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Too Much of a Good Thing: Video Game Addiction and ADHD

Video games have always been promoted as amazing sources of entertainment. But not much is said about the impact they have on a gamer’s health.

Back in 1980, when the big, jumbo-sized arcade games first came out, some gamers developed Pac Man’s elbow – a tendonitis caused by spending too much time manipulating the gaming joystick. Today, this trend has continued and we have Nintendonitis, or Nintendo thumb. Along with the notion that video games can have a negative impact on a player’s health.

However, while these consequences are attributed to excessive video game playing, not all of them are physical. Today, there is the notion of video game addiction (VGA), and the thought that regulating gaming time is not as easy as one might hope.

So, what is VGA, and what does this have to do with ADHD?

To start off, let’s consider what an addiction is and how an addiction develops.

Addiction is a physical or psychological need for, and use of, a habit-forming substance (i.e., heroin, cocaine, alcohol) or behaviour (i.e., gambling, video games). Eventually, this need takes over a person’s life, and what was once pleasurable soon becomes compulsive, interfering with responsibilities and activities of daily life.

Typically, the following occurs:

  1. The substance/behaviour is important, and occupies a huge chunk of your thoughts. It’s nearly impossible to get it off your mind.
  2. The substance/behaviour is used to change your mood. It is an escape, making you happy when you were previously sad, or helping you to forget the worries and problems of life.
  3. Tolerance develops. So, you need to consume larger amounts of the substance/participate in the behaviour longer to achieve the same effect as before (happiness, distraction, etc.).
  4. Withdrawal occurs, and you start to feel anxious, agitated, irritated or depressed if unable to continue with the substance use/behaviour.
  5. You begin to have problems with relationships, jobs and other aspects of life.
  6. Realizing something needs to change, you try to quit. But, every time you stop, you relapse, and end up returning to the substance/behaviour.

Some people might argue that addiction only makes sense in the context of substances – specifically alcohol and drugs. After all, they are well studied and we are well aware of them. But, gambling is a behavioural addiction, and we are well aware of it as well.

The only reason that we are less familiar with the concept of VGA is that it was only mentioned for the first time in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (which is pretty much the handbook on diagnosing psychiatric conditions) in 2013.

Now, even if, prior to 2013, VGA (a subtype of Internet Gaming Disorder (IGD)) was not recognized by the American Psychiatric Association and listed in the DSM, this did not mean that researchers weren’t concerned about the impact that video games were having on the brain. In fact, studies have been looking into the impact of video games for decades. The only challenge is that, prior to 2013, we didn’t have a unifying set of criteria to define the condition. This meant that most studies used their own criteria to define problematic and pathologic gaming.

Coincidentally, the majority used a variation of the criteria used to define pathological gambling – a behavioural addiction – which closely mirrors what was published in the DSM.
So, while not perfect, the studies and their data are a good starting point, and here’s what they’ve found.

First, some studies took images of the brain while people were playing video games. It was found that IGD/VGA shared certain similarities with other addictions – including substance dependence. Specifically, playing video games was associated with a release of dopamine in the reward pathways of the brain comparable to substances that release dopamine.

Having identified this, other studies went on to look at what risk factors were associated with IGD/VGA.

Primarily, research has found that younger males are at a higher risk of developing IGD/VGA than any other population. After this, the risk factors are based on the structural characteristics of the game and the mindset of the gamer.

Video games are designed to draw the gamer in and entice them to keep playing, regardless of how much time they have already been playing. This is achieved through a combination of rapid-fire stimuli requiring an equally rapid response paired with immediate rewards. Although these rewards don’t come at a set interval (a tactic designed to specifically keep gamers gaming), the gamer knows that they are coming, and could be just seconds away. Then, when they do come… SUCCESS! And these are only the random surprise rewards. This has nothing on the sense of accomplishment – the high – that comes with completing another level or winning another title.

With regards to gamers, one of the bigger risk factors is a desire for escape. Say a gamer is fighting with depression, social isolation, self-esteem problems, or emotional distress (all also risk factors for developing IGD/VGA). In the gaming world, all of this is forgotten and, in essence, disappears.

