Gaming Disorder and Parenting Style: A Case Series - iKnow

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08/22/2020

Gaming Disorder and Parenting Style:

A Case Series

Kristiana Siste, MD, PhD,* Enjeline Hanafi, MD,* Diana Jamtani, MD,*

Belinda J. Murtani, MD,* Evania Beatrice, MD,* Hans Christian, MD,*

Reza Damayanti, MD,* Karina K. Firdaus, MD,*

and Raden I. Ismail, MD, PhD†

Abstract

Objectives:

The increasing prevalence of gaming disorder poses new challenges in terms of detection and prevention.

Identification of risk factors is necessary to predict, diagnose, treat, and form health policies as regards to gaming disorders. The objective of this study was to report cases in regard to the identification of parenting style as a risk factor for gaming disorder and its role in the management of the condition.

Methods:

Through clinical case descriptions, we present 2 cases where patients were brought to our addiction clinic due to excessive gaming causing social and academic dysfunction.

Results:

These cases portray 2 different parenting styles, authoritarian and permissive, both contributing heav- ily to the gaming disorder they endured. The patients were provided with family therapy along with motivational enhancement and pharmacotherapy which re- sulted in improvement in their Internet Addiction Test scores.

Conclusions:

This case series presents 2 cases of gaming disorder in Indonesia wherein parenting style plays an important role in predisposing individuals to gaming disorder. To our knowledge, this report is the first to explore cases of gaming disorder in Indonesia and the treatment plans implemented in these cases can be used as a clinical recommendation for the management of gaming disorders in Indonesia. Expectantly, information regarding the association of parenting styles and gaming can aid in screening and treatment of gaming disorders.

Key Words: gaming disorder, addiction, parenting style, adolescence, risk

(Addict Disord Their Treatment 2020;19:185–190)

T

he inescapable utilization of the internet across a multitude of plat- forms has made gaming an immensely popular activity in today’s society. As a result, there has been a lot of interest with regard to the phenomenon of

internet and gaming disorders. A systematic review studying epidemiological studies of gaming disorder found that its prevalence in each study varied extensively, with European studies varying from 0.7% (Germany) to 27.5%

(France) and Asian studies varying from 1.7% (Korea) to 15.7% (China).¹ This wide range of gaming disorder prevalence is partially attributed to inconsis- tent naming and definitions of gaming disorder—a problem that encompasses not only diagnostic and epidemiological difficulties but also treatment strategies and health policies.^1,2

In 2013, after roughly a decade of research,The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), proposed a criteria set in its section “Conditions for Further Study” for internet gaming disorder (IGD) with the intention of providing a common language to ease further research.³Likewise, in 2018, the World Health Organization (WHO) classified gaming disorder in the 11th edition of the International statistical classification of diseases and related health problems (ICD-11)—a classification grounded on studies and expert opin- ions from 20 countries.⁴

The implementation of these new criteria has incited multifaceted debates in recent times with regard to the place- ment of gaming addiction as a stand- alone diagnosis or even a diagnosis at all.⁵A primary argument is that defining excessive gaming behavior as an addictive disorder will lead to overdiagnosis in the current era of widespread gaming and internet use.^5,6Nevertheless, gaming disorder shares key features with

Volume 19, Number 3 September 2020

From the *Department of Psychiatry, Addiction Psychiatry Division;†Department of Psychiatry, Child and Adolescent Psychiatry Division, Dr. Cipto Mangunkusumo General Hospital—Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.

Supported by the Faculty of Medicine Universitas Indonesia Research Grant 2019 (Hibah Simlitabmas 2019).

The authors declare no conflict of interest.

Correspondence to: Raden I.

Ismail, MD, PhD, Jalan Salemba Raya 6, Senen, Central Jakarta 10430, DKI Jakarta, Indonesia (e-mail: [email protected]).

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addiction, mainly symptoms of impaired impulse control, cravings, and continued use in spite of negative effects.

These common features favor the classification of gaming disorder as a form of behavioral addiction.^7,8As is the case in our center, individuals with gaming disorder might not seek treatment with excessive gaming as their chief com- plaint but instead seek help due to the negative consequences that appear due to behavioral addiction. Excessive gaming has been associated with mental health problems such as anxiety and depression, physical problems, impairment of academic and work productiv- ity, and social isolation.^7,9,10

The previously mentioned epidemiological study also suggests that geo- graphic region is not a major factor associated with gaming disorder.¹ Although the prevalence of gaming disorders in Indonesia is currently un- known, a study conducted in 2013 estimated that 10.15% of middle and high school students in Indonesia suf- fered from online game addiction.¹¹ Moreover,∼20 patients visit our addiction clinic each year due to gaming disorder. In relation to this high esti- mate, this article also attempts to provide a perspective of gaming disorders in Indonesia.

A vital part of diagnosing and pre- dicting gaming disorder is ascertaining risk factors in patients. A few of the risk factors that have been found to be associated with gaming disorders include impulsivity, anxiety, weekday game time, and parenting style.^12,13

Limited studies exist with regard to the relationship between gaming disorder and family dynamics or parenting style. Previous studies that have at- tempted to understand the influence of parenting style on gaming disorders seem to report mixed findings, as it is still unclear whether parents are actually aware of the magnitude of their child’s involvements in internet gaming. Anoth- er muddling factor is the constancy of restrictive methods used by parents and whether permissiveness or restrictiveness in parenting was applied before or after excessive gaming began.¹⁴Con- trary to research concerning the relationship between parenting and use of addictive substances wherein parenting

styles are found to be strong factors for the addiction, studies as regards parenting styles and gaming tend to deduce that the poor quality of parent and child relationships arise in response to excessive gaming, as opposed to being a predictor for the disorder.^15,16As such, this case series aims to highlight parenting styles as a predisposition for gaming disorder.

Furthermore, a number of studies have found extensive relationships between gaming disorders, psychopathologies, and psychiatric comorbidities.^7,17,18 Owing to the substantial burden of gaming disorder and its tangible upsurge in our current era, studies and reports with regard to this condition are imperative to acknowledge the real and significant consequences of gaming disorders. Identify- ing predisposing factors for gaming disorders and consequently being able to provide them with the appropriate treatment and intervention practices are of utmost importance in implementing preventative guidelines, preventing pro- gression of the disorder, and increasing quality of life. This article aims to illustrate readers with 2 cases portraying substantial social and emotional impairment caused by gaming disorders, with risk factors relating to parenting style that fit the appointed diagnostic criteria sets of the DSM-5 and ICD-11, alongside the psychopathologies commonly associated and the improvements made after receiv- ing treatment, as specified by the Young Internet Addiction Test (IAT).¹⁹

CASE PRESENTATIONS Case A

Budi, a 20-year-old man, was brought to the psychiatric clinic by his mother due to agitation after being told to stop playing games. He was raised with a permissive parenting style with Budi’s father always spoiling him because he was their only child and because Budi was often sickly as a child.

His mother treated him stricter than his father, but her decision would always be overshadowed by the father. Budi had been given a gaming console since ele- mentary school, and the gadget had been continually upgraded into the

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latest version over time. Budi had been playing online games for ∼18 hours a day for 6 months. Budi said that he loved playing mobile legend with his friends. He thought that his playing habit was not problematic because his team had successfully obtained second place in a national tournament. How- ever, other people around him had observed that he looked tired in the morning because he always played online games the whole night. Budi was a dentistry student, and hence his lack of concentration and absence in class af- fected his academic status. Budi consid- ered himself as a popular young man and a role model to his friends, as he was often praised for his game-playing abil- ities. Despite that, Budi felt that he was a failure because he could not fulfill his parents’ wish of becoming a dentist.

