# data[].attributes.headline
A 2021 journal article from Akadémiai Kiadó entitled "Depression and anxiety symptoms associated with internet gaming disorder before and during the COVID-19 pandemic: A longitudinal study"

# data[].attributes.subject
A 2021 journal article from Akadémiai Kiadó entitled "Depression and anxiety symptoms associated with internet gaming disorder before and during the COVID-19 pandemic: A longitudinal study"

# data[].attributes.headline
A research article from CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING entitled "Mental Health Help-Seeking Behavior of Male Video Game Players: An Online Survey"

# data[].attributes.subject
A research article from CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING entitled "Mental Health Help-Seeking Behavior of Male Video Game Players: An Online Survey"

# data[].attributes.headline
A journal article from Elsevier entitled "Incorporating objective behavioral data in gaming disorder research: Associations between time spent gaming and gaming disorder symptoms "

# data[].attributes.subject
A journal article from Elsevier entitled "Incorporating objective behavioral data in gaming disorder research: Associations between time spent gaming and gaming disorder symptoms "

# data[].attributes.headline
A 2024 opinion article from AAMC.org entitled "Men and mental health: What are we missing?"

# data[].attributes.subject
A 2024 opinion article from AAMC.org entitled "Men and mental health: What are we missing?"

# data[].attributes.attachment_link.readable_text
Editor's note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.
Men in the United States die by suicide at a rate four times higher than women. And yet, men are diagnosed with depression and mood disorders at far lower rates. Why is this?

Too often, society blames men themselves for their struggles. They are the ones who often turn to substance abuse and violent behavior rather than getting help for their mental health. They are the ones who struggle to keep up with a changing workforce and gender norms. They are the ones who too often embrace unhealthy attitudes and beliefs at the expense of their own well-being.

But this approach of placing blame on individuals has produced little by way of clinical, social, or structural interventions to improve men's mental health.

Men aren't the problem. The way that we - society as a whole and health care providers specifically - treat them is.

It is time that primary care physicians, mental health service providers, and policymakers look critically at the accuracy and utility of their assumptions and explanations for men's rates of depression, anxiety, burnout, substance abuse, and other common mental health conditions. The current framework has limited our ability to offer real solutions that meet men where they are and give them the tools to not only survive, but to thrive.

Unfortunately, in the United States, men's health and well-being has reached a critical point. The COVID-19 pandemic exacerbated the crisis of men's mental health. Studies found that during the pandemic, U.S. men reported slightly lower rates of anxiety than women, but had higher rates of depressive symptoms and suicidal ideation than their female counterparts. The uncertainty of the pandemic, loneliness from social distancing, financial stresses, relationship challenges, and other contextual factors contributed to increased rates of men having difficulty sleeping, alcohol and substance use, and post-traumatic stress disorder (PTSD) symptoms triggered by the experience of mechanical ventilation treatment and hospitalization. Consequently, at one point in 2020, the rates of men seeking mental health care services in the United States increased more than five-fold over the prior year. These rates were greater than the rates of women seeking mental health care services during this time. Yet, by 2021, just 40% of men with a reported mental illness received mental health care services in the past year, compared with 52% of women with a reported mental illness, according to the National Institute of Mental Health.

Even when men seek care, that care often falls short. Data from Canada and the United States found that more than 60% of men who died by suicide had accessed mental health care services within the previous year. When men do seek mental health care services, it is not uncommon for them to feel that providers mislabel and underestimate their needs, and that these providers do not seem to have a genuine interest in their problems. For some time, research has shown that mental health providers may miss or misdiagnose psychological problems in men because of their own gender biases. They might believe that men simply need to "man up" and stop showing weakness, or that the symptoms they present are not consistent with diagnostic tools. Mental health providers may not consider that these tools do not take into account gender differences in experience or symptoms that men are more likely to exhibit.

For men to seek mental health care in the first place is already a challenge, with social barriers such as societal stigma, fear of judgment, and lack of skills to communicate emotions keeping many from doing so. It's unconscionable that bias and a lack of effective treatment approaches on the part of mental health providers would create even more barriers. Men do bear a responsibility to seek help, but it's far from illogical when they choose to avoid it.

The impetus is on those of us in the medical and mental health fields to ensure we're empathetic to the struggles that men face in a changing world. Research has shown that men often struggle to differentiate depression from stress, and to know when to seek help if symptoms are severe enough. Men (and health care providers) may not label men's symptoms as depression if the symptoms are tied to an external factor like unemployment. Traditionally, men are socialized to define their worth by their ability to contribute economically to a household. However, as the labor market has shifted away from traditionally male-dominated jobs, men must now redefine their worth outside of their employment, income, and home. The notion of " precarious manhood," which is the belief that manhood is an achieved social status that must be earned and constantly defended, means that men may feel it is their character - rather than their behavior - being judged during more tumultuous economic times.

Even men who do achieve and maintain a certain level of manhood they perceive as successful are likely to put unreasonable expectations on themselves that can lead to burnout. An imbalance between job demands and job skills, lack of control over tasks at work, lack of reward or acknowledgement of effort, and prolonged work stress are some of the leading factors contributing to burnout. As we think about the ways gender influences how men present with mental health symptoms, it is important to keep these contextual factors in mind.

The fact that men are diagnosed with depression at lower rates than women, despite their higher rates of suicide, substance use, and violent behavior, suggests that more could be done to improve the tools used to diagnose men with depression. Several scholars have noted the importance of increasing the capacity of mental health care service providers' ability to consider gender in the presentation of mood disorders among men. While some mental health care service providers may be gender sensitive and recognize the ways that aggressiveness, alcohol use, and risky behavior are part of the presenting symptoms men with depression may exhibit, there are few courses and trainings that focus on gender differences in mental health, potentially leading to mental health care service providers being less equipped to serve and offer gender-sensitive resources to men.

Given the data and the unique contexts and aspects of men's mental health, there is a need to create more opportunities for health care providers who serve men to learn to be sensitive and responsive to their male patients' needs. Along with efforts like the Movember Foundation's Rooted and Rising Collective and the Canadian Men's Health Foundation MindFit Toolkit, Table 1 below highlights selected programs and e-health tools that have been designed to be sensitive to the presentation, needs, and preferences of men. These resources demonstrate examples of gender-sensitive interventions to promote men's mental health. Part of what makes these programs successful is that they recognize that men are not a monolith, and that it is critical to develop culturally sensitive interventions that consider the ways groups of men are unique.

