Problematic gaming in adolescents: Identifying parent and family factors relevant for treatment

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Thesis

Reference

Problematic gaming in adolescents: Identifying parent and family factors relevant for treatment

NIELSEN, Philip

Abstract

It is of clinical relevance to identify possible parental and family factors linked to adolescent problematic gaming (APG). This thesis contains two parts. In the first part I undertook two systematic literature reviews in an effort to identify these factors. In the second part I undertook a randomised controlled trail (RCT) to test the effectiveness of family therapy in treating APG. Results of part 1: parental strategies directly addressing screen use - also called parental mediation techniques - seem to be less effective than general parenting approaches fostering warm and close relationships between the adolescent and the parents.

Results of part 2: the family therapy approaches tested within this RCT both had a positive impact on Internet gaming disorder symptoms and overall well-being; the evidence-based approach (multidimensional family therapy) outperforming the family therapy approach as practiced locally. Targeting parental and family factors are a promising therapeutic avenue to treating APG.

NIELSEN, Philip. Problematic gaming in adolescents: Identifying parent and family factors relevant for treatment. Thèse de doctorat : Univ. Genève, 2021, no. FPSE 783

DOI : 10.13097/archive-ouverte/unige:153771 URN : urn:nbn:ch:unige-1537712

Available at:

http://archive-ouverte.unige.ch/unige:153771

Disclaimer: layout of this document may differ from the published version.

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Section de Psychologie

Sous la direction de Prof. Nicolas FAVEZ

Problematic gaming in adolescents

Identifying parent and family factors relevant for treatment

THESE

Présentée à la

Faculté de psychologie et des sciences de l’éducation de l’Université de Genève

pour obtenir le grade de Docteur en Psychologie

par

Philip Frederick NIELSEN de

Berne Thèse No 783

GENEVE Juin, 2021

Numéro d’étudiant : 86313350

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1 To Henk.

Thanks for everything.

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Acknowledgments

Heartfelt thanks to:

Henk Rigter, my mentor through this whole adventure, and beyond,

Howard Liddle for the brainstorming sessions, clinical discussions, and showing me the power of evidence-based family therapy,

Nicolas Favez, for coaxing me into this endeavour and supporting me all along, The jury: Joël Billieux, Martin Debbané and Olivier Desrichard, for taking their time and expertise to judge this piece of work,

Craig Henderson, and especially Max Christensen for the statistical work and helping grasp that realm,

Eva Cardenoso-Wark, Cécilia Soria, Aviva Bourezg-Véron, Sandra Privet, Christine Merino, Sabrina Cappuccio, Veronica Rato, my dear family therapy colleagues who participated in the RCT,

Merryl Schoepf, Alessia Renevey and Aurore Hertz for collecting the RCT data, Cindy Rowe and Gayle Dakof for training me in MDFT,

Marina Croquette-Krokar for trusting me to set up and head a treatment centre for adolescents,

Marie-Françoise De-Tassigny, Marc Balivet and the Phénix Foundation for backing this research project and giving me access to the data,

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Mafalda Burri and Muriel Leclerc, Service de référence, University of Geneva Library, for assisting me in identifying search terms, developing the search strategies and equations, and for carrying out the database searches linked to the SLRs,

Céline Bonnaire and Olivier Phan for contributing to the adaptation of MDFT for IGD treatment purposes,

My wife, Isabelle, for putting up with me during these studious times,

My children, Julie and Thomas, and my mom: my cheerleaders in this doctoral process,

And last, but not least, all the adolescents and parents with whom we undertook therapy and who placed their trust in me and us.

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Foreword

If I had to pinpoint the moment at which this whole adventure took off, I would place the cursor somewhere in the heart of Summer 2004. I had recently been hired by Marina Croquette-Krokar, the future general director of the Phénix Foundation, with the mission of setting up an outpatient unit for adolescents with substance use disorders. The Summer days were slow – we were not yet on the clinical map in terms of referral – and I was leafing through the Swiss Health Ministry’s information letter. In it, a short article summed up the outcomes of the pilot phase of a yet-to-be vast European trial (INCANT or International Cannabis Need of Treatment;

Switzerland was participating) testing the effectiveness of family therapy against individual therapy in treating adolescents with cannabis use disorder. The article also described the tested form of therapy: multidimensional family therapy (MDFT). It was portrayed as a research-based approach, which did therapeutic work not only with the youth, but also his/her parents, other family members, and significant others from the teen’s ecosystem: school, neighbourhood, friends, justice system. Emphasis was put on therapists honing skills and knowledge about risk and protective factors linked to substance use disorders by delving in the vast body of research on the subject. It was in this dialogue between therapeutic intuition and scientific knowledge that the therapist would call his/her shots and ultimately make the correct therapeutic decision. As a young therapist struggling to justify my work efforts, this caught my attention. My agenda was certainly empty on that fateful afternoon, so I wrote to the author of the article and asked to be informed and updated about the main study results. Soon thereafter I received from the Health Ministry an invitation to Bern to

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present my clinical work as a family therapist working with addicted teens. Needless to say, I was surprised that the Ministry would be interested in some random therapist setting up shop in remote Chêne-Bougeries. Of course, at the time I was clueless about the fact that the Ministry was in fact searching for a treatment centre willing to take over the clinical part of the main study, since those participating in the pilot study were not selected to continue. So, naïvely I set off for Bern, presented my work, and came back with exactly that proposal.

Between 2006 and 2010 I trained to become a MDFT therapist, supervisor and then trainer. My team and I – under the medical supervision of Marina – successfully completed the Swiss leg (as did the four other participating countries: Belgium, France, Germany, the Netherlands). And I became acquainted and started working with Henk Rigter, the master planner of the INCANT study, and Howard Liddle, the developer of MDFT. These relationships would turn out to be game changers in my career as a therapist and my approach to therapy.

After the INCANT trial had ended and the results were published, Henk set out to implement MDFT in Europe.

I went back to my practice at Phénix.

