Gaming disorder and tips for parents: an interview with Professor Mark Griffiths

In May 2019, the World Health Organisation (WHO) agreed to recognise gaming disorder as a mental health diagnosis and confirmed its place in the new behavioural addictions section of the International Classification of Diseases 11th edition (ICD-11), which is expected to come into effect in 2022. Considering this development and the continued public debate surrounding the impact of video games on mental health, we decided it was time to revisit the topic. We spoke to Professor Mark Griffiths to get his perspective on the disorder and to explore his thoughts on the elements within games that may lead to problematic playing behaviour.

Professor Griffiths is a Professor of Behavioural Addictions and Director of the International Gaming Research Unit at Nottingham Trent University. He has been publishing research on the psychological and mental health impacts of video games since the early 90s and positions himself somewhere between the two more entrenched camps who have been vocal in the debate on gaming disorder: those who view problematic gaming as an urgent public health concern and those who urged the WHO to wait until more research was undertaken (Müller and Wölfling, 2017; van Rooij, et al., 2018). In addition to his academic work, Griffiths professes to having been a big fan of Tetris, to the point of re-experiencing the music and visuals of the game when trying to sleep, a phenomenon which has been dubbed the "Tetris Effect" (Strickgold et al., 2000). He is also a father of teenagers who regularly play games. In this interview, he offers novel ideas on the disorder, provides tips for parents, discusses his proposed diagnostic criteria and finally speaks to how games compel players to keep playing.

Griffiths is a member of the WHO committee on gaming disorder and contributed to the decision to classify gaming disorder as a mental health condition. Though not a clinician himself, he has been involved in setting up clinical services for gaming disorder in Spain based on psychological treatment approaches in Spain. He takes the opinion that if a single case of a disorder can be demonstrated to exist, this should be enough for its recognition. But regardless, he feels that there is plenty of evidence to justify recognition of the disorder. He does, however, believe that true cases are few and far between, which puts him at odds with some of his more pro-disorder contemporaries, who he says accuse him of minimising the issue. He suggests that if the prevalence was as high as even 1 or 2%, there would be far more demand for assessment and treatment than there currently is, as every school and community would feature many cases. Furthermore, he points out the average age of a gamer is now 29-31, yet very few adults seek help for gaming related problems, despite having grown up playing video games.

Not only does he see the prevalence of gaming disorder as being less than 1%, he also has his own proposed criteria for diagnosis, which are arguably more stringent than those in the ICD-11. He is mindful of the risk of over-diagnosis and believes many parents pathologise their children's gaming simply because they find it concerning if their children play games for 3-4 hours a day. Griffiths goes on to suggest that, in his experience, over-diagnosis is particularly problematic in South East Asia, specifically in South Korea, where some clinicians and policy makers claim gaming disorder prevalence rates are much higher, and where 'boot camp'-like treatment centres are far more common. In the UK, he sees a generation gap, with older adults who are unfamiliar with gaming more likely to pathologise gaming in their children.

Defining the disorder

Before we discuss Griffiths' criteria for diagnosis, it is worth revisiting the ICD-11 gaming disorder criteria, which are: impaired control over gaming, increasing priority given to gaming to the extent that gaming takes precedence over other life interests, and continuation or escalation of gaming despite negative consequences. The problem should be present for at least 12-months duration, though this time criterion doesn't need to be met if the impacts are sufficiently severe. Long before the WHO's ICD-11 decision, back in 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), was published and included a provisional diagnosis of 'Internet Gaming disorder' (IGD) as a condition for further research. Whilst it shares similarities to the ICD-11 criteria, it additionally includes symptom criteria of preoccupation, withdrawal, tolerance, deception and mood modulation, for a total of nine symptoms, of which five were required to meet the provisional diagnosis (Pontes et al., 2014).

Griffiths suggests that the DSM-5 criteria are stricter than the ICD-11's, and his own criteria seem to sit somewhere between the two. He has six key criteria that must be met in order to diagnose gaming disorder: salience (total preoccupation with gaming), mood modification (using games to improve negative mood states), tolerance, withdrawal, conflict (the gaming behaviour compromises relationships at work, school, etc), and intrapsychic conflict (being unable to cut down, loss of control, relapse and guilt). He would apply the same criteria to other disordered behaviours involving exercise, sex, or even work, but again he stresses that the true number of people meeting all criteria for such a diagnosis should be very small. He believes his diagnostic criterion of 'tolerance' is the most challenging to define, because even heavy, regular play can be completely normal. He sees 'withdrawal' as being critical to the diagnosis, as a hallmark of addiction. As evidence that withdrawal symptoms occur, he notes case reports suggesting people with disordered gaming behaviour can experience increased moodiness, irritability and anxiety, and physical symptoms of hand sweats and stomach cramps, when they stop gaming.

Griffiths acknowledges the importance of allowing clinicians some flexibility regarding the required duration of the symptoms, to prevent severe cases from being excluded purely on basis of short duration. He thinks it's unlikely that anyone who has played a game intensely for a month or two would be given a diagnosis of gaming disorder, as this sort of behaviour is typical for people enjoying a game. Though he resists stipulating an arbitrary cut-off for abnormal period of intense play, he sees a duration of around 3 months being a likely minimum to indicate consideration in clinical practice.

Perhaps controversially for some, he thinks that a child or adult playing games or using social media for 3-4 hours a day is normal, and suggests four questions parents should ask of a child who plays a lot of games to assess for potential harms: are they doing their school work and homework? Are they engaged in physical activity? Do they have a wide range of peer friendships? Do they do the chores you want them to do around the house? If a parent can genuinely answer yes to these four questions, Griffiths believes they should not be overly concerned.