The reasons men may need mental health resources and support are not simply due to how men think, or because of their attitudes about masculinity. Using a lens this narrow hampers our capacity to effectively address and improve men's health. It is important to consider the gender sensitivity of mental health services, and the broader contextual and structural factors that influence men's mental health and well-being. It is time we consider men's mental health in its full context, and shift the focus to the ways our health care systems and providers are equipped to deliver services to improve men's mental health.

Program or Initiative

Overview

What can public health professionals do?

What can health care providers do?

ALEC and R U OK? provide a guide map for how to check in on those who you think may be struggling.

Aim to focus more research and resources related to the specific signs of male suicide.

Provide more opportunities for conversations with male patients to help overcome the stigma related to talking about mental health, and help improve the overall status of mental health among men.

# data[].attributes.attachment_link.title
Men and mental health: What are we missing?

# data[].attributes.attachment_link.description
Physicians need better training and empathy for the distinct symptoms and societal expectations men face to treat them effectively.

# data[].attributes.headline
A 2025 opinion article from The Guardian entitled "Video games can’t escape their role in the radicalization of young men"

# data[].attributes.subject
A 2025 opinion article from The Guardian entitled "Video games can’t escape their role in the radicalization of young men"

# data[].attributes.attachment_link.title
Video games can’t escape their role in the radicalisation of young men | Keith Stuart

# data[].attributes.attachment_link.description
Those of us who spend our lives gaming can no longer deny knowledge that our online communities are awash with disturbing hate speech and violent rhetoric

# data[].attributes.headline
A 2024 public health article from Children and Screens entitled "Boys, Health, and Digital Media"

# data[].attributes.subject
A 2024 public health article from Children and Screens entitled "Boys, Health, and Digital Media"

# data[].attributes.attachment_link.title
Boys, Health, and Digital Media - Children and Screens

# data[].attributes.attachment_link.description
“One hundred percent of my clients who are coming for tech addiction in the last 12 years were assigned the gender at birth of male with no exceptions, which is pretty striking,” says digital addiction expert and psychologist Ed Spector, PsyD. Spector posits that one reason behind the disparity in tech use patterns may be the natural tendency in male adolescence for “rough and tumble” play. “I think of gaming as a sort of modern day electronic version of ‘rough and tumble play,’” says Spector, “and this may explain why there’s such a disparity in how guys and girls use technology.”

# data[].attributes.headline
A 2023 Research Article from Taylor & Francis Online entitled "Building resilience to hate in classrooms: Innovation in practice and pedagogy to prevent extremism and violence in U.S. schools"

# data[].attributes.subject
A 2023 Research Article from Taylor & Francis Online entitled "Building resilience to hate in classrooms: Innovation in practice and pedagogy to prevent extremism and violence in U.S. schools"

# data[].attributes.attachment_link.title
Building resilience to hate in classrooms: Innovation in practice and pedagogy to prevent extremism and violence in U.S. schools

# data[].attributes.attachment_link.description
Reimagine Resilience (2023), designed and established at Teachers College, Columbia University, is an innovative program that builds awareness and understanding among educators and educational pers…

# data[].attributes.headline
A 2021 news article from neaToday entitled "How Educators Can Prevent Student Radicalization"

# data[].attributes.subject
A 2021 news article from neaToday entitled "How Educators Can Prevent Student Radicalization"

# data[].attributes.attachment_link.readable_text
When Columbia University professor Amra Sabic-El-Rayess was a teenager in the former Yugoslavia, she never imagined that her best friend wouldn't be her best friend someday. They shared everything-except a religion.

But when charismatic Serbian nationalists came to power in the '90s, they nurtured "a victim narrative," convincing Serbs they were under threat and must protect white Christian people, says Sabic-El-Reyess. Stories about Bosnian Muslims feeding Serb babies to zoo animals appeared in Serb media.

The result? Ordinary Serbs turned on their former friends, and raped, tortured and killed thousands of Bosnian Muslims.

Today, in the U.S., Sabic-El-Reyess sees history repeating itself. The intolerance and violence she experienced in the Bosnian genocide is mirrored by White supremacists who attack Asian people on the street, take automatic rifles into Black churches, and spread conspiracy theories about Jews. Like in Bosnia, the perpetrators often are ordinary people who have been radicalized.

They need to be stopped. They need to be educated-and NEA members have an important role in doing so, says Sabic-El-Reyess, who teaches in Columbia's Teachers College.

"We are at a tipping point in our country's history where we need to actively counter both racism and radicalization to preserve our democracy," warned Sabic-El-Reyess, in a recent speech to NEA's National Council of Urban Education Associations (NCUEA) members.

"As educators, you are our democracy's first responders," she told NCUEA members. "Your work in our schools can prevent the targeted violence that we're increasingly seeing on our streets and communities."

Why Did that Kid Become a Neo-Nazi?

The word "radicalization" is startling, admits Iowa 8 th-grade teacher Sara Earleywine, an NCUEA leader who introduced Sabic-El-Rayess in June. "It almost sounds alarmist, kind of crazy, 'oh, radicalization!' But we have to pay attention."

Youth radicalization is on the rise, experts agree. Across the U.S., increasing numbers of teenagers and 20-somethings are using violence to espouse the ideology of White supremacists or the Islamic State or...whatever. The specific ideology doesn't matter much, experts say. It's not what draws them in. The teens who are most vulnerable to radicalization feel deprived or excluded; they don't have a sense of belonging or hope for the future. What matters to them is that radicalization offers all of those things, plus power.

"We are at a tipping point in our country's history where we need to actively counter both racism and radicalization to preserve our democracy."

"They're searching for three very fundamental human needs: identity, community and a sense of purpose," wrote two Northern Ireland researchers in 2017-the same year a 20-year-old neo-Nazi rammed his truck into anti-racism protesters in Charlottesville, Va., killing one and injuring 35.