In those years, unknowingly to me, World of Warcraft and other Massively Multiplayer Online Role-Playing Games or MMORPGs were conquering the computer screens of many Geneva adolescents. Slowly, but steadily, cases of “cyberaddiction” were trickling into our expanding treatment unit. And so I began treating adolescents caught up (or said to be caught up by their parents and teachers) in problematic online gaming activities. As I started using MDFT with these adolescents and their

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families, I felt the need of acquiring a deeper understanding of the ‘problematic gaming’ phenomenon, and especially of Internet Gaming Disorder (IGD) as

provisionally defined by the DSM-5 classification system of mental disorders. Were diverse parent and family issues putting the adolescent at risk of developing

problematic gaming or even IGD and could other parent and family factors offer protection in this respect? Secondly, I wondered if the therapy approach I was relying on was effective in treating IGD. The latter question brought me back to Howard Liddle, who carries treatment development in his genes. Although Howard was not familiar with IGD, his curiosity was certainly piqued. So, together, Howard, Henk, MDFT colleagues in Paris – Céline Bonnaire, Nathalie Bastard and Olivier Phan –, my own MDFT team members – Eva Cardenoso Wark, Cécilia Soria – and I set off to develop an IGD adaptation of MDFT which was tested in a randomised controlled trial and with support of the Phénix Foundation.

To address the issues that puzzled me, I had to become a researcher, or more precisely: a researcher-clinician. That is how I met Nicolas Favez, at the Geneva University. Nicolas, I learned, forcefully strives to bridge the gap between family therapy as taught by the various schools and practiced in the various treatment settings, on the one hand, and evidence-based knowledge on the other. We started talking about work, family therapy, evidence-based approaches. Then he invited me to give lectures about MDFT at the Geneva University. We had a few pizzas together, did some more discussing, and once I was totally reeled in, he suggested I start a thesis on the subject of IGD and the effectiveness of MDFT in treating the disorder. I applied and was readmitted to Geneva University in 2017.

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It is through this intricate crisscrossing of paths and relationships, for which I am so grateful, and through the encounters with people motivated by a shared concern for the well-being of the families who place their trust in our hands, that this thesis has come to fruition.

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Summary

In my work as family therapist I have been seeing many adolescents with alcohol, drug and/or delinquency issues. About fifteen years ago, an additional group of teens sought treatment, this time because their online gaming behaviour was deemed problematic, if not by themselves then by people close to them (parents, school staff).

Like in cases of substance abuse and delinquency, parent and family (PF) factors appeared to play a role in the problems that had led the adolescent and his or her parents to seek guidance and help.

I decided to examine the impact of PF factors. Is adolescent problematic gaming indeed associated with PF factors? If one could modify these factors in positive ways, would that have a beneficial therapeutic effect? The current thesis reflects the

research work I have done since I joined the evolving field of gaming research. This work includes two systematic reviews and one randomised controlled trial.

Parents of adolescents with gaming problems often expect the therapist to teach them rules and strategies – collectively known as ‘parental mediation techniques’ – that they could use to keep their teen on the right track, away from indulging too much in playing games. In the first literature review (Study 1), four forms of parental mediation were assessed: (1) no mediation, i.e., refraining from action; (2) co-viewing or co-gaming with the adolescent; (3) active mediation (talking to the adolescent about gaming); and (4) restrictive mediation (limiting access to games). Nine

publications relating data on the prevalence of problematic gaming (PG) to parental mediation practices were analysed. The study participants were mostly school pupils.

The review concluded that none of the major parental mediation techniques can be

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considered to be an established risk or protective factor for problematic gaming. That is, none of the mediation practices was consistently linked to lower or higher rates of PG (or, in another set of studies, to problematic use of the Internet in general).

Refraining from parental mediation tended to be harmful, increasing screen use problems. Restrictive mediation worked out negatively or positively, depending on the type of restriction and on family attachment and functioning. In contrast to the

parental mediation techniques, family cohesion and family conflict had consistent effects on PG rates (beneficial and harmful, respectively).

The apparent importance of family cohesion and conflict was reason to carry out a second systematic literature review, this time focused on cohesion and conflict variables (parent and family factors). This review (Study 2) identified 27 research publications relating problematic gaming rates to parent and family factors. Six categories of PF factors were distinguished: problems faced by the parents; child abuse; co-parental teamwork; parenting style; family attachment; and family

functioning. These categories comprise both risk and protective factors, which were disentangled by regrouping the factors into four classes: 1. positive parenting

(positive parenting style and positive co-parental teamwork); 2. negative parenting (negative style and teamwork; child abuse; problems of the parents); 3. positive family dynamics (positive family attachment and family functioning); and 4. negative family dynamics (negative family attachment and functioning).

The review showed positive parenting and positive family dynamics to be associated with lower rates of PG, and negative parenting and negative family dynamics to be linked to higher PG rates. Most effect sizes reported in the reviewed studies were statistically significant, although rather small. The effect sizes for the PF factors,

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which are interpersonal factors, were compared with those for a range of

intrapersonal adolescent risk and protective factors and found to be of the same order of magnitude.

Having established that PF factors are linked to adolescent problematic gaming, the next step was to examine if decreasing the impact of PF risk factors and increasing the impact of PF protective factors would have a beneficial effect on problematic gaming behaviour. One form of treatment that explicitly addresses PF factors is family therapy. Family therapy has been found effective in treating adolescents with substance use disorders and delinquency. One treatment programme with a

particularly good track record in this respect is multidimensional family therapy (MDFT). The outpatient treatment centre where I worked, Centre Phénix-Mail in Geneva, mounted a randomised controlled trial comparing MDFT with the other form of family therapy offered in the centre, family therapy as usual (FTAU) (Study 3.a and 3.b). Study participants were 42 adolescents meeting the criteria for Internet gaming disorder (IGD), as defined – provisionally, for the moment – by the DSM-5

classification system. Measures included IGD symptoms, mental health symptoms, quality of life, parental supervision and school functioning. Assessments were made at baseline, at 6 months (after completion of the treatment) and at 12 months.

With one exception, all adolescents recruited for the trial were boys. They were rather young (on average 15 years) and about half of them came from broken families. Most adolescents met 6 or 7 out of the nine IGD criteria, the most often endorsed criteria being ‘Continued gaming despite problems’ and ‘Impaired control over gaming’.

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Several findings indicated that the adolescents had issues with family and school.

Most of them had been referred to the treatment centre by their parents and/or school. There were frequent episodes of youths being absent from school. The adolescents and the parents held discordant views as to the severity of the gaming problems and the mental health problems of the youth.

At baseline, the parents rated their child’s gaming problems as being large, in contrast to their teens, who considered the gaming problems to be small. This discrepancy in judgment diminished across the study period as parents became milder in rating problem severity.

Both family therapies decreased the prevalence of IGD across the one-year period.

They also reduced the number of IGD criteria met, with MDFT outperforming FTAU.

