Policy, prevention, and regulation for Internet Gaming Disorder.

In this commentary, I discuss the recent paper by Király et al. (2018), which provides a systematic review of current and potential policies addressing problematic gaming and suggesting current approaches include those (a) limiting video game availability, (b) reducing risk and harm, and (c) supporting gamers. This commentary uses a number of points raised by Király et al. (2018) to address the issue of policy context by discussing (a) the sociocultural environment and (b) the gamer and the game environment to (c) create the case for prevention to reduce risk and harm and to provide support for gamers and their families.

Introduction

In this commentary, I discuss the recent paper by Király et al. (2018), which provides a nuanced and comprehensive systematic review of current and potential policies addressing problematic gaming and suggests the most currently available policies exist in Asian countries, including the Republic of Korea and the People’s Republic of China. A total of 12 papers were identified, resulting in the authors classifying the available approaches as follows: those that (a) limit the availability of games, (b) reduce risk and harm, and (c) provide support for gamers. Altogether, Király et al. (2018) argued that based on the collected evidence, the current policy and regulation approaches adopted were not sufficiently effective and were not adequately assessed; therefore, they called for more integrative approaches to improve current policies. This commentary uses a number of points raised by Király et al. (2018) to address the issue of policy and regulation context by discussing its (a) sociocultural environment and (b) the gamer and the game environment to (c) create the case for prevention to reduce risk and harm and to provide support for gamers and their families.

Policy and Regulation Context

The policy and regulation context in which gaming is taking place plays an important role in increasing the potential of developing problems as a consequence of excessive gaming. In this section, I will be looking at the sociocultural environment, the gamer, and the game environment.

The sociocultural environment

Given several currently available policies that exist in the Republic of Korea, Király et al. (2018) outline the sociocultural environment in that country: the online games market makes up 19% of the global games market in the Republic of South Korea, whereas the mobile games market makes up 14%, which can be considered significant proportions. Following the 1995 Framework Act on Informatization Promotion (Ministry of Information and Communication, 1995), which aimed to promote the information and communications industry, high-speed Internet penetration has become the norm in the Republic of Korea with 90% of Koreans having enjoyed high-speed Internet access in 2015. Moreover, high-speed WiFi can be accessed for free on public transport and in streets and public buildings, in contrast to many other countries (such as the UK), where Internet speed is relatively slow and connection prices are still relatively high (Rail Safety and Standards Board Limited, 2016). The Internet and technology infrastructure considerably contributes to people’s behaviors and attitudes regarding technology use. In China, Internet addiction has been classified as mental disorder in 2008, whereas in Europe, the World Health Organization (WHO) has included Gaming Disorder as official diagnosis only 10 years later, suggesting there is a discrepancy in how pressing the associated problems appear in the respective geographical regions. Moreover, in some Asian countries, Internet and gaming addiction are considered a serious public health threat, whereas the situation appears to be significantly more on the conservative side in Western countries, including the UK. For instance, in the UK, Her Majesty’s Government Green Paper on the Internet Safety Strategy (HM Government, 2017) has not dealt with any addiction-related problems regarding Internet use. Accordingly, as part of the UK Council for Child Internet Safety Evidence Group (UKCCIS-EG), I drafted a response to raise the issue:

“The EG (UK Council for Child Internet Safety Evidence Group) has also raised a concern about gaming disorder and this is of particular relevance now that the WHO has decided to include Gaming Disorder in the new ICD-11. A key issue regarding how to use the Internet safely and responsibly has not been addressed sufficiently, namely, the extent to which excessive Internet use may lead to significant impacts on mental health, including addiction. If this matter is being addressed by the UK Department of Health, we would like to know what form that response will take. To date, many studies have covered addiction symptoms as a consequence of excessive use of gaming (e.g., Kuss, Griffiths, & Pontes, 2017) and social networking sites (e.g., Kuss & Griffiths, 2017), as well as the detrimental impact of smartphone notifications on people’s mental health and well-being (e.g., Kanjo, Kuss, & Ang, 2017). This research indicates that there is empirical evidence suggesting there may be significant and detrimental impacts of overuse of technology and the Internet on individuals’ mental health, including symptoms of depression, anxiety, and addiction. The American Psychiatric Association has decided to include ‘Internet Gaming Disorder’ in the most recent version of their diagnostic manual (DSM-5; American Psychiatric Association, 2013) as a condition which requires further research to be included in the main manual. Similarly, the WHO is now discussing the inclusion of ‘Gaming Disorder’ in the upcoming diagnostic manual, the ICD-11, to be published in 2018. The scientific and clinical reach and importance of the issue of excessive Internet use deserve closer scrutiny and more research focus.”