In high school, the Charlottesville killer, James Fields Jr., openly shared his admiration for Nazis and the Third Reich. His favorite teacher challenged his thinking and attempted to steer him in different directions, but Fields was isolated by mental illness and unable to connect with peers or family members.

"I feel like I failed and that we all failed," his teacher told a Cincinnati journalist. "There are others like him out there- we as a society have to do a better job of figuring out how to reach them."

The Art of Online Radicalization

When then-21-year-old Dylann Roof walked into a Charleston church and shot to death nine Black worshippers in 2015, he had been "self-radicalized" by reading and watching White supremacist propaganda online, federal prosecutors said.

Teenagers commonly spend hours a day on YouTube, TikTok, and Snapchat. "These kids are online all the time-and they're listening," says Kumar Rashad, a high-school math teacher in Louisville, Ky., and an NCUEA Executive Committee member. "They're always coming to class and telling me what they've heard...and it could be positive or negative."

In 2018, Twitter suspended 4,000 accounts for terrorism-related content. "The internet is the most valuable tool for extremists," Becca Lewis, a Stanford University researcher, told NCUEA members in June. Basically, they use it as their own "distorted version of a classroom," where they teach their false ideas and propaganda.

You might imagine that radicals are lurking on some secret corner of the internet, said Lewis. In reality, it's happening on YouTube and TikTok. "[Extremists] know they have to meet average kids in the spaces where they are," said Lewis. As a result, they're occupying the most mainstream, accessible social-media sites.

When teens find their videos and other materials, these extremists don't sound racist or radical. In fact, they often sound like teachers. "They take on the language of educators to make their claims more plausible," said Lewis. "Some present their false facts as sad, but true. Others make them seem like secret knowledge." Their videos seem intimate and authentic-and convincing.

Merely fact-checking or dismissing those ideas won't work, warns Lewis. "[Extremist] propaganda is specifically built to resist these tactics," she said. For example, if you say there's no evidence to these claims, extremists will argue that the evidence has been covered up. If you present counterevidence, they'll likely say you're just a sheep with the wool pulled over your eyes.

Educators Can-and Must-Help

So, what can educators do?

Educators need to understand what drives their students to radicalizing spaces in the first place, suggests Lewis, such as "quest for knowledge, gravitation toward community, a need for mentor."

Many teenagers are a little lost, says Rashad. "They're looking for something to validate or invalidate themselves, depending on their mindset. That's what they're doing online all day," he says. As an educator, Rashad counters online or other influences by developing relationships with his students, getting them internships, and leading them in community service-all things that provide them with a sense of purpose and connectedness.

In this way, Rashad is building resiliency to hate, which is the best approach to counter extremists, Sabic-El-Rayess told NCUEA members in June.

Educators should incorporate diverse viewpoints in their classrooms, talk about real-life issues and teach students how to negotiate and compromise, Sabic-El-Rayess said. Not only will this improve their empathy and critical thinking skills, but these exercises will engage them in a classroom community. "When educators fail to engage students on issues that matter to them, students will look elsewhere," she warned.

Curriculum in all subject areas-math, science, history, literature-should include different life experiences, Sabic-El-Rayess told NCUEA educators. "We need curriculum filled with stories that inspire critical thinking, collective empathy and resilience to counter the narratives of victimization and white supremacy."

"In the end, genuine education is the best defense against radicalization," said Lewis.

It has been decades since Sabic-El-Rayess emigrated to the U.S., earned a doctorate degree, and began teaching in Ivy League classrooms. But her work today is rooted in her past, as a survivor of the Bosnian genocide.

She will never forget the days when she and her brother were so weak with hunger that they couldn't get out of bed, or the nights when they didn't eat or choked down a meal of cow udder. "Every day, somebody I loved-or played with-died," she told NCUEA members. "It felt like I was in line for execution. It was only a question of how and when."

Today, out of a sense of responsibility to the dead, Sabic-El-Rayess feels obligated to work with educators, to tell her story and use her voice to help build a "collective resistance to hate and extremism."

This is exhausting and painful work-but also promising and life-affirming. "The power to alter and interrupt the path to radicalization is in our hands as educators," Sabic-El-Rayess promised NCUEA members. "We are the ones who can bring our communities closer together and compel our new generations to collective action."

# data[].attributes.attachment_link.title
How Educators Can Prevent Student Radicalization | NEA

# data[].attributes.attachment_link.description
An increasing number of U.S. teens are getting "radicalized" online by White supremacists or other extremist groups. The best place to prevent that radicalization is U.S. classrooms.

# data[].attributes.headline
A 2021 opinion article from EducationWeek.org entitled "The Scary Truth About Student Radicalization: It Can Happen Here"

# data[].attributes.subject
A 2021 opinion article from EducationWeek.org entitled "The Scary Truth About Student Radicalization: It Can Happen Here"

# data[].attributes.attachment_link.authors[].name
The Cat I Never Named: A True Story of Love, War and Survival

# data[].attributes.attachment_link.title
The Scary Truth About Student Radicalization: It Can Happen Here (Opinion)

# data[].attributes.attachment_link.description
How do children grow into hate-filled adults? Researcher Amra Sabic-El-Rayess, a Bosnian genocide survivor, explains.

# data[].attributes.headline
A 2017 review article from National Library of Medicine entitled "Family factors in adolescent problematic Internet gaming: A systematic review"

# data[].attributes.subject
A 2017 review article from National Library of Medicine entitled "Family factors in adolescent problematic Internet gaming: A systematic review"

# data[].attributes.attachment_link.readable_text
Abstract

Background and aims

Familial influences are known to affect the likelihood of an adolescent becoming a problem gamer. This systematic review examined some of the key findings in empirical research on family factors related to adolescent problem gaming.

Methods

A total of 14 studies in the past decade were evaluated. Family-related variables included: (a) parent status (e.g., socioeconomic status and mental health), (b) parent-child relationship (e.g., warmth, conflict, and abuse), (c) parental influence on gaming (e.g., supervision of gaming, modeling, and attitudes toward gaming), and (d) family environment (e.g., household composition).