The amount of time spent on gaming remained stable throughout the trial. MDFT better retained families in treatment than FTAU.

The IGD outcomes confirm the hypothesis that family therapy, especially MDFT, was effective in treating adolescent IGD. Improvements in family relationships may

contribute to the treatment success. The findings are promising but need to be replicated in larger study.

In some respects, such as defining criteria, gaming disorder is still ill-understood and in need of further examination. The results reported in this dissertation render it likely that, at least in some cases of IGD (DSM-5) or Gaming Disorder (GD; WHO, ICD-11), gaming disorder should be seen in social context. The adolescent knows that his or her gaming is problematic in the eyes of others, such as the parents, but not

unbearably so in his or her own perception. This discordance in views may lead to

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conflicts and distress, which may aggravate the gaming problems and increase the therapeutic challenges.

Quality of relationships is a core target of family therapy. Therapists work hard to transform hate and rejection into love and inclusion. Family therapists are convinced that behavioural problems occurring during the crucial period of adolescence are intimately linked to deep issues of bonding, sense of meaning and identity. This may be part of the explanation of why these approaches appeared to work in mitigating gaming problems.

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Introduction

Adolescents needing treatment for behavioural problems

During adolescence teens strive for autonomy. This developmental process can be bumpy at times and behavioural problems may arise that require guidance and treatment. In my work as a therapist, I have seen many adolescents who had a substance use disorder – addiction to alcohol and/or drugs –, were committing criminal offences, or were involved in both types of maladjusted behaviour. I learned from research and clinical experience how important parent and family (PF) factors are, negatively and positively, in guiding the behavioural choices an adolescent makes. And I learned to apply family therapy to weaken these factors if they posed a risk and to reinforce them if they offered protection.

Over a decade ago, adolescents started to show up at the treatment centre where I worked who generally were not abusing alcohol or drugs and were not delinquent.

They had problems with reigning in their playing of online games. Although in many respects they were quite different from youth with substance use disorders, they seemed to have one thing in common: parent and family factors appeared to be at play.

I got interested in the fast-growing field of gaming research, with two main questions in mind. First, are PF factors indeed sources of risk and protection for disordered gaming to develop and subside, respectively? And if so, could existing family therapy targeting PF factors – in addition to other factors – be used to effectively treat teens

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with gaming issues? This thesis reports on the journey I have made to address these questions.

This Introduction starts with outlining the concept of problematic gaming (PG) and a diagnosable form of it: Internet gaming disorder (IGD). Next, I discuss a theoretical model to explain problem behaviour of adolescents, wondering if it also could shed light on problematic gaming. One set of risk and protective factors distinguished by the model are PF factors. The Introduction continues with a brief discussion of the evidence that family therapy may decrease substance use disorders and delinquency in adolescents by influencing PF factors, before concluding with the central theme of this thesis: Can family therapy also modulate PF factors in adolescents with

problematic gaming, thus mitigating this type of problem behaviour as well?

Internet gaming by adolescents

Video gaming has become a source of entertainment worldwide. Just over the last five years, the estimated number of gamers has risen from 1.5 to over 2.5 billion (Statistica, 2020). Stated otherwise, over 30% of the current world population play video games, a 10% rise since 2015.

For most adolescents, gaming is a pleasurable leisure activity. For a small proportion of the teen population, though, gaming may become so problematic that it affects significant life domains of the adolescent. The research literature pictures a continuum spanning from unproblematic – including recreational and also high- engaged (Billieux et al., 2013; Deleuze et al., 2017) - to hazardous gaming (King et al., 2018) and ultimately gaming disorder (Paulus, Ohmann, Von Gontard, & Popow, 2018). In this thesis, I use the term ‘problematic gaming’ (Mannikko, Ruotsalainen,

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Miettunen, Pontes, & Kaariainen, 2020) when referring to studies that reported on adolescents with ‘gaming issues’ without requiring the researchers to have properly diagnosed the behavioural pattern concerned (which in most studies they failed to do).

In 2013, the American Psychiatric Association introduced Internet gaming disorder, or IGD, in its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a tentative disorder needing further research (APA, 2013). The disorder is phrased in similar terms as the only other behavioural addiction referenced in the DSM-5, gambling disorder, which in turn is based on the nine criteria of substance use disorders (SUD). To diagnose IGD, at least five out of the nine DSM criteria must be met for 12 months. The criteria are (1) preoccupation with playing online games, (2) withdrawal symptoms, (3) tolerance, (4) loss of control over gaming, (5) loss of interest in other activities, (6) continued gaming despite ensuing problems, (7) deceiving others about gaming, (8) playing games to escape from negative feelings or moods, and (9) jeopardising significant relationships.

More recently, in 2019, the World Health Organization entered Gaming disorder (GD) in its 11^th revision of the International Classification of Diseases, ICD-11 (WHO, 2018). Including both offline and online gaming, GD is characterised by four criteria, to be met for 12 months: (1) impaired control over gaming, (2) increasing priority given to gaming over other activities, (3) continuation or escalation of gaming despite the occurrence of negative consequences, and (4) the gaming behaviour impairs personal, family, social, educational, occupational, or other important areas of functioning.

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There is debate about the diagnostic validity, clinical utility, and prognostic value of the criteria to be used for establishing gaming disorder. In a recent Delphi study (Castro-Calvo et al., 2021) an attempt was made to seek consensus. An international panel of experts judged three of the nine DSM-5 IGD criteria to be valid, clinically useful, and valuable for prognostic purposes, i.e., loss of control over gaming, continued gaming despite ensuing problems, and gaming jeopardising significant relationships. A fourth criterion, loss of interest in other activities, was deemed valid for diagnostic purposes but there was lack of consensus as to its clinical and

prognostic usefulness. The panel agreed that three other IGD criteria (tolerance [nr. 3 above], deceit [7] and escape [8]), were not valid and useful. All four ICD-11 GD criteria were rated valid and three were rated useful (the exception being criterion [2], increasing priority given to gaming over other activities, for which the panel did not reach the pre-set level of consensus).

Undoubtedly, the search for appropriate criteria for establishing gaming disorders will go on. Clearly, a strict definition of gaming disorder is needed. The (epidemiological) literature on problematic gaming abounds with reports claiming to have measured

“gaming addiction”. Often, the screening tools used were inadequate for measuring such “addiction” (King, Chamberlain, et al., 2020). The current chaos in the rapidly expanding gaming research field was keenly summed up by Starcevic and

colleagues (Starcevic, King, et al., 2020), who commented: “Diagnostic inflation will not resolve taxonomical problems in the study of addictive online behaviors”.

