1

Kuss, D. J., & Griffiths, M. D. (2012). Online gaming addiction in children and
adolescents: A review of empirical research. Journal of Behavioral Addictions,
1(1), 3-22.

This is the post-print version of the original article. The final published version can be
accessed online at:
http://dx.doi.org/DOI: 10.1556/JBA.1.2012.1.1

ABSTRACT

Research suggests that excessive online gaming may lead to symptoms commonly
experienced by substance addicts. Since games are particularly appealing to children and
adolescents, these groups may be more at risk than other groups of developing gaming
addiction. Given these potential concerns, a literature review was undertaken in order (i) to
present the classification basis of online gaming addiction using official mental disorder
frameworks, (ii) to identify empirical studies that assess online gaming addiction in children
and adolescents, and (iii) to present and evaluate the findings against the background of
related and established mental disorder criteria. Empirical evidence comprising 30 studies
indicates that for some adolescents, gaming addiction exists and that as the addiction
develops, online gaming addicts spend increasing amounts of time preparing for, organizing,
and actually gaming. Further evidence suggests that problematic online gaming can be
conceptualized as a behavioral addiction rather than a disorder of impulse control.

Keywords: Internet gaming addiction, online games, adolescents, children, literature review,
classification
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INTRODUCTION

Play is an innate human drive that begins in very early childhood (Caillois, 1961).
Today, much game play has been transferred from the real (i.e., the embodied world) to the
online world. This is certified by software sales. In 2010, both video and PC game software
retail sales amounted to approximately $15.5 (US) billion (Johnson, 2011). The general
preference with regards to online games is The Sims 3 followed by World of Warcraft’s
Wrath of the Lich King. This suggests that ‘Simulation Games’ and ‘Massively-Multiplayer
Online Role-Playing Games’ (MMORPGs) are favored by gaming communities (The NPD
Group, 2010). These games allow players to (i) inhabit massive game worlds concurrently,
(ii) develop virtual alter egos, namely avatars, and (iii) play with others all over the world
anytime and anywhere. Furthermore, they enable immersion in a reality that is both
simultaneously fantastic and poignantly real. Therefore, these games can be seen as
“systems[s] in which reality itself […] is entirely captured, fully immersed in a virtual image
setting, in the world of make believe, in which appearances are not just on the screen through
which experience is communicated, but they become the experience” (Castells, 1996, p. 404).
The manifold possibilities that online games offer for aficionados and novices alike
clearly highlight the wide appeal of these games. Moreover, according to the latest report of
the Entertainment Software Association (ESA), 25% of the computer and video game players
are under the age of 18 years and 60% are male. The ESA also reported that 25% of parents
do not impose time limits on their children’s Internet use and 17% of parents do not impose
time limits on video and computer game playing (ESA, 2010). From these statistics, it appears
that gaming, and particularly online gaming, is an integral element of children and
adolescents’ leisure time activities.
Whilst gaming is a pleasurable pastime activity, research suggests that excessive online
gaming may in extreme cases lead to symptoms commonly experienced by substance addicts,
namely salience, mood modification, craving, and tolerance (Hsu, Wen, & Wu, 2009; Ko,
Liu, Hsiao, Yen, Yang, Lin, Yen, & Chen, 2009; Mehroof & Griffiths, 2010; Wölfling,
Grüsser, & Thalemann, 2008; Young, 2009). A recent systematic literature review suggests
that it is particularly excessive engagement with MMORPGs that can lead to addiction in a
small minority of players (Kuss & Griffiths, 2011b). Since online and offline video and
computer games are particularly appealing to children and adolescents (ESA, 2010), it
appears reasonable to suggest that these groups may be particularly at risk (i.e., more
vulnerable and susceptible) of developing gaming addiction. Furthermore, it has been argued
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that because of the 24/7 nature and almost mandatory excessive play required in playing
MMORPGS (such as World of Warcraft and EverQuest), online gaming may be more
problematic for ‘at risk’ individuals than offline gaming (Griffiths & Meredith, 2009).
Assessing online gaming addiction in children and adolescents is relevant for several
reasons. With regards to developmental psychopathological findings, it appears that
addictions tend to have precursors within the period of adolescence (Hawkins & Fitzgibbon,
1993). Also, it is relatively common that substance dependencies develop in early adulthood
(APA, 2000). Therefore, prevention efforts must be established that target adolescents who
have their first experiences with addictive substances and behaviors during their pubescence.
During this period of time, the adolescent is confronted with a variety of cumulated stressors,
such as physical and hormonal changes, as well as shifts in personal value and belief systems.
Parental influence is diminished whereas the peer group gains more importance. Peer pressure
may lead to a variety of problems (Silbereisen & Kastner, 1998) that may eventuate in the
development of pathological behaviors, such as chemical and behavioral addictions (Wölfling
& Müller, 2009).
Adolescents may use online games as a way of coping with stressors and gaming can
become a dysfunctional media-focused coping strategy (Thalemann, 2009). Similarly,
relationships between problematic gaming and the ways in which adolescents cope with
stressors and frustrations have been reported (Wölfling, Thalemann, & Grüsser, 2008). For
instance, problematic gamers play games significantly more frequently than non-problematic
gamers as a reaction to anger and frustration. Thus, they appear to use gaming as a strategy
for emotion regulation in order to decrease negative feelings. This seems particularly
problematic because those adolescents who play online games excessively are likely to get
little chance to actually develop healthy ways of coping with stressors because they are
constantly occupied with playing online games instead. Therefore, their psychosocial
development may be significantly impaired. The consistent blocking out of and passive
coping with stressful experiences is a strategy that may be successful in the short-term.
However, viewed from a long-term perspective, it may limit the potential to have fundamental
experiences that are necessary for developing a protective way to cope. In this case, it appears
more likely that once new stressors appear, adolescents continue to use escapist and media-
focused coping mechanisms. This results in a vicious circle (Wölfling & Müller, 2009).
A wide variety of empirical and prospective studies have investigated the negative
consequences of stressors upon psychological and physiological parameters when the former
are inadequately dealt with. Therefore, a repertoire of coping strategies that is deficiently
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developed may be seen as a risk factor for the development of a variety of negative
psychological and psychosomatic problems. These entail direct effects on the immune system
(Charlton, 2002) as well as negative affectivity (Kim, Ryu, Chon, Yeun, Choi, Seo, & Nam,
2006) and psychosomatic problems (Batthyány, Müller, Benker, & Wölfling, 2009).
Moreover, patients including adolescents aged 17-19 years treated for their pathological
gambling and online gaming addiction at the Outpatient Clinic for Gaming Addictions in
Mainz, Germany, have been found to suffer from depressive symptoms, anxiety, and
somatization (Wölfling & Müller, 2009). Such clinical observations hint at the importance of
assessing excessive and potentially pathological online gaming behavior more specifically in
children and adolescents.

Clinical diagnosis
Behavioral addictions, such as online gaming addiction, have typically categorized
either within the frameworks of impulse control disorders or substance dependencies (Grüsser
& Thalemann, 2006). To date, criteria developed for the diagnosis of online gaming addiction
in empirical studies have been based on either the criteria for pathological gambling or the
criteria for substance dependence. According to the American Psychiatric Association’s
official diagnosis (2000), pathological gambling is an impulse control disorder not otherwise
specified (see Table 1). The main characteristic of impulse control disorders is the “failure to
resist an impulse, drive, or temptation to perform an act that is harmful to the person or to
others” (APA, 2000, p. 663).

Table 1: Diagnostic Criteria for 312.31 Pathological Gambling

A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of
the following:
(1) is preoccupied with gambling (e.g., preoccupied with reliving past gambling
experiences, handicapping or planning the next venture, or thinking of ways to get
money with which to gamble)
(2) needs to gamble with increasing amounts of money in order to achieve the desired
excitement
(3) has repeated unsuccessful efforts to control, cut back, or stop gambling
(4) is restless or irritable when attempting to cut down or stop gambling
(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g.,
feelings of helplessness, guilt, anxiety, depression)
(6) after losing money gambling, often returns another day to get even (“chasing” one’s
losses)
(7) lies to family members, therapist, or others to conceal the extent of involvement with
gambling
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(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance
gambling
(9) has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of gambling
(10) relies on others to provide money to relieve a desperate financial situation caused by
gambling
B. The gambling behavior is not better accounted for by a Manic Episode.
Note. The criteria presented originate from the American Psychiatric Association’s taxonomy (2000,
p. 674), which is similar to the World Health Organization’s classification of pathological gambling
within the category of “habit and impulse disorders, F63.0” (1992).

An alternative approach to assessing online gaming addiction is the reliance on the

official criteria for substance dependence or the dependence syndrome (APA, 2000; WHO,
1992). The discriminative features of substance dependence are “a cluster of cognitive,
behavioral, and physiological symptoms indicating that the individual continues use of the
substance despite significant substance-related problems” (APA, 2000, p. 192). The relevant
diagnostic items for substance dependence are presented below in Table 2.

Table 2: Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or

distress, as manifested by three (or more) of the following, occurring at any time in the same
12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or
desired effect
(b) markedly diminished effect with continued use of the same amount of the
substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the (respective) substance
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal
symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting
multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or
recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because
of substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
the substance (e.g., current cocaine use despite recognition of cocaine-induced
depression, or continued drinking despite recognition that an ulcer was made worse by
alcohol consumption)
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Note. The criteria presented originate from the American Psychiatric Association’s classification of
“substance dependence” (2000, p. 197), which is similar to the World Health Organization’s
classification of the “dependence syndrome” (1992).

