What is Internet Gaming Disorder?

Patient Presentation
A 15-year-old male came to clinic for his health maintenance examination. He was doing well, but his mother complained that he was spending more and more time playing computer games. She said that she had been able to curb some of the use because he was in school, but over the summer break he was unsupervised during the day when she was working. He said that he was spending time online with friends playing networked games. He didn’t see a problem with it as long as he had done whatever tasks his mother had asked him to do that day. He did say that he actually was spending more time playing games than he had previously told his mother – up to 8 hours or more/day. He still did his other activities including bike riding, swimming, soccer and doing some pleasure reading. He denied any problems with eating, sleeping or mood. He said that he could cut down or stop whenever he wanted but his mother wasn’t sure about this. The pertinent physical exam showed normal vital signs and growth parameters in the 75-90% and tracking. He was Tanner IV.

The diagnosis of a healthy male with increased online gaming and Internet use that was beginning to affect his life. The pediatrician voiced concern about the amount of screen time. He recommended that the teenager only have 2 hours/day which was met with great distress by the teenager. He complained, “but there will be nothing to do.” The physician talked about other activities the teen could pursue. His mother said that she thought it would get a little better once school started but she was still worried. The physician counseled that the problem of Internet and gaming use was increasing. He noted that the computer use was already causing some conflict at home and if the parent felt that it was affecting the teenager in other activities in daily life or he was having a problem stopping the gaming then counseling to help with the behavior was recommended. The mother thought that counseling would be good as she felt she was having other communication issues with her son. The teen did not want to go to counseling, but after he seemed to not be able to control the computer use when school started, he and his mother began in individual and family counseling.

Computers are a part of most people’s daily lives. They are used for finance, transportation, communication, healthcare, business, manufacturing, utilities, construction and just about everywhere else. They offer incredible work saving, monitoring, data collection and storage applications that improve people’s lives.

In the past few years these incredible pieces of technology have taken a logarithmic advance in their capabilities and also use by the common person for more and more daily activities as a brief review of the history of computers shows:

  • Pre-19th Century – abacus, slide rule, Antikythera mechanism
  • 1833 – First mechanical computer developed by Charles Babbage
  • 1930s-70 – Massive computers in a large centralized locations for mainly government or business operations
    • 1930s – First electromagnetic computers – mainly vacuum tubes
    • 1936 – Turing machine developed by Alan Turing
    • 1955 – Computers with transistors
    • 1957 – Computers with integrated circuits
    • 1967 – ARPANET – first early packet switching network – the basic infrastructure of the Internet
  • 1970s-80s – Personal computers mainly for stationary use at home or work by individuals
    • 1973 – Xerox Alto which had a graphic user interface
    • 1975 – Internet protocol developed (TCP/IP) – method to do higher speed packet switching for networking
    • 1976 – First Apple® 1 developed by Steve Wozniak and Steve Jobs
    • 1977 – Commodore® PET = first successful mass marketed computer –
    • 1977 – Apple II introduced
    • 1980’s – Laptop computers
    • 1989 – Tim Berners Lee develops the World Wide Web (sometimes also referred to as the Internet)
  • 1990s-Present – Mobile Computers for non-stationary use by individuals
    • 1993 – Apple Newton – personal digital assistant
    • 1996 – Palm Pilot® – personal digital assistant with handwriting recognition
    • 1999 – SmartPhones released for mass market in Japan
    • 2008 – Apple App store and Google Play® (app store) opens fueling mobile revolution

  • Present to Near Future – Integrated computing – computers ubiquitously integrated into products for home, business, goverment that send/receive data and are networked with the potential for self-regulation or human interaction.