Most prevalence studies in the literature did not strictly establish IGD or GD but rather problematic gaming (PG), measured in widely varying ways. The vagueness of the umbrella concept of problematic gaming renders the reported prevalence rates

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for PG hard to interpret. PG prevalence estimates for samples of school pupils fluctuate between 0.8% (Mößle & Rehbein, 2013) and 30.4% (Cui, Lee, & Bax, 2018). Published prevalence estimates for IGD also range widely, from 0.7% to 27.5% worldwide and from 1% to 10% in Europe (Mihara & Higuchi, 2017). Part of this variance may be due not to definition or measurement issues but to differences in the characteristics of the samples surveyed. A recent meta-analysis factored in this heterogeneity, which resulted in a worldwide prevalence of 3.05% (confidence

interval: [2.38, 3.91]), and just 1.96% [0.19, 17.12] when considering only the studies meeting the most rigorous methodological criteria (M. W. Stevens, Dorstyn,

Delfabbro, & King, 2020).

The influence of parent and family factors on gaming disorder in adolescents: theoretical underpinning

In this thesis, I distinguish six categories of PF factors (Nielsen, Favez, & Rigter, 2020): (1) problems faced by one or both parents (mental health, addiction, handicap, or somatic disease); (2) child abuse; (3) co-parental teamwork (collaborative/supportive, discordant/conflictive); (4) parenting style

(uninvolved/neglectful, permissive, indulgent, authoritative, authoritarian); (5) family attachment (the teen feels secure and protected, or insecure and unprotected); and (6) family functioning, as reflected in rules and regulations, family organisation, communication, and rituals. These categories comprise both risk and protective factors. Risk factors increase the risk that the adolescent will develop problem behaviour or persist in such behaviour (examples: a parent being addicted; child abuse; failing co-parental teamwork; low level of family attachment), protective

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factors decrease this risk (examples: supportive teamwork; authoritative parenting style; harmonious within-family relationships).

A key theory to explain the role of PF and other social-system factors in problem behaviour in adolescents is Bronfenbrenner’s bioecological model (Ashiabi & O’Neal, 2015; Bronfenbrenner, 1979; Bronfenbrenner & Morris, 2007). This theory stresses that the adolescent is part of and surrounded by diverse social systems (the ‘context’, layered as peels of an onion), including family, school or work, friends and peers, leisure time circles, the neighbourhood and general society and culture. Positive and negative factors from each of these domains affect the way the teen develops during adolescence. Problem behaviour of the adolescent is to be seen as the product of individual factors (characteristics of the youth) and social-system factors, with a major role for PF.

In Bronfenbrenner’s view, the adolescent’s behaviour is shaped by his or her context, but the youth is not passive in this process. He or she actively influences the social context and is influenced back by the counterreactions and feedback from context persons (at the microsystem level, the parents are the prime example) or from mesosystems (collections of microsystems; people interacting with each other [adolescent and parents, parents with X, and adolescent with X]), exosystems (groups/agencies around the teen influencing the adolescent through varying belief systems), and macrosystems (the society at large, cultures and subcultures).

In the interactions between youth and systems, developmentally important topics are at stake, such as who plays which role, who can enforce hierarchy or adherence to rules. Crucial, too, are unity and communication within and between systems.

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Bronfenbrenner’s bioecological model is echoed in recent theories focusing on PG and IGD (Paulus et al., 2018). Paulus and co-workers perceive IGD to be a complex biopsychosocial construct in which “External and internal factors are interrelated with each other and with IGD. IGD may aggravate existing deficits and vice versa; poor social relations will motivate for gaming and spending increasing time with gaming will aggravate poor relationships, thus further reinforcing IGD.” (p 654). It is safe to conclude that present-day theories of IGD are in line with Bronfenbrenner’s model, confirming the importance of systems factors, such as PF, for understanding diverse adolescent problem behaviour, including PG.

Treating adolescents with Internet gaming disorder

When perusing the literature base on Internet gaming disorder treatment, two things stand out. First, there is a dearth of treatment effectiveness studies. Moreover, of the investigations that have been done so far, many were flawed because of inadequate study design (no randomised controlled trial; no follow-up assessments beyond the treatment period (King et al., 2017) or the use of weak gaming disorder measurement tools (King, Chamberlain, et al., 2020)).

Second, cognitive-behavioural therapy (CBT) dominates the types of treatment tested. According to systematic reviews of the literature, IGD symptoms may decrease during the CBT treatment episode, but there is insufficient proof that this effect is maintained for longer periods of time (M. W. R. Stevens, King, Dorstyn, &

Delfabbro, 2019; Zajac, Ginley, & Chang, 2020).

CBT focuses on intra-personal characteristics of the youth: personality traits, skills, emotions, and behavioural tendencies. This is important and should be part of any

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therapy. However, as just noted, adolescent gaming is not only associated with intrapersonal features of the teen but also with PF factors and other social variables (Paulus et al., 2018; Richard, Temcheff, & Derevensky, 2020; Sugaya, Shirasaka, Takahashi, & Kanda, 2019) This calls for a treatment that not only addresses characteristics of the adolescent but also PF and other system factors.

Several family therapies have been identified as being effective in treating adolescents with diverse problem behaviour (Baldwin, Christian, Berkeljon, &

Shadish, 2012; Davis et al., 2015; van der Pol et al., 2017). One of these treatment programmes is multidimensional family therapy (MDFT). This therapy targets the adolescent, addressing his or her thoughts, emotions, and behaviours, but also risk and protective factors from developmentally influential social domains, such as family, friends, and school (Liddle, 2016; Liddle & Rigter, 2013).

MDFT outperforms a variety of therapeutic approaches, including CBT, in reducing substance use disorders, delinquency and comorbidity and in improving family harmony and school performance (Liddle, 2016; van der Pol et al., 2017). The decrease in problem behaviour was linked to increases in family functioning and performance at school (Hoogeveen, Vogelvang, & Rigter, 2016; Liddle et al., 2001;

Liddle, Rowe, Dakof, Henderson, & Greenbaum, 2009).

Research questions

Having sketched the possible associations between parent and family factors,

problem behaviour and treatment potential, the three major research questions (RQ) to be addressed in this dissertation can now be formulated:

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RQ1 Are PF factors linked to problematic gaming in adolescents?

