Contextualising the link between adolescents' use of digital technology and their mental health: a multi-country study of time spent online and life satisfaction.

BACKGROUND: Evidence on whether the amount of time children spend online affects their mental health is mixed. There may be both benefits and risks. Yet, almost all published research on this topic is from high-income countries. This paper presents new findings across four countries of varying wealth. METHODS: We analyse data gathered through the Global Kids Online project from nationally representative samples of Internet-using children aged 9 to 17 years in Bulgaria (n = 1,000), Chile (n = 1,000), Ghana (n = 2,060) and the Philippines (n = 1,873). Data was gathered on Internet usage on week and weekend days. Measures of absolute (comparable across countries) and relative (compared to other children within countries) time use were constructed. Mental health was measured by Cantril's ladder (life satisfaction). The analysis also considers the relative explanatory power on variations in mental health of children's relationships with family and friends. Analysis controlled for age, gender and family socioeconomic status. RESULTS: In Bulgaria and Chile, higher-frequency Internet use is weakly associated with lower life satisfaction. In Ghana and the Philippines, no such pattern was observed. There was no evidence that the relationship between frequency of Internet use and life satisfaction differed by gender. In all four countries, the quality of children's close relationships showed a much stronger relationship with their life satisfaction than did time spent on the Internet. CONCLUSIONS: Time spent on the Internet does not appear to be strongly linked to children's life satisfaction, and results from one country should not be assumed to transfer to another. Improving the quality of children's close relationships offers a more fruitful area for intervention than restricting their time online. Future research could consider a wider range of countries and links between the nature, rather than quantity, of Internet usage and mental health.

Author Correction: Addressing violence against children online and offline.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A weak scientific basis for gaming disorder: Let us err on the side of caution.

We greatly appreciate the care and thought that is evident in the 10 commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people whose play of video games is related to life problems. We believe that understanding this population and the nature and severity of the problems they experience should be a focus area for future research. However, moving from research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of evidence and the clinical utility should be extremely high, because there is a genuine risk of abuse of diagnoses. We provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better demarcation of the subject area that includes a rationale for focusing on gaming particularly versus a more general behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical approaches that treat potentially underlying issues, such as depressive mood or social anxiety first. We acknowledge there could be benefits to formalizing gaming disorder, many of which were highlighted by colleagues in their commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the gravity of diagnostic classification and its wider societal impact, we urge our colleagues at the WHO to err on the side of caution for now and postpone the formalization.

When addiction symptoms and life problems diverge: a latent class analysis of problematic gaming in a representative multinational sample of European adolescents.

The proposed diagnosis of Internet gaming disorder (IGD) in DSM-5 has been criticized for "borrowing" criteria related to substance addiction, as this might result in misclassifying highly involved gamers as having a disorder. In this paper, we took a person-centered statistical approach to group adolescent gamers by levels of addiction-related symptoms and gaming-related problems, compared these groups to traditional scale scores for IGD, and checked how groups were related to psychosocial well-being using a preregistered analysis plan. We performed latent class analysis and regression with items from IGD and psychosocial well-being scales in a representative sample of 7865 adolescent European gamers. Symptoms and problems matched in only two groups: an IGD class (2.2%) having a high level of symptoms and problems and a Normative class (63.5%) having low levels of symptoms and problems. We also identified two classes comprising 30.9% of our sample that would be misclassified based on their report of gaming-related problems: an Engaged class (7.3%) that seemed to correspond to the engaged gamers described in previous literature, and a Concerned class (23.6%) reporting few symptoms but moderate to high levels of problems. Our findings suggest that a reformulation of IGD is needed. Treating Engaged gamers as having IGD when their poor well-being might not be gaming related may delay appropriate treatment, while Concerned gamers may need help to reduce gaming but would not be identified as such. Additional work to describe the phenomenology of these two groups would help refine diagnosis, prevention and treatment for IGD.

Lost in the chaos: Flawed literature should not generate new disorders.

The paper by Kuss, Griffiths, and Pontes (2016) titled "Chaos and confusion in DSM-5 diagnosis of Internet Gaming Disorder: Issues, concerns, and recommendations for clarity in the field" examines issues relating to the concept of Internet Gaming Disorder. We agree that there are serious issues and extend their arguments by suggesting that the field lacks basic theory, definitions, patient research, and properly validated and standardized assessment tools. As most studies derive data from survey research in functional populations, they exclude people with severe functional impairment and provide only limited information on the hypothesized disorder. Yet findings from such studies are widely used and often exaggerated, leading many to believe that we know more about the problem behavior than we do. We further argue that video game play is associated with several benefits and that formalizing this popular hobby as a psychiatric disorder is not without risks. It might undermine children's right to play or encourage repressive treatment programs, which ultimately threaten children's right to protection against violence. While Kuss et al. (2016) express support for the formal implementation of a disorder, we argue that before we have a proper evidence base, a sound theory, and validated assessment tools, it is irresponsible to support a formal category of disorder and doing so would solidify a confirmatory approach to research in this area.

How can we conceptualize behavioural addiction without pathologizing common behaviours?

Following the recent changes to the diagnostic category for addictive disorders in DSM-5, it is urgent to clarify what constitutes behavioural addiction to have a clear direction for future research and classification. However, in the years following the release of DSM-5, an expanding body of research has increasingly classified engagement in a wide range of common behaviours and leisure activities as possible behavioural addiction. If this expansion does not end, both the relevance and the credibility of the field of addictive disorders might be questioned, which may prompt a dismissive appraisal of the new DSM-5 subcategory for behavioural addiction. We propose an operational definition of behavioural addiction together with a number of exclusion criteria, to avoid pathologizing common behaviours and provide a common ground for further research. The definition and its exclusion criteria are clarified and justified by illustrating how these address a number of theoretical and methodological shortcomings that result from existing conceptualizations. We invite other researchers to extend our definition under an Open Science Foundation framework.

Conceptualizing Internet use disorders: Addiction or coping process?

This paper problematizes the tendency to study Internet use disorders from a perspective of addiction. It is argued that an addiction perspective, grounded in our understanding of substance use disorders, has not contributed much to an improved understanding of the antecedents and etiology of Internet use disorders. Despite this, researchers continue to frame Internet use disorders as an addiction, recently exemplified by the inclusion of Internet gaming disorder in the DSM-5 research appendix as a behavioral addiction. This paper claims that the decision to use an addiction framework to study Internet use disorders has consequences for the way in which results are interpreted, which impacts the potential for theoretical and etiological contributions negatively. The paper argues that a perspective of addiction may not be the most useful approach because it causes a mismatch between theory and findings in empirical work: it is not uncommon to find that a study is positioned as a study of addiction, but presents findings more illustrative of coping behaviors. The paper draws on two examples from the literature to illustrate this mismatch and discusses how this hinders theoretical and etiological development. The question that is asked going forward is what alternative explanations we might identify by not exclusively adhering to an addiction framework for purposes of research. Recommendations are given for how to usefully approach the study of Internet use disorders outside a framework of addiction. It also discusses how scholars who still prefer a framework of addiction might strengthen their conceptual position to ensure improved contributions to etiology and theoretical development.

Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal.

Concerns about problematic gaming behaviors deserve our full attention. However, we claim that it is far from clear that these problems can or should be attributed to a new disorder. The empirical basis for a Gaming Disorder proposal, such as in the new ICD-11, suffers from fundamental issues. Our main concerns are the low quality of the research base, the fact that the current operationalization leans too heavily on substance use and gambling criteria, and the lack of consensus on symptomatology and assessment of problematic gaming. The act of formalizing this disorder, even as a proposal, has negative medical, scientific, public-health, societal, and human rights fallout that should be considered. Of particular concern are moral panics around the harm of video gaming. They might result in premature application of diagnosis in the medical community and the treatment of abundant false-positive cases, especially for children and adolescents. Second, research will be locked into a confirmatory approach, rather than an exploration of the boundaries of normal versus pathological. Third, the healthy majority of gamers will be affected negatively. We expect that the premature inclusion of Gaming Disorder as a diagnosis in ICD-11 will cause significant stigma to the millions of children who play video games as a part of a normal, healthy life. At this point, suggesting formal diagnoses and categories is premature: the ICD-11 proposal for Gaming Disorder should be removed to avoid a waste of public health resources as well as to avoid causing harm to healthy video gamers around the world.

Commentary on: Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research. Problems with atheoretical and confirmatory research approaches in the study of behavioral addictions.

BACKGROUND AND AIMS: This commentary is written in response to a paper by Billieux, Schimmenti, Khazaal, Maurage and Hereen (2015) published in the Journal of Behavioral Addictions. METHODS: It supports and extends the arguments by Billieux, Schimmenti et al. (2015): that the study of behavioral addictions too often rests on atheoretical and confirmatory research approaches. This tends to lead to theories that lack specificity and a neglect of the underlying processes that might explain why repetitive problem behaviors occur. RESULTS: In this commentary I extend the arguments by Billieux, Schimmenti et al. (2015) and argue that such research approaches might take us further away from conceptualizing psychiatric diagnoses that can be properly validated, which is already a problem in the field. Furthermore, I discuss whether the empirical support for conceptualizing repetitive problem behaviors as addictions might rest on research practices that have been methodologically biased to produce a result congruent with the proposal that substance addictions and behavioral addictions share similar traits. CONCLUSIONS: I conclude by presenting a number of ways of going forward, chief of which is the proposal that we might wish to go beyond a priori assumptions of addiction in favor of identifying the essential problem manifestations for each new potential behavioral addiction.