Portal de Periódicos da CAPES

Gaming Disorder Among Female Adolescents: A Hidden Problem?

2020; Elsevier BV; Volume: 66; Issue: 6 Linguagem: Inglês

10.1016/j.jadohealth.2020.03.011

1879-1972

Daniel L. King, Marc N. Potenza,

Gambling Behavior and Treatments

The global popularity of online gaming continues to grow, as the gaming industry diversifies its products and leverages new technologies to expand its market [[1]King D.L. Koster E. Billieux J. Study what makes games addictive.Nature. 2019; 573: 346Crossref PubMed Scopus (23) Google Scholar,[2]King D.L. Delfabbro P.H. Gainsbury S.M. et al.Unfair play? Video games as exploitative monetized services: An examination of game patents from a consumer protection perspective.Comput Hum Behav. 2019; 101: 131-143Crossref Scopus (28) Google Scholar]. Although the mainstream media tend to focus on best-selling competitive online shooter games, such as Fortnite and Call of Duty, gaming has become quite diverse and wide ranging. Gaming innovations have occurred in genres (e.g., role-playing, simulation, and puzzles), hardware and accessibility (e.g., smartphones, tablets, and virtual reality), social features (e.g., cooperation and teamwork), and playability (e.g., interactive narrative and content creation). The industry has also expanded its social functionality by linking and integrating games with social media and streaming platforms (e.g., Twitch and Mixer) [[3]King D.L. Delfabbro P. Internet gaming disorder: Theory, assessment, treatment, and prevention. Academic Press, Cambridge, MA2018Google Scholar]. Such developments have likely contributed to changing demographic profiles of gamers, which include an increasing female adolescent population involved in gaming activities, particularly those that intersect with social media and related online activities. Academic and industry research confirms that the "gender gap" in gaming participation has been closing, particularly in the last decade. According to Statista [[4]StatistaDistribution of computer and video gamers in the United States from 2006 to 2019, by gender.https://www.statista.com/statistics/232383/gender-split-of-us-computer-and-video-gamers/Date accessed: March 5, 2020Google Scholar], in 2006, approximately 38% of U.S. gamers from 4,000 households were female compared with 46% in 2019. Similarly, industry research in Australia has reported that 38% of gamers were female in 2005 compared with 47% female in 2019 [[5]Brand J.E. Jervis J. Huggins P.M. Wilson T.W. Digital Australia 2020. Eveleigh, NSW: IGEA.https://igea.net/wp-content/uploads/2019/08/DA20-Report-FINAL-Aug19.pdfDate accessed: March 1, 2020Google Scholar]. Australian females aged 14–25 years play games for an average of 81 minute/day [[5]Brand J.E. Jervis J. Huggins P.M. Wilson T.W. Digital Australia 2020. Eveleigh, NSW: IGEA.https://igea.net/wp-content/uploads/2019/08/DA20-Report-FINAL-Aug19.pdfDate accessed: March 1, 2020Google Scholar], and approximately 1% play games for 9 hours or more on a weekday [[6]Lawrence D. Johnson S. Hafekost J. et al.The mental health of children and adolescents: Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing.https://www.health.gov.au/internet/main/publishing.nsf/Content/9DA8CA21306FE6EDCA257E2700016945/%24File/child2.pdfDate accessed: March 1, 2020Google Scholar]. The proportion of female developers in the gaming industry increased from 11% in 2005 to 21% in 2017 [[7]StatistaDistribution Of game developers worldwide from 2014 to 2017, by gender.https://www.statista.com/statistics/453634/game-developer-gender-distribution-worldwide/Date accessed: March 5, 2020Google Scholar,[8]International Game Developers AssociationGame developer demographics: An exploration of workforce diversity.2005https://gamesindustryskills.files.wordpress.com/2009/11/igda_developerdemographics_oct05.pdfDate accessed: March 5, 2020Google Scholar], and their influence on game content may be related to increased female engagement in gaming. With the "hazardous gaming" (QE22) and ''gaming disorder'' (GD; 6C51) criteria included in the latest revision of the International Classification of Diseases, 11th Revision [[9]Saunders J. Hao W. Long J. et al.Gaming disorder: Its delineation as a serious condition for diagnosis, management and prevention.J Behav Addict. 