The hypothesis here reads that PF factors are connected to PG, both as risk and protective factors. The approach for testing the hypothesis was to carry out

systematic literature reviews of studies examining associations between PF factors and problematic gaming. This work is reported in Part 1 of the thesis.

RQ2 Is family therapy effective in mitigating IGD in adolescents?

RQ3 Does MDFT outperform family therapy as usual in this respect?

Family therapy might be a helpful treatment for IGD as PF factors feature among the therapy’s targets. Therapy effectiveness was tested in a randomised controlled trial comparing two forms of family therapy, the hypothesis being that MDFT would outperform family therapy as usual in decreasing IGD. This is reported in Part 2.

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Part 1:

Parental Mediation Techniques and Parent/Family factors linked to adolescent problematic gaming and problematic Internet use.

In this part of the thesis, I report on two systematic literature reviews. The first one is on a parent factor: mediation techniques applied by parents to help their adolescent make proper use of the Internet for playing games and for other Internet-based

activities. The second one examines emotional-relational parent and family factors as sources of risk and protection regarding problematic gaming (PG) and problematic Internet use in general (PIU). PIU studies were included to increase the harvest of papers to be reviewed, as relatively few PG papers met the review’s literature selection criteria, and secondly to be able to compare PG findings with data on Internet use in general.

Note: in the first review, the abbreviation POG was used: Problematic Online Gaming. In later publications, I opted for the acronym PG, Problematic Gaming.

Introduction to Study 1: Parental Mediation Techniques (PMTs)

Parental mediation techniques (PMTs) are approaches and methods parents can apply to guide or coerce their teen child to change his or her screen use behaviour.

Clinicians working with families of PG adolescents know that what parents want most at the start of treatment is being instructed in a proper PMT. Parents often are

convinced that if they find the right PMT, all problems will be solved, and their child will become obedient. Discussions on PMTs overpower any other topic in the initial

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therapy sessions, until the therapist succeeds in changing the focus of the parents. It would be most helpful, for therapist and family members, to know which PMTs may work given certain conditions. This prompted me and colleagues to carry out Study 1, the first of the two systematic literature reviews presented here.

Questions surrounding the effectiveness of PMTs did not arise for the first time in the age of the Internet. They were already identified and studied as television became a central household object which worried parents and made them consider how to limit its perceived negative influence on their children (Livingstone & Helsper, 2008;

Teimori et al., 2014). Back then, researchers and clinicians recommended that parents monitor television time, reduce the child’s exposure to advertisement and disturbing content, and reflect on how their own use of television – role-modeling - could impact their offspring’s habits (McLeod, Fitzpatrick, Glynn, & Fallis, 1982).

Three types of strategies of parental regulation were proposed: active mediation defined as talking to the child about the medium and its content; restrictive mediation defined as setting rules on time and content in order to limit access; and co-viewing, meaning watching along with the child (Nathanson, 1999).

As the Internet took over the media realm in homes around the world, PMT efforts naturally shifted from TV to digital devices. Children spent more and more time on laptops and smartphones. Parental mediation challenges grew accordingly. For one, televisions tend to be bulky and heavy and thus sit in one spot: often a communal area like the living room. This allows easy parental monitoring of content and time.

Digital devices, on the other hand, are light and nimble and designed to be carried around. This creates real and difficult challenges for parents who feel they have lost

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control over the screen use of their children. Also, online risks are higher than with television, including exposure of youths to cyberbullying, cyberpedophilia, extreme violence and privacy or contact risk with strangers.

Yet, parents appear to use similar parental mediation

strategies regarding video gaming as with television: active and restrictive mediation, and co-gaming replacing co-viewing of the TV era (Nikken & Jansz, 2007). Whether or not these strategies are as effective as for television remains to be seen. This led me and colleagues to review the PMT literature in relation to problematic gaming and problematic Internet use.

This review is relevant for research question RQ1, as formulated in the Introduction:

“Are PF factors linked to problematic gaming in adolescents?”. For Study 1, this question was specified in two sub-questions:

RQ1.a

Which parental mediation techniques, if any, increase the risk of adolescents to develop PG, and which of these techniques offer protection from PG?

RQ1.b

Which parental mediation techniques, if any, increase the risk of adolescents to develop PIU, and which of these techniques offer protection from PIU?

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Linking parental mediation practices to adolescents’ problematic online screen use. A systematic literature review

Abstract

Background and aims. To remedy problematic Internet use (PIU) and problematic online gaming (POG) in adolescents, much is expected from efforts by parents to help youths to contain their screen use. Such parental mediation can include (1) refraining from acting; (2) co-viewing or co-gaming with the teen; (3) active mediation;

and (4) restrictive mediation. We evaluated if parental mediation practices are linked to PIU and POG in adolescents.

Methods. For a systematic literature review, we searched for publications presenting survey data and relating parental mediation practices to levels of PIU and/or POG in adolescents. The review’s selection criteria were met by 18 PIU and 9 POG

publications, reporting on 81.002 and 12.915 adolescents, respectively. We extracted data on gaming problems, mediation interventions, study design features, and

sample characteristics.

Results. No type of parental mediation was consistently associated with lower or elevated problematic screen use rates in the adolescents. Refraining from parental mediation tended to aggravate screen use problems, while active mediation (talking to the teen) may mitigate such problems in PIU, but less clearly in POG. The link of restrictive mediation with problematic screen use varied from positive to negative, possibly depending on type of restriction. In both PIU and POG, family cohesion was

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related to lower rates of the problem behaviour concerned and family conflict to higher rates.

Discussion and Conclusions. Parental mediation practices may affect problematic screen use rates for better or worse. However, research of higher quality, including observations of parent-teen interactions, is needed to confirm the trends noted and advance the critical issue of the possible association between PIU, POG and family interactions.

This article was published as:

Nielsen, P., Favez, N., Liddle, H., & Rigter, H. (2019). Linking parental mediation practices to adolescents’ problematic online screen use: A systematic literature review. Journal of Behavioral Addictions, 8(4), 649-663.

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31 Introduction

As television started to dominate mid-20^th century family life, communication research focused on how parents could protect their children against the negative impact this medium might have (Clark, 2011). The term ‘parental mediation’ was coined, i.e., behavioural strategies parents can apply to contain their child’s television use (Valkenburg, Krcmar, Peeters, & Marseille, 1999). With the rapid expansion of the Internet, parental concerns have shifted to their child’s online screen use (Boyd &

Hargittai, 2013).