The UKCCIS-EG’s effort of raising awareness from a government perspective is in line with Király et al.’s (2018) point that “policy measures should be applied and evaluated locally” as they have clearly addressed the variations in governmental influence which may impact the kinds of policies and regulations which may be implemented in different countries. They point out that policy actions that strictly limit individuals’ engagement with digital games, which have already emerged in Asian countries, may not be acceptable in Western countries, given they may be viewed as an attack on civil liberty. Taking into account the considerable differences in technology use-related behaviors and attitudes, political structure, and governmental influence across countries and geographical regions across the world, considerations regarding public policy, regulation, and prevention of problematic technology and gaming use need to be addressed against the background of the respective culture in which they are taking place (Kuss, 2013). Policies and initiatives that appear effective in one cultural context may not work in other contexts due to varying degrees of public acceptability and the aforementioned cross-cultural differences in sociocultural behavioral norms and governmental influence.

The gamer and the game environment

Király et al. (2018) also raise the issue that a “one-size-fits-all” solution is not appropriate when considering gamers who have different motivations and play games with varying structural characteristics. Moreover, research has shown that the same behavior (such as playing games for excessive periods of time, e.g., 14 hr a day) does not necessarily lead to comparable outcomes across gamers (Griffiths, 2010). Time spent is not sufficient as criterion demarcating non-problematic from problematic gaming (Király, Tóth, Urbán, Demetrovics, & Maraz, 2017). Other factors are more important in predicting addiction symptoms, namely the respective gaming motivations (Kuss, Louws, & Wiers, 2012) and the extent to which the technology is used in order to cope with daily life stressors (Kuss, Dunn, et al., 2017). The gamer’s context is a significant factor that may be instrumental in demarcating excessive gaming from gaming addiction, and the game environment can gain particular importance for gamers, depending on their life situation and gaming preferences. Moreover, the game-culture context is relevant and needs to be considered as it embeds the gamer in a community with shared beliefs and practices, which contributes to gaming behaviors and associated attitudes (Kuss, 2013).

The Case for Prevention

In the context of reducing risk and harm and preventing gaming-related problems from occurring in the first place, Király et al. (2018) suggest that customizing the warnings in games depending on the time gamers spend gaming (e.g., 25 or more weekly hours spent in game) appears as a good solution and therefore targeted prevention approaches may be appropriate. This strategy allows targeting problem behaviors specifically without affecting the non-problematic gamers’ enjoyment of a largely healthy pastime activity (Billieux, Schimmenti, Khazaal, Maurage, & Heeren, 2015).

Moreover, Király et al. (2018) suggest that self-regulation can be adopted across the gaming industry, so that carefully designed and tested parental controls and targeted warning messages can be included in game ratings by default (Van Rooij, Meerkerk, Schoenmakers, Griffiths, & van de Mheen, 2010). Current age-appropriate ratings based on violent and sexual content are provided by the Pan European Game Information rating system in Europe and the Entertainment Software Rating Board in North America. Additional information concerning the addictive qualities of these games can be tested in the future to understand the extent to which such an approach will be influential in encouraging better game purchasing choices regarding safeguarding the gamers’ mental health and well-being.

Previous research has suggested that prevention approaches should be prioritized over treatment approaches once problems as a consequence of excessive Internet and gaming use have been manifested (Turel, Mouttapa, & Donato, 2015). This approach has seen support, with the Chair of the National Institute for Health and Care Excellence stating prevention is better than cure (NICE, 2015). Preventing disorders from developing in the first place is (a) cheaper from a public healthcare funding perspective, (b) decreases patients’ morbidity, (c) increases quality of life and well-being, (d) increases the productivity of the workforce, and (e) decreases the utilization of healthcare services (O’Connell, Boat, & Warner, 2009), all of which are strong arguments in favor of why a preventative approach to Internet Gaming Disorder is preferable to treating the disorder once it has manifested.

Based on the available international literature on prevention and policy, King et al. (2017) found that targeted prevention approaches appear promising, and recognizing Gaming Disorder as a formal disorder [which has been achieved by WHO’s updated classification of diseases (ICD-11) published in 2018] supports the development of targeted initiatives. Upcoming prevention approaches can benefit from models that have proven successful in countries such as the Republic of Korea, while being adapted to the sociocultural context of the countries where those initiatives are being used. Raising awareness should be encouraged, while safeguarding Internet users and supporting individuals and families to make informed decisions.

Conclusions

With a view to the future, we have a collective responsibility as scientists, clinicians, parents, teachers, governments, NGOs, and game developers to raise awareness of the consequences of technology overuse and to safeguard individuals from developing problems due to their excessive Internet and gaming use. We need to ensure that we collaboratively establish the research and healthcare framework to enable cost-efficient and targeted prevention approaches to be implemented, supported by relevant governmental policy and regulatory approaches that do not diminish the enjoyment of digital games and that pay respect to the individual and sociocultural context in which gaming takes place.