Unlike pathological gambling, a diagnosis for substance dependence requires the

presence of the respective criteria within the period of 12 months. Thus, it adds a time
criterion to diagnosis that is relevant for the identification of genuine pathology. Moreover,
another main distinguishing feature is the absence of a withdrawal criterion in the case of
pathological gambling relative to substance dependence. Therefore, for pathological
gambling, the actual activity of engaging in the potentially maladaptive behavior takes a
prime role over any other possible negative consequences the engagement may result in.
Typically, the reliance on substance dependence criteria is used for the classification of
behavioral addictions (Batthyány & Pritz, 2009; Grüsser & Thalemann, 2006). With
behavioral addictions such as online gaming addiction, no psychotropic substances are
ingested. Instead, the psychotropic effect results from biochemical changes in the body. These
are triggered by rewarding activities that are then engaged in excessively (Holden, 2001).
Given the variety of potential classification frameworks for online gaming addiction, it
appears to be crucial to evaluate each one individually. For this purpose, a literature review
was undertaken. The specific aims of this review were to (i) present the classification basis of
online gaming addiction using frameworks of officially recognized mental disorders as
outlined in the current versions of the Diagnostic and Statistical Manual for Mental Disorders
IV-TR (APA, 2000) and the International Classification of Mental and Behavioral Disorders-
10 (WHO, 1992), (ii) identify contemporary empirical studies that assess online gaming
addiction in children and adolescents, and (iii) present and evaluate their findings against the
background of the established official criteria. For this purpose, the empirical studies
identified from the current scientific knowledge base will be delineated and evaluated
subsequently.

METHOD

The database Web of Knowledge was used to identify all empirical studies published up to
October 31, 2011. Web of Knowledge not only contains peer-reviewed articles and conference
proceedings from various social sciences (e.g., medicine and psychology), but it also makes
use of papers in the natural sciences and arts and humanities. Therefore, it can be considered
to be considerably more comprehensive than other commonly used databases, such as
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Psycinfo or Pubmed. For the purpose of broad coverage, further studies were accessed via
Google Scholar. The search terms utilized to detect the relevant studies were “online gam*”,
“Internet gam*”, “computer gam*”, “video gam*”, “addict*”, “dependen*”, “excess*”, and
“patholog*”. The inclusion criteria upon which the studies were selected were: (i) the
inclusion of empirically collected data, (ii) an assessment of online gaming addiction in some
form, (iii) the inclusion of children and adolescents (aged 8-18 years) in the sample, (iv)
publication in peer-reviewed journals, (v) full text availability, (vi) publication after the year
2000, and (vii) written in either English or German language as these are the native languages
of the authors. This timeframe was applied because studies that were published earlier than
2000 were assumed to have a focus different from online games (i.e., they specifically
assessed console or arcade video games without an equivalent on the Internet). Following the
comprehensive literature search, 30 empirical studies were identified as meeting the inclusion
criteria.

RESULTS

Following a thorough review of the current empirical studies, the latter were classified in
accordance with the diagnostic framework that the authors’ utilized to identify potentially
pathological online game use. Online gaming addiction in these 30 studies was assessed using
different classification schemes. These included those based on the criteria for pathological
gambling (n = 18), those based on the criteria for substance dependence (n = 3), those based
on a combination of both pathological gambling and substance dependence (n = 3), those
based on parental referral (n = 2), and those based on other miscellaneous classification
criteria (n = 4). Each of these will be described and subsequently evaluated. An overview is
presented in Table 3 below.
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Table 3: Empirical studies examining adolescent gaming and their main findings

Study Sample and design Instruments Addiction criteria, symptoms and prevalence
Allison, von - N = one male adolescent playing Variety of psychological tests incl. WAIS, MMPI, - “Game addiction”
Wahlde, computer games excessively (age = psychiatric interviews, and social work evaluation - No specific diagnostic tool used
Shockley, & 18) of his family - 12-16 hours game play per day
Gabbard (2006) - Participant underwent - No sleep, limited real-life social contacts
multidisciplinary assessment for - Escapism motivation, obsession with gaming
three days at a psychiatric clinic - Symptoms: gaming “overshadowed” participant’s life,
continuously missed classes at school, diminished energy,
poor concentration, fatigue, muscle tension

Batthyány, - N = 1,231 students (in grades 3-5) - Assessment of Computer Game Addiction in - “Excessive computer game play” found in 12% (n = 1068;
Müller, Benker, in Vienna (46% female) Children – Revised (CSVK-R) (Thalemann, 10% abusive, 3% dependent behavior)
& Wölfling - Survey Albrecht, Thalemann, & Grüsser, 2004) - Based on criteria of substance dependence (DSM IV-TR
(2009) and ICD-10)
- Distinction between normal, salient, abusive and addicted

Bear, Bogusz, & - N = 102 adolescents (age range = - Self-devised Computer/Gaming-station Addiction - Addiction score significantly correlated with higher
Green (2011) 11-17 years) from out-patient Scale (CGAS) assessing criteria derived from difficulties, less prosocial behavior in both child and parent
psychiatric clinics in Canada impulse-control and substance-abuse disorder reports (i.e., positive correlations with emotional, conduct,
- Surveys completed by children (based on Ko, Yen, Chen, Chen, & Yen, 2005b) on and peer problems, and hyperactivity, and negative
and their parents a continuum correlation with prosocial behavior), and functional
- Strength and Difficulties Questionnaire impairment (i.e., family, learning, life skills, self-concept,
(Goodman, Ford, Simmons, Gatward, & Meltzer, and social activity)
- Clear distinction between increased gaming time and
2000)
addiction (gaming time did not correlate with any of the
- Weiss Functional Impairment Rating Scale-parent
measures)
(WFIRS-P) (Weiss, 2008)
Chan & - N = 72 adolescents (in grades 8-9) - Young’s Internet Addiction Scale, modified for - “Excessive console and Internet video game use”
Rabinowitz recruited from high school and N = VGs (YIAS-VG) (Widyanto & McMurran, 2004) - Six components of addiction: salience, excessive use,
72 parents with good internal consistency, reliability and neglecting work, anticipation, lack of control, neglecting
- Survey with sections for validity social life
adolescents and their parents - Time spent playing VGs, watching TV, using the
Internet
- Conners’ Parent Rating Scale (CPRS; Conners,
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Sitarenios, Parker, & Epstein, 1998) incl. sections

on oppositional, hyperactivity, inattention, and
ADHD categories
Chiu, Lee, & - N = 1.228 students (in grades 5-8) - Game Addiction Scale (based on Buchman & - “Video game addiction”, unspecified
Huang (2004) sampled from 20 primary and junior Funk, 1996; Clymo, 1996) - 9-item self-devised scale that assesses two factors: game
high schools in Northern Taiwan - Demographics including academic achievement addiction and game concern; α = 0.86
- Survey - Sensation seeking (including being assertive, bold, - Female, lower function, higher sensation seeking, and
and ambitious) higher boredom inclination predict game addiction
- Boredom Inclination Scale (based on Farrell,
1990)

Choo, Gentile, - N = 2,998 primary and secondary - Pathological Video-Gaming Scale (Gentile, 2009) - Prevalence of pathological gaming 8.7% (12.6% boys,
Sim, Li, Khoo, & school children in Singapore (73% based on DSM-IV criteria for pathological gambling 4.7% girls)
Liau (2010) male; mean age = 11 years, SD = 2 (minimum of 5/10 criteria had to be fulfilled for - Compared to non-pathological gamers, pathological
years) diagnosis) gamers play twice as much, significantly more likely to
- Survey questionnaire - General Media Habits Questionnaire (GMHQ) have video-game system in bedroom, visit LAN centres,
(Anderson & Dill, 2000) receive poorer grades, more impulse control problems,
- Adult Involvement in Media Scale poorer social competence, greater hostile cognitions, more
video-gaming related problems (including health problems),
- Barratt Impulsiveness Scale (Patton, Stanford, &
fights with parents over video games, getting little sleep,
Barratt, 1995) being late for school, decrease in social contacts, neglect of
- Personal Strengths Inventory – II (Liau, Chow, self-care, relying on friends for homework
Tan, & Senf, 2011) - Amount of gaming itself insufficient to define
- Hostile cognition (Huesmann & Guerra, 1997) pathological gaming
- General Mental Health Survey (Crystal, Chen,
Fuligni, Stevenson, Hsu, Ko, Kitamura, & Kimura,
1994)
- Functional impairment (adapted from Charlton,
2002)
- Raven’s Standard Progressive Matrices Plus (SPM
Plus) (Raven, Styles, & Raven, 1998)
Cultrara & Har-El - N = one 17-year old boy with - Medical examinations - “Excessive video game play”
(2002) suprahyoid muscular hypertrophy - Patient’s history, physical, radiologic, - No specific diagnostic tool used
caused by video game play intraoperative, and pathologic findings - Muscle hypertrophy secondary to increased activity
- Case report - Patient stopped video game play and within 4 months,
sub-mental mass decreased in size
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Dongdong, Liau, - N = 161 secondary school students - Pathological Gaming Scale (Choo, et al., 2010): - Pathological gaming explained as a function of actual-
& Khoo (2011) in Singapore with MMO gaming 10-item scale based on pathological gambling ideal self-discrepancy, depression, and escapism
experience (age range = 13-15 criteria with acceptable reliability (Cronbach’s α = - Escapism found to have strongest direct influence on
years; mean age = 14 years, SD = 0.75) pathological gaming
0.7 years; 49% boys) - Self Attribute Statement Scale (based on Dittmar, - No gender difference in pathological gaming found
- Questionnaire
2005)
- MMO Player Motivation Scale (modified from
Yee, 2007)
- Asian Adolescent Depression Scale (Woo, Chang,
Fung, Koh, Leong, Kee, & Seah, 2004)