Notice that over time, the time periods are much shorter, and computers become smaller and are much less expensive. Today, smartphones are considered such a low cost product that they are given even to toddlers and infants to play with. With any technology there is an upside and a downside. Heat keeps us warm, and cooks our food giving us improved bodily comfort and nutrition, but if not controlled it can burn or cause fires. Computer technology is similar. There are great advantages but without controls it can cause hazards to our physical and mental health. Smartphones and other mobile or integrated computer devices are so prevalant today that there is an expectation that all persons have access to them and the computer networks they connect to at all times. Again this can be wonderful for everyone to have these tools, but that also means that people are expected to use them during a significant portion of their day (i.e. use the Internet all the time). This can lead to problems when people feel they cannot stop using them and have problem Internet use or behaviors similar to addiction.

Learning Point
Although gambling disorder is the only behavioral addiction (as opposed to a substance addiction) in the DSM-5, Internet gaming disorder (IGD) is included as an emerging disorder needing further study. IGD is defined as “Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress.” (DSM-5 2013).
In a review of research publications from 1998-2016, the overall prevalence of IGD was 0.7-15.6% with an average of 4.7% across the years. There was one paper in 1998, none between 1999-2006 and then an overall steady trend. This study also found that “Internet gaming disorder, …, affects a small subset of the population exposed to online games, and does not appear to have increased in prevalence to the extent the [I]nternet usage has increased.”

Data shows “[s]ignificant overlap in the neurobiology underlying both [gaming and Internet] addictions and substance use disorders have been found in animal models and human brain imaging studies.” People with IGD can have similar symptoms to people with substance abuse disorders including building tolerance for the activity (i.e. needing more) and having withdrawal symptoms.

Another study of the addictive potential for the Internet in adolescent (12-19 years) generalized Internet users (GIU) and Internet gamers (IG) found that gaming had the strongest addictive potential in boys followed by social networking and chatting (β= 0.29, 0.19, and 0.17 respectively). For girls, chatting and social networking had the strongest addictive potential followed by gaming (β= 0.24, 0.23, and 0.14 respectively). Other activities evaluated included gambling, sexual content, shopping, emailing and researching information. Overall problematic IG had more psychosocial problems including high psychosocial burden and dysfunctional coping strategies, than non-problematic IG.

IGD and high levels of Internet use are being recognized as public health problems and the World Health Organization and various countries are evaluating or making policies to try to assist their citizens. First there is a necessary increased recognition of the actual problem by individuals, governments and agencies. Types of intervention include educational programs including school-based, online education, workshops, and public health messaging, and technical interventions (mandatory blocking/shutdown of device or software, censoring of software) including legislation of such interventions. Some of the education focuses on what is healthy use, creating appropriate environments physically (e.g. device-free bedrooms) and online (e.g. age appropriate applications). Selective prevention could include restricted hours of Internet availabliity (e.g. not during school or later in evening/night), limit setting software, and alternative to Internet use (e.g. use a wrist watch to check time instead of phone). Some people may need more intervention including group or individual counseling or rehabilitation. An overview of prevention strategies for hazardous Internet use can be found here ).

Questions for Further Discussion
1. What other recommendations do you offer for healthy computer/device use and how do those change in different ages?
2. What musculoskeletal problems can be caused by computer use and how can they be prevented?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Internet Safety and Compulsive Gambling.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Computer History Articles. Wikipedia.

Feng W, Ramo DE, Chan SR, Bourgeois JA. Internet gaming disorder: Trends in prevalence 1998-2016. Addict Behav. 2017 Jun 16;75:17-24.

Rosenkranz T, Muller KW, Dreier M, Beutel ME, Wolfling K.
Addictive Potential of Internet Applications and Differential Correlates of Problematic Use in Internet Gamers versus Generalized Internet Users in a Representative Sample of Adolescents. Eur Addict Res. 2017;23(3):148-156.

King DL, Delfabbro PH, Doh YY, Wu AMS, Kuss DJ, Pallesen S, Mentzoni R, Carragher N, Sakuma H. Policy and Prevention Approaches for Disordered and Hazardous Gaming and Internet Use: an International Perspective.
Prev Sci. 2017 Jul 4. doi: 10.1007/s11121-017-0813-1.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa