Problematic Video Game Play and ADHD Traits in an Adult Population

Abstract

This study examined the relationship between problematic video game play (PVGP), video game usage, and attention deficit hyperactivity disorder (ADHD) traits in an adult population. A sample of 205 healthy adult volunteers completed the Adult ADHD Self-Report Scale (ASRS), a video game usage questionnaire, and the Problem Video Game Playing Test (PVGT). A significant positive correlation was found between the ASRS and the PVGT. More specifically, inattention symptoms and time spent playing video games were the best predictors of PVGP. No relationship was found between frequency and duration of play and ADHD traits. Hyperactivity symptoms were not associated with PVGP. Our results suggest that there is a positive relationship between ADHD traits and problematic video game play. In particular, adults with higher level of self-reported inattention symptoms could be at higher risk of PVGP.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a behavioral disorder defined by an attentional dysfunction, hyperactive/impulsive behavior, or both (DSM-V¹). ADHD is the most common neurodevelopmental disorder² and its worldwide prevalence in children and adolescence is between 0.85 and 10 percent.^3,4 In roughly half of the children diagnosed with ADHD, symptoms persist into adulthood.⁵ Therefore, ADHD has also been validated as an adulthood disorder, with remaining symptoms in adults including distractibility and difficulties with maintaining goal-directed behavior rather than hyperactivity.

Mainstream video games first appeared in the 1970s and their popularity has been steadily increasing since. Video games can vary in theme and style, can be played online or offline, can encourage cooperation or competition, and they are played on various devices (e.g., consoles, computers, mobile phones). Recently, the idea of problematic video game play (PVGP) has emerged. Such behavior refers to persistent, recurrent, and excessive video game play, which can disrupt an individual's functioning on various settings (e.g., social, academic).⁶ The percentage of players affected by PVGP vary among different countries but its prevalence is estimated to be around 7.5 percent.^7,8

The increasing number of individuals affected by PVGP resulted in its inclusion in the latest version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-V.¹ PVGP is included under the term, “Internet Gaming Disorder”.⁶ Previous research has shown that massively multiplayer online role-playing game are most often associated with PVGP.⁹ However, Internet use is not a required element for PVGP^9,10; offline role-playing games have also been linked to problem use.^9,10 As a result both online and offline video games were considered in this study.

Behaviors associated with PVGP are similar to those exhibited in gambling and Internet “addiction.”¹¹ In addition to this, pathological gaming as characterized by DSM-V, resembles substance use disorders. Individuals who exhibit PVGP usually play video games longer than the average user (>50 hours per week¹²). This behavior can lead to neglecting other responsibilities and developing an increased level of emotional and social problems, resulting in psychological dependence. However, it is worth noting that extensive play does not necessarily predict PVGP. Many players spend a significant amount of time playing video games without reporting any behavioral or addiction problems.¹³

A number of factors have been associated with PVGP including poor time management, underlying personal problems, or mental health problems.¹⁴ ADHD has been repeatedly associated with addiction. Certain traits found in those with ADHD (e.g., impulsivity, boredom, restlessness) pay a key role in addiction.¹⁵ More specifically, ADHD has been linked to illegal substances at a younger age, when not treated with medication and stimulant therapy² and demonstrate problem behavior with forms of interactive media.¹⁵ There is some emerging evidence suggesting that children and adolescents with ADHD exhibit more problematic video game behaviors^13,17 compared to typically developing children.

The majority of studies so far have focused on children and adolescents.^13,17 However, problematic video game use is also common among adults.¹⁸ ADHD psychopathology can be viewed dimensionally, with inattentive and hyperactive/impulsive symptoms distributed continuously in the general population.^19,20 Higher level of ADHD symptoms could potentially predict PVGP. To our knowledge, only one study²¹ has investigated the relationship between PVGP and ADHD traits in an adult population. Even though a positive relationship was found, the researchers did not examine potential differences in the contribution of inattention and hyperactivity ADHD symptoms. Evidence from substance use disorders research suggests that there are potential ADHD subtype differences in the prevalence of addiction.²² The main aim of this study was to examine the contribution of inattention and hyperactivity, along with overall ADHD traits, to PVGP.

Materials and Methods

Participants

Two hundred five participants took part in the study (105 women). The mean age was 27.4 (SD = 10, range = 41). The majority (65.4 percent) had an undergraduate degree. Only individuals who played video games for at least 1 hour per week were invited to take part in the study. Participants completed the study online after receiving a personal e-mail.