Budi was diagnosed with gaming disorder, depression, avoidant personality trait, and obesity. His IAT score was 90, indicating that he had a severe de- pendency on internet gaming. He was treated with escitalopram 30 mg/d and aripiprazole 5 mg/d alongside 12 sessions of motivational enhancement therapy within 3 months and family therapy

—specifically with regard to parenting style. His IAT score after 3 months dropped down to 40 (mild depend- ency).

Case B

Umay is an 18-year-old male ac- counting student in a state university outside Jakarta. As an only child in the family, Umay was spoiled by his father, and his needs were always fulfilled.

Umay spent most of his time playing online games,point blankand occasion- ally obtained money from selling his account. He played∼4 to 20 hours per day. When Umay and his parents lived together, his parents had been overinvolved with his life. Umay felt that his life at home was filled with rules and lacked warmth. Umay was never able to do activities he enjoyed without being reprimanded by his parents, and he could not convey his feelings, as com- municating with his parents always felt like a one-way conversation. However, as he had currently been living sepa- rately from his parents, his parents

could not control his playing habits.

He decided to make his own choices with regard to how he spent his time without his parents’interference. Umay lied to his parents about playing online games all day long and not attending classes. Because of his lack of communication skills, Umay did not have friends in real life, but he had many online friends and thought of himself as a prominent player in the gaming community. He scored 75 on the IAT score, indicative of his severe gaming addiction and was diagnosed with gaming disorder and adjustment disorder.

He was medicated with sertraline 75mg/d and counseled with 12 sessions of motivational enhancement therapy. His parents also participated in family therapy to focus on and resolve their overinvolved parenting style. Three months later, his IAT scored improved to 30.

DISCUSSION

The DSM-5 cites IGD as“persistent and recurrent use of the Internet to engage in games, often with other play- ers, leading to clinically significant impairment or distress, as indicated by 5 (or more) criteria in a 12-month period.” These criteria include preoccupation, withdrawal, tolerance, failure to stop playing, loss of interest in other life activities, continued overuse of Internet games despite knowing the impact it has, dishonesty, usage of internet games to relieve anxiety or guilt, and jeopard- izing opportunities or relationships due to internet games. However, due to in- adequate data, IGD was placed in under

“Condition for Further Study”, hence was not intended for clinical use.³

Five years later, the ICD-11 clas- sifies gaming disorder as a “pattern of persistent or recurrent gaming be- haviour (“digital gaming” or “video- gaming”)” both online or offline that is exhibited by impaired control over gaming, prioritizing gaming over other life interest and daily activities, and escalation of gaming despite negative consequences that are of “sufficient severity to result in significant impairment.” The ICD-11 also adds that this pattern “may be continuous or episo- dic”over 12 months, but“the required

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duration may be shortened if all diagnostic requirements are met and symptoms are severe”.⁴

Parenting styles are generally classified into authoritarian, authoritative, permissive, and uninvolved styles on the basis of dimensions of parental warmth and parental control.²⁰Limited studies exist on the relationship between specific parenting styles and gaming disorders, and most studies largely focus on family dynamics such as engagement of social activities with parents, parental affection, and family environment.¹⁴ Consequently, parenting styles cannot, as of yet, be predictors of gaming disorder. Nonetheless, the cases in this article portray circumstan- ces wherein parenting styles largely contribute to the development of gaming disorder. Cases A and B display permissive and authoritarian parenting styles, respectively.

In Case A, Budi’s parents’lack of control, regulation, and involvement toward his gaming behavior permitted him to ignore other social responsibil- ities. The pervasiveness of technology in today’s society allows for a more lax and permissive media-based parenting.