However, when controlling for age and sex, the most significant risk factor identified with developing IGD/VGA is inattentive and/or impulsivity symptoms. Specifically, a diagnosis of ADHD.
As it turns out, ADHD has been found to be highly comorbid among people with IGD/VGA. In the general population, ADHD occurs at a rate of ~5%. In people with IGD/VGA, it is found to occur at roughly 30%. And, the severity of inattentive and impulsivity symptoms has been found to correlate with the severity of IGD/VGA – the more severe a person’s ADHD symptoms, the more severe the addiction.

Currently, there are two theories that try to explain the relationship between ADHD and VGA.

First, it has been suggested that people with ADHD are more susceptible to video games because of their design.

People with ADHD are known to have issues with attention and impulsivity, along with completing tasks that don’t provide immediate feedback or rewards. In daily life, this causes challenges. On the other hand, video games, which require a rapid response to stimuli and provide immediate feedback and rewards, turn these same issues into advantages. In fact, a few studies have featured parent-reports stating that their children appear to have better attention and more success when playing video games compared to their performance and completion of other tasks in life. If this is true, why wouldn’t children with ADHD want to spend all their time playing video games? After all, all people want to be successful.

Second, it’s been suggested that people with ADHD are using video games as a form of self-medication.

Research has indicated that a deficiency of dopamine in the brain is associated with hyperactivity, impulsivity, and inattention – the main features of ADHD. Consequently, it has been suggested that people with ADHD try to find ways to stimulate dopamine release in the brain to make up for the deficit. This includes participating in risky behaviours, such as driving recklessly or using substances (i.e., illicit drugs) that release dopamine in the brain. As mentioned before, playing video games releases dopamine in the brain.

Additionally, one small study looked at children with ADHD who had never been on medication, and also had an issues problematic gaming. As the study reported, after the children were treated with either methylphenidate or atomoxetine for 8 weeks, both ADHD symptoms and problematic gaming decreased.

Taken together, these findings have led researchers to suggest that the high comorbidity between ADHD and IGD/VGA is because people with ADHD are self-medicating with video games in order to stimulate dopamine release in the brain.

Now, while the medical literature discussed in this blog is only preliminary, and further research is required, there is enough data to have raised some concerns in the medical community. Before signing off, here are a few recommendations about video games and VGA:

  1. Create limits on the amount of time spent video gaming. While this can be determined on a family-basis, a starting point can be to follow the Canadian Pediatrics Society’s guidelines for screen time (TV, computers, video games, tablets, etc.).
    a. Screen time for children under 2 years old is not recommended.
    b. For children 2 to 5 years, limit screen time to under 1 hour per day.
    c. Ensure that sedentary screen time is not a routine part of child care for children younger than 5 years old.
    d. Maintain daily ‘screen-free’ times, especially for family meals and book-sharing.
    e. Avoid screens for at least one hour before bedtime, given the potential for melatonin-suppressing effects.
  2. Encourage balance. While video games can be fun, they are not the only engaging and entertaining part of childhood. Encourage a balance between video games and healthy alternatives, such as reading, outdoor play and creative, hands-on activities. If possible, make these alternatives family events.
  3. Use a timer. If you are encountering difficulties with getting your child to stop playing video games (you’re always the bad guy when you tell them ‘times up’), use a timer. This way, they know how much time they get to play for when the timer is set, they can see how much time they have left to play, and, when time’s up, it’s the timer’s fault (not yours).
  4. Don’t pull the plug! Forcibly preventing addicted gamers from playing can result in violent or destructive behaviour.

If you have concerns that you or someone you care about are starting to experience problematic gaming, bring it up with your healthcare team. Together, you’ll be able to develop a safe way of dealing with the problem.

Amanda Marchak, BSc Materials Engineering, MD Candidate (Class of 2019)
Amanda Marchak completed a Bachelors of Science in Materials Engineering at the University of Alberta, with a special interest in biomedical applications. After realizing that her interests were more clinical-based as opposed to research-based, she began pursuing a medical degree at the University of Calgary. Amanda is set to graduate in 2019, and hopes to pursue a career in pediatrics. As a volunteer at the the CanLearn Society in Calgary, Alberta, she works in collaboration with a team of psychologists and physicians to help provide information to individuals, and their families, about ADHD and Learning Disabilities.