Gentile, Choo, - N = 3,034 children in grades 3 (n = - Pathological video game use (Gentile, 2009) - “Pathological gaming”
Liau, Sim, Li, 743), 4 (n = 711), 7 (n = 916), 8 (n - Problematic gaming (Charlton, 2002) - Definition based on APA criteria: minimum of 5/10 items
Fung, & Khoo = 664) from six secondary schools endorsed for pathology classification
- General Media Habits Questionnaire (Anderson, et
(2011) (five boys’ schools) - Pathological gaming prevalence: 9%
- Two-year longitudinal study al., 2007; Gentile, et al., 2004) - Risk factors for pathological gaming: much gaming, low
- Barratt Impulsiveness Scale (Patton, et al., 1995) social competence, greater impulsivity
- Personal Strengths Inventory II (Liau, et al., 2011) - Outcomes of pathological gaming: depression, anxiety,
- Children’s Empathic Attitudes Questionnaire social phobias, lower school performance
(Funk, Fox, Chan, & Curtiss, 2008)
- Normative beliefs about aggression (Huesmann &
Guerra, 1997)
- Hostile attribution bias (Crick, 1995)
- Aggressive fantasies (Huesmann & Eron, 1986;
Nadel, Spellmann, Alvarez-Canino, Lausell-Bryant,
& Landsberg, 1996)
- Self-report of aggression (Linder, Crick, &
Collins, 2002)
- Parent-family connectedness (Resnick, Bearman,
Blum, Bauman, Harris, Jones, Tabor, Beuhring,
Sieving, Shew, Ireland, Bearinger, & Udry, 1997)
- ADHD screen (University of Massachusetts
Medical School, 2007)
- Asian adolescent depression scale (Woo, et al.,
2004)
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- Anxiety (Birmaher, Khetarpal, Brent, Cully,

Balach, Kaufman, & Neer, 1997)
- Social phobia (Connor, Davidson, Churchill,
Sherwood, & Weisler, 2000)
- School performance
Gentile (2009) - Stratified sample of N = 1,178 US - Pathological Gaming Scale (pathological = - 8.5% of gamers (88% gamers in total sample) classified as
residents (8-18 years) with equal satisfies minimum of 6/11 criteria) pathological
gender and age distribution - Several items for children’s video-game habits - Compared to non-pathological gamers, pathological
- 20-minute omnibus online survey (adapted from Anderson, et al., 2007; Gentile, et al., gamers were significantly more likely to play for more
2004) years, play more frequently and for more time, be more
familiar with video-game rating symbols, have worse
grades in school, have difficulties with attention and
ADHD, have more health problems, feel addicted to games
and have friends that were addicted to games

Grüsser, - N = 323 children, age range = 11- - Assessment of Computer Game Addiction in - “Excessive computer/ video game play” present in 9% of
Thalemann, 14 years, M = 12 years, SD = 1; Children – Revised (CSVK-R) (Thalemann, et al., sample
Albrecht, & 54% males 2004) - Based on criteria of substance dependence (DSM IV-TR
Thalemann - Questionnaire distributed in school and ICD-10)
(2005) - Distinction between normal, salient, abusive and addicted

Han, Lee, Na, - N = 62 children with ADHD (52 - Internet Addiction Scale (Young, 1996b; Korean - 52% comorbidity between “Internet video game
Ahn, Chung, males; mean age = 9 years, SD = 2 version) with good internal consistency addiction” and ADHD
Daniels, Haws, & years)
- ADHD rating scale (So, Noh, Kim, Ko, & Koh,
Renshaw (2009) - Questionnaire and visual
continuous performance test 2002)
- Computerized Neurocognitive Function Test
(Kim, Shin, Kim, Yang, Shin, & Yoon, 2006)
Han, Lee, Yang, - N = 79 male ‘excessive Internet - Internet Addiction Scale (Young, 1998) with good - “Excessive Internet game players” have higher prevalence
Kim, Lyoo, & game players’ and 75 healthy internal consistency of Taq1A1 and low activity
Renshaw (2007) controls recruited from high schools - Reward Dependence (RD) scale of Cloninger’s (COMTL) alleles
in South Korea (mean age = 16 Temperament and Character Inventory
years, SD = 1 year) - Frequencies of 3 dopamine polymorphisms
- Self-report questionnaires and - SCID I (First, Gibbon, Spitzer, & Williams, 1996)
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genotyping
Kim & Kim - Phase 1: Problematic Online Game Use Scale (based on - “Problematic online game use”
(2010) N = 1422 5th graders (47% female, Armstrong, Phillips, & Saling, 2000; Caplan, 2002; - Criteria assessed: euphoria, health problem, conflict,
mean age = 12 years) recruited from Charlton & Danforth, 2007; Lee & Ahn, 2002; failure of self-control, preference for virtual relationship
seven private elementary schools in Young, 1999) with good reliability, convergent and
South Korea discriminant validity
- Phase 2:
N = 199 8th graders (mean age = 15
years) from private junior high
school
- Phase 3:
N = 393 11th graders
(50% females, mean age = 18 years)
from two public high schools
- Survey

King & - N = 38 (23 adolescents (15 males, Questions on playing motivations, and psychosocial - “Excessive video game play”
Delfabbro (2009) mean age = 16 years, SD = 1 year; context of excessive video game playing behavior - No specific diagnostic measure used
video game playing = 15 hrs/week, - Online Role-Playing Games more rewarding than casual
SD = 12 hours); 15 adults (11 games  more addictive
males, mean age = 30 years, SD = 7
years; video game playing = 18
hours a week, SD = 11 hours a week
- Pilot interview study with seven
semi-structured group interviews
Ko, Yen, Chen, - N = 221 online game playing - Chinese Internet Addiction Scale (Chen, Weng, - Males significantly more likely to be addicted to playing
Chen, & Yen adolescents (63% males; mean age Su, Wu, & Yang, 2003): continuous measure online games than females
(2005a) = 13.8 years, SD = 0.7 years, range including 26 items that assess five dimensions, - For males, older age, lower self-esteem, and lower daily
= 13-15 years) recruited in junior namely compulsive use, withdrawal, tolerance, life satisfaction predicted online gaming addiction
high school interpersonal relationships, health and time
- Survey management (Cronbach’s α = 0.96)
- Rosenberg Self-Esteem Scale (Rosenberg, 1965)
- Questionnaire for Playing Online Games to asses
age of gaming begin, time and money spent playing,
location of play, and motives for play; daily life
satisfaction and total number of stressors
encountered in daily life
Kwon, Chung, & - N = 1,136 middle school students - Internet Game Addiction (IGA) (modified from - Main finding: IGA is a consequence of escape from self
in Seoul, Korea (61% males; mean - IGA most strongly predicted by escape, followed by
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Lee (2011) age = 14 years, SD = 0.5 years) Young, 1996a) perceived parent hostility, real-ideal self discrepancy, and
- Questionnaire - Real-Ideal Self Discrepancy (R-I self) (Hoge & parental supervision
- Study provides empirical evidence for Baumeister’s
McCarthy, 1983)
escape from self theory (Baumeister, 1991)
- The Escape from Self Scale (Shin, 1992)
- Current Negative Mood Scale (Lee, 1991)
- Peer Intimacy Scale (Ray & Cohen, 1997), Korean
version
- Perceived Parent-Child Relationship Scale - Parent
(Lee, 1981)
- Perceived Parental Supervision Scale (Korean
Institute of Criminal Justice Policy, 1998)
Lemmens, - N = 851 Dutch adolescents (543 - Pathological gaming (Lemmens, Valkenburg, & - “Pathological gaming”
Valkenburg, & gamers; age range 11-17 years, M = Peter, 2009) with good convergent validity & - Criteria: salience, tolerance, mood modification, relapse,
Peter (2011b) 13.9 years, SD = 1.4 years; 51% criterion validity withdrawal, conflict, problems
male) - Time spent on games - Social competence, self-esteem, and loneliness predicted
- Two-wave panel study including a pathological gaming six months later
- UCLA Loneliness Scale (Russell, 1996)
paper-and pencil survey distributed - Low psychosocial well-being is antecedent and loneliness
in schools - Satisfaction with Life Scale (Diener, Emmons, is consequence of pathological gaming
Larsen, & Griffin, 1985)
- Social competence (based on Buhrmester, Furman,
Wittenberg, & Reis, 1988; Inderbitzen & Foster,
1992)
- Self-Esteem Scale (Rosenberg, Schooler, &
Schoenbach, 1989)
Lemmens, - N = 851 Dutch adolescents (age - Pathological gaming (Lemmens, et al., 2009) with - “Pathological gaming”
Valkenburg, & range 11-17 years, M = 13.9 years, good convergent validity & criterion validity - Salience, tolerance, mood modification, relapse,
Peter (2011a) SD = 1.4 years; 51% male; 540 - Time spent on games withdrawal, conflict, problems
game players, 30% female) - Violent game play (games played analyzed for - More gaming predicted more time spent on gaming six
- 2-wave panel study including a violent content using Pan-European Game months later
paper-and pencil survey that was Information database using weighted measure of - Pathological gaming increased physical aggression in
distributed in schools time spent on violent games) boys
- Physical Aggression Subscale of Aggression
Questionnaire (Buss & Perry, 1992)
Lemmens, - Two independent samples of - Game Addiction Scale for Adolescents with good - “Game addiction”
Valkenburg, & Dutch game-playing adolescents (N reliabilities and concurrent validity - Criteria measured: salience, tolerance, mood modification,
Peter (2009) = 352 and 369) recruited from six - Time spent on games relapse, withdrawal, conflict, problems
 14

schools of secondary education - UCLA Loneliness Scale (Russell, 1996) - Game addiction correlated with use, loneliness, life
(32% girls; age range: 12-18 years, - Satisfaction with Life Scale (Diener, et al., 1985) satisfaction, social competence, and aggression
mean age = 15 years, SD = 1.5
- Social competence (based on Buhrmester, et al.,
years)
- Two surveys 1988; Inderbitzen & Foster, 1992)
- Physical Aggression Subscale of Aggression
Questionnaire (Buss & Perry, 1992)

