English (pdf)
Article in xml format
Article references
Automatic translation
Send this article by e-mail
Cited by SciELO 
Cited by Google 
Similars in
SciELO 
Similars in Google 
Permalink
Introduction
VIDEO GAMES, in general terms, are defined as interactive applications accessed through various electronic devices (e.g., consoles, smartphones, tablets, and computers). They can be played online -this involves the use of the Internet- or offline- where no connection is required-, which suggests that users are put against an electronic device or set to explore an electronic world (Mills, Mettler, Sornberger, & Heath, 2016).
Video game addiction, gambling disorder, pathological use of video games, problematic gambling behavior, or internet gambling disorder are some of the different names that have been used to signal when excessive or compulsive use of video games interferes with daily life in a significant way (Benarous et al., 2019; Dieris-Hirche et al., 2020; Esposito et al., 2020; Fumero, Marrero, Bethencourt, & Penate, 2020; Kim, Hughes, Park, Quinn, & Kong, 2016; Stockdale & Coyne, 2020; Yesilyurt, 2020). The term "internet gaming disorder" (IGD) was proposed by the American Psychiatric Association in the fifth edition of its Diagnostic and Statistical Manual (DSM-5), where it presents the condition and the need for more clinical studies on the subject (American Psychiatric Association, 2013). Currently, the World Health Organization (WHO) has incorporated the concept of "video game use disorder" (VGD) in its 11th revision of the International Classification of Diseases (ICD-11), and it describes it as a persistent or recurrent pattern of gambling behavior online or offline, primarily characterized by: (a) a loss of control over gambling, (b) an increase in the priority given to gambling (over other interests and daily activities), and (c) the maintenance or increase of gambling despite negative consequences. All of this in addition to a significant impairment of personal, familial, social, educational, occupational, and other important areas of functioning, and the fact that this pattern of behavior continues for at least 12 months or less if all diagnostic requirements are met and symptoms are severe (WHO, 2020).
Using video games is one of the most popular leisure activities for children and adolescents, and while many of them are able to regulate their interaction with games, a significant proportion do not (Brunborg et al., 2013; Mohammadi et al., 2020). As a result, some European studies report that adolescents (secondary-school pupils of 13-14 years on average) with excessive use of video games may present various signs of addiction, such as constant preoccupation with the act of playing, multiple problems both in family and social relations, and a considerable fluctuation in mood (Bonnaire & Phan, 2017; Griffiths, Király, Pontes, & Demetrovics, 2015; Vadlin, Åslund, Hellström, & Nilsson, 2016; Wartberg, Kriston, Kramer, Schwedler, Lincoln, & Kammerl, 2017). Latin American evidence on VGD or its effects on adolescents is rather limited, and previous reviews have not reported relevant findings (Brandão et al., 2019; Loayza-Jerjes, 2010; Sánchez-Domínguez, Telumbre-Terrero, & Castillo Arcos, 2021). Because of this and the growing and progressive expansion of video games on various digital platforms, it is justified and relevant to clearly establish the manifestation of this disorder in adolescents, the different elements that characterize it, and provide evidence that advances its understanding and approach.
Thus, in this study we intend to characterize video game use disorder in adolescents, identifying the particularities of those who present it, its effects on the brain, the related risk factors, and the existing measurement instruments. To accomplish this objective, we performed a systematic review of scientific publications available on Scopus over a period of five years (2014-2018). This database has the largest coverage within the scientific world, with more than 24,600 titles from 5,000 international publishers and 16 million author profiles, of diverse topics and disciplines, which makes it a valid and reliable source of evidence on this subject (Ferrer & Delgado, 2018; Polanco-Carrasco, 2016; Rojas-Jara et al., 2019).
Method
This review was guided by the PRISMA method, which allows to organize the exploration, classification, and analysis of evidence (Liberati et al., 2009; Moher et al., 2009). Thus, the selection procedure was divided into four progressive stages: (a) design of a literature search strategy, (b) selection of publications according to defined inclusion and exclusion criteria, (c) data extraction from selected studies, and (d) critical analysis of the information according to the quality of the evidence.