Measures

Problem video game playing

PVGP was assessed using the Problem Video Game Playing Test (PVGT).²² The PVGT is an adapted version of the Internet Addiction Test, a 20-item questionnaire designed by Young²³ to measure clinical features of Internet use. Each item is scored on a 5-point Likert scale ranging from “1 = Never” to “5 = Always.” Thus, total scores range from 20 to 100. The PVGT measures aspects of problematic involvement in video games and is based on the six core features of Brown's addiction model; salience (“Do you feel preoccupied with video games when not playing”), mood modification (“Do you play video games as a means of altering your mood”), tolerance (“Do you often find yourself playing video games for longer than you intend”), withdrawal (“Do you feel depressed, moody or nervous when not playing video games, that goes away when you are back playing video games”), relapse (“Do you try and cut down on the amount of time spent playing video games and fail”), and conflict (“Do you spend more time playing video games than with others”).

The internal consistency of the scale in our study was good (a = 0.94). This was consistent with previous research.¹¹

Video game usage

Participants were asked to disclose the number of hours per week they spend playing games and the duration spent playing before taking a break from play.

ADHD traits

ADHD traits were measured with the Adult ADHD Self-Report scale (ASRS).²⁴ The ASRS is an instrument consisting of the 18 DSM-IV-TR criteria and was developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD. The scores obtained through the ASRS have been found to be predictive of symptoms consistent with ADHD.²⁵ The ASRS contains 18 items from DSM-IV-TR (American Psychiatric Association, 2000) but measures the frequencies of the symptoms. The subjects are asked to report how often they experience each symptom in a period of 6 months on a 5-point Likert scale that ranges from 0 for never, 1 for rarely, 2 for sometimes, 3 for often, and 4 for very often.^25,26 The ASRS has a two factor structure that includes an inattention scale and a hyperactivity/impulsivity scale. Each subscale contains nine items. The ASRS examines only current adult symptoms of ADHD. The reliabilities (Cronbach's α) for the two subscales of inattention (0.75) and impulsivity (0.77) as well as for the total ASRS (0.82) are satisfactory.²⁶ The original questionnaires are formatted with darkly shaded boxes in certain items that signify more severe symptoms, but these were removed from the questionnaire administered to our participants to avoid potential bias in the responses.

Results

Descriptive analyses

Participants reported spending an average of 8.6 hours per week playing video games (SD = 11.1, range = 80). Players took a break from playing every 1.8 hours (SD = 1, range = 4). The mean score on the PVGT was 36.5 (SD = 14) and the distribution was slightly positively skewed (Skewness = 0.5, Standard Error of Skewness = 0.16). This distribution is consistent with the literature, which states that only a minority of players experience significant disruption as a result of excessive video game playing.

PVGT scores were positively correlated with hours spent playing video games (r = 0.58, p < 0.001) and frequency of breaks from playing (r = 0.56, p < 0.001). Age was negatively correlated with PVGT scores (r = 0.23, p < 0.001), with older participants reporting fewer problematic behaviors.

There was a significant difference between men and women in PVGT scores, t = −6.1, p < 0.001. Men reported higher levels of problematic behaviors (M = 42.04, SD = 13.2) compared to women (M = 31.14, SD = 12.5). Gender differences were also observed in the hours spent playing per week, t = −5.9, p < 0.001, and time before taking a break, t = −4.9, p < 0.001.

The average score on the ASRS was 27.1 (SD = 11, range =64). Participants reported more inattentive than hyperactive symptoms; the mean on the ASRS inattentive subscale was 14.8 (SD = 5.9) compared to 12.3 (SD = 5.6) on the hyperactive subscale. No gender differences were found in the ASRS scores. Age did not correlate with the ASRS or any of its subscales.

Relationship between ADHD traits and PVGP

The relationship between ASRS and PVGT along with the time spent playing video games and time between breaks was examined (Table 1). A weak correlation was found between overall ADHD traits (r = 0.22) and the inattention subscale of the ASRS (r = 0.3). No association was found between ASRS and time spent on video games per week or time between breaks.

Table 1.

Correlations Among Attention Deficit Hyperactivity Disorder Traits and PVGP Variables

Variables	1	2	3	4	5	6
1. ASRS total	—
2. ASRS inattention	0.92^**	—
3. ASRS hyperactivity	0.91^**	0.68^**	—
4. PVGT	0.22^**	0.3^**	0.12	—
5. Time spent playing video games	−0.08	−0.00	−0.1	0.58^**	—
6. Time between breaks	−0.03	0.06	−0.11	0.55^**	0.54^**	—

p < .001.

ASRS, Adult ADHD Self-Report Scale; PVGT, Problem Video Game Playing Test; PVGP, problematic video game play.