2017; 6: 271-279Crossref PubMed Scopus (151) Google Scholar,[10]King D.L. Potenza M.N. Not playing around: Gaming disorder in the ICD-11.J Adolesc Health. 2019; 64: 5-7Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar], it is timely to consider the importance of gender in understanding excessive and addictive gaming. In our view, more research and clinical attention on female gamers is needed, including greater female representation in current research in addition to more studies to understand female gaming experiences. Selective sampling of males for convenience or based on reasoning that males are more vulnerable to GD contributes to the view that GD is largely a male disorder, despite evidence that females are also at risk [[11]Bonnaire C. Baptista D. Internet gaming disorder in male and female young adults: The role of alexithymia, depression, anxiety and gaming type.Psychiatry Res. 2019; 272: 521-530Crossref PubMed Scopus (47) Google Scholar]. Girls spend more time involved and become problematically involved with social media than gaming [12Bányai F. Zsila Á. Király O. et al.Problematic social media use: Results from a large-scale nationally representative adolescent sample.PLoS One. 2017; 12 (0169839)Crossref PubMed Scopus (226) Google Scholar, 13Durkee T. Kaess M. Carli V. et al.Prevalence of pathological internet use among adolescents in Europe: Demographic and social factors.Addiction. 2012; 107: 2210-2222Crossref PubMed Scopus (411) Google Scholar, 14King D.L. Delfabbro P.H. Zwaans T. et al.Clinical features and axis I comorbidity of Australian adolescent pathological Internet and video-game users.Aust N Z J Psychiatry. 2013; 47: 1058-1067Crossref PubMed Scopus (103) Google Scholar, 15Wartberg L. Kriston L. Thomasius R. Internet gaming disorder and problematic social media use in a representative sample of German adolescents: Prevalence estimates, comorbid depressive symptoms and related psychosocial aspects.Comput Hum Behav. 2020; 103: 31-36Crossref Scopus (48) Google Scholar, 16Vigna-Taglianti F. Brambilla R. Priotto B. et al.Problematic internet use among high school students: Prevalence, associated factors and gender differences.Psychiatry Res. 2017; 257: 163-171Crossref PubMed Scopus (44) Google Scholar], but gaming may be a critical part of the online ecosystem in which some girls develop excessive habits. Speculatively, teenage girls' involvement in a wide range of online activities may contribute to greater risk of later problematic internet use. Research from other addictions field has shown that females tend to engage in addictive behaviors later in life but develop problems more quickly, a phenomenon known as "telescoping" [[17]Zakiniaeiz Y. Cosgrove K.P. Mazure C.M. et al.Does telescoping exist in male and female gamblers? Does it matter?.Front Psychol. 2017; 8: 1510Crossref PubMed Scopus (13) Google Scholar,[18]Zakiniaeiz Y. Potenza M.N. Gender-related differences in addiction: A review of human studies.Curr Opin Behav Neurosci. 2018; 23: 171-175Google Scholar]. The extent to which telescoping is applicable to GD and other forms of problematic use of the internet warrants direct examination. Epidemiological research shows that female problematic gaming is not uncommon and should not be downplayed [19King D.L. Delfabbro P.H. Deleuze J. et al.Maladaptive player-game relationships in problematic gaming and gaming disorder: A systematic review.Clin Psychol Rev. 2019; 73: 101777Crossref PubMed Scopus (31) Google Scholar, 20Mihara S. Higuchi S. Cross-sectional and longitudinal epidemiological studies of internet gaming disorder: A systematic review of the literature.Psychiatry Clin Neurosci. 2017; 71: 425-444Crossref PubMed Scopus (164) Google Scholar, 21Rehbein F. Kleimann M. Mößle T. Prevalence and risk factors of video game dependency in adolescence: Results of a German Nationwide Survey.Cyberpsychol Behav Soc Netw. 2010; 13: 269-277Crossref PubMed Scopus (301) Google Scholar]. A meta-analysis by Fam et al. [[22]Fam J.Y. Prevalence of internet gaming disorder in adolescents: A meta-analysis across three decades.Scand J Psychol. 