The inclusion criteria defined in this review considered the search for: (a) scientific articles only, (b) empirical studies about VGD in adolescent population, (c) published between the years 2014 and 2018, and (d) research in English language.
The search for articles, carried out on September 16, 2019 in the Elsevier Scopus database, included the terms "Gaming disorder", "Videogames addiction", "Videogames use disorder", "Adolescents", "Adolescence", "Teens", and "Youth" in titles, abstracts, and keywords, according to the MesH (Medical Subject Descriptors) and Decs (Health Science Descriptors) thesaurus, and the use of the respective Boolean operators for the search algorithm ["Gaming disorder" OR "Videogames addiction" OR "Videogames use disorder" AND "Adolescents" OR "Adolescence" OR "Teens" OR "Youth"]. The result was a total of 230 matches.
In this search, we excluded: (a) editorials, letters, books, and book chapters, (b) other systematic reviews, (c) purely theoretical articles on VGD, (d) articles on VGD in children or adults, (e) articles outside the established publication range (2019 was not considered since that editorial year was still ongoing at the time of the search), (f) research in languages other than English, and (g) duplicated articles. This left an initial total of 120 full-text records. Subsequently, we evaluated their eligibility using a single ad hoc form designed for this purpose. Taking as a basis the inclusion criteria and the suitability of the content for the central objectives of this research, 72 of the texts were discarded for presenting incomplete, partial, or irrelevant information, leaving a final count of 48 articles for the qualitative analysis. This analysis involved distributing the evidence in clusters that coincided among the articles, in order to organize their description and further presentation in the following sections (see Figure 1).
Results
In the end, the screening process rendered 48 scientific publications, which were considered for this review. Initially, we will present their bibliometric information (i.e., authors, year of publication, country, journal, objectives, and main results; see Table 1), and then, in the discussion, we will provide a narrative analysis and synthesis of their central contents.
Discussion
Characteristics of adolescents with VGD
Context of the appearance of VGD in adolescents. Adolescents with vgd are usually incorporated into the world of games since childhood when they grow up in family environments where parents and siblings enjoy games. Therefore, they develop a progressive interest in playing and use games as a mechanism for interaction with their peers during their adolescence (Seok, Lee, Park, & Park, 2018).
Various authors agree that the essential factors for the appearance of VGD in adolescents are: (a) difficulties in recreating themselves through an alternative to video games, (b) the pleasure in winning, (c) the value given to the successful player, (d) the desire to relate to others through play, and (e) the perception of video games as a refuge for adolescent suffering or as an escape from a deteriorated family environment (Bon-naire & Phan, 2017; Choi et al, 2018; Lyu, 2017; Martin-Fernandez et al., 2017; Seok et al., 2018).
Families, in general, tend to be permissive towards the use of video games and do not necessarily exercise extensive control over this behavior. Some of them establish rules as time limits, schedules, or the prohibition of playing. However, in the case of adolescents with VGD these rules are not considered, which leads to longer than allowed playtime or adolescents playing at non-agreed times (Bonnaire & Phan, 2017; Seok et al., 2018). Along the same lines, some studies report that teens with VGD have significantly more screens available at home and often have a laptop or game console in their room (Bonnaire & Phan, 2017; King & Delfabbro, 2016).
Furthermore, research on adolescents with VGD has observed the presence of various problems in their psychosocial relationships, as difficulties in interpersonal contact, low emotional support and relational tension, deficits in social skills, feelings of loneliness, social anxiety, decreased self-esteem, and alterations in school performance. Based on this, the desire of adolescents with VGD to relate to others through video games would be understandable (Bonnaire & Phan, 2017; Martín-Fernández et al., 2017, Seok et al., 2018; Rasmussen et al., 2014; Van Rooij et al., 2014).
Other findings in this area show that adolescents with VGD consider playing as a positive influence on their social interactions as they experience a warm social exchange in meeting their playmates (Bonnaire & Phan, 2017; Seok et al., 2018). On this basis, some research argues that VGD influences increasing problems in the development and maintenance of real social relationships, as social interaction through play fails to replace other types of social relationships (Mills et al., 2016; Rasmussen et al., 2014).