Results

The majority of studies have focused on parent-child relationships, reporting that poorer quality relationships are associated with increased severity of problem gaming. The paternal relationship may be protective against problem gaming; therefore, prevention programs should leverage the support of cooperative fathers.

Discussion

The intergenerational effects of problem gaming require further attention, in light of adult gamers raising their children in a gaming-centric environment. Research has been limited by a reliance on adolescent self-report to understand family dynamics, without gathering corroborating information from parents and other family members. The very high rates of problem gaming (>10%) reported in general population samples raise concerns about the validity of current screening tools.

Conclusions

Interventions for adolescents may be more effective in some cases if they can address familial influences on problem gaming with the active co-participation of parents, rather than enrolling vulnerable adolescents in individual-based training or temporarily isolating adolescents from the family system.

Keywords: Internet gaming disorder, addiction, family, adolescence, risk, DSM-5

Introduction

Internet gaming activities play a major role in the leisure and social pursuits of adolescents. Research has identified benefits associated with normal engagement in gaming, such as improved relationships with family ( Durkin & Barber, 2002) and peers ( Kuntsche et al., 2009; Valkenburg & Peter, 2009), as well as some physical and cognitive benefits ( Blumberg, Altschuler, Almonte, & Mileaf, 2013; Subrahmanyam, Greenfield, Kraut, & Gross, 2001). However, excessive gaming can increase the risk of depression and anxiety ( King, Delfabbro, Zwaans, & Kaptsis, 2013), and negative impact on school achievement, exercise, and sleep ( Ferguson, Coulson, & Barnett, 2011; Kim et al., 2010). In 2013, Internet gaming disorder (IGD) was proposed as a condition warranting further study in Section III of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). The IGD classification aimed to improve consistency in the conceptualization of gaming-related problems, which had interchangeably been referred to as an "addiction," "pathology," "syndrome," or "impulse control disorder," among other terms ( King, Haagsma, Delfabbro, Gradisar, & Griffiths, 2013). The DSM-5 IGD category has also been used to guide interventions for adolescents who screen positively for problem gaming ( King et al., 2017). Given some interventions for Internet addiction (including gaming) have employed family approaches (e.g., Liu et al., 2015), or involved modification of family-related variables (e.g., parent-child communication) ( Yeun & Han, 2016), it was considered timely to evaluate the evidence based on family factors related to problematic gaming behaviors in adolescence.

Several familial influences, such as the parent-child relationship, parental restriction and monitoring of media use, and parents' marital and socioeconomic status, may affect the likelihood that an adolescent becomes a problem gamer. A large body of empirical research has examined the association between adolescents' electronic media use and family functioning, with much of this work drawn from East Asian populations ( Koo and Kwon 2014; Xiuqin et al., 2010); however, studies with a specific focus on problem gaming are less common. Chiu, Lee, and Huang ( 2004) reported that Taiwanese youth from families with higher functioning relationships had much lower levels of problematic gaming. The authors suggested that family functioning may be protective against problem gaming because more diligent family members are likely to direct the adolescent's attention away from games and toward other activities. Similarly, a study of 600 adolescents by Jeong and Kim ( 2011) reported that less engagement with family activities was associated with problematic gaming. It is often unclear from these studies and others whether family and gaming variables are in fact causally related. Excessive gaming may displace opportunities for family interaction, or poor family relationships may lead an adolescent to seek out social engagement in gaming activities ( Wang & Wang, 2013). Another possibility is a third, more underlying factor, such as a developmental disorder, might explain a preference for gaming and lack of normal bonding or social interests.

Research studies of parental restriction and monitoring of gaming appear to be more equipped to examine the impact of parenting style. This is because the line of questioning is often more explicit in reference to the parents' influence on gaming, asking questions such as Do you set limits on how long your child can play games? However, there is still uncertainty about whether parents are aware of the extent of gaming activities and whether parental restrictions or other strategies are consistently employed. This may partly consider for the mixed findings in relation to parental supervision and problem gaming ( Choo, Sim, Liau, Gentile, & Khoo, 2015; Kwon, Chung, & Lee, 2011; Liau et al., 2015; Rehbein & Baier, 2013). It may also depend on whether parents' restrictiveness or permissiveness had preceded or developed after the gaming problem began. For example, in a study of 2,021 adolescents, Wu, Wong, et al. ( 2016) reported that parental restriction was 1.9 times higher in adolescents who used the Internet excessively compared with other adolescents. More restrictive parents may attempt, perhaps unsuccessfully, to respond to gaming problems after they have emerged or restriction may increase the adolescent's desire for gaming, thereby creating a vicious cycle of further restriction and increasing parent-child conflict.

Other studies report that adolescents with family relational trauma may use online activities as a coping mechanism. Schimmenti, Passanisi, Gervasi, Manzella, and Fama ( 2014) surveyed 310 young adults to assess problematic Internet use and relational trauma. They reported that problematic Internet users were significantly more likely to have suffered childhood experiences of physical and sexual abuses and report insecure attachment attitudes. Another study by Schimmenti, Guglielmucci, Barbasio, and Granieri ( 2012) surveyed 250 players of massively multiplayer online games about their attachment styles. Almost half (47%) of the problem gamers reported features of disorganized attachment and playing to escape from painful memories of abuse. These findings highlight the complex family backgrounds in some cases of problem gaming, the limitations of basic demographic surveys for capturing this information, and the challenge of addressing a gaming problem when gaming may be seen as the only viable coping strategy in an unstable, rejecting, or risky family environment ( Li et al., 2016).

In response to the perceived growing public health threat of problem gaming, there has been an increase in prevention studies targeting adolescent gaming ( King et al., 2017). A meta-analysis by Yeun and Han ( 2016) identified 37 studies, including a total of 1,490 participants, with most conducted in schools, usually in groups, and employing cognitive-behavioral strategies and other training programs. The majority of these studies (36/37) have been conducted in South Korea. A report by Lim ( 2012) provides a useful account of the reasons that young people in East Asian regions may be particularly vulnerable to problem gaming. Lim stated that the growing accessibility and affordability of gaming resulting from industrialization, the declining birth rate and single-child family structure (e.g., the one-child policy in China), and cultural and familial pressures to attain high academic achievement have led to lonely, stressed, and shamed adolescents who retreat into Internet cafes. Standard interventions in these regions have involved stress management, self-discipline, and thought challenging ( Yeun & Han, 2016), on the assumption that this equips the adolescent to better handle familial and cultural expectations and reduce reliance on gaming. It may be debated whether such interventions can in fact address familial influences that drive problem gaming behaviors, including the possibility that certain programs may reinforce shame and resentment by punishing adolescents and isolating them from their parents (e.g., "boot camp" approaches; see Koo, Wati, Lee, & Oh, 2011) or indirectly absolving the parent of offering support or having other responsibilities by not including them in interventions.