Today, a major challenge for parents is how they can protect their youths from engaging in harmful online activities (Livingstone & Helsper, 2008). Internet use offers young people information and entertainment and allows them to learn skills, to have social contacts, and to express their feelings and opinions (Louge, 2006). Yet, online activities may become problematic for some adolescents. We increasingly see such teens in our clinical practice, where we also face their parents who need

guidance. Looking for effective forms of guidance, we wondered what can be learned from the television-era parental mediation practices. To find out, we conducted a systematic literature review.

Problematic screen use in adolescents

There is no consensus how to define Internet use problems. The term ‘Internet addiction’ has been proposed (Young, 2017), but so far this concept has not been accepted as a diagnosis in the DSM-5 (Diagnostic Statistical Manual) and ICD-11 (International Classification of Diseases; WHO) catalogues of mental health disorders. Alternative labels have been suggested: Internet use being compulsive

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(Koning, Peeters, Finkenauer, & van den Eijnden, 2018; van den Eijnden,

Spijkerman, Vermulst, van Rooij, & Engels, 2010), excessive (Kalmus, Blinka, &

Ólafsson, 2015), or pathological (Chng, Li, Liau, & Khoo, 2015). We prefer the term

‘problematic’ (Bleakley, Ellithorpe, & Romer, 2016; Gomez, Rial, Brana, Golpe, &

Varela, 2017; Kammerl & Wartberg, 2018), with acronym PIU referring to problematic Internet use. For behaviour to qualify as PIU, a case must meet personal and social harm criteria. Just accessing Internet frequently or even “excessively” does not suffice to consider a youth to be a problematic user (Aarseth et al., 2017). PIU, in our view, is characterised by impaired control over screen use, with screen use taking precedence over other life interests and daily activities, and by inability to stop or de- escalate screen use despite experiencing negative consequences.

Apart from problematic Internet use in general, the literature also reports on

specific problematic screen-related behaviours, such as smart phone (Roberts, Yaya,

& Manolis, 2014) and social media use (Koning et al., 2018). A special category is online gaming.

Problematic online gaming in adolescents

The research community is divided if online gaming can develop into addiction (Aarseth et al., 2017). Nevertheless, DSM-5 has entered Internet Gaming Disorder (IGD) as a provisional diagnosis, to be validated in further research. ICD-11 lists Gaming Disorder (online or offline) as an established disorder. Yet, to be on the safe side we use here the term ‘problematic online gaming’ (POG). POG has the same characteristics as just defined for PIU, with ‘gaming’ to be substituted for ‘screen use’.

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Definition of parental mediation practices targeting screen use

Parental mediation practices focusing on screen use have been modelled after those from the television era. Five types of mediation have been distinguished (Collier et al., 2016; Livingstone & Helsper, 2008; Nathanson, 2001, 2002, 2016; Nikken &

Jansz, 2007):

1. No mediation: the parents take no action. They do not limit or encourage their teen’s screen use.

2. Co-using, referring to a parent and the adolescent accessing an Internet-based screen jointly, without the parent resorting to criticism. We use the term co- viewing for shared Internet use such as watching a movie together via a streaming site, and co-gaming for playing games together (Nikken & Jansz, 2007).

3. Active mediation, i.e., a parent talking with the adolescent about screen use and screen content without indulging in criticism.

4. Monitoring. For instance, the parents may check which sites the adolescent accesses and which games he or she plays and for how long, without discussing this knowledge with the teen – that would be active mediation. Just knowing that his or her parents are paying attention may influence an adolescent’s screen use (Benrazavi, Teimouri, & Griffiths, 2015).

5. Restrictive mediation. This consists of setting rules and limits to the adolescent’s access to screens. The restrictions – mild or severe (even punitive) – can be verbal, but also technical, i.e., parents employing software to limit Internet access and time on the Internet (Benrazavi et al., 2015).

These categories are not mutually exclusive. Parents may combine practices.

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34 Aims of this study

We here report on a systematic review assessing any links between the listed

parental mediation practices on the one hand and the rate of (a) problematic Internet use and (b) problematic online gaming among adolescents, on the other. We

examined if diverse parental mediation practices might be beneficial or harmful in influencing problematic screen use.

The review was carried out in two parts, one addressing PIU and the other POG.

We treated problematic Internet use and problematic online gaming as separate entities, for two reasons. Unlike POG, PIU has not yet been accepted as a disorder by DSM-5 or ICD-11. Second, there is no conclusive evidence to consider POG as being part of PIU. The two conditions may be similar or distinct (Király, Nagygyörgy, Griffiths, & Demetrovics, 2014).

Quite a few of the publications we sampled for this dual review also reported on another set of factors that may influence the development and persistence of PIU and POG in teens, i.e., family cohesion and family conflict (Bonnaire, Liddle, Har, Nielsen, & Phan, 2019; Bonnaire & Phan, 2017). As the setting for parental mediation to take shape is the family, we decided to include, when mentioned, the association between family cohesion/conflict and PIU and POG rates.

Methods

Both parts of the review adhere to the guidelines of the PRISMA Group (Moher, Liberati, Tetzlaff, & Altman, 2009). We wrote a review protocol, listing search terms, and developed and pilot tested a PIU and POG coding form (all available from PN) to note down key characteristics of the selected studies, i.e., type (cross-sectional,

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prospective, with or without a comparison sample) and the size of the study samples (the number of adolescents surveyed, and if relevant the number of parents), the country where the study had been carried out, and the setting from which the samples were taken (school [including college and university]; general population).

For each sample of adolescents, we recorded the adolescents’ mean age and age range, the gender distribution, and comorbidity findings. Household income and other indicators were used to estimate the socioeconomic status of the families at issue.

Further, we registered the method to assess PIU or POG. We took note of the type of mediation applied by the parents and how it was measured, and of any statistically significant correlations between these practices and the adolescent’s screen use.

Finally, we abstracted information on family cohesion and family conflict.

Inclusion and exclusion criteria

We searched for publications issued between 1 January 2000 and 31 December 2018 that presented original quantitative research data linking parental mediation practices to the adolescent’s level of either Internet use, including phone and social media use, or online gaming. We sampled reports of cross-sectional and prospective studies with measures of (1) problematic Internet use or online gaming, and (2) parental mediation practices. Publications were excluded if written in a language other than English, Dutch, German and French. Excluded too were publications on site content (cyber bullying, sexual harassment, porn) rather than on PIU or POG.

Case reports, literature reviews and meta-analyses were not considered.

