain a better understanding of biopsychosocial factors of IGD.

The literature search utilized a systematic and structured approach adopting the PRISMA guidelines for systematic reviews and meta-analyses [23]. The search included all publication years (up to February 2018) using the major medical and psychological literature databases, including PubMed, MEDLINE, and PsycINFO. The title or abstract keywords used for the systematic search were: (“internet” or “online” or “computer”) AND (“game” or “gaming”) AND (“addiction” or “addictive” or “disorder” or “problematic” or “pathological” or “excessive” or “overuse” or “abuse” or “compulsive”) AND (“child” or “teenager” or “adolescent” or “minor”). Furthermore, the reference lists of selected articles were also examined for additional suitable publications. With respect to PsycINFO, we narrowed the search to research articles written in English and including participants aged 28 years or younger because the search refinement option for age of PsycINFO allows selecting only samples aged “0 to 18” and “18 to 28.”

The inclusion criteria upon which the studies were selected were as follows: (1) written in English, (2) the inclusion of minors younger than 20 years in the sample because The World Health Organization defines an adolescent as any person aged 10–19 years, (3) publication as an original paper but not as a review or case report, (4) full text availability, and (5) investigation of biopsychosocial characteristics in minors with IGD. The purpose of our review is to summarize the multi-dimensional characteristics of children and adolescents with IGD; thus, we excluded the studies that evaluated only the degree of problematic internet game use in the general population.

Figure 1 presents a summary of the search and inclusion process for this review. The database search in PubMed identified 98 manuscripts. Sixty-seven manuscripts were identified from MEDLINE. The database search in PsycINFO identified 144 manuscripts. One hundred and eight duplicate manuscripts among the three databases were excluded. The evaluation of titles and abstracts resulted in the exclusion of 177 studies as they did not meet the inclusion criteria (8 manuscripts written in languages other than English; 6 manuscripts of studies involving participants older than 20 years; 4 review articles; 159 manuscripts of studies that did not involve individuals with IGD). Twenty-seven studies were identified from the reference lists of those identified articles. We identified 51 potential articles for inclusion in this review.

Authors, experienced in IGD studies, selected articles that met the inclusion criteria and confirmed the study content. Subsequently, we classified the content of each article into the following categories: prevalence and classification of IGD, profile of IGD symptoms, psycho-social features, psychological intervention, and biological features.

In this review, the term “IGD” is used when we refer to the results of the studies using the DSM-5 classification. Regarding the studies that used other methods of classification, we quote the name of the disorder used in each study (e.g., problematic Internet game user, pathological computer game player).

The results regarding the prevalence of IGD show slight differences depending on the method of classification used. Thus, the results of studies that used different questionnaires prior to the DSM-5 may be effectively referenced to studies that employed the DSM-5 for classification. Additionally, studies of participants including adults reported a prevalence of IGD of 0.5–27.5% [63, 64]; thus, variation in the prevalence of IGD appears to differ between adolescent samples and samples including adults. One possible reason for this is that the gaming time in minors could be controlled by environmental factors because school-age children may be prevented from online game play during their time in school. However, more important is that previous investigations of students did not include minors who stop attending school as participants. Thus, these investigations could have missed minors who start missing school owing to severe IGD. Future studies should focus on minors who were not included as participants in previous studies. Male adolescents are likely to have problematic online game use, consistent with the results of previous studies including adult participants. Mentzoni et al. [65] noted that 15.4% of male adolescents aged 16 to 21 years and 9.7% of young men aged 22 to 27 years had problematic video game use, while the rates in all other age and sex groups were under 3%. Regarding game genre, MMORPGs and FPSs were predominantly played by minors with IGD and strongly predicted the severity of IGD [5, 12]. Müller et al. [12] suggested that the characteristics of MMORPGs, including overstimulation of sensory and cognitive components of curiosity, social interactions, role-playing, and competition with like-minded individuals, could contribute to enhanced absorption in online game playing. The FPSs are “kill-or-be-killed” games from the player’s perspective, thus FPS players may be easily immersed in the game compared with third-person shooter games.

In minors, the presence of IGD interferes with daily living relating to schoolwork, including skipping school classes [14] and academic performance [12]. The severe sleep disturbances shown in minors with IGD [14] might be related to these interferences in school work. Further, students with poor school performance could be more likely to have IGD.

Family relationships were reported as an important social factor in minors with IGD. A systematic review reported that poor quality parent-child relationships are associated with increased severity of problem gaming, and that the paternal relationship may be protective against problem gaming [66]. Given the results of our review and the previous systematic review, parent-child relationships may be related to the presence or severity of IGD. Family therapy for adolescents with IGD was reported to be effective in improving IGD symptoms and brain activation changes in response to online game playing cues and images depicting parental love; one report concluded that family cohesion may be an important factor in the treatment of IGD in adolescents [50]. A study that surveyed players of MMORPGs aged 18–32 showed that almost half (47%) of the problem gamers reported features of disorganized attachment and playing to escape from painful memories of abuse [67]. Domestic abuse should be investigated as one of the risk factors for the development of IGD in children and adolescents. Regarding parental involvement in the development of IGD in children, our review indicated that parental attitudes that hinder or foster IGD could differ by the sex of the minors; rules about gaming use are important in male adolescents to prevent IGD, while for female adolescents a ban from gaming could prevent excessive gaming use [44]. A systematic review suggested that the support of cooperative fathers may play an important role in preventive programs because longitudinal evidence indicated that the paternal bond was a protective factor against problematic game use [66]. Thus, in addition to the sex of minors, family members may be important in the development of IGD, including both the mother and the father and others who intervene in children’s game use. Additionally, both the mental health of minors and their parents were reported to be associated with the presence of IGD [46]; thus, therapists should consider parents’ mental health in cases of minors with IGD.