The present review

The objective of this review was to summarize the research on family factors associated with adolescent problem gaming. The aim was to identify the factors with consistent links to problem gaming, while highlighting potential weaknesses or inconsistencies for the attention of future research. A critical examination of this literature may help researchers and practitioners to pay greater attention to more external influences, particularly modifiable variables that could be targeted in interventions, rather than focusing on the personality traits, capabilities, and difficulties of a vulnerable population. Reviewing familial influences may also inform holistic models of problem gaming and related behavioral addictions.

Methods

Inclusion criteria

The scope of this review included quantitative studies of adolescent problem gaming published in the last decade (2007-2016). This time frame (10 years) was chosen because (a) it was a standard time frame in reviews and (b) gaming activities had not greatly changed within this period, in terms of their online capabilities and presence within the family home. To be eligible for inclusion, studies were required to include a measure of problem gaming, present data on participants aged under 18 years, and include at least one family-related variable. Family-related variables included: (a) parent status (e.g., gender, socioeconomic status, and mental health), (b) parent-child relationship (e.g., warmth, conflict, and abuse), (c) parental influence on gaming (i.e., supervision of gaming, modeling, and attitudes toward gaming), and (d) family environment (e.g., household composition and quality of family relationships). Note that the term "parent" is used to refer collectively to the primary carer of the child and includes primary caregivers who are not biological parents.

Identification of studies

Database searches were conducted using the following databases: Medline, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection (via EBSCOhost), Web of Science, and ScienceDirect. Each database was searched by one of the authors (LAS) in July 2016. The search terms and logic were developed by two authors (LAS and DLK). Searches involved combinations of keywords, subject headings, and MeSH terms. Each database required some minor adjustments due to variations in functionality. For example, where one database enabled searching by "subject headings," another enabled keyword searches only. Search terms were arranged into four groupings reflecting: (a) family factors, (b) problem gaming, (c) technology-related term (e.g., "video gaming" and "Internet"), and (d) the population of interest. The four groupings were separated by "AND" to ensure essential components were captured by the search. The complete search results and reference list for each database search are available from the corresponding author.

Figure 1 presents a summary of the search and inclusion process for this review. The database searches identified a total of 5,039 manuscripts across the six databases. After removing duplicates, 3,678 articles remained for the next stage of screening. The evaluation of titles and abstracts resulted in 3,573 studies being excluded due to not meeting inclusion criteria. Two studies were identified from the reference lists of those included articles. Of the 105 full-text articles evaluated by the first author and an independent reviewer, a total of 14 studies were identified as suitable for review.

Figure 1.

Flow diagram of study selection

Data extraction

Table 1 presents an overview of the extracted information from the 14 studies. These included authors and date, country of data collection, sample size, age of participants (mean, standard deviation, and range), study population, study design, problem gaming measurement, family factors under study, and the main findings and significance of the study.

Table 1.

Authors

Country

N

Age range

Sample

Design

IGD measure

Family factors

Findings

Parental restriction on child's video gaming

Family environment

Gaming activities with parents

Negatively associated with self-efficacy in real world

Positively associated with social efficacy in virtual world

Negatively associated with social activities with parents

Negatively related to parental attitude toward gaming

Adolescents' attitude toward parents' parenting

Socioeconomic status

Parental supervision

Parental involvement in child's media use

Parental supervision

Family environment

ICD-10 dependency

Parental physical abuse

Parental devotion

Parental supervision

Conflict between parents

Parental physical abuse

Parental education/occupation

2,967 children

Parental mental health

Family functioning

Study 2: 242

Study 2: 12-18

Threats and violence between parent/s and child

Parental marital status

Family economic status

Family harmony

Parental gaming use

Parental gaming invitations

Parental education

Results

Study design and context

Nine of the 14 studies were cross-sectional survey studies. The remaining five were longitudinal survey studies, with follow-up at 1 year ( Choo et al., 2015; Zhu et al., 2015), 2 years ( Liau et al., 2015), 3 years ( Da Charlie et al., 2011), and 5 years ( Rehbein & Baier, 2013). Most studies were conducted in East Asian nations, including Singapore ( n = 3), South Korea ( n = 3), Taiwan ( n = 1), China ( n = 1), and Hong Kong ( n = 1), with remaining studies from Germany ( n = 2), Australia ( n = 1), Sweden ( n = 1), and Turkey ( n = 1). The majority of studies were conducted in either primary, middle, or secondary schools, or a combination of these contexts ( Choo et al., 2015; Da Charlie et al., 2011; Jeong & Kim, 2011; Kim & Kim, 2015; Kwon et al., 2011; Liau et al., 2015; Rehbein & Baier, 2013; Rehbein et al., 2010; Wang et al., 2014; Wu, Ko, et al., 2016; Zhu et al., 2015; Zorbaz et al., 2015).

Two studies presented nationally representative survey data ( Rehbein et al., 2010; Rikkers et al., 2016). Vadlin et al. ( 2016) recruited a prospective community-based cohort and a sample of adolescents seeking first contact with child and adolescent psychiatric clinics in Sweden. All studies with one exception ( Rikkers et al., 2016) surveyed only the child or adolescent and did not collect data from the parent or caregiver, or another external rater. The mean sample size of the included studies was 2,894 ( SD = 4,214) and ranged from 396 participants ( Zorbaz et al., 2015) to 15,168 participants ( Rehbein et al., 2010). Not including Rehbein et al. ( 2010), the mean sample size was 1,793 ( SD  = 1,674).

Problem gaming: Measurement

There was a considerable variability in problem gaming instrumentation. Three studies ( Choo et al., 2015; Da Charlie et al., 2011; Liau et al., 2015) employed a screening tool based on the DSM-IV-TR pathological gambling criteria ( American Psychiatric Association, 2000). Three studies ( Jeong & Kim, 2011; Kwon et al., 2011; Zhu et al., 2015) employed modified and translated versions of the Young Internet Addiction Test ( Young, 1998). Two studies ( Rehbein & Baier, 2013; Rehbein et al., 2010) used measures based on the ICD-10 ( World Health Organization, 1992). Six studies employed modified and/or translated instruments ( Kim & Kim, 2015; Rikkers et al., 2016; Vadlin, Åslund, & Nilsson, 2015; Wang et al., 2014; Wu, Wong, et al., 2016; Zorbaz et al., 2015). Although not consistently reported, the prevalence estimates of problem gaming (or "gaming addiction," as it was often termed) were high, including figures of 9.8% ( Vadlin et al., 2016), 9.9% ( Choo et al., 2015; Liau et al., 2015), 11.7% ( Da Charlie et al., 2011), 13.4% ( Kim & Kim, 2015), and 15.6% ( Wang et al., 2014).

Family factors: Overview of variables

The most frequently studied family factor was the parent-child relationship, which was presented in 11 studies. This factor was assessed with self-report measures of parent-child closeness or attachment in seven studies ( Choo et al., 2015; Da Charlie et al., 2011; Kim & Kim, 2015; Kwon et al., 2011; Liau et al., 2015; Rehbein & Baier, 2013; Zhu et al., 2015). In the remaining studies, the parent-child relationship was inferred by the adolescent's perceptions of the family environment, family harmony, parenting quality, and social engagement with parents ( Jeong & Kim, 2011; Rikkers et al., 2016; Wang et al., 2014; Zorbaz et al., 2015). Only three studies distinguished between maternal and paternal relationships ( Da Charlie et al., 2011; Kim & Kim, 2015; Rehbein & Baier, 2013). All measurements of the parent-child relationship involved a self-report survey. Studies did not include interviews, observations, or external reports to complement the surveys.

The second most common factor was parent status. Eight studies examined variables related to the parent/s, such as marital status ( n = 3; Rehbein & Baier, 2013; Rikkers et al., 2016; Wang et al., 2014), mental health status ( Rikkers et al., 2016), and socioeconomic status ( n = 7; Choo et al., 2015; Kim & Kim, 2015; Rehbein & Baier, 2013; Rikkers et al., 2016; Wang et al., 2014; Zhu et al., 2015; Zorbaz et al., 2015). Four studies used proxy measures of socioeconomic status, including house size and type (i.e., government housing, private, etc.; Choo et al., 2015) and parental education ( Rehbein et al., 2010; Wang et al., 2014; Zorbaz et al., 2015). In Kwon et al.'s ( 2011) study, the school administrators informed the researchers that most students were from middle socioeconomic class families.

The third factor was parental influence on gaming. Five studies examined parent's knowledge and attitudes toward gaming, parental involvement in gaming, and parental supervision of the adolescent's activities (including supervision of non-gaming activities) ( Choo et al., 2015; Jeong & Kim, 2011; Liau et al., 2015; Rehbein & Baier, 2013; Wu, Ko, et al., 2016). Of the 14 studies, only three specifically asked participants about parental restriction of Internet gaming ( Choo et al., 2015; Liau et al., 2015; Rehbein & Baier, 2013). These three studies contained survey questions about parental restriction of certain types or genres of games and limits on the duration of gaming time.

The final and least studied variable was parental abuse of the child, which was assessed in three studies, all conducted in Europe. Rehbein et al. ( 2010) investigated the frequency of severe physical abuse sustained by the child before the age of 12 years, whereas Rehbein and Baier ( 2013) asked participants whether they had sustained physical abuse from a parent in the past 4 weeks. Rehbein and Baier ( 2013) included a survey item related to conflict between parents. Vadlin et al. ( 2016) examined family maltreatment with items concerning threats and violence between parents, and between parent and child.

Family factors: Main findings

The most consistent finding was a poorer parent-child relationship that was associated with increased problem gaming ( Choo et al., 2015; Da Charlie et al., 2011; Kim & Kim, 2015; Zhu et al., 2015). Related findings included: (a) problem gamers spent less time engaged in social activities with their parents ( Jeong & Kim, 2011), (b) problem gamers reported greater parental hostility and less parental affection ( Kwon et al., 2011), and (c) problem gamers reported receiving lower quality parenting ( Kim & Kim, 2015) and having a worse family environment compared with normal gamers ( Da Charlie et al., 2011; Rikkers et al., 2016; Wang et al., 2014; Zorbaz et al., 2015). The three studies that differentiated between paternal and maternal relationships reported inconsistent findings. For example, paternal devotion was negatively correlated with problem gaming, whereas maternal devotion was not significant ( Rehbein & Baier, 2013). In Kim and Kim's ( 2015) study, both maternal and paternal rearing attitudes and alienation scores were negatively correlated with problem gaming, but paternal trust and communication were not significantly related to problem gaming. Finally, in Da Charlie et al.'s ( 2011) study, problem gamers reported better relationships with mothers than fathers, but overall had poorer relationships with both parents than normal gamers.

Longitudinal studies reported that a positive parent-child relationship may ameliorate the risk for later problem gaming or reduce existing problem gaming symptoms. Liau et al. ( 2015) reported that parent-child connectedness and positive perceptions of the family environment were protective against later problem gaming, and that greater warmth in the family environment was associated with decreases in problem gaming. Choo et al. ( 2015) reported that greater parent-child closeness at baseline was associated with fewer symptoms of problem gaming at 1-year follow-up, particularly for male gamers. Zhu et al. ( 2015) reported that the relationship between negative parent-child relationship and problem gaming was mediated by decreasing school connectedness and greater association with deviant peers.