We focused on youths between 12 and 19 years old. If these adolescents were part of a sample with a wider age range (across all selected PIU and POG

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publications, age ranged from 8 to 20 years), we included the whole sample if the group of 12 to 19 olds could not be parcelled out.

The literature surveyed addressed parental attempts to prevent or mitigate adolescents’ problematic screen use. We excluded publications if they considered relational and emotional parent-teen interactions, or parenting styles, but failed to present data on actual parental mediation practices. The dividing line between

parental mediation and parental style is thin; we opted for a strict sampling approach, only selecting papers that clearly specified which mediation practices had been investigated.

Searching for publications

We looked for relevant publications on PIU and POG (papers, books/book chapters, PhD theses) in five databases, viz., Web of Science, Embase, Cochrane Database of Systematic Reviews, Medline/PubMed, and PsycINFO. The searches took place on 25 and 26 April 2018, except for PsycINFO (first week of May 2018), with further searches done from May through December 2018. Also, we consulted our self- maintained Dropbox file of Internet use and online gaming publications.

The search of Web of Science yielded most records (291), followed in number – after removing modest overlap (160 overlap cases in total) – by Medline/PubMed (207), PsychINFO (153), Embase (123) and Cochrane (11). In the first assessment round, PN and HR independently from each other abstracted the Abstracts and Methods sections of all these publications using the coding form’s list of ‘relevance criteria’ (cross-sectional/prospective study design, being a research paper, involving adolescent cases, focus on problematic screen use, mentioning concrete mediation

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practices). There were a few cases (in the Web of Science search 22 papers; 7%) where the two reviewers differed in degree of certainty about selecting a paper (‘yes’

versus ‘question mark’), but this was resolved in discussions.

We wrote the corresponding author of each identified publication, asking him or her for a copy of any other relevant published or non-published paper from the same research group. We also invited the authors to comment on our summary of their sampled study; one correction was received.

The first assessment round yielded 117 publications (67 Web of Science, 9

Embase, 8 PsychINFO, 4 Medline/Pubmed, 0 Cochrane, 29 further publications from our Dropbox file and from the reference lists of selected papers). Both reviewers re- assessed this initial selection of publications using all coding form entries including the full list of inclusion and exclusion criteria for PIU and POG. In this second round, they in full agreement identified 27 publications meeting the inclusion criteria, i.e., 18 for PIU and 9 for POG (Tables 1 and 2). Thus, 90 publications were excluded: 44 because they did not focus on parental mediation but rather on parenting style or general parent-child relationship issues, 19 for failing to present a measure of problematic Internet use/online gaming (11) or of parental mediation (8), and 11 because they addressed site content rather than screen use. Sixteen publications were excluded for other reasons. See Figure 1 for the flow diagram.

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38 Figure 1. Study selection flow diagram

Search terms

We used synonyms for ‘adolescent’ (youth, teen, teenager, young adult), ‘Internet use’ (social media, cell phone, screen use; addicted, problematic, compulsive, excessive use(s)/misuse/usage/user(s)/using), ‘Internet gaming problems’ (disorder;

addiction; problematic, compulsive or excessive gaming); and for ‘parental mediation’

(parental restriction, regulation, control, monitoring, style). As an example, the Web of Science PIU + POG query was:

TS = (teenager or adolescen* or teen* or ‘‘young adults’‘ or youth*) AND TS = (‘‘internet abuse’‘ or ‘‘internet addict*’‘ or ‘‘compulsive internet use’‘ or ‘‘compulsive internet usage’‘ or ‘‘excessive internet use’‘ or ‘‘excessive internet usage’‘ or Identification

•Records identified through database searches: N=816

•Records after duplicates had been removed: N=657

Screening

•Records screened: N=657

•Records excluded: N=540

Elegibility

•Assessed for eligibility in full-text analysis: N=117

•Excluded after full-text analysis: N=90

Included

•Studies selected for the Internet use review: N=18

•Studies selected for the online gaming review: N=9

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‘‘internet addiction disorder’‘ or ‘‘internet dependenc*’‘ or ‘‘internet misuse*’‘ or

‘‘internet gaming disorder’’ or ‘‘internet over-use’‘ or ‘‘internet overuse’‘ or ‘‘online addiction’‘ or ‘‘pathologic* internet usage’‘ or ‘‘problematic online usage’‘ or

‘‘gaming addict*’‘ or ‘‘compulsive computer use’‘ or ‘‘computer addict*’‘ or

‘‘pathological computer use’‘ or ‘‘smart phone addiction’‘ or ‘‘smart phone addict*’‘) AND TS = (‘‘parental mediation’‘ or ‘‘parental restriction’‘ or ‘‘parental regulation’‘

or ‘‘parental control’‘ or ‘‘parental supervision’‘ or ‘‘parental involvement’‘ or

‘‘parental attitude*’‘ or ‘‘family functio*’‘ or ‘‘family cohesion’‘ or ‘‘family relationships’‘ or ‘‘parenting’‘).

The full string of search terms for each database is available from PN.

Assessing the quality of the selected studies

For lack of a published checklist to rate the quality of this type of study, we developed our own assessment sheets. The one for PIU is shown in Annex 2, the one for POG (available from PN) is similar, substituting ‘POG’ for ‘PIU’. The forms addressed sampling methods, study design features, measurement methods, and completeness of reporting on key variables.

We deemed methods (tools/questionnaires) for evaluating PIU valid and reliable if they had been included in Table 1 of the review by Lortie and Guitton (2013). The tools listed in that table scored well on validity and reliability measures, except in some cases for criterion validity, i.e., the capability to distinguish between normal and problematic Internet use. We followed these reviewers’ procedure for evaluating the tools described in papers published from 2013 onwards, arriving at similar

conclusions as reported in a second review (Anderson, Steen, & Stavropoulos,

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2016). Tools meeting the Lortie and Guitton lenient standard got a quality score of 2, those with limited testing of reliability and validity a score of 1, and those that were not or poorly evaluated a score of 0.

For methods to assess POG, we took Table 2 from the review of King and co- workers (King, Haagsma, Delfabbro, Gradisar, & Griffiths, 2013) as departure point.

A quality score of 2 was assigned to assessment questionnaires with 8 or more DSM- 5 relevant items, a score of 1 if the tool contained 5 to 7 of such items or had been incompletely tested for validity and reliability. Score 0 was given to questionnaires with less than 5 DSM-5 items, or poorly tested for validity and reliability.