Various psychological and social factors were found in minors with IGD. In particular, the problem of impulsiveness was reported as an important psychological factor in IGD. Young [4] defined Internet addiction, including IGD, as an impulse control disorder. Given the results of our review, impulsiveness was related to cognitive dysfunction found in brain imaging studies. A cognitive-behavioral model of IGD indicated that executive function promoting cognitive and behavioral control inhibits the craving for online game use, and that online gaming behavior disturbs executive function [68]. The executive function underlying impulsiveness may be targeted as an important component of psychological treatment of IGD, including in cognitive behavioral therapy and cognitive enhancement therapy. Sakuma et al. [51] demonstrated the effectiveness of a therapeutic residential camp that included cognitive behavioral therapy sessions for decreased gaming time and increased self-efficacy in adolescents with IGD. Additionally, 4-week virtual reality therapy displaying relaxing videos, gaming cues, and aversion-inducing stimuli for adults with online gaming addiction also reduced the severity of online gaming addiction, showing effects equivalent to those of cognitive behavior therapy, and enhanced balance of the cortico-striatal-limbic circuit [69]. The development of effective psychological interventions for minors with IGD is an urgent issue that requires further research. In a clinical setting, detecting a problem at an early stage and providing appropriate treatment has a marked influence on patient prognosis. In particular, the personality of adolescents is still immature. Before the brain matures, adequate interventions and actions must be performed to promote brain development. This is applicable not only to IGD but also to many psychiatric problems [70].

Park et al. [39] longitudinally demonstrated a correlation between IGD severity and impulsiveness as selected characteristics of ADHD in adolescents with ADHD and IGD. Previous studies reported high comorbidity of ADHD and internet addiction [71]. A self-rating survey reported that college students who screened positive for ADHD were more likely to be problematic internet users [72]. Minors with ADHD appear to be vulnerable to developing problematic video game use [73, 74]. A correlation between visual working memory and methylphenidate efficacy has been reported previously [75, 76]. Linking clinical symptoms and visual attention, Pasini et al. [77] suggested that impairments in visual-object working memory might be a neuropsychological trait of ADHD (inattentive or combined subtypes). A previous study using the Stroop task reported that individuals with IGD showed impairments in both visual and cognitive control ability while processing gaming-related words [78]. Thus, impaired cognitive function could mediate the relationship between IGD and ADHD.

A review of brain imaging studies in young adults with IGD indicated that the more relevant abnormalities were localized to the superior temporal gyrus, limbic system, and medial frontal and parietal regions in the resting state. Fewer than half of the task-related fMRI studies reported behavioral differences between patients and controls, but all such studies found significant differences in cortical and subcortical brain regions involved in cognitive control and reward processing: OFC, insula, ACC, posterior cingulate cortex, temporal and parietal regions, brain stem, and caudate nucleus [79]. Our review also indicated similar characteristics in minors. The PFC, including both the ventromedial and dorsolateral regions, is considered to play an important role in cognitive processes [80‐86]. Brain imaging studies in individuals with IGD have supported the existence of a relationship between the PFC and impaired executive function, including basic cognitive processes such as cognitive inhibition, inhibitory control, or working memory. Ding et al. [34] suggested that the PFC may be involved in impulse control, and that impairments in its function may underlie the high rate of impulsivity in adolescents with IGD. Some studies including adults with IGD have indicated impaired cognitive control ability [87‐91]. Additionally, Cai et al. [55] demonstrated an important role of the striatum, caudate nucleus, and NAc in cognitive control and the severity of IGD in adolescents. A study of individuals with IGD [92] including adults also indicated that the caudate volume was correlated with impaired cognitive control. The caudate nucleus has biological connections with the PFC, particularly the DLPFC, as a prefrontal-striatal circuit [87], and both the DLPFC and the prefrontal-striatal circuits play a crucial role in cognitive control [93]. The caudate nucleus is most frequently mentioned as an important target for dopamine in addiction since it plays a major role in conditioned reinforcement and reward expectation [94]. Reduced dopamine receptor availability in the dorsal caudate nucleus has been detected in individuals with IGD [95]. In late adolescents, including participants aged 20 or above, with online gaming addiction, Yuan et al. [90] reported increased thickness of the left precentral cortex, and cortical thickness of the left precentral cortex correlated with the duration of online gaming addiction. Taken together, cortical thickness changes may be associated with the process of acquiring better playing skills, namely transforming from a “rookie” to an “advanced player.” Persistent pathological online gaming since childhood could aggravate abnormal brain function, and preventive care and early intervention is increasingly important.

Genetic features and environmental factors, including family relationships, could increase the vulnerability to IGD in minors, and abnormal brain function could maintain cognitive, behavioral, emotional, and biological symptoms.

We summarized biopsychosocial features in children and adolescents with IGD by reviewing relevant previous studies. The presence of IGD has a negative effect on sleep and schoolwork in minors. Family factors, including the quality of the parent-child relationship, are important social factor in minors with IGD, and both the mental health of minors and their parents may be associated with the presence of IGD. Given the results from adults, domestic abuse should be investigated as a risk factor for the development of IGD in minors. Additionally, many brain imaging studies in minors with IGD have indicated that their impaired cognitive control functions are associated with abnormal function in the PFC and striatum. Persistent pathological online game use from childhood could aggravate abnormal brain function. Preventive care and early intervention for IGD in minors is important. Although the effectiveness of cognitive behavioral therapy for minors with IGD has been supported, effective psychological intervention for minors with IGD is an urgent issue that requires further research.