2018; 59: 524-531Crossref PubMed Scopus (70) Google Scholar] reported that the pooled prevalence of GD among female adolescents was 1.3% and higher in Asian countries, particularly China [[23]Long J. Liu T. Liu Y. et al.Prevalence and correlates of problematic online gaming: A systematic review of the evidence published in Chinese.Curr Addict Rep. 2018; 5: 359-371Crossref Scopus (32) Google Scholar]. This prevalence is comparable to the prevalence of problem gambling among adults [[24]Calado F. Griffiths M.D. Problem gambling worldwide: An update and systematic review of empirical research (2000–2015).J Behav Addict. 2016; 5: 592-613Crossref PubMed Scopus (235) Google Scholar]. Relatively lower problematic gaming prevalence among girls has been attributed to tendencies to play casual, simulation, and puzzle games [[25]Laconi S. Pirès S. Chabrol H. Internet gaming disorder, motives, game genres and psychopathology.Comput Hum Behav. 2017; 75: 652-659Crossref Scopus (83) Google Scholar,[26]Lemmens J.S. Hendriks S.J. Addictive online games: Examining the relationship between game genres and Internet gaming disorder.Cyberpsychol, Behav Soc Netw. 2016; 19: 270-276Crossref PubMed Scopus (60) Google Scholar] compared with males who engage in competitive games that often require longer play [[27]Rehbein F. Staudt A. Hanslmaier M. et al.Video game playing in the general adult population of Germany: Can higher gaming time of males be explained by gender specific genre preferences?.Comput Hum Behav. 2016; 55: 729-735Crossref Scopus (43) Google Scholar]. The risk of GD among females may increase as more time consuming games become more appealing to females. Neurobiological studies by Dong et al. have examined the gender gap in problematic gaming, which has identified (1) more craving-related activations to gaming cues in males compared with females [[28]Dong G. Wang L. Du X. et al.Gender-related differences in neural responses to gaming cues before and after gaming: Implications for gender-specific vulnerabilities to internet gaming disorder.Soc Cogn Affect Neurosci. 2018; 13: 1203-1214Crossref PubMed Scopus (34) Google Scholar]; (2) gender-related differences with respect to craving-related functional connectivity between executive control and reward systems linked to the dorsolateral prefrontal cortex and striatum [[29]Dong G. Wang Z. Wang Y. et al.Gender-related functional connectivity and craving during gaming and immediate abstinence during a mandatory break: Implications for development and progression of internet gaming disorder.Prog Neuro-psychoph. 2019; 88: 1-10Crossref PubMed Scopus (32) Google Scholar]; and (3) greater differences in left dorsolateral prefrontal cortex activation in the GD versus subclinical groups in females compared with males, suggesting that females with GD may have greater difficulty in controlling their gaming under craving conditions [[30]Dong G. Zheng H. Liu X. et al.Gender-related differences in cue-elicited cravings in Internet gaming disorder: The effects of deprivation.J Behav Addict. 2018; 7: 953-964Crossref PubMed Scopus (26) Google Scholar]. However, only a very limited number of imaging studies have involved females. A meta-analysis by Yao et al. [[31]Yao Y.W. Liu L. Ma S.S. et al.Functional and structural neural alterations in internet gaming disorder: A systematic review and meta-analysis.Neurosci Biobehav Rev. 2017; 83: 313-324Crossref PubMed Scopus (66) Google Scholar] reported that only two of 27 functional magnetic resonance imaging studies, and four of 10 2voxel-based morphometry studies, included females. Voxel-based morphometry studies suggest that greater alterations exist in the anterior cingulate cortex, supplementary motor area, and orbitofrontal cortex regions in females with GD. Similarly, research on response inhibition involving neurocognitive tasks administered to GD patients has been almost exclusively conducted with males [[32]Argyriou E. Davison C.B. Lee T.T. Response inhibition and internet gaming disorder: A meta-analysis.Addict Behav. 