Characteristics of adolescents with vgd. The average teenager with vgd is mostly male (King & Delfabbro, 2017; Mérelle et al., 2017; Park et al., 2018; Schneider, King, & Delfabbro, 2018; Van Rooij et al., 2014; Yu & Cho, 2016), uses five times more hours per week to play than teenagers without vgd (King & Delfabbro, 2016; Schneider et al., 2018), spends eight times more hours per week playing with strangers online (King & Delfabbro, 2017) and devotes more than three hours per day playing (Bonnaire & Phan, 2017; Yu & Cho, 2016). Additionally, adolescent males with vgd spend a greater amount of time playing compared to females with the same disorder (Bonnaire & Phan, 2017) and prefer to use weekends or vacations for gaming since they must use their time during the week for schoolwork (Seok et al., 2018).
Research also indicates a preference for action games, shooting games, sports games, massively multiplayer online games, role-playing games, and online battle arenas. Several studies agree that due to high accessibility, visibility, and immersion time these last two types of games are associated with increased addictive power (Bonnaire & Phan, 2017; Choi et al., 2018; King & Delfabbro, 2016; Donati, Chiesi, Ammannato, & Primi, 2015; Martin-Fernandez et al., 2017, Torres-Rodríguez, Griffiths, Carbonell, & Oberst, 2018; Van Rooij et al., 2014).
Adolescents with VGD show greater symptoms of anxiety, depression, aggression, loneliness, impul-sivity, poor school performance, and low self-esteem than individuals without this disorder (Saquib et al., 2017; Su et al., 2018; Tian et al., 2018; Van Rooij et al., 2014; Yu & Cho, 2016). Specifically, regarding low self-esteem, studies indicate that adolescent males and females with VGD have lower perceptions of themselves in the domains of school competence and general social skills (Mills et al., 2016). In addition, one would expect to find in adolescents with VGD fluctuations in mood, intra and interpersonal conflicts, social withdrawal, relapse symptoms, presence of suicidal thoughts, and behavioral problems (Mérelle et al., 2017; Yu & Cho, 2016).
The evidence refers to the predominance of a distressed personality type (described by some researchers as Type D personality) among adolescents with VGD, which is characterized by a negative view of themselves and the world, the experience of negative emotions over time, and a disconnect between external signs and internal feelings. In addition, they exhibit certain personality traits such as introversion, inhibition, submission, interpersonal sensitivity, obsessive-compulsive tendencies, phobic anxiety, and hostility, as well as paranoid and borderline traits (Kim et al., 2016; Torres-Rodríguez et al., 2018).
At the family level, adolescents with VGD present severe conflicts that interfere with family interaction, communication, and cohesion (Bonnaire & Phan, 2017; Müller et al., 2015; Seok et al., 2018; Torres-Rodríguez et al., 2018).
In adolescents with comorbidity there is also an increase in problems in both family and school environments (Martín-Fernández et al., 2017), and, unlike males, adolescent females are given greater support by their families (Torres-Rodríguez et al., 2018; Yuh, 2018).
Psychological changes in the adolescent derived from the vgd. vgd progressively generates diverse psychological alterations in adolescents, as emotional instability and changes in their personality, mood, diet, sleep patterns, and behavior (aggressive and obsessive). These adolescents are generally aware of the appearance of these changes but do not consider them problematic (Rasmussen et al., 2014; Seok et al., 2018).
At a mental level, VGD generates maladaptive cognitions regarding gambling: (a) overvaluing the rewards and identities of the characters, (b) inflexibility and prejudices in gambling situations, (c) excessive dependence on social acceptance to satisfy self-esteem needs, and (d) overvaluing the immediate result and neglecting the future (King & Delfabbro, 2016; Tian et al., 2018). Moreover, male adolescents with VGD are perceived to have a greater sense of self within the domains of athletic competition and physical appearance, while females prioritize the domains ofbehavior and close friendship. These results challenge the stereotype of the VGD player as an anti-social, non-athletic, and unattractive teenage male (Mills et al., 2016).
