Thinking more broadly about policy responses to problematic video game use: A response to Király et al. (2018).

Király et al. (2018) did an excellent job of reviewing policies that are undertaken to prevent and respond to problematic video game use. I argue that there has been a failure of imagination when considering public policy - generally, we only think of governmental or legislative policies. This paper identifies several other ways we could consider public policy, providing examples of some that have already been enacted and suggesting others that could be, all without governmental intervention. These types of policies may not only be more practical, but also be more effective.

Introduction

Király et al. (2018) did an admirable job of reviewing policies that are undertaken to prevent and respond to problematic video game use. The research community has spent much of its effort arguing how problem gaming should be named and defined (c.f., Griffiths et al., 2016; Petry et al., 2014, 2016), despite “scholars tend[ing] to agree that problematic gaming exists in a sense that the aforementioned minority of gamers play so excessively that their life suffers detrimentally as a consequence” (Király et al., 2018, pp. 1–2). In my experience, no matter how I have defined or measured it, I get essentially the same results. This is not surprising. Most mental health disorders are primarily defined by how much disruption they cause to normal functioning – that is, how dysfunctional they are. Different people will demonstrate dysfunction in somewhat different but overlapping ways. The World Health Organization (WHO, 2017), in their draft of the upcoming International Classification of Diseases-11 (ICD-11), defines gaming disorder as requiring that “The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning”. Accepting this as the core of any definition allows us to move past arguments about which scale to use or what to name it and to focus on the critical issues, such as how to prevent and treat it. This is where policy responses become important.

The review is an excellent starting place for policy discussions (Király et al., 2018). When most people consider policy, however, they tend to focus primarily on governmental and legislative approaches. Although these are potentially beneficial, they require a great deal of political will and may have effects that are broader than desired or be difficult to implement at a national scale. However, there are other public policy options, which may provide more effective solutions.

Scientific and Public Health Organizations

One valuable locus for policy development includes major scientific and public health organizations. For example, after reviewing the scientific literature, the American Psychiatric Association added Internet gaming disorder to the appendix of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This signaled that the early research on problematic gaming appeared strong, but that more was needed. This fueled important new research. In only 4 years since that policy change, PsychINFO reports over 1,200 peer-reviewed papers have been published on this topic, compared to 486 reports that were published in the 4-year period prior to the DSM-5 [searching within title only for the conjunction of the words (video game* OR video game* OR Internet OR gaming) and (addiction OR problem* OR pathological OR disorder)]. Partly because of this new research, the WHO proposed adding gaming disorder to the ICD-11 (WHO, 2017). This announcement garnered press attention in several countries, thus alerting parents, educators, physicians, and other policy-makers to the issue. In other words, we rely on major public health organizations to vet the research and make independent scientific determinations about it. These determinations have consequences, such as increasing scientific study and public discussion. Perhaps most importantly for those who are suffering in the United States where medical care is typically paid for by insurance companies, people cannot receive care for problematic gaming until it is recognized by key medical organizations as diagnosable. Once it becomes classified as a bona fide mental health disorder, treatment can be paid for. The increase in research, public discussion, and possibility that treatments may soon become available to more people demonstrates that changes in policy by scientific and public health organizations have real and beneficial consequences. Therefore, it is distressing that partners of the video game industry immediately began attacking the WHO’s recommendation by falsely claiming that it was “scapegoating” games and “jumping to premature conclusions” with “very little scholarly evidence,” with the goal to “broadly seek to stigmatize” “billions of players worldwide” (Higher Education Video Game Alliance, 2018). This misinformation damages the public’s trust in the institutions that we need to help provide independent scientific determinations and undermines the ability to craft appropriate policy. In fact, it is entirely possible that recognizing gaming disorder may decrease its prevalence, because when parents, educators, and physicians are aware that it is a serious problem for some people, they may be able to spot the warning signs and get help before it becomes a full-fledged personal crisis. But, as long as people keep claiming that there is no problem, societies will continue to ignore it and will not be able to develop effective public policies. It is possible that this is what some industry groups desire, specifically because they (incorrectly) assume that policies need to be legislative.

Smaller public health and scientific organizations also have a critical place in public policy. The American Association of Pediatrics (AAP), for example, has been particularly effective in releasing summaries of the scientific evidence on media’s effects on children and generating policy responses for pediatricians. For example, the AAP reviewed the scientific evidence on the effects of media violence and then made recommendations to pediatricians, such as asking about media in well-child checkups and advising parents that they limit children’s total amount and the violent content of media consumption (American Academy of Pediatrics Commitee on Communications and Media, 2009; American Academy of Pediatrics Committee on Public Education, 1999, 2001). This is a useful public policy, because many parents rely on their pediatricians to know the science and to direct them for optimal child health and wellness.

Similarly, scientific organizations such as the Society for the Psychological Study of Social Issues, the American Psychological Association, and the International Society for Research on Aggression have convened panels of experts to review the scientific literature and provide summaries on topics relating to violent media and child health [Anderson, Bushman, Donnerstein, Hummer, & Warburton, 2016; APA Task Force on Violent Media, 2015; Media Violence Commission, International Society for Research on Aggression (ISRA), 2012]. These reviews included policy recommendations, such as to increase public education, to address gaps in the research, and to consider media literacy training in schools.