At present, parents are able to use media as a babysitter and allow their children to play games on their gadgets, as opposed to letting them engage in activities, as it allows them to monitor their children and lets them know that their children are safe in view.²¹ By continuously upgrading Budi’s gaming equipment, his parents also indirectly encouraged his gaming behavior. This relationship is indicative of behavioral impairment caused by a lack of control and monitoring.²⁰ Furthermore, freedom from restriction through a permissive parenting style has been linked to increased impulsivity in young adults.²²A recent study found that adolescents who overindulged in online gaming were more likely to have parents who had more permissive parenting styles.¹³ Studies with regard to family dynamics and gaming have also suggested that family engagement and involvement in high functioning families were protective factors of problematic gaming, as they are able to divert the gamers’ attention toward other activities.¹⁴

Conversely, overinvolvement in terms of restriction has been observed to negatively impact gaming behavior. A study has reported that adolescents who overused the internet were 1.9 times more likely to have restrictive parents, and another has observed that restrictions with regard to gaming were not effective in reducing symptoms of gaming.^15,23 However, the correlation between restrictiveness and gaming disorder is yet unclear, as restrictiveness may arise as a response to the emer- gence of gaming problems and not as its precursor. Alternatively, restrictions may, in turn, intensify an individual’s desire to play games, and, in so doing, creates a cycle of family dysfunction.¹⁴

As opposed to western culture wherein authoritative parenting is associated with the most positive connota- tions, Asian parents tend to practice strict control and more commonly lean toward authoritarian parenting styles.

Asian parents generally demand more from their children and often believe that parental control and monitoring are necessary to impose obedience, self-control, and academic ambition.

This common practice of parenting style is associated with cultural beliefs where, in Asian families, strictness and high levels of control are often used to convey parental concern and involvement, as is observed in Case B.^24,25

Restrictiveness and parent overinvolvement also corresponds to one of the criteria for gaming disorder: escapism. Gaming disorder may arise in individuals who use gaming as a way to escape from their psychological burden, as portrayed in Case B, wherein the constant hovering and involvement of Umay’s parents on his life led him to use gaming as a means of escape.²⁶ The increasing popularity of parental overinvolvement has led to formation of the term “helicopter parenting” wherein children are strictly supervised in all aspects of their lives, including social interactions. Helicopter parenting results in children preferring to spend more time socializing through electronic devices, as Umay does in his online gaming community.²⁷However, Umay’s escapism eventually turned into an addiction, and he was unable to stop playing despite moving out of his parents’

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home, and instead abused his new- found freedom. This parallels with a study that reported internet addicted children were more likely to have overinvolved parents and suggested that internet addiction can ensue parental overinvolvement in their child’s day to day life, having higher expectations, and paying little attention to their children’s emotions. These parenting characteristics often lead to poor life and communication skills and, subse- quently, upon reaching adolescence, gaming becomes an outlet for their in- ner dissatisfaction.²⁸

Although the number of gaming disorder cases encountered in our clinic is not as prevalent as other psychiatric diagnoses, every person suffering from the negative effects of excessive gaming requires the same level of attention and care. Akin to the treatment modalities applied in our cases, the numerable factors relating to gaming disorder call for tailor-made treatments. Aside from parenting factors, both cases also displayed the relationship between psychiatric comorbidities and gaming disorder. This association is important for clinicians to keep in mind when dealing with patients with gaming disorder, specifically to look for and address underlying problems or psychopathologies caused by the behavioral addiction. Special attention must be given to the selection of pharmacotherapy required by patients with multiple psychiatric comorbidities.

Gaming disorder, not unlike substance addiction, requires a multifacto- rial intervention approach. It is vital to consider the risk factors and comorbidities of the afflicted patient to minimize distress and increase his or her quality of life. Family therapy is important in aid- ing a patient’s recovery process and should include educating parents on the underlying factors that attributed to their child’s excessive gaming behavior.

Keeping in mind the effects of parenting on the development of gaming disorder, clinicians can investigate the parenting style to apply a customized approach to family therapy. Family therapy can also be used to focus on helping parents understand the recovery process of addiction including relapse triggers and establishing reasonable boundaries and restrictions with their child.²⁶

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