Different research reports that teenagers with VGD show greater interest in the virtual world than in the real world, which affects the way they act and think. Thus, adolescents become deeply immersed in games to the point of rumination in different contexts (e.g., school, home, and other activities), and distance themselves from the demands of the real world (e.g., schoolwork, housework, or socialization), considering them unimportant, too difficult, or uncontrollable (Rehbein, Kliem, Baier, Mößle, & Petry, 2015; Schneider et al., 2018; Seok et al., 2018). When teenagers with VGD are very accustomed to the virtual world, they may begin to believe that the virtual self or the game character is a real person or even themselves. Teens may present significant identity conflicts and require help exploring their real self, due to their excessive attachment to the virtual self (Choi et al., 2018).
On a behavioral level, teens with VGD can be seen playing for hours. This is reinforced by obtaining greater rewards from the video game as more time is dedicated to it, however, at the same time, their functioning in the real world is diminished, leading to deprivation of adequate sleep, omission of food, chronic fatigue, and, as previously noted, neglect of other important activities (Choi et al., 2018; Seok et al., 2018; Yu & Cho, 2016). When play is restricted for adolescents with VGD, they may experience negative emotions, such as frustration and irritability, or the feeling of being unable to cope with the deprivation or forced reduction of play (Evans, King, & Delfabbro, 2018; Martín-Fernández et al., 2017).
Keys to the psychological treatment of the vgd.
Several studies establish crucial suggestions for the treatment of vgd in adolescents. Among them are: (a) to identify the motivation to play since it offers a conative parameter to understand the behavior (Hellström, Nilsson, Leppert, & Àslund, 2015), (b) to strengthen the level of family cohesion since the evidence shows the mediating value of this variable in the presentation of the playing behavior (Bonnaire & Phan, 2017), and (c) to act on impulsivity through the use of drugs for the management of attention deficit hyperactivity disorder (adhd) (e.g., atomoxetine, methylphenidate, etc.), as they reduce the impulsive symptoms characteristic of vgd (Park, Lee, Sohn, & Han, 2016).
Effects of vgd on the brain
At the brain level, research has found links between impulsivity -which, as we have reviewed, has a close relationship with VGD in adolescents- and increased or decreased activation in certain areas of the brain (Qi et al., 2016). For example, scientists have observed that alterations in the prefrontal cortex -involved in the circuitry that modulates impulsivity- may be the basis of thoughtless behavior (Ding et al., 2014). Studies on cerebral connections have revealed a decrease in areas (e.g., prefrontal lobe, upper and lower frontal gyrus) related to cognitive control, decision making, and impulsive management (Wang, Yin, et al., 2015). Additionally, it has been observed that microstructural changes in the right occipital subcortical white matter could also be related to high impulsivity (Du et al., 2017; Wang, Jin, et al., 2015). And other studies of adolescents with VGD show a weaker activation of the anterior cingulate cortex, implying altered prefrontal cognitive control and difficulty in emotional regulation (Lee et al., 2015).
Under functional magnetic resonance imaging (fivmi), researchers have observed significantly more activations (in post-central, lower frontal and pre-central convolutions, cerebellum, occipital lobe, anterior cingulate cortex, temporal pole, and medial prefrontal cortex) in adolescents with VGD than in adolescents without this disorder. During testing, teens with VGD showed higher brain activity (medial prefrontal cortex and anterior cingulate cortex) when thinking about their virtual self in comparison to their real self (Choi et al., 2018).
According to other findings, there is an inverse relationship between playtime and brain functional connectivity, as longer playtime predicted significantly lower functional connectivity between the dorsal putamen and overlapping brain regions - including the right precentral and postcentral cortexes- and, at the same time, predicted significantly higher functional connectivity between the dorsal putamen and bilateral inferior temporal cortexes, which could underlie the VGD (Hong et al., 2015).
Through the evaluation of quantitative electroencephalograms (QEEG), adolescents with VGD in comorbidity with ADHD showed decreased relative delta-band power and higher relative beta-band power values in temporal regions compared to adolescents with ADHD alone, which could be associated with the requirement of a certain degree of alertness and agile attention management. Following the same line, the severity of ADHD symptoms was found to be positively correlated with intrahemispheric coherence of delta, theta, alpha, and beta bands in parieto-occipital regions in the ADHD and VGD group (Park et al., 2017).