Rau, Peng & - N = 64, age range: 9-20 years; n = - Internet Addiction Self-test (IAT; based on Young, - “Internet addiction” found in 8%
Yang (2006) 26 expert players (only males), n = 1996a) - Discrepancy between self-report and questionnaire scores
38 novices (16 females); education - Experiment: Participants were playing Diablo in
levels: from elementary to graduate cybercafe
school
- Experimental study

Rehbein, Psych, - N = 44,910 German 9th graders - Video Game Dependency Scale based on Internet - “Video game dependency“: diagnosed in 3% of male,
Kleimann, (mean age = 15 years, SD = 1 year; Addiction Scale (Hahn & Jerusalem, 2001) adapted 0.3% of females
Mediasci, & 51% male; mean VG usage a day = for video game dependency (Rehbein & Borchers, - 3% classified as at risk and 2% as dependent on video
Mossle (2010) 2 hours) games (mainly boys: 5% at risk and 3% dependent; girls:
2009) with good discriminatory power
- German nationwide survey, 0.5% are at risk and 0.3% are dependent)
conducted by Criminological - 90% of youths at risk, 91% of dependents are males
Research Institute of Lower Saxony - Based on ICD-10 criteria of dependency
(KFN) - Criteria: preoccupation/ salience, conflict, loss of control,
withdrawal symptoms, tolerance

Salguero & - N = 223 Spanish adolescents (age - Problem Video Game Playing Scale (PVP; self- - “Problem video game playing”
Moran (2002) range: 13-18 years, mean age = 15 devised scale, unidimensional, acceptable internal - Self-devised questionnaire (9 items) assessing problem
years, SD = 1 year; 53% male) consistency, good construct validity) video game playing based on DSM criteria for substance
- Questionnaires distributed during - Severity of Dependence Scale (Gossop, Darke, dependence and pathological gambling present in previous
tutorials in school Griffiths, Hando, Powis, Hall, & Strang, 1995b) year cross-validated with results of Severity of Dependence
- Demographics Scale (Gossop, Darke, Griffiths, Hando, Powis, Hall, &
Strang, 1995a)

Skoric, Teo, & - N = 333 elementary school video - Assessment of addiction tendencies (based on - “Video game addiction”
Neo (2009) gamers from Singapore (age range APA, 2000; Danforth, 2003) with good internal - Criteria: behavioral salience, conflict, withdrawal
= 8-12 years, mean age = 10 years, reliability symptoms (based on Brown, 1991, 1993) and further
SD = 1 year; 54% males, 57% unspecified DSM-IV items
- Assessment of engagement tendencies (based on
Chinese, 34% Malay)
- Two survey studies Brown, 1991)
 15

- Demographics
- Amount of time spent playing video games
- School grades
Thomas & Martin - N = 1.326 students (990 secondary - Addiction (adapted from Fisher, 1994; Young, - “Video-arcade/ computer game/ Internet addiction”
(2010) and 335 college students, 657 1998) - Salience, mood modification, tolerance, withdrawal, loss
females, grades 7-13) and N = 705 - Participation habits of control, conflict, relapse, and escape (minimum of 5/8
(509 female, mean age = 22years, met for addiction classification)
SD = 7 years; 84% Australian) - Addiction to video-arcade games (4%), computer games
university students (5%) and the Internet (5%)
- Questionnaire distributed in - Prevalence of social computer game users (55%) and
schools Internet addiction (56%)

Van Rooij, - N = 3,048 Dutch adolescent online - Compulsive Internet Use Scale (Meerkerk, Van - “Online video game addiction” found in 3%,
Schoenmakers, gamers (first four classes of Dutch Den Eijnden, Vermulst, & Garretsen, 2009) with representative of 1.5% of 13-16 year old Dutch children
Vermulst, van secondary school, age range: 13-16 good concurrent, construct validity, and internal - Loss of control, preoccupation, conflict, withdrawal
den Eijnden, & years) consistency symptoms, and coping
van de Mheen - Sample stratified according to - Weekly hours online gaming
(2011) region, urbanization, and education
- Rosenberg’s Self-Esteem Scale (Rosenberg, et al.,
level
- Repeated cross-sectional survey 1989)
study with a longitudinal cohort - UCLA Loneliness Scale (Russell, Peplau, &
based on Dutch Monitor Study Cutrona, 1980)
Internet and Youth including a one- - Depressive Mood List (Engels, Finkenauer,
hour questionnaire completed in Meeus, & Dekovic, 2001; Kandel & Davies, 1986;
schools Kandel & Davies, 1982)
- Revised Social Anxiety Scale for Children (La
Greca & Stone, 1993)
Van Rooij, - N = 4920 (in 2007) and 4753 (in - Compulsive Internet Use Scale (Meerkerk, et al., - Loss of control, preoccupation, conflict, withdrawal
Schoenmakers, 2008), mean age = 14 years, SD = 1 2009) with good concurrent, construct validity, and symptoms, and coping
van den Ejinden, year; 78% Dutch adolescents internal consistency - Online gaming have strongest association with
& van de Mheen - Survey study - Online communications, games, and other Internet “Compulsive Internet Use”
(2010) - Data obtained from Monitor Study functions
Internet and Youth
Wan & Chiou - Study 1: - Internet Addiction Scale for high schoolers in - “Online game addiction”
(2006a) N = 177 Taiwanese adolescents (age Taiwan with good internal consistency, construct - Compulsive use/ withdrawal, tolerance, related problems
range: 16-24 years) and discriminatory validity (adapted from Lin & of family, school, and health, and related problems of peer
- Study 2: interaction and finance
 16

N = 182 frequent MMORPG Tsai, 1999)

players (age range: 16-22 years) - Optimal experience/flow state (Choi, Kim, & Kim,
- Survey studies
2000)
- Self-developed Two-factor Evaluation on Needs
for Online Games (TENO) to measure intensity of
psychological needs on satisfaction and
dissatisfaction dimensions
Wan & Chiou - N = 10 Taiwanese adolescents - Internet Addiction Scale for high schoolers in - “Online game addiction”
(2006b) with online game addiction (six Taiwan with good internal consistency, construct - Emergent themes: (1) addicts’ psychological needs and
chosen from Internet cafés, four and discriminatory validity (adapted from Lin & motivations; (2) online games as the everyday focus of the
were referred), seven male, eight Tsai, 1999) addicts; (3) the interplay of real self and virtual self; (4)
students, all spent more than 48hrs a - Sentence completion test and semi-structured online games as the compensatory or extensive satisfaction
week in game interviews, four realms: (1) surface motivations, (2) for addicts’ needs; and (5) addicts’ self-reflections
- In-depth interviews source motivations, (3) self-conception, and (4)
interpersonal relationships in real life

Wan & Chiou - Study 1: - Internet Addiction Scale with good internal - “Online game addiction”
(2007) N = 199 adolescents (age range: 16- consistency, construct and discriminatory validity
23 years) (adapted from Lin & Tsai, 1999)
- Study 2: - Online Gaming Motivation Scale (based on Choi
N = 426 adolescents (age range: 17- & Kim, 2004; Chou & Hsiao, 2000; Ng & Wiemer-
24 years)
Hastings, 2005)
- Survey studies
 17

Online gaming addiction based on the criteria for pathological gambling

Based on the database literature search, 18 studies were identified that assessed online gaming
addiction by means of using adapted diagnostic criteria for pathological gambling and
impulse control disorders not otherwise specified (Chan & Rabinowitz, 2006; Dongdong, et
al., 2011; Gentile, 2009; Gentile, et al., 2011; Han, et al., 2009; Han, et al., 2007; Kwon, et al.,
2011; Lemmens, et al., 2009, 2011a, 2011b; Rau, et al., 2006; Thomas & Martin, 2010; van
Rooij, et al., 2010; van Rooij, et al., 2011; Wan & Chiou, 2006a, 2006b, 2007).
In order to assess online gaming addiction, six studies (Chan & Rabinowitz, 2006; Han,
et al., 2009; Han, et al., 2007; Kwon, et al., 2011; Rau, et al., 2006; Thomas & Martin, 2010)
used an adapted version of Young’s (1998) Internet Addiction Scale (Widyanto & McMurran,
2004; Young, 1996a, 1996b, 1998). More specifically, the IAS assesses the following
addiction components: (i) salience, (ii) excessive use, (iii) neglecting work, (iv) anticipation,
(v) lack of control, and (vi) neglecting social life. The scale was found to have good internal
consistency, reliability and validity (Widyanto & McMurran, 2004). In three studies,
pathological gaming was measured by means of the Game Addiction Scale for Adolescents
(Lemmens, et al., 2009, 2011a, 2011b). The scale has good reliability and good concurrent,
convergent and criterion validity, and measures the following addiction symptoms: salience,
tolerance, mood modification, relapse, withdrawal, conflict, and problems (Lemmens, et al.,
2009).
In three other studies (Choo, et al., 2010; Gentile, 2009; Gentile, et al., 2011),
pathological gaming was assessed using the Pathological Video Game Use Scale (Gentile,
2009). This scale uses the DSM-IV-TR criteria for pathological gambling and diagnoses
addiction when at least five (of ten) symptoms are met. Similarly, in another study
(Dongdong, et al., 2011), the Pathological Video Gaming Scale (Choo, et al., 2010) was used.
It is yet another measure utilizing the official DSM-IV criteria for pathological gambling and
includes ten items. Moreover, two studies have used the Compulsive Internet Use Scale
(Meerkerk, et al., 2009) to assess online video game addiction (van Rooij, et al., 2010; van
Rooij, et al., 2011). The scale measures symptoms that relate particularly to the compulsive
and impulse control elements of the behavior, including loss of control, preoccupation,
conflict, withdrawal symptoms and coping. It was found to have good concurrent and
construct validity, as well as good internal consistency (Meerkerk, et al., 2009). Finally, three
studies (Wan & Chiou, 2006a, 2006b, 2007) used the adapted version of the Internet
Addiction Scale1 (Lin & Tsai, 1999). This scale measures compulsive use and withdrawal,
1
Lin and Tsai’s scale (1999) is loosely based on Young’s original Internet Addiction Test (1998), it is an the
former is a self-devised scale that shares the same name since it measures a similar phenomenon.
 18