2017; 71: 54-60Crossref PubMed Scopus (41) Google Scholar]. The literature on interventions for GD has demonstrated a similar male bias [[33]Han D.H. Renshaw P.F. Bupropion in the treatment of problematic online game play in patients with major depressive disorder.J Psychopharmacol. 2012; 26: 689-696Crossref PubMed Scopus (60) Google Scholar,[34]Müller K.W. Beutel M.E. Egloff B. et al.Investigating risk factors for internet gaming disorder: A comparison of patients with addictive gaming, pathological gamblers and healthy controls regarding the big five personality traits.Eur Addict Res. 2014; 20: 129-136Crossref PubMed Scopus (100) Google Scholar], and therefore, our knowledge of treatment efficacy for females is limited. A clinical trial by Wölfling et al. [[35]Wölfling K. Müller K.W. Dreier M. et al.Efficacy of short-term treatment of internet and computer game addiction: A randomized clinical trial.JAMA Psychiatry. 2019; 76: 1018-1025Crossref Scopus (44) Google Scholar], for example, involved a manualized cognitive behavioral therapy administered to males only. A craving behavioral intervention study involved solely males [[36]Zhang J.-T. Yao Y.-W. Potenza M.N. et al.Effects of craving behavioral intervention on neural substrates of cue-induced craving in Internet gaming disorder.Neuroimage Clin. 2016; 12: 591-599Crossref PubMed Scopus (49) Google Scholar]. Retreats for adolescents that focus on "technology detox," developing social skills, and learning self-control have also tended to involve males only [[37]Sakuma H. Mihara S. Nakayama H. et al.Treatment with the self-discovery camp (SDiC) improves internet gaming disorder.Addict Behav. 2017; 64: 357-362Crossref PubMed Scopus (43) Google Scholar]. Aside from the lower prevalence of GD in females, the rationale for excluding females has been the lack of females seeking treatment for gaming-related problems. Lau et al. [[38]Lau C. Stewart S.L. Sarmiento C. et al.Who is at risk for problematic video gaming? Risk factors in problematic video gaming in clinically referred Canadian children and adolescents.Multimodal Tech Interaction. 2018; 2: 19Crossref Scopus (10) Google Scholar] examined the records of 5,820 clinically referred youth in the Canadian mental health system and reported that the prevalence of excessive gaming that interferes with daily functioning was 19.2% in males and 4.9% in females. Based on correspondence with Cam Adair, who operates the online self-help group Game Quitters (https://gamequitters.com), between 5% and 10% of site visitors who seek help or advice are female, which suggests an unmet treatment need. Although presently speculative, female problematic gaming and GD may be less detected because of other comorbid issues (depression and personality issues), other immediate concerns or crises (e.g., self-harm and family conflict), and/or other internet-based issues (e.g., risky social media use). Here we have only briefly considered some evidence and gaps in understanding of gender-related differences in GD. Nonetheless, it is evident that some female adolescents are avid gamers and report problematic gaming, albeit generally to a lesser extent than males. However, females are an understudied and less detected population in important areas of clinical research. With growing scientific interest in a range of excessive behaviors and how they may be interconnected [[39]Potenza M.N. Higuchi S. Brand M. Call for research into a wider range of behavioural addictions.Nature. 2018; 555: 30Crossref PubMed Scopus (41) Google Scholar], it is important that vulnerable teenage girls do not remain "hidden" because of their exclusion from research. Greater efforts are needed to improve our knowledge of female gamers and their needs and develop best practice guidelines for prevention and other interventions for this smaller but important population. This work received financial support from Discovery Early Career Researcher Award DE170101198 funded by the Australian Research Council . M.N.P. was supported by a Center of Excellence grant in Gambling Research from the National Center for Responsible Gaming , the Connecticut Council on Problem Gambling, and the Connecticut Department of Mental Health and Addiction Services .