Furthermore, adolescents with VGD in comorbidity with ADHD or major depression disorder displayed an association between chronic exposure to games with increased connectivity in all regions (anterior insula, dorsal anterior cingulate and frontal eye fields; ipsilateral dorsolateral prefrontal cortex and temporoparietal junction; and between auditory and motor cortex) that are linked to rapid motor responses to visual and audiovisual stimuli and semantic memory (Han et al., 2017).
vgd-related risk factors
Different factors may increase the risk of VGD in adolescents. Among them are being male (Chiu, Pan, & Lin, 2018; King & Delfabbro, 2017); having anxiety, a depressive disorder (Yu & Cho, 2016) or ADHD; being impulsive (Park et al., 2016; Seok et al., 2018) or aggressive (Kim et al., 2018; Yuh, 2018); and having low self-esteem, low emotional self-control (Che et al., 2017; Seok et al., 2018), high sensation seeking (Hu, Zhen, Yu, Zhang, & Zhang, 2017), problems with social skills (Martín-Fernández et al., 2017), and negative coping styles (Schneider et al., 2018).
Adolescents in contexts of vulnerability and attention problems have a higher risk of presenting VGD (Peeters, Koning, & van den Eijnden, 2018). Likewise, the use of illegal drugs, in adolescents as cannabis according to Mérelle et al., (2017), or legal, such as nicotine and alcohol, increase the chances of presenting VGD (Van Rooij et al., 2014).
Game-specific risk factors that may increase the likelihood of VGD include playing with strangers online (King & Delfabbro, 2017), preference for multiplayer games (Wang et al., 2014), game versatility (Donati et al., 2015), and free access to games (Bonnaire & Phan, 2017; Seok et al., 2018).
Risk factors can also be found in family settings, where adolescents are prone to conflicts (Bonnaire & Phan, 2017; Yuh, 2018), lack of communication (Lyu, 2017), low cohesion (Yuh, 2018; Seok et al., 2018), disharmony (Wang et al., 2014), poor parental supervision (Lyu, 2017), lack of rules on video game use (Bonnaire & Phan, 2017), high parental video game use (Wu, Ko, Wong, Wu, & Oei, 2016), and low level of closeness with parents (King & Delfabbro, 2017; Seok et al., 2018).
However, certain factors may decrease the risk of presenting VGD: (a) school engagement, as it facilitates real and healthy social relationships that prevent excessive video game use (Yuh, 2018), (b) self-control combined with brief abstinence (Evans et al., 2018), and, against all expectations, (c) having a criminal record (Ong, Peh, & Guo, 2016).
vgd measuring instruments
Several authors have based their research on nine criteria established for Internet Gaming Disorder in the DSM-V, to develop different measurement instruments (Chiu, Pan, & Lin, 2018; Koo, Han, Park, & Kwon, 2017; Pontes, Macur, & Griffiths, 2016; Vadlin, Àslund, & Nilsson, 2015). Among them is the Game Addiction Identification Test (GAIT) developed in Sweden. This instrument was created to measure game-related addictive factors in adolescents aged 12 and older, and to be used in clinical settings, communities, school health care, social services, etc. (Vadlin et al., 2015).
Instruments as the School-based Child Health Behavior Survey (HBSC) standardized in Denmark -which covers 11 to 15-year-old adolescents in school settings- aim to develop new and short measurement tools for non-clinical research on problems related to video games and internet use (Holstein et al., 2014). Other ones, as the Internet Gaming Disorder Scale - Short-Form (IGDS9-SF), validated in Slovenia with a representative sample of 12 to 16-year-olds, consist of nine Likert scale items (Pontes, Macur, & Griffiths, 2016).
In South Korea, researchers developed the Structured Clinical Interview for Internet Gambling Disorder (SCI-IGD) based on a sample of 236 high school students of 13 years on average. This interview consists of 12 items that assess six components that meet VGD criteria: concern, abstinence and tolerance, loss of control, mood modification, and negative consequences. It is important to note that the test-retest reliability examined in the interview over four weeks showed significant estimates from a moderate level to a near-perfect level (Koo et al., 2017).