Major science-based health organizations could also create policies that affect all of their members in a way that then influences the public at large, although I am unaware of any organizations yet taking this step. For example, the American Medical Association could create a policy requiring all medical students to get 6 hr of training on media effects research during residents’ pediatrics rotations. Notice that all the aforementioned policies mentioned may be effective, but none of them would require governmental or legislative involvement.

Public Education and Ratings

Király et al. (2018) noted that parents can be given ways to monitor and control children’s video game and computer use. They unfortunately claim that there is “no evidence on the efficacy” of parental controls. This is not accurate. There is a fairly substantial body of literature on the efficacy of different types of monitoring as well as on the value of informational and rating systems designed to give parents useful information (Anderson, Gentile, & Buckley, 2007; Austin, 1993; Austin, Pinkleton, & Fujioka, 2000; Cantor, 1997b, 1998; Children Now, 1996; Gentile, Maier, Hasson, & de Bonetti, 2011; Gentile, Nathanson, Rasmussen, Reimer, & Walsh, 2012; Gentile & Walsh, 2002; Kaiser Family Foundation, 1999; Lin & Atkin, 1989; Walsh & Gentile, 2001). There are four main ways that parents can monitor children’s media use: (a) co-viewing/co-playing – where parents sit and watch or play together with their children; (b) restrictions on the amount of media use; (c) restrictions on the content of media use; and (d) active mediation – where parents discuss the themes, meaning, points of view, and effects of the media with their children. To summarize, active mediation appears to be the most protective for children, although it is the hardest to do well. Restrictions on amount and content also appear to have multiple benefits. One longitudinal study found that children whose parents set limits on the amount and content of TV and video games early in a school year were getting more sleep, had lower weight gain, had better grades, were more prosocial in their behaviors, and were less aggressive at the end of the school year (Gentile, Reimer, Nathanson, Walsh, & Eisenmann, 2014). This research demonstrates why people may believe that parental monitoring is not effective – no parent could know that their child had gained less weight or was less aggressive than he or she would have been if the parent had not had restricted media. We can only know what our children are, not what they might otherwise have been. We only see the fight that we have with our children over the rules; we cannot see the benefits that those rules yielded. In contrast to the evidence on active and restrictive mediation, however, co-viewing tends to predict poorer child outcomes, because co-viewing provides tacit approval to any harmful media messages (Coyne et al., 2017). Overall, studies demonstrate that parents are in a much more powerful position than they realize.

For parents to wield this power effectively, they need a minimum of two supports, both of which can be created by public policy initiatives. First, they need reliable and valid information on which to base their decisions. This, for example, is why media ratings are necessary. As noted by Király et al. (2018), the self-regulatory bodies that already create their own ratings could also include information on the addictive potential of games. Unfortunately, most of the scientific research on the video game (and other) ratings in the United States has found that they do not provide accurate or useful information, which likely explains why so few parents use them regularly (e.g., Cantor, 1997a; Federal Trade Commission, 2000; Gentile et al., 2011; Haninger & Thompson, 2004; Kunkel et al., 2001; Linder & Gentile, 2009; Thompson & Haninger, 2001; Thompson, Tepichin, & Haninger, 2006; Walsh & Gentile, 2001). Public policies could create a reliable, valid, and accessible universal rating system, making it independent of the media companies themselves, and by requiring that the ratings be tested regularly to maintain a high level of scientific reliability and validity (for a more comprehensive list of policy recommendations about ratings, see Gentile, 2008).

Even if parents have appropriate information available, however, it will not matter if they have no motivation or reason to use them. This is the second critical support needed by parents – they need to be educated why it matters that they monitor and set limits on children’s media use. The media industries and their supporters have a history of sowing doubt about media research and the researchers’ motivations (Entertainment Software Association, 2011; Higher Education Video Game Alliance, 2018). In essence, they tell parents that there is no need to use the ratings or to pay attention to children’s video game use, because there is no evidence of any harmful effects (which is not true). The media industries and their rating organizations could institute a policy to change their narrative. Although the industries might view research as a threat, they could use it to be perceived as the heroes. Rather than attacking and denying the research, they could make statements about how parents should use the parental controls and ratings, precisely because there is research demonstrating that it matters.

Public education is therefore of critical importance. If the public do not believe that gaming can become problematic, then there is no reason for them to pay attention. Once they recognize that gaming can become a serious problem for some players, then people will pay more attention and become more likely to take appropriate action when needed. Unfortunately, public education is difficult in the current environment. People get the majority of their information directly from the media industries, but reporters are trained to get “both sides of every story.” This is useful when the issue is one of mere opinion, but not as useful when describing valid scientific findings. Thus, when researchers or public health organizations make statements about scientific facts, reporters often find someone to say the opposite, which leaves the public thinking that we do not know anything yet. News organizations and journalism schools could make policies about how to vet experts, how to determine what is credible science, and when to seek opposing opinions. Interestingly, the BBC did this exactly a few years ago in the context of scientific findings on global warming. They publically announced that they would no longer provide equal time to scientific deniers on this issue (BBC Trust, 2014).

Ultimately, I would argue that most of the public policy attempts in the United States have been unsuccessful because we have limited ourselves to thinking about policy at the legislative levels and have ignored the many other levels at which effective policies could be made. Recognizing that public policy does not only mean governmental restrictions may also make the media industries less defensive and willing to partner in public education campaigns.