Adolescents from single-parent ( Rehbein & Baier, 2013) and blended ( Rikkers et al., 2016) families were at greater risk of reporting problem gaming than those from two-parent families. However, Wang et al. ( 2014) found no significant effect of parental marital status on gaming problems. Choo et al. ( 2015) reported that living in private housing, which reflected the highest level of socioeconomic status, was negatively related to symptoms of problem gaming, whereas six other studies found no relationship between socioeconomic status and gaming problems. Problem gaming was more prevalent among adolescents with parents with histories of mental health issues ( Rikkers et al., 2016).

Studies on parental attitudes toward gaming and parental gaming behavior have produced inconsistent findings. Wu, Ko, et al. ( 2016) reported significant positive relationships between the frequency of parental gaming, the frequency of parental invitations to play games, and adolescent problem gaming. Jeong and Kim ( 2011) reported that negative parental attitudes toward gaming were associated with more symptoms of problem use. In two studies ( Kwon et al., 2011; Rehbein & Baier, 2013), parental supervision was negatively associated with problem gaming, whereas two other studies reported no significant associations ( Choo et al., 2015; Liau et al., 2015). Only one of the three studies that examined parental physical abuse reported that adolescents with a history of maltreatment were more likely to report problem gaming ( Vadlin et al., 2016).

Further findings from longitudinal studies

Longitudinal studies support the notion that the parent-child relationship can influence the likelihood of developing problem gaming behavior. Choo et al. ( 2015) reported that greater parent-child closeness at baseline was associated with decreased problem gaming 1 year later. They also reported that parental restriction of gaming at baseline had no effect on problem gaming 1 year later, irrespective of the quality of the parent-child relationship. Liau et al. ( 2015) reported that both parent-child connectedness and a warm family environment at baseline were protective factors for problem gaming at 2-year follow-up. Moreover, greater family warmth at baseline was associated with reductions in problem gaming 1 year later. Zhu et al. ( 2015) reported that the longitudinal relationship between parent-child relationship and problem gaming was mediated by school connectedness and deviant peer affiliation. A 5-year longitudinal study by Rehbein and Baier ( 2013) reported that increased paternal devotion and higher parental supervision in childhood predicted lower rates of problem gaming in adolescence. A 3-year study by Da Charlie et al. ( 2011) reported that problem gaming was associated with reductions in the quality of the parent-child relationship over time. While there was no initial difference between problem and normal gamers in terms of their parent-child relationships, by the third year, problem gamers reported significantly poorer relationships with their parents.

Discussion

This review examined the frequently overlooked role of family factors in adolescent problem gaming. A consistent finding in this review was poorer quality of the parent-child relationship that was associated with increased severity of problem gaming. Both maternal and paternal relationships were negatively associated with problem gaming, with longitudinal evidence indicating that the paternal bond in particular was a protective factor against problem gaming. Long-term adolescent problem gaming also has marked negative effects on the family system. One longitudinal study reported an increasing deterioration of the parent-child relationship over a 3-year period following onset of problem gaming ( Da Charlie et al., 2011). This review shows that parenting can increase the risk of problem gaming in multiple ways. For example, Zhu et al.'s ( 2015) study reported that the parent-child relationship may influence problem gaming via the mediating influence of decreasing school connectedness and greater association with deviant peers. The negative familial influence on gaming behavior may therefore be more pronounced when it impacts on the adolescent's sense of belonging across multiple social contexts.

The findings of this review underscore the need for families to be involved in interventions for adolescents exhibiting symptoms of problem gaming. The family approach to problem gaming, while less researched than individual-based therapies ( Yeun & Han, 2016), has already been trialed with some successful outcomes. For example, a study by Liu et al. ( 2015) assessed a family-based intervention, which involved reducing high and unreasonable expectations and criticism by parents, and identifying alternative ways for adolescents to satisfy needs for competence and relatedness. The authors reported that the rate of problem gaming reduced from 100% at baseline to only 4.8% at the end of the intervention. The rate of problem gaming was only 11.1% at the 3-month follow-up assessment. Such a finding demonstrates the value of recognizing and conceptualizing the dysfunctional family dynamics in cases of adolescent problem gaming. Prevention approaches that focus on working with adolescents only may be perceived by the adolescent as blaming and fail to address one of the primary reasons for using games excessively.

Studies of parental supervision and gaming have produced some mixed evidence. While Kwon et al. ( 2011) and Rehbein and Baier ( 2013) reported negative associations between parental supervision and problem gaming, Liau et al. ( 2015) found no such relationship. Similarly, in Choo et al.'s ( 2015) longitudinal study, level of parental supervision did not influence subsequent development of problem gaming. Notably, the studies by Liau et al. ( 2015) and Choo et al. ( 2015) only measured the parental supervision of adolescent gaming, whereas the studies by Kwon et al. ( 2011) and Rehbein and Baier ( 2013) included more general measures of parental supervision and involvement in adolescents' activities [e.g., " When I am outside, my mother knows where I am" ( Kwon et al., 2011)]. These differences suggest that parental monitoring and regulation of gaming devices may not be effective on their own, but broader parental supervision and involvement are required. Educational materials and awareness campaigns should, therefore, consider promoting messages on supervision of gaming media within broader statements on parental care and responsibility.

There was some evidence that parental modeling can impact on adolescents' gaming attitudes and behaviors. Potential intergenerational effects of problem gaming may become increasingly relevant as more children are born to parents who play games or have gaming histories. Positive parental attitudes toward gaming and greater parental involvement in gaming were associated with increased gaming by adolescents. Liau et al. ( 2015) reported that parents who modeled high levels of gaming increased the risk of having children engaged in excessive gaming, irrespective of the restrictions on gaming in the household. Therefore, gaming restrictions and monitoring may be compromised by parents if their modeling is inconsistent with their rules and restrictions. Given that males are known to be generally more likely to play games excessively ( Ferguson et al., 2011), fathers may tend to be the stronger negative modeling influence. On this basis, including cooperative fathers who play games in family-based interventions for adolescents may be beneficial to all parties.