tolerance, related problems of family, school, and health, and related problems of peer
interaction and finance. It was found to have good internal consistency, construct and
discriminatory validity (Lin & Tsai, 1999).
The samples used in these 18 studies included 72 adolescents in grades eight and nine
(mean age = 15 years, SD = 1 year) as well as their parents (Chan & Rabinowitz, 2006), 62
children (mean age = 9 years, SD = 2 years) with Attention Deficit Hyperactivity Disorder
(ADHD) (Han, et al., 2009), 154 male adolescents (mean age = 16 years, SD = 1 year), half of
which were excessive Internet game players (Han, et al., 2007), 161 secondary school
students in Singapore with MMO experience (mean age = 14 years, SD = 0.7 years)
(Dongdong, et al., 2011), large samples (the respective sample sizes ranged from more than
800 to less than 5000 participants) of Dutch adolescents (mean age = 14 years, SD = 1 year)
(Lemmens, et al., 2011a, 2011b; van Rooij, et al., 2010) and adolescent Dutch online game
players (Ns = 721 and 3048; age range = 13-17 years) (Lemmens, et al., 2009; van Rooij, et
al., 2011), American youths (N = 1,178, age range = 8-18 years with equal gender and age
distribution) (Gentile, 2009), Korean adolescents (N = 1136, mean age = 14 years, SD = 0.5
years; 61% male) (Kwon, et al., 2011), and Singaporean youth (N = 2,998, mean age = 11
years, SD = 2 years, 73% male), 64 children and adolescents (age range = 9-20 years) (Rau, et
al., 2006), 3,034 secondary school children (mean age = 11 years, SD = 2 years) (Gentile, et
al., 2011), 1,326 secondary school and college students (mean age = 22 years, SD = 7 years)
(Thomas & Martin, 2010), 177 Taiwanese adolescents and young adults (age range = 16-24
years) (Wan & Chiou, 2006a, 2007), and 182 Taiwanese adolescent and young adult
MMORPG players (age range = 16-22 years) (Wan & Chiou, 2006a), and ten Taiwanese
adolescents with no explicit age specification with online game addiction (Wan & Chiou,
2006b).
With regards to classification, van Rooij et al. (2010) contend that compared to using
the Internet for other applications (e.g., downloading, social networking, using messenger,
chatting, blogging, etc.), online gaming has the strongest association with compulsive Internet
use. This indicates that a subgroup of compulsive Internet users should be classified as
compulsive online gamers. Based on these assessments, a prevalence estimate of compulsive
Internet use in secondary school (age range = 9-16 years) and college students (mean age = 21
years, SD = 6 years) was provided by four studies (Choo, et al., 2010; Gentile, et al., 2011;
Thomas & Martin, 2010; van Rooij, et al., 2011). Online video game addiction was found to
be present in 3% of Dutch adolescent online gamers, which is representative of 1.5% of 13-16
year old Dutch adolescents (van Rooij, et al., 2011). Pathological gaming was found in 8.5%
 19

of US youth online gamers (Gentile, 2009) and in 9% of secondary school children in

Singapore (Choo, et al., 2010; Gentile, et al., 2011). Finally, 4%, 5%, and 5% of secondary
school and college students were found to be addicted to video-arcade games, computer
games, and the Internet, respectively. In addition, lifetime participation, frequency, and
duration of playing games as well as the prevalence of addiction was found to be larger for
Internet and computer games relative to video-arcade games (Thomas & Martin, 2010).
In terms of play patterns and motivations, in comparison to a healthy control group,
adolescent excessive Internet game players in South Korea were reported to play more, play
longer, and to have higher reward dependence (Han, et al., 2007). Similarly, children and
adolescent expert online game players were reported to have started playing online games
earlier and to play longer than novice players (Gentile, 2009; Rau, et al., 2006). Also, the
expert players underestimated the time they spent playing online games (Rau, et al., 2006).
Similarly, more time spent on games predicted gaming addiction (Choo, et al., 2010; Gentile,
2009; Gentile, et al., 2011; Lemmens, et al., 2009, 2011a). Moreover, it has been reported that
‘flow’ state2 during game play was not predictive of addiction. Related to this, the absence of
playing online games generated dissatisfaction (Wan & Chiou, 2006a, 2006b). Furthermore,
Taiwanese adolescent online game addicts indicated that playing online games was a focus in
their lives and the interplay between their real and their virtual selves was important to them
(Wan & Chiou, 2006b). In addition, another study of Taiwanese adolescent and young adults
reported online game addicts exhibited higher intrinsic motivation to play games rather than
an extrinsic motivation compared to non-addicted adolescents (Wan & Chiou, 2007). Finally,
escapism appeared as the most important factor predicting Internet gaming addiction (Kwon,
et al., 2011) and pathological gaming (Dongdong, et al., 2011), followed by perceived parent
hostility, real-ideal self-discrepancy, and parental supervision (Kwon, et al., 2011), and
actual-ideal self-discrepancy and depression (Dongdong, et al., 2011).
With respect to psychosocial characteristics, it has been reported that low social
competence was related to pathological gaming (Choo, et al., 2010; Lemmens, et al., 2011b),
and that psychosocial well-being and self-esteem predicted pathological gaming six months
later, with the same being true for high loneliness (Lemmens, et al., 2011b). Moreover, low
psychosocial well-being was found to be an antecedent, whereas loneliness was a
consequence of pathological gaming (Lemmens, et al., 2011b). Similarly, studies have shown
that game addiction correlates with loneliness (Lemmens, et al., 2009; van Rooij, et al., 2011),
low self-esteem (van Rooij, et al., 2011), low life satisfaction (Lemmens, et al., 2009), and
2
According to Czikszentmihalyi (1990), the flow state is characterized by an optimal experience, where the level
of challenge of a task is matched with the person’s skill.
 20

low social competence (Choo, et al., 2010; Gentile, et al., 2011; Lemmens, et al., 2009) and
that pathological gamers are significantly more likely to have decreasing social contacts
compared to non-pathological gamers (Choo, et al., 2010). With regards to aggression,
ambivalent findings were reported. In one study, no association was found between playing
video games and oppositional and/or aggressive behavior (Chan & Rabinowitz, 2006). In two
other studies, time spent gaming and pathological gaming increased physical aggression in
boys (Lemmens, et al., 2009, 2011a) and was found to be related to having more hostile
cognitions (Choo, et al., 2010), and greater impulsivity was reported to be a risk factor for
pathological gaming (Choo, et al., 2010; Gentile, et al., 2011). Moreover, online gaming
addiction was found to be associated with lower grade point average and school performance
(Chan & Rabinowitz, 2006; Choo, et al., 2010; Gentile, 2009; Gentile, et al., 2011).
Regarding comorbidity, findings indicate a significant association between time spent
playing games for more than one hour per day and Internet addiction, inattention, and number
and intensity of ADHD symptoms (Chan & Rabinowitz, 2006; Gentile, 2009). Similarly, it
was reported that 52% of children who had previously been diagnosed with ADHD were
diagnosed with Internet video game addiction as well (Han, et al., 2009). Moreover, the
outcomes of pathological gaming included depression (Dongdong, et al., 2011; Gentile, et al.,
2011; van Rooij, et al., 2011), anxiety, and social phobias (Gentile, et al., 2011; van Rooij, et
al., 2011), as well as physical health problems, such as hand and wrist pain (Choo, et al.,
2010; Gentile, 2009), and neglect of self-care (i.e., skipping meals, and insufficient personal
hygiene) (Choo, et al., 2010). With regards to pathophysiology, one study has reported that
adolescent excessive Internet game players had a significantly higher number of Taq1A1 and
low activity alleles (COMTL) relative to a healthy control group (Han, et al., 2007). This
suggests that genetic polymorphisms contribute to online gaming addiction. Overall, the
presented studies suggest that online gaming addiction is reasonably similar to pathological
gambling. Moreover, research indicates that children and adolescents who use online games
in a way that is clinically noticeable experience symptoms that are typically experienced by
those suffering from pathological gambling. Nevertheless, a number of pathological gambling
symptoms are not entirely commensurate with online gaming addiction. These include the
involvement of money that is increased throughout the gambling career as well as borrowed
from family members and friends, the chasing of losses, and engaging in illegal acts. In light
of pathological gambling, these symptoms appear to clearly demarcate excessive engagement
from addiction. Since this does not hold true for online gaming addiction, it appears
questionable in how far an exclusive reliance on pathological gambling criteria for the
 21

classification of online gaming addiction is appropriate, particularly when considering the

monetary involvement.
However, some evidence suggests that rather than playing for money, gamblers play for
the excitement and get aroused by taking risks (American Psychiatric Association, 2000).
Risk taking, in this regard, may include making larger bets. Similarly, gamers can take risks
when they play online games, such as choosing to fight high-level opponents and working
together with new group members. Similarly, they often pay monthly subscription fees to
participate in the game, and often buy in-game items. Therefore, even the criterion of
monetary involvement for pathological gambling appears to have a near equivalent in gaming
addiction. Nevertheless, the chasing of losses appears to be unique to pathological gambling.
As a consequence of this it follows that first, gaming addiction is closely related to
pathological gambling due to symptom similarity. Second, gaming addiction cannot entirely
be equated with pathological gambling because it appears to manifest itself reasonably
differently. Accordingly, exclusively basing a diagnosis of gaming addiction on pathological
gambling criteria is not sufficient.