In Taiwan, the Chinese version of the Internet Gaming Disorder Ten-item Internet Gaming Disorder Test (IGDT-10) was also validated based on the nine DSM-V criteria for the assessment of VGD. This test was administered to adolescents between 10 and 18 years, and it established a 3.1% prevalence rate of VGD in Taiwanese students, with a predominance of males (Chiu, Pan, & Lin, 2018).
Conclusions
Evidence on VGD in adolescents comes from different latitudes of the world, with studies from Asia (58.3%), Europe (31.3%), Oceania (8.3%), and North America (2.1%). However, this review found no documentation on VGD for adolescents in Latin America.
Considering our main objective and the results of the analysis of the aforementioned investigations, we can characterize VGD in adolescents according to the following elements:
First, regarding the context of adolescents with VGD, it can be pointed out that they come from environments with high availability of electronic devices that facilitate early contact with video games and where a permissive family culture in the use of video games is maintained until adolescence. Additionally, the evidence demonstrates that adolescents with VGD present important relational problems with their families and/or group of peers and avoid them through virtual interactions with games. Thus, video games and their virtuality are described as a safeguard for adolescent suffering or as an alternative to real contexts (e.g., home, school, etc.) that can be seen as aversive.
Second, on the characteristics of adolescents with VGD, the evidence reviewed indicates that they are mostly boys who spend more hours - daily and weekly- playing than those without this disorder, and display a significant level of anxious, depressive, aggressive, impulsive, low self-esteem, isolation, and distressing personality traits. In addition, they have a greater preference for role-playing and battleground games, which turn out to be the most addictive because of their accessibility, visibility, and time spent on them.
Third, the psychological changes caused by VGD in adolescents can be differentiated. On an emotional level, we find affective instability, mood swings, and the appearance of anxious-depressive states. At a cognitive level, we observe a ruminant thought about the game and an attachment to the virtual identity over the real one, which generates relevant conflicts in the self-concept. At a behavioral level, research has identified alterations in behavior that influence a lower amount of sleeping hours, quality and feeding times, and a distancing from real social interactions, generating progressive isolation.
Fourth, at a cerebral level, the studies consulted agree that VGD causes an increase or decrease in the activation of different areas in the brain, and that this has an effect on the appearance and evolution of this disorder. Thus, elements that we have described as typical of VGD in adolescents (impulsivity, problems of emotional regulation, and a predilection for a virtual self in replacement of the real self) would have a cerebral correlate linked, on the one hand, to an under-activation of the prefrontal lobe, the upper and lower frontal gyrus, and the anterior cingulate cortex, and on the other hand, to an over-activation of the occipital lobe, the cerebellum, and the post and pre-central gyrus.
Fifth, evidence shows the presence of various risk factors with respect to VGD in adolescents. On a personal level, they refer to being male, having low emotional control, difficulties in basic social skills, negative or insufficient coping styles, low self-esteem, impulsivity, drug use, and the presence of other disorders such as ADHD, anxiety, and depression. At the familial level, there are conflicts, low communication and cohesion, and poor or absent parental supervision. At the gaming level, risk factors involve playing with strangers, multiplayer video games, versatile games (different modalities and roles), and free access games. However, the observed studies also demonstrate the existence, although to a lesser extent, of some protective factors, such as school commitment and maintaining real social exchange relationships, positive family communication and supervision, and self-supervision in the use of video games.
Sixth, it should be noted that all the measuring instruments are designed based on the DSM-5'S criteria and come mainly from Asia and Europe. Nevertheless, the progress being made in the description of this disorder, as the definition of new diagnostic criteria by the World Health Organization, poses a challenge: developing new instruments to include it.
Despite this study's limitations, in order to expand its results, it is desirable to broaden the search for evidence in other databases and explore more specific documentation on the intervention and approach to VGD in adolescents. Additionally, the low number of Latin American publications related to this topic not only reveals the state of the research developed in these countries but also presents an opportunity to increase them (Polanco-Carrasco, 2017).
Finally, the evidence consulted offers key elements to better understand VGD in adolescents. This includes the identification of gaming motives, both conscious and unconscious, the value of family cohesion in the manifestation and treatment of VGD, and the importance of multilevel approaches where a therapeutic process can be complemented by psychoactive drugs that are indicated for the impulse regulation of other disorders such as anxiety or ADHD.