Adolescents from single-parent or blended families were reportedly at greater risk of problem gaming than those from two-parent families. This was consistent with studies of problematic Internet use ( Ko, Yen, Yen, Lin, & Yang, 2007; Lam, Peng, Mai, & Jing, 2009; Li, Garland, & Howard, 2014; Tsitsika et al., 2011; Yen, Yen, Chen, Chen, & Ko, 2007), but multiple reasons could account for these differences. First, it may reflect an adolescent's desire to escape from the stress of a complex family situation (e.g., a strained relationship with a step-parent). Second, adolescents living with a single parent may direct greater frustration toward this parent or wish to seek out surrogate parental figures, thereby making the opportunities for stress release and social connectivity in online games more appealing. It is also possible that adolescents in single-parent families have fewer opportunities for alternative activities due to the parent having less time and fewer resources to support the adolescent's interests. Another, less studied, variable was parental physical abuse, which was positively associated with problem gaming in one of the three studies. Vadlin et al. ( 2016) reported that adolescents with a history of family maltreatment were 2.5 times more likely to be problem gamers. The sensitive nature of this topic may make it difficult to examine effectively in self-report survey studies, particularly in the school context where the adolescent may fear personal information being disclosed. The intersection of adolescent gaming issues with complex family backgrounds also presents challenges for interventions. There may be special circumstances where a family-based approach, or the involvement of specific guardians or family members, is contraindicated due to irresolvable conflicts or risk issues. Collaboration and respect between parent and adolescent are essential to overcome this barrier. As noted by Ramirez et al. ( 2011), parental restriction of screen time was only effective when there was joint agreement on the rules. When there was disagreement, parents tended to implement more rules that led to increased media use by the adolescent.

It is often assumed that adolescents with family-related difficulties engage in gaming not only to escape but also to seek out more comfortable or less threatening online relationships ( Caplan, 2010; King & Delfabbro, 2014). However, studies have not yet examined the types of social connectivity that occur in adolescent gaming and how they may relate to problem gaming. There may be varying risks across types of games based on their capability to facilitate social status, group bonds, and obligations among players. For example, some online games with cooperative elements may be used to satisfy an adolescent's need for social inclusion and desire for acceptance and validation by others. In contrast, skill-based games with online ranking systems may meet an adolescent's need to be recognized for achievement or mastery, which may be lacking in their family environment. In addition to these varying online gaming subcultures, this review highlights the need to consider family factors within the relevant cultural context. Current knowledge of the families of adolescent problem gamers is predominantly based on East Asian experiences, and it is likely that family dynamics and responses to gaming problems vary across regions.

Limitations and future directions

This review has limitations that warrant acknowledgment. Many of the identified studies predated the DSM-5 IGD classification, and therefore, some inconsistency in screening for problem gaming should be expected. This review focused on problem gaming, as distinct from general Internet use, which has a larger research base, and therefore, some studies of potential relevance may have been excluded. Studies not published in English were also not identified by the search protocol. The methods of this review highlighted the consistencies in results but did not provide meta-analytic insights. Relatedly, the presented analysis considered familial factors discretely to identify general trends across studies, rather than examining interactions among familial influences with other variables.

The family factors documented in this review may provide a useful guide for further empirical research. Like other areas of investigation into IGD, the research base is limited by inconsistent approaches to screening, and the high prevalence rates of IGD (>10%) in general population samples suggest a need for more careful delineation of normal and problem gaming. There is also a relative lack of longitudinal studies and no family interview-based studies, which would offer major advantages over cross-sectional surveys. Relying on cross-sectional surveys may affect the quality of detail and understanding of the causal pathways between family factors and adolescent problem gaming. Future research could include a more comprehensive assessment of family factors to examine potential interactions. Finally, studies should recruit from youth mental health services to include verified clinical cases.

Conclusions

Although problem gaming is a growing area of study, relatively less research has assessed the important role of familial influences on adolescent gaming and problem gaming. This may reflect an unintended bias to consider adolescents in much the same way as adults, as independent, autonomous individuals, rather than a special population whose gaming tends to occur and interact within a family system. This review found that almost all studies on family factors have not collected data from families, but have instead relied on adolescents' own insight and view of family dynamics. Notably, too, the same screening tools used in studies of adult gamers are also used for adolescents, including children as young as 10 years old (e.g., Choo et al., 2015), with reported prevalence rates that exceed other known mental disorders in this population (e.g., 15%; Wang et al., 2014). Considering adolescents as adults may overlook relevant contributing factors that explain the development of problem gaming, particularly when problems can be traced to families with fewer nurturing relationships, less structure and more conflict, and low support for alternative activities. The influence of the family system is vitally important to address within interventions for adolescents.

Acknowledgements

The authors would like to thank Dr. Ashleigh Smith for guidance on conducting the systematic review and Ms. Amy Garrett for secondary screening of the selected full-text articles.

Funding Statement

Funding sources: This work received financial support from a Discovery Early Career Researcher Award (DECRA) DE170101198 funded by the Australian Research Council.

Authors' contribution

LAS designed the review and wrote the protocol. LAS conducted the review under DLK's supervision. LAS wrote the first draft of the manuscript under DLK's supervision and all authors contributed to and have approved the final manuscript.

Conflict of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

References

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association. [Google Scholar]

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed). Washington, DC: American Psychiatric Association. [Google Scholar]

3. Lim S. S. (2012). Regulatory initiatives for managing online risks and opportunities for youths - The East Asian experience In Walrave M. (Ed.), e-Youth: Balancing between opportunities and risks? (pp. 271-290). Brussels, Belgium: Peter Lang. [Google Scholar]

4. Schimmenti A., Guglielmucci F., Barbasio C., Granieri A. (2012). Attachment disorganization and dissociation in virtual worlds: A study on problematic Internet use among players of online role-playing games. Clinical Neuropsychiatry, 9, 195-202. [Google Scholar]

5. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: World Health Organization. [Google Scholar]

6. Young K. S. (1998). Caught in the net: How to recognize the signs of Internet addiction - And a winning strategy for recovery. New York, NY: John Wiley & Sons. [Google Scholar]

Articles from Journal of Behavioral Addictions are provided here courtesy of Akadémiai Kiadó

# data[].attributes.attachment_link.title
Family factors in adolescent problematic Internet gaming: A systematic review

# data[].attributes.attachment_link.description
Familial influences are known to affect the likelihood of an adolescent becoming a problem gamer. This systematic review examined some of the key findings in empirical research on family factors related to adolescent problem gaming. A total of 14 ...