Online gaming addiction based on the criteria for substance dependence

Three studies were identified in the database search that adapted the official criteria for
substance dependence in order to classify online gaming addiction (Batthyány, et al., 2009;
Grüsser, et al., 2005; Rehbein, et al., 2010). The basis of assessment were the official criteria
for substance dependence and the dependence syndrome as based on the international
classification manuals (APA, 2000; WHO, 1992). More specifically, in two studies
(Batthyány, et al., 2009; Grüsser, et al., 2005), excessive computer game play was diagnosed
with the Assessment of Computer Game Addiction in Children – Revised (Fragebogen zum
Computerspielverhalten bei Kindern, CSVK-R; Thalemann, et al., 2004). Using this
instrument, computer game play is classified as pathological when children and adolescents
score a minimum of seven out of 27 points on the scale. The psychometric qualities of the
scale have been validated (Thalemann, et al., 2004). Moreover, video game dependency was
diagnosed with the Video Game Dependency Scale (Rehbein & Borchers, 2009) that was
adapted from the Internet Addiction Scale 3 (Hahn & Jerusalem, 2001). It assesses the
following addiction criteria: preoccupation and salience, conflict, loss of control, withdrawal
symptoms, and tolerance. Its discriminatory power was found to be good (Rehbein &
Borchers, 2009).
3
Similar to Lin and Tsai’s scale (1999) Hahn and Jerusalem’s Internet Addiction Scale (2001) is a self-devised
measurement instrument that is not identical to Young’s Internet Addiction Test (1998).
 22

The studies’ samples included 1,231 Austrian students in grades three to five (mean age
= 14 years, SD = 1 year) (Batthyány, et al., 2009), 323 children in Germany with a mean age
of 12 years (SD = 1 year) (Grüsser, et al., 2005), and a representative sample of 44,910
German ninth-graders with a mean age of 15 years (SD = 1 year) (Rehbein & Borchers,
2009). In terms of online gaming addiction prevalence, the German nationwide study
indicated that 3% of the entire sample was classified as at risk and 2% was classified as being
dependent on video games. Also, there appeared a clear gender trend, with 91% of dependents
being male. More specifically, 3% of male adolescents and 0.3% of female adolescents were
diagnosed as dependent on playing video games, with 5% of males and 0.5% of females at
risk of developing dependence (Rehbein, et al., 2010). Furthermore, using the cut-off point of
7 which includes both computer game abuse and addiction (i.e., dependence), it was reported
that 9% of German children (Grüsser, et al., 2005) and 12% of Austrian children (Batthyány,
et al., 2009) played computer games excessively. Of the latter, 10% were abusing computer
games, whereas 3% were classed as dependent.
The primary motivation for playing video games was for coping with daily stressors
(Batthyány, et al., 2009; Grüsser, et al., 2005). Psychosocial problems that were found to be
related to excessive computer game use included increased social conflict, stress (Batthyány,
et al., 2009), lower school achievement, increased truancy, and limited leisure time activities
(Rehbein, et al., 2010). Moreover, related psychopathological problems and comorbidities
comprised concentration deficits, psychosomatic challenge, school phobia (Batthyány, et al.,
2009), reduced sleep time and increased thoughts of committing suicide (Rehbein, et al.,
2010).
From these studies, it appears that the symptoms of online gaming addiction in children
and adolescents are commensurate with the official symptoms for substance dependence. The
only distinguishing feature is the lack of the ingestion of a psychoactive substance for people
suffering from online gaming addiction. Moreover, the only nationwide prevalence study
conducted in Germany (Rehbein & Borchers, 2009) suggests that 2% of adolescents are
addicted to playing online games. This is an important finding as it appears to show that
online gaming addiction appears to be a genuine health problem for youth on a relatively large
scale. Furthermore, this is emphasized by the deleterious effect that online gaming addiction
has on adolescent health, including anxiety, psychosomatic, psychosocial and academic
problems, and suicidal ideation.

Online gaming addiction based on the criteria for both pathological gambling and
substance dependence
 23

Three studies have made use of a classification framework based on self-devised scales
combining both pathological gambling and substance dependence adapted criteria in order to
diagnose potentially addictive online gaming behaviors (Bear, et al., 2011; Salguero &
Moran, 2002; Skoric, et al., 2009). Salguero and Moran (2002) designed a 9-item scale that
they cross-validated with results from the Severity of Dependence Scale (Gossop, et al.,
1995a) in a sample of 223 Spanish adolescents aged 13-18 years. They reported that their
Problematic Video Game Playing Scale measured a unidimensional construct, and had an
acceptable internal consistency and good construct validity. Moreover, the authors concluded
that problem video game play is similar to the dependence syndrome (Salguero & Moran,
2002).
Similarly, Skoric et al. (2009) developed a scale based on the American Psychiatric
Association’s criteria for pathological gambling and substance dependence (2000) as well as
Danforth’s classification of online game addiction (2003). The specific criteria included were
behavioral salience, conflict, and withdrawal symptoms (based on Brown, 1991, 1993), as
well as further unspecified DSM-IV symptoms (Skoric, et al., 2009). They used a sample of
333 elementary school video gamers from Singapore aged 8-12 years. The findings indicated
that online game addiction correlated negatively with performance in school. However,
neither time spent playing games nor the engagement in games correlated with poor school
performance (Skoric, et al., 2009).
Bear et al. (2011) also created a scale that investigates both adolescents’ as well as their
parents’ reports. It is based on criteria for Internet addiction for adolescents as proposed by
Ko et al. (2005) and it includes the official criteria for impulse control and substance abuse
disorder. The items specifically assessing addiction criteria include (i) a preoccupation with
computer/gaming-station activities, (ii) a failure to resist the impulse to use, (iii) tolerance,
(iv) withdrawal, (v) longer than intended use, (vi) unsuccessful efforts to cut down, (vii)
excessive efforts put into trying to use, and (viii) continued use despite the knowledge that it
causes problems. Bear et al.’s Computer/Gaming-station Addiction Scale (CGAS) (2011)
investigates these criteria on a continuum with addiction scores ranging from 8 to 40 points.
In order to assess the patterns of computer and gaming station use in youth, they surveyed 102
adolescents aged between 11 and 17 years as well as their parents. The results indicate that the
addiction score significantly correlated with higher difficulties experienced in life as well as
less prosocial behavior as reported by both adolescents and their parents. Furthermore, the
addiction score significantly correlated with functional impairments across multiple life
 24

domains, namely family, learning, life skills, self-concept, and social activity (Bear, et al.,
2011).
The studies included in this section highlight two important facts. First, although in all
three cases the authors relied on both substance dependence and pathological gambling
criteria in order to assess online gaming addiction, from the information provided it appears
that their focus was indeed on diagnostic criteria for substance dependence. To be more
precise, Salguero and Moran (2002) specifically point out that online gaming addiction in
adolescents is similar to the dependence syndrome, which indicates that the former is a
genuine addiction worthy of clinical management. Second, the studies were conducted in
Singapore, Spain and Canada and therefore the results may have varied because of the
sociocultural embedding of the participants in their respective home country. Consequently, it
would appear highly important to assess online gaming addiction in children and adolescents
cross-culturally. Depending on the sociocultural context in which gaming occurs, in addition
to the connotations online gaming has, gaming practices, the prevalence of online gaming
addiction, and online gaming addictions symptoms may differ. Future researchers should
therefore be encouraged to assess online gaming addiction in children and adolescents cross-
culturally, using assessment instruments that are commensurate with an official clinical
diagnosis of the disorder, and that pay respect to the cultures they are used in.