To determine the relative contribution of these variables to the PVGT score, a simultaneous linear regression was conducted with PVGT score as the dependent variable and the following independent variables: time spent playing video games per week, ASRS scores, ASRS inattention subscale. The results indicated that time spent playing video games (b = 0.57, t = 10.7, p < 0.001) and ASRS inattentive scores (b = 0.3, t = 5.3, p < 0.001) remained significant predictors of PVGT. Overall ASRS score was not significant predictor of PVGT (p = 0.92), when controlling for the above variables. The model could predict 41 percent of variance in PVGT.

Discussion

In this study we examined the relationship between PVGP and ADHD traits in an adult sample. Our findings indicate that higher level of ADHD traits is associated with more problematic behavior in video game play. This is consistent with previous research on children and adolescents with ADHD.^{13,17,18,27,28} Inattention symptoms and time spent playing video games were the best predictors of PVGP. These findings suggest that subclinical ADHD symptoms, especially inattention symptoms, could contribute to PVGP in adults.

Men reported a higher number of PVGP compared to women. This is consistent with results from previous studies that have shown that men score on average higher.²⁷ No differences in ADHD traits, however, were found between men and women.

A few possible explanations can be offered for the relationship between problematic video game behaviors and ADHD symptoms. Video games include potent attention grabbing cues (e.g., interactivity, sound effects, flickering light levels).²⁹ There is some evidence suggesting that video game play increases the release of dopamine within the nucleus accumbens.³⁰ Abnormalities in local dopamine metabolism have been associated with ADHD.^31,32 Furthermore, several studies have demonstrated that frequent video game play can improve various aspects of visual attention,³³ a function often impaired in ADHD.³⁴ Playing video games may temporarily increase dopaminergic tone, which may temporarily enhance arousal and cognitive control functions. Thus, video game play might be used for self-medication by individuals with ADHD or high ADHD traits.

It is worth noting that ADHD traits were not associated with extensive game play sessions or infrequent breaks between sessions. Studies in children and adolescents have found a positive relationship between ADHD symptoms and time spent playing video games.^14,20 It is possible that adults with ADHD traits reduce the frequency of play. However, the relationship between ADHD and PGVP remains positive. This could potentially affect future interventions for video game addiction.

We do not claim that problematic video game use among individuals with ADHD traits always leads to detrimental effects. In this study we demonstrate that ADHD traits, especially inattention symptoms, are associated with problematic video game use in an adult nonclinically diagnosed population. Future studies need to examine whether this finding generalizes to adult clinical ADHD samples and what effect it has in their everyday lives. In addition to this, previous research using the PVGT to measure problematic video game use only found weak associations with measures of psychological distress.³⁵ Follow-up should focus on players with high PVGT scores and assess their risk of anxiety or depression.

This study examined the relationship between PVGP and ADHD traits without considering differences in video game genre preferences. Previous studies in children with developmental disorders have shown that there is an interaction between video game genre preferences and PVGP.²⁴ In particular, specific game genres, such as role-playing games may provide its own unique contribution in the prediction of problematic game use.^13,24 Future studies should attempt to investigate the relationship between genre preferences, ADHD traits, and PVGP.

Finally, our findings are similar to those obtained in studies with clinical populations.^14–16 This further supports the dimensional theory of ADHD and shows that using subclinical populations could provide us with information of clinical relevance.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association.

Faraone

, Sergeant

, Gillberg

, et al. The worldwide prevalence of ADHD: is it an American condition. World Psychiatry, 2003; 2:104–113.

Seixas

, Weiss

, Müller

. Systematic review of national and international guidelines on attention-deficit hyperactivity disorder. Journal of Psychopharmacology, 2011; 26:753–765.

Polanczyk

, de Lima

, Horta

, et al. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry, 2007; 164:942–948.

Spencer

, Biederman

, Wilens

, et al. Novel treatments for attention deficit/hyperactivity disorder in children. The Journal of Clinical Psychiatry, 2002; 63(Suppl 12):16–22.

Smith

, Hummer

, Hulvershorn

. Pathological video gaming and its relationship to substance use disorders. Current Addiction Reports, 2015; 2:302–309.

Festl

, Scharkow

, Quandt

. Problematic computer game use among adolescents, younger and older adults. Addiction, 2013; 108:592–599.

Gentile

. Pathological video-game use among youth ages 8 to 18 A National Study. Psychological Science, 2009; 20:594–602.

Elliott

, Ream

, McGinsky

, et al. The contribution of game genre and other use patterns to problem video game play among adult video gamers. International Journal of Mental Health and Addiction, 2012; 10:948–969.

10.

Király

, Griffiths

, Urbán

, et al. Problematic internet use and problematic online gaming are not the same: findings from a large nationally representative adolescent sample. Cyberpsychology, Behavior, and Social Networking, 2014; 17:749–754.

11.