He feels it's critical that clinicians use a holistic approach when assessing problematic gaming. For example, such behaviour may be symptomatic of an underlying relationship problem, where gaming is used as a means to avoid conflict or confrontation. He suggests that a functional analysis type approach, i.e. one that looks at all the factors within a person's life that may drive or potentially diminish a behaviour, may help explain and treat problematic gaming. He also highlights that there is no clinically valid diagnostic instrument available for gaming disorder and diagnosis should occur only after a clinical assessment by appropriately trained clinical psychologists or psychiatrists. He also stresses that while gaming disorder may be comorbid with other psychiatric conditions such as depression, the occurrence of co-morbid conditions shouldn't preclude the diagnosis and treatment of gaming disorder.

The root of the problem

If we accept that a minority of people can develop disordered behaviour with video games, we should consider what parts of a game may lead to a loss of control over play. Griffiths believes that there are many potential elements within games that are worth considering. In a paper he co-authored with Daniel King and Paul Delfrabbro (King et al., 2010), five categories of structural features in games were proposed to influence gaming behaviour: the social aspects, such as being a member of a guild or clan; control features, such as when a player can save their progress in a game; narrative and identity features, such as avatar creation and role playing; presentation features, such as exciting and pleasing visuals; and reward and punishment features, like winning in-game currency at the end of a mission or losing potential gains if a mission is lost. Ultimately, Griffiths views gaming disorder through a behaviourist lens. Originally informed by the ideas of B.F. Skinner, behaviourists see operant conditioning, i.e. increasing the likelihood of a behaviour or response being repeated by administering rewards or punishments, as being the core feature of behavioural addiction, and therefore, of gaming disorder.

King et al. (2010) list several features in games that use operant conditioning, such as the reward of experience points (XP) after completing tasks, which can be used to level up the player's character. As increasingly more XP is needed for each subsequent level, the reward of levelling occurs on a variable ratio reinforcement schedule.

Loot boxes are probably the most controversial element in games that exploit operant conditioning techniques. For the uninitiated, loot boxes contain chance items that are either awarded directly to the player in-game or can be purchased with either real-world or in-game currency. Typically, the loot box has the appearance of a treasure chest with a hidden item. The act of opening the loot box allows the player to reveal the contents which may include items of value. More valuable items tend to be rarer. It is typically not possible to predict the number of boxes that will need to be opened to receive a desirable item. So, loot boxes offer a reward at a variable ratio schedule, like a fruit machine or a scratch card, and in common with those gambling games the reward is often presented in a visually stimulating fashion. In the operant conditioning field, this is type of reward is thought to lead to a higher likelihood of the response (opening a loot box) being repeated. The vast majority of players don't buy loot boxes at all, but an extreme minority can be compelled to spend thousands of pounds on them.

It is worth noting that the vast majority of games do not contain loot boxes and there are limitations to operant conditioning models of addiction which have been criticised for failing to consider the protective factors that exist in a human's real-world environment, such as family, friends and other commitments such as school, work or other social activities (Eitan et al., 2017; Venniro et al., 2018). There's evidence that people with high levels of psychological needs satisfaction in their daily lives are less likely to develop symptoms of disordered gaming (Weinstein et al., 2017), which suggests those most at risk may lack basic psychosocial supports in real life.

In some countries such as Belgium and the Netherlands, loot boxes have been banned from games over fears that such elements constitute gambling. The UK Parliament's Digital, Culture, Media and Sport select committee recently published their report on "Immersive and Addictive Technologies" which also recommended that loot boxes should be removed from games aimed at children. Griffiths agrees that loot boxes are akin to gambling and he has advised the Gambling Commission that loot boxes should be regulated as any other form of gambling would be.

Finally, I brought up the prospect of gaming companies using in-game algorithms and user information to manipulate player behaviour, in particular because Electronic Arts (EA), who publish major titles such as FIFA and Battlefield, recently denied the use of 'Dynamic Difficulty Adjustment' (DDA), which was reported to be a technique that allows a game's difficulty to be changed on-the-fly to encourage the player to keep playing, based on the player's performance. Such techniques may simply be a way of improving in-game experience by adjusting difficulty when a player is struggling, but as DDA had the stated aim of "maximising a player's engagement throughout the entire game" (Eurogamer, 2019), many gamers voiced concerns online that DDA and similar techniques could become problematic for people struggling to control their gaming behaviour or in-game spending. Griffiths believes there is evidence for the use of similar algorithms within the gambling industry and he wouldn't be surprised if such elements were being used in games, but this is not something he has studied, yet.

This thought-provoking discussion highlights many issues for clinicians, academics, policy makers, the games industry and the public. For example, whilst some argue that the classification of gaming disorder within the ICD-11 will help combat over-pathologisation by increasing research on clinical cases, such official recognition could also be used to legitimise the pathologisation of gaming as a socially undesirable behaviour. So, clinicians who may use ICD-11's gaming disorder criteria in the future should be mindful of motivations, by individuals, families and society, to pathologise what is nearly always going to be a benign or even protective behaviour. Further research is needed into how structural elements within games interact with a person's social environment and psychological well-being to cause disordered gaming. Loot boxes and other chance items may eventually be removed from some games via legislation or through public pressure on the industry, but some of the big players in the industry appear resistant to change. Perhaps some sensible and ethical practice from all those involved could eliminate the need for further pathologisation of players and games.

Authored by Stephen Kaar

References

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