Online gaming addiction based on parental reports

In two studies (Allison, et al., 2006; Cultrara & Har-El, 2002), the psychopathological status
of two cases of male adolescents addicted to online gaming was based on their parents’
reports. Allison et al. (2006) reported the case of an 18-year old male adolescent whose life,
according to his parents, had been taken over by playing online role-playing games. The
adolescent was sectioned into a psychiatric hospital by his parents where he underwent a
variety of psychological and psychiatric assessments for three days, including an intelligence
test, a personality test, and diagnostic and psychosocially based interviews. It was reported
that he played online games for up to 16 hours a day. His primary motivation was to escape
real life problems. His gaming resulted in a variety of psychosocial (limited real life social
contacts, missing classes at school), psychosomatic (poor concentration, muscle tension), and
psychopathological problems (diminished energy, fatigue) (Allison, et al., 2006). Similar
results have been noted in case studies of adult excessive gamers (Griffiths, 2010).
In a more unusual case, Cultrara and Har-El (2002) reported the account of a 17-year
old male adolescent who, during video game play, continuously moved his lower jaw up and
 25

down, repeatedly grimaced and swallowed, and protruded and retruded his tongue. This
resulted in muscle hyperthrophy that was found to be secondary to the actual activity of his
excessive video game playing. Once he stopped playing video games, the sub-mental mass
that he had developed decreased in size (Cultrara & Har-El, 2002).
The above studies are significant for at least two reasons. First, they provide a
qualitative account of how adolescents experience online gaming addiction as well as the
symptoms associated with it. These in-depth insights not only provide a more elaborate
description of individual experience, but they aid researchers in discerning what it actually
means for adolescents to be addicted to playing online games. Second, the studies highlight
the fact that for many children and adolescents, it is their parents who initially realize that
their children’s online gaming moves beyond pure enjoyment of playing and can in fact be
problematic. In fact, a recent study suggests that contact with the Outpatient Clinic for
Gaming Addictions in Mainz (Germany) was initiated by mothers of potentially addicted
adolescents in 86% of the cases (Beutel, Hoch, Wölfling, & Müller, 2011). This indicates that
parental referral is important for some adolescents who have not yet discerned that their
behavior may indeed be problematic. It also hints at the significance of social support
particularly for young people because (i) they find themselves in critical periods of cognitive,
behavioral, and social development in this specific stage of their lives, and (ii) they cannot
overcome their problems by themselves and are thus in need of both social and professional
assistance. Notwithstanding this, a professional evaluation of the situation and the
adolescents’ addiction status is an essential second step that may potentially lead to clinical
treatment of online gaming addiction.

Online gaming addiction based on other miscellaneous classification criteria

Four studies (Chiu, et al., 2004; Kim & Kim, 2010; King & Delfabbro, 2009; Ko, et al.,
2005a) could not be categorized in any of the aforementioned frameworks. Each of these is
addressed in turn. Chiu et al. (2004) aimed to assess video game addiction in 1,228 children
and adolescents in grades 5-8 in Taiwan. They used the self-devised Game Addiction Scale
(based on Buchman & Funk, 1996; Clymo, 1996) comprising a 9-item scale that assesses two
factors, namely game addiction and game concern. The reported internal consistency has a
Cronbach’s alpha of 0.86. Unfortunately, from the information the authors provide in their
paper, it is unclear how their term “video game addiction” was defined and what kinds of
symptoms it included. Moreover, none of the referenced articles specifically addresses
addiction and pathology. Nevertheless, they found that video game addiction correlated
 26

negatively with academic achievement and positively with hostility. Furthermore, lower
function, higher sensation seeking, and higher boredom inclination predicted game addiction.
Counter-intuitively, female gender predicted game addiction (Chiu, et al., 2004).
Kim and Kim (2010) aimed to develop a measure of problematic online game use by
identifying factors that underlie problematic online game use and to test the external validity
of their scale by having three independent samples of 5 th, 8th and 11th-graders in South Korea
(n = 2,014) participating in their survey. They devised the Problematic Online Game Use
Scale (based on Armstrong, et al., 2000; Caplan, 2002; Charlton & Danforth, 2007; Lee &
Ahn, 2002; Young, 1999) that assessed the following criteria: euphoria, health problem,
conflict, failure of self-control, and preference for virtual relationships. They reported that
their scale had good reliability, as well as convergent and discriminatory validity. Moreover,
problematic online game use negatively correlated with academic self-efficacy and
satisfaction with daily life and it positively correlated with anxiety and loneliness (Kim &
Kim, 2010).
King and Delfabbro (2009) investigated the psychological and social context of video
game playing in order to understand excessive video game play using pilot group interviews
with a sample of 23 adolescents (mean age = 16 years, SD = 1 year) and 15 adults. Their
findings indicated that online role-playing games were more rewarding and hence more
addictive than casual games. In their paper, video game playing was defined as excessive
when it “create[d] adverse personal and social consequences in a person’s life” (p. 62). As
hypothesized, they found that excessive video game players experienced a variety of
problems, such as conflicts with important life responsibilities, they neglected their social
relationships, their scholastic and professional productivity suffered, they ignored their
household duties and they had irregular sleeping patterns (King & Delfabbro, 2009).
Finally, Ko, Yen, Chen, Chen, and Yen (2005a) assessed gender differences and related
factors affecting online gaming addiction among 221 Taiwanese adolescents aged 13 to 15
years (mean age = 13.8 years, SD = 0.7 years) by a survey. They used the Chinese Internet
Addiction Scale (Chen, et al., 2003), a continuous measure that includes 26 items to assess
five dimensions of problems related to Internet use, adapted to measure online gaming
experiences exclusively. Investigated Internet-related problems include compulsive use,
withdrawal, tolerance, interpersonal relationships, health, and time management. Originally,
the scale was found to have a good internal consistency with a Cronbach’s alpha of 0.96
(Chen, et al., 2003). The findings indicate that males are significantly more likely to be
addicted to playing online games. Moreover, for males, several other factors predicted online
 27

gaming addiction, namely older age, lower self-esteem, and lower daily life satisfaction (Ko,
et al., 2005a).
Due to the fact that the aforementioned studies used miscellaneous classification
frameworks, they will be evaluated in turn. As mentioned previously, Chiu et al.’s (2004)
study suffered from a variety of methodological and conceptual problems, such as the
omission of defining video game addiction. Moreover, the finding that female gender
predicted addiction appears questionable since numerous studies indicate the opposite (e.g.
Rehbein & Borchers, 2009). This suggests that there may be some flaw in the analysis
possibly related to the fact that the measure used lacked sensitivity and specificity.
Alternatively, one could argue that female gender is likely to be a better predictor of certain
aspects of addiction because it is less commonly associated with addiction. When male gender
is commonly associated with addiction, it fails to discriminate features of addiction. In either
case, these findings require further investigation.
Next, the particularly insightful aspect of Kim and Kim’s study (2010) was their
reliance on game-imminent factors. They designed a scale that specifically assessed online
gaming addiction, such as a preference for virtual relationships. Although their scale has been
validated in different samples, its utility as clinical assessment tool to clearly demarcate
online gaming addiction from mere engagement (Charlton, 2002) has not been established
yet. With regards to the symptoms it assesses, it also appears questionable in how far euphoria
can be used as an addiction symptom from a conceptual point of view. Specifically, it has
been asserted that healthy enthusiasm adds to life whereas addiction takes away from it
(Griffiths, 2002). This suggests that euphoria does not necessarily have to feature within an
addiction framework, as suggested by Charlton and Danforth (2007). In sum, although Kim
and Kim’s study (2010) takes a definite approach with regards to the specifics of online game
addiction as being entirely based on the virtual world, the respective criteria used for
classifying online gaming addiction may prove less useful in a clinical context.
King and Delfabbro’s interview study (2009) indicated that adolescents that play online
games excessively experience a variety of problems because of their game play. Nevertheless,
in this study, no validated measurement tool was utilized to actually validate the participants’
addiction status. Therefore, it appears relatively problematic to deduce implications for online
gaming addiction and mental health status in adolescents from their study.
Finally, Ko et al.’s survey study (2005) did not use an assessment instrument that was
based on officially established diagnostic criteria. Only very loosely are the criteria their
measurement instrument uses commensurate to substance dependence because criteria such as
 28

tolerance and withdrawal were included. Other than that, it is unclear on what basis the other
criteria haven been chosen and how online gaming addiction has been defined. No cut-off
values are provided. Therefore, clinical diagnosis is not possible. The authors however
contend that “[b]efore constructing specific diagnostic criteria, it would be practical to
measure levels of addiction to Internet use with a multidimensional and continuous
questionnaire such as the CIAS” (Ko, et al., 2005a, p. 277). However, they do not offer a
reasonable explanation for why utilizing a continuous measure would make sense in the first
place. Therefore, their logic seems flawed and puts the use of the CIAS into question.
Ultimately, assessments of online gaming addiction must go beyond the purpose of furthering
research endeavors in the area by specifically targeting potential clinical practices. Only then
are the individuals who suffer from a potentially debilitating mental disorder be heard and
helped.

DISCUSSION

This systematic literature review provides important insights into the state of current
knowledge of online gaming addiction in children and adolescents. From the identified
empirical studies, it appears that different classification schemes have been adopted, typically
based on the official criteria for pathological gambling, substance dependence, or a
combination of the two. Additionally, parents’ reports and other miscellaneous criteria and
assessment instruments have been used to determine gaming addiction. From the identified
studies, it appears that the large majority of studies adapted pathological gambling criteria in
order to assess the extent to which online gaming addiction is present in samples of children
and adolescents. This appears acceptable since online gaming and online gambling share a
variety of similar characteristics that have been extensively discussed in the psychological
literature for over 20 years (Griffiths, 2005; Johansson & Götestam, 2004). This indicates that
monetary reward is not necessary in order to classify an excessive engagement with games as
potential addiction and could potentially be substituted by a higher likelihood for risk-taking.
Similarly, traditionally land-based gambling is gradually moving towards Internet portals
(Kuss & Griffiths, 2011a) and there are now a number of overviews highlighting the
convergence between Internet, gaming and gambling (e.g., Griffiths, 2008; King, Delfabbro &
Griffiths, 2010). This suggests that the (potentially pathogenetic) gaming and gambling
activities are progressively converging.
 29