For both PIU and POG, the term ‘quality’ refers to the adequacy of the studies to address our review questions but not to objectives of the investigations beyond the scope of our review.

Results

All selected publications, issued between 2010 and 2018, were journal papers. Table 1 lists the 18 PIU papers, including one on smart phone use and one on social media use. Table 2 presents the 9 papers on POG.

The maximum quality score for a study was 20 (Appendix). The rating scales we developed are yet to be validated, so cut-off levels were not defined. Scores were similar in two separate ratings scheduled three months apart from each other. The quality scores for PIU studies varied from 7 to 16 (Table 1), those for POG studies from 9 to 12 (Table 2). Main reasons for low quality scores were suboptimal survey design – cross-sectional rather than prospective in most cases –, lack of (full) random

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sampling, failure to include a sample of parents, and inadequate measurement of PIU, POG, or of mediation practices.

Research sites

PIU: All studies were performed in either Europe (8) or East Asia (9), except for one U.S. survey (Table 1). The European investigations were carried out in Germany, Greece, the Netherlands (2x), Poland, and Spain (two studies of one sample of adolescents (Gómez, Harris, Barreiro, Isorna, & Rial, 2017; Gomez et al., 2017)).

One survey covered 25 European countries. The Asian studies were from Hong Kong (2x), Malaysia (1x), Singapore (1x), South Korea (2x), and Taiwan (3x).

POG: The core research groups were from Eastern Asia (3x South Korea, 2x China, 1x Malaysia, 1x Singapore, 1x Taiwan), with two exceptions (1 France, 1 the

Netherlands). See Table 2.

Participants' characteristics and gaming related factors PIU

A total of 81,002 adolescents were surveyed. They were mostly part of school

convenience samples (13 out of 18 surveys). Five studies sampled adolescents from the general population.

The mean age of the adolescents ranged from 12.4 to 16.1 years. The proportion of boys varied from 40% to 52% and the proportion of adolescents meeting PIU criteria ranged from 4% to 25% (Table 1). Problematic screen use was more

prevalent among boys than girls (e.g., Chang et al., 2015; Chng et al., 2015; Chou &

Lee, 2017, Wu, Ko, Wong, Wu, & Oei, 2016). According to the single paper on

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problematic smart phone use (H. Lee, Kim, & Choi, 2017); smart phone use was more problematic among girls than boys.

The socioeconomic status of the adolescent’s family was measured in just two PIU studies (Chang et al., 2015; C. S. T. Wu et al., 2016) and two POG studies. In the Wu, Wong et al. (2016) survey, low family income was associated with higher teen PIU rates, but not in the other PIU survey or in the two POG studies reporting on social-economic status (Choo, Sim, Liau, Gentile, & Khoo, 2015; Cui et al., 2018).

Adolescents’ mental comorbidity was not assessed in any of the PIU and POG investigations, except for one PIU study that measured symptoms of depression (Chang et al., 2015). PIU youths had elevated rates of depression symptoms.

POG

These studies surveyed 12.915 adolescents, all from school convenience samples.

Their mean age varied from 11.2 to 13.2 years, with one outlier of 19.6 years (Benrazavi et al., 2015), and the proportion of boys from 49% to 73%. The

prevalence of POG ranged from 9% to 30% (Table 2), with rates being higher for boys than girls (Bonnaire & Phan, 2017; Choo et al., 2015; Cui et al., 2018; C. Lee &

Kim, 2016).

Three POG studies addressed the role of game genre (Bonnaire & Phan, 2017;

Cui et al., 2018; C. Lee & Kim, 2017). Playing MMROPG (Massively Multiplayer Online Role-Playing Games), rather than other games, was linked to higher

adolescent POG rates in France (Bonnaire & Phan, 2017) and South Korea (Cui et al., 2018), but not in China where playing action games was most clearly associated with POG (Cui et al., 2018).

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Frequent playing of online games correlated with a high rate of problematic online gaming. Further, playing games after midnight was associated with higher POG rates (Bonnaire & Phan, 2017; Cui et al., 2018; Lee & Kim, 2017), perhaps even more so when games were played at a mobile device (Lee & Kim, 2017). Such ‘after-midnight’

concerns were not reported in the PIU papers.

Table 1. Characteristics of 18 Problematic Internet Use studies and findings at the baseline (cross-sectional surveys) or follow-up assessment (prospective surveys)

Authors Country/

city

Study design

Study quality score^s

Nr. of youths^b

Sample from

Age^c (years)

Gender (%

boys)

Youths with PIU^d (%)

Mediation type examined

Link with PIU^f

Problematic Internet use (general)

Bleakley et al. (2016) USA

Cross- sectional

12 629 + 629 parents

General population

14,8 51 10,8 Co-viewing +

Active +

Restrictive + Chang et al.

(2015) Taiwan

Cross- sectional

12 1867 Schools NR 46 15,8 Active +

Monitoring 0 Restrictive + Chng et al.

(2015) Singapore

Cross- sectional

14 3079 Schools 13,0 50 15,9 Active 0

Restrictive +

12 3169 Schools NR 49 NR Active +

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Chou & Lee (2017) Taiwan

Cross- sectional

Restrictive ‒

Gómez, Harris, et al.

(2017a) Gómez, Rial et al. (2017b) Spain

Cross- sectional

9 39.993 Schools 14,1 50 16,3 No

mediation

‒

Restrictive +

Kalmus et al (2015) 25 European countries

Cross- sectional

13 18.709 General population

NR 50 NR Active +

Restrictive +

Kammerl &

Wartberg (2018) Germany

Cross- sectional

16 1095 + 1095 parents

General population

13,0 51 15,3^b Active 0

Monitoring 0 Restrictive 0

Ko et al.

(2015) Taiwan

Prospective 12 1801 Schools 12,4 51 9,0 Restrictive +

Lee (2013) South Korea

Cross- sectional

12 566 + 566 parents

General population+

schools

NR 51 NR Restrictive 0

Leung & Lee (2012)

Cross- sectional

11 718 House-

holds

14,5 44 NR Co-viewing 0

Active 0

Problematic gaming in adolescents: Identifying parent and family factors relevant for treatment

Thesis

Reference

Problematic gaming in adolescents: Identifying parent and family factors relevant for treatment

Problematic gaming in adolescents

Identifying parent and family factors relevant for treatment

THESE

Table of contents

Acknowledgments

Foreword

Summary

Introduction

Part 1:

Parental Mediation Techniques and Parent/Family factors linked to adolescent problematic gaming and problematic Internet use.