King

, Delfabbro

. Understanding and assisting excessive players of video games: a community psychology perspective. Australian Community Psychologist, 2009; 21:62–74.

12.

Griffiths

, Davies

, Chappell

. Breaking the stereotype: the case of online gaming. CyberPsychology and Behavior, 2003; 6:81–91.

13.

Mazurek

, Shattuck

, Wagner

, et al. Prevalence and correlates of screen-based media use among youths with autism spectrum disorders. Journal of Autism and Developmental Disorders, 2012; 42:1757–1767.

14.

Bioulac

, Arfi

, Bouvard

. Attention deficit/hyperactivity disorder and video games: a comparative study of hyperactive and control children. European Psychiatry, 2008; 23:134–141.

15.

Zhang

, Mei

, Li

, et al. The relationship between impulsivity and internet addiction in Chinese college students: a moderated mediation analysis of meaning in life and self-esteem. PLoS One, 2015; 10:e0131597.

16.

Yoo

, Cho

, Ha

, et al. Attention deficit hyperactivity symptoms and internet addiction. Psychiatry and Clinical Neurosciences, 2004; 58:487–494.

17.

Yen

, Ko

, Yen

, et al. The comorbid psychiatric symptoms of Internet addiction: attention deficit and hyperactivity disorder (ADHD), depression, social phobia, and hostility. Journal of Adolescent Health, 2007; 41:93–98.

18.

Tejeiro

, Espada

, Gonzálvez

, et al. Psychometric properties of the Problem Video Game Playing scale in adults. Revue Européenne de Psychologie Appliquée/European Review of Applied Psychology, 2016; 66:9–13.

19.

Hudziak

, Heath

, Madden

, et al. Latent class and factor analysis of DSM-IV ADHD: a twin study of female adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37:848–857.

20.

Panagiotidi

, Overton

, Stafford

. Attention-deficit hyperactivity disorder-like traits and distractibility in the visual periphery. Perception, 2016; 301006616681313.301006616681313.

21.

Clure

, Brady

, Saladin

, et al. Attention-deficit/hyperactivity disorder and substance use: symptom pattern and drug choice. The American Journal of Drug and Alcohol Abuse, 1999; 25:441–448.

22.

Tolchinsky

, Jefferson

. Problematic video game play in a college sample and its relationship to time management skills and attention-deficit/hyperactivity disorder symptomology. Cyberpsychology, Behavior, and Social Networking, 2011; 14:489–496.

23.

Young

. Internet addiction a new clinical phenomenon and its consequences. American Behavioral Scientist, 2004; 48:402–415.

24.

Mazurek

, Engelhardt

. Video game use and problem behaviors in boys with autism spectrum disorders. Research in Autism Spectrum Disorders, 2013; 7:316–324.

25.

Kessler

, Adler

, Ames

, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychological Medicine, 2005; 35:245–256.

26.

Reuter

, Kirsch

, Hennig

. Inferring candidate genes for attention deficit hyperactivity disorder (ADHD) assessed by the World Health Organization Adult ADHD Self-Report Scale (ASRS). Journal of Neural Transmission, 2006; 113:929–938.

27.

Bioulac

, Arfi

, Bouvard

. Attention deficit/hyperactivity disorder and video games: a comparative study of hyperactive and control children. European Psychiatry, 2008; 23:134–141.

28.

Gentile

, Swing

, Lim

, et al. Video game playing, attention problems, and impulsiveness: evidence of bidirectional causality. Psychology of Popular Media Culture, 2012; 1:62.

29.

Tejeiro Salguero

, Morán

. Measuring problem video game playing in adolescents. Addiction, 2002; 97:1601–1606.

30.

Koepp

, Gunn

, Lawrence

, et al. Evidence for striatal dopamine release during a video game. Nature, 1998; 393:266–268.

31.

Krause

, Dresel

, Krause

, et al. Increased striatal dopamine transporter in adult patients with attention deficit hyperactivity disorder: effects of methylphenidate as measured by single photon emission computed tomography. Neuroscience Letters, 2000; 285:107–110.

32.

Dougherty

, Bonab

, Spencer

, et al. Dopamine transporter density in patients with attention deficit hyperactivity disorder. The Lancet, 1999; 354:2132–2133.

33.

Green

, Bavelier

. Action video game modifies visual selective attention. Nature, 2003; 423:534–537.

34.

Jonkman

, Kenemans

, Kemner

, et al. Dipole source localization of event-related brain activity indicative of an early visual selective attention deficit in ADHD children. Clinical Neurophysiology, 2004; 115:1537–1549.

35.

King

, Delfabbro

, Zajac

. Preliminary validation of a new clinical tool for identifying problem video game playing. International Journal of Mental Health and Addiction, 2011; 9:72–87.