On the other hand, some researchers claim that the classification of behavioral
addictions within the framework of pathological gambling appears relatively insufficient and
it can have negative consequences for actual treatment when no use is made of therapy
elements for patients suffering from substance dependence (Poppelreuter & Gross, 2000).
Moreover, in light of the diagnostic criteria for pathological gambling, impulsivity is the main
distinguishing characteristic. However, this seems relatively inadequate because a deficiency
in impulse control is also considered to be one of the main features of substance dependence
(Volkow & Fowler, 2000). This indicates that applying knowledge from substance
dependence treatments to treatments of behavioral addictions may actually be beneficial over
and above treatment as usual for pathological gamblers. Similarly, the framework of
behavioral addictions as based on its similarities with substance dependence seems
particularly appealing as it entails the craving of behavioral addicts for engaging in their
behavior and it also includes the physical and psychological discomfort and irritability they
experience when they cannot engage in the behavior, which mirror both the symptoms of
craving as well as withdrawal (Holden, 2001; Orford, 2001).
Furthermore, with substance-unrelated addictions, it appears that tolerance is another
criterion that is not accounted for by a classification that is based on pathological gambling.
However, tolerance appears to play an important role in behavioral addictions because addicts
need to increase their engagement (i.e., the time and effort they invest in engaging in the
activity) over the course of time in order to experience pleasurable effects, which may be seen
as a homeostatic restoration of balance within the body (Grüsser & Thalemann, 2006). Thus,
online gaming is used as a form of self-medication (Han, et al., 2009). With regards to
excessive online gamers, both individual accounts of behaviors as well as empirical
quantitative findings show that as their addiction develops, online gaming addicts spend
increasing amounts of time preparing for, organizing, and actually gaming (Chan &
Rabinowitz, 2006; Kim & Kim, 2010; King & Delfabbro, 2009; Lemmens, et al., 2011a).
There is further evidence to suggest that problematic online gaming be conceptualized
as a behavioral addiction rather than a disorder of impulse control. From a clinical
perspective, patients suffering from behavioral addictions present with problems that are
similar to those experienced by people suffering from substance dependencies (Poppelreuter
& Gross, 2000; Shaffer & Kidman, 2003). In comparison to the phaseology model of
alcoholism (Jellinek, 1946), it appears that those addicted to certain behaviors progress
through different phases in their addiction as well, which was found to be true for
pathological gamblers (Custer, 1987). This does not mean that a behavioral addiction, such as
 30

online gaming addiction, should be classified in the same way pathological gambling is,
namely within the spectrum of impulse control disorders. Instead, both online gaming
addiction and pathological gambling appear to fit better within the classification akin to
substance dependencies, namely behavioral addictions. This is furthermore supported by the
efforts of the American Psychiatric Association to include ‘Gambling Disorder’ in the
category of substance-related and addictive disorders rather than impulse control disorders in
the new fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (2011).
Viewing pathological gambling as an addictive disorder (i.e., a behavioral addiction) can
therefore be seen as the first step towards a reconceptualization of both substance-related and
substance unrelated addictions as spectrum disorders, as suggested by Shaffer et al. (2004).
Another argument in favor of this conjecture relates to the high comorbidity rates of
behavioral addictions with substance dependencies and vice versa (Poppelreuter & Gross,
2000). Similarly, comorbidities frequently experienced by substance users, such as affective
and anxiety disorders as well as attention-deficit hyperactivity disorder, are experienced by
pathological online gamers (Kuss & Griffiths, 2011b). These comorbidities do not occur with
persons who suffer from obsessive-compulsive disorders (Blanco, Moreyra, Nunes, Saiz-
Ruiz, & Ibanez, 2001). Also, there are further similarities between substance dependence and
several behavioral addictions, namely with regards to the gender distribution as well as
neuropsychology and neurocognition (Bechara, 2003; Rugle & Melamed, 1993). In terms of
psychophysiology, it furthermore appears that there are additional analogies between
substance dependence and pathological gambling (Reuter, Raedler, Rose, Hand, Glascher, &
Büchel, 2005) and online gambling addiction (Han, Hwang, & Renshaw, 2010; Hoeft,
Watson, Kesler, Bettinger, & Reiss, 2008; Ko, et al., 2009). With regards to molecular
genetics, polymorphisms in the D2 dopamine receptor genes and the Val158Met in the
Catecholamine-O-Methyltransferase (COMT) genes have been found in pathological
gamblers (Blum, Wood, Sheridan, Chen, & Commings, 1995) and those addicted to online
gaming (Han, et al., 2007). These findings clearly substantiate the contention that online
gaming addiction may indeed be viewed as behavioral addiction.
Additionally, it has been reported that pathological gamblers and alcoholics share an
“excessive attachment” to their addiction of choice (Orford, Morison, & Somers, 1996).
Furthermore, Shaffer et al. (Shaffer, LaPlante, LaBrie, Kidman, Donato, & Stanton, 2004)
contend that both behavioral and substance-related addictions share the same etiology. That
is, antecedents for addiction include neurobiological (i.e., genetic risk) and psychosocial
elements (i.e., psychological and sociological risk factors) that all contribute to the
 31

vulnerability for developing addiction. In addition to this, exposure and interaction with the
substance/behavior of choice as well as a desirable shift in subjective state (i.e., the mood-
modifying properties of the substance/behavior) serve as further antecedents. Once
biopsychosocial events occur and the substance/behavior is paired with a desirable shift
repeatedly, addiction may be developed (Shaffer, et al., 2004).
The manifestations and sequelae shared between different addictions are related to the
biological cluster (i.e., tolerance, withdrawal, neuroanatomical changes, and genetic
expression), the psychological cluster (i.e., psychopathology and comorbidity), the social
cluster (i.e., deviant behaviors, social drift), natural history (i.e., exposure, relapse, sequencing
of recovery), treatment non-specificity (i.e., psychopharmacological or cognitive-behavioral
therapy), and object substitution (i.e., replacing the addiction of choice with another
addiction). On the other hand, addictions differ in their expression (i.e., substance-related
versus behavioral) and their unique manifestations and sequelae. For instance, drinking
alcohol can lead to liver cirrhosis, whereas pathological gambling can lead to financial debt.
In sum, the similar etiology of addictions indicates that instead of viewing respective
addictions as separate pathological entities, they are better viewed as a syndrome (Shaffer, et
al., 2004). This gives strong support to the conjecture that pathological online gaming should
be understood as behavioral addiction rather than an impulse-control disorder.
With regards to children and adolescents who are potentially vulnerable to becoming
addicted to playing online games, classification is essential because it will help to develop and
initiate prevention efforts. Only when online gaming addiction is more clearly and
comprehensively understood, can risk variables be targeted and protective factors fostered
from a mental health point of view and on a large scale. Among groups of young people,
prevention efforts may include both psycho-education as well as provision of information and
tools that focus on developing healthy ways of coping with daily stressors. The earlier
preventive efforts are initiated, the greater the chance that children and adolescents are
protected from the dangers and ramifications of online gaming addiction.
The empirical studies examining online gaming addiction in children and adolescents in
this review suffer from a variety of limitations. A major limitation is the frequent lack of
sensitivity and specificity of measures used. On the one hand, it appears difficult to judge the
extent to which the assessment tools utilized are sensitive enough to actually determine online
gaming addiction status within children and adolescents. Thus, the question of sensitivity
remains. On the other hand, it seems questionable in how far the measurement instruments
identify adolescents who are not addicted to online gaming, therewith limiting their
 32

specificity. In addition to this, the almost exclusive utilization of self-report measures calls
into question the accuracy of diagnosis. Psychological and psychiatric assessments as well as
parental reports appear to be indispensable complements for judging whether and to what
extent a child or adolescent is actually addicted to online gaming particularly in light of a
variety of symptoms that are commonly experienced comorbidly.
Another problem that materialized with the large majority of identified studies was the
utilization of small, specified, self-selected, and/or mixed samples. Small samples are not
representative of whole populations and therefore establishing representative prevalence
estimates is obstructed. Furthermore, if samples are particularly specified (i.e., using a limited
age group in a particular country, etc.), the participants’ responses cannot be generalized to
larger populations either. The opposite problem occurs if samples are mixed. It is unclear to
what extent the findings can be generalized to specified populations. Self-selected samples
comprise only those people who were enthused enough to participate and therefore these
samples are somewhat unrepresentative of most target populations. Each of these problems
calls for improvements in future research in order to increase the external validity of the
studies’ results. In addition, research in the field calls for studies that assess online gaming
addiction cross-culturally because by comparing and contrasting the disorder within diverse
sociocultural contexts, the differences and similarities can be discerned and treatment
approaches can be tailored to the respective needs of particular cultural groups.
Conclusively, establishing a nosology of online gaming addiction satisfies two crucial
aims. First, it enables the actual classification of the disorder within the classification systems.
Second, it allows for the appropriate choice of relevant psychotherapeutic and/or
psychopharmacological treatments (Du, Jiang, & Vance, 2010; Griffiths & Meredith, 2009;
Lee & Mysyk, 2004). As long as there is no coherent diagnostic framework upon which to
base online gaming addiction diagnosis, not only does conceptual confusion ensue, but both
further research endeavors as well as potential treatment plans are seriously complicated.
Correspondingly, once this framework is established and accepted, the efforts of including
online gaming addiction in the official diagnostic manuals (APA, 2007; Block, 2008; O'Brien,
2008) will finally come to fruition. Prevention efforts may be developed that specifically
target children and adolescents who appear to be particularly at risk to developing online
gaming addiction as well as associated developmental problems and disorders. Moreover,
awarding online gaming addiction with an official status as mental disorder will enable
diagnosis, communication about, study, treatment and prognosis of this psychopathology
(Kemper, 2008; Springer, 2009; te Wildt, 2009).
 33

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