By Professor Tony Attwood and Dr Michelle Garnett
The parents of autistic teenagers and young adults are increasingly worried about how much time their son or daughter spends on Internet gaming, whilst the autistic person is worried that their time could be reduced by their parents. Clinicians and parents may be concerned that a young autistic person’s interest in Internet gaming could evolve into addiction.
Gaming disorder or video game addiction is recognised worldwide. It has increased with the advent of broadband technology, games allowing for the creation of avatars, ‘second life’ games and MMORPGs (massive multiplayer online role-playing games). World of Warcraft has the largest MMORPG community online, and there have been studies confirming the addictive qualities of the game. Indeed, modern computer games have adopted aspects of the gambling industry, for example, purchasing Loot Boxes within the game. The content of a Loot Box is unknown and purchased directly or available during play, with the gamer subsequently buying “keys” to redeem them. Game developers see loot boxes as a way of generating ongoing revenue and keeping player interest in gaming through loot-box reward systems. This can contribute to the addictive nature of Internet gaming.
The diagnosis of internet gaming disorder
The recent edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revised, provides diagnostic criteria for Internet Gaming Disorder (DSM-5-TR; APA 2022, p.p. 913-916). There are nine criteria, and confirmation by a clinician of five or more are likely to confirm the diagnosis. The nine criteria are:
- Preoccupation with Internet games, such that gaming has become the dominant activity in daily life.
- Withdrawal symptoms when Internet gaming is taken away.
- Tolerance – the need to spend increasing amounts of time engaged in Internet games.
- Unsuccessful attempts to control participation in Internet games.
- Loss of interest in previous hobbies and entertainment.
- Continued excessive use of Internet games despite knowledge of psychosocial problems.
- Has deceived family members, therapists, or others regarding the amount of Internet gaming.
- Use of Internet gaming to escape or relieve a negative mood.
- Has jeopardised or lost a significant relationship, job or educational or career opportunities because of participation in Internet gaming.
The DSM-5 work group reviewed more than 240 research articles and found some behavioural similarities between Internet gaming and gambling disorder and substance use disorders. The DSM-5 describes individuals with Internet gaming disorder as sitting at a computer and engaging in gaming activities while neglecting other activities and typically devoting 8-10 hours or more each day and at least 30 hours per week. The mean prevalence of gaming disorder among typical adolescent boys was estimated as 6.8% and adolescent girls 1.3%. A recent study of the prevalence of gaming addiction in autistic teenagers and young adults indicated that 9.1% reported symptoms over the cut-off for gaming disorder (Murray et al., 2022).
Research on gaming addiction and autism
A recent systematic review of the research literature on autism and video game use confirmed that autistic children, adolescents and adults are at greater risk of problematic video gaming than typical peers (Craig et al. 2021). The studies indicated that, on average, autistic individuals spend over 2 hours playing Internet games each day with a weekly average of 12-17 hours. This is below the level of gaming to confirm a formal diagnosis of Internet Gaming Disorder but greater than typical peers and paediatric guidelines. Autistic children also play more Internet games than their non-autistic siblings and spend more time playing Internet games than other extracurricular activities.
A study of over 100 autistic adolescents by Hirota, McElroy, and So (2021) identified that a characteristic of their Internet gaming was defensive and secretive behaviours and concealment of Internet use from their parents. The subsequent issues included the effects on school grades, decreased ‘healthy’ social engagements and neglecting household chores to spend more time online.
Research on autistic adolescents’ sense of self-identity included an analysis of the answers to the question. What do you enjoy most? The most enjoyable experience was access to technology and gaming (Clarke and Adams 2020).
Why do autistic individuals spend so much time on Internet gaming?
The reasons typical adolescents and young adults engage in Internet gaming are:
- Achieve a temporary escape to help deal with stress and get away from a current situation.
- Create a sense of community and connection to meet like-minded people.
- Experience instant gratification and feedback to confirm progress in the game.
- A challenge to overcome and to have a sense of purpose, a goal to work towards.
All these reasons apply to an autistic person, but there are additional reasons. These include being popular with fellow gamers who seek and admire their gaming abilities, knowledge, and guidance. Popularity with peers can seem elusive for autistic adolescents.
There is little, if any, social chit-chat and no requirements to process non-verbal communication or follow social conventions. There is also the possibility of becoming an avatar, creating an alternative non-autistic persona and reality.
Our clinical experience is that engaging in Internet gaming provides a high level of excitement and enjoyment for someone who may be depressed and have little to enjoy and look forward to. Internet gaming also acts as a thought blocker and a means of escape from anxious or depressed thinking, and a means of alleviating loneliness and a lack of social connection. There is also an association between longer periods engaging in Internet gaming and having attention deficit hyperactivity disorder (ADHD), and the majority of autistic adolescents also have signs of ADHD. Thus there are many reasons why autistic individuals are of concern to their families and clinicians for the amount of time they engage in Internet gaming.
Consequences of Internet gaming
The consequences of engaging in too much Internet gaming can include a deterioration in mental and physical health, lost opportunities for learning important life skills, and reduced achievements. Research with participants in the general population has indicated that excessive Internet gaming can increase depressive and anxiety symptoms and increase the risk of substance abuse. Physical symptoms include a weakened immune system due to lack of sleep and daylight, exercise loss and effects on physical fitness, obesity, increased risk for carpal tunnel syndrome, and eye and back strain. There can also be a reduction in academic performance, real-life social relationships and increased family disharmony and conflict.
Reducing the time engaged in Internet gaming
To reduce the amount of Internet gaming time, it is essential to understand why an individual player engages in Internet gaming. Each of the reasons described above needs to be explored and evaluated and to find other ways to meet those needs.
There are programmes designed for non-autistic gamers, such as the Internet and Technology Addicts Anonymous (ITAA), founded in 2017. It is a 12-step programme supporting compulsive Internet users. Media Addicts Anonymous (MAA) is another 12-step programme for media addiction.
Cognitive Behaviour Therapy with Internet Addicts (CBT-IA) has been designed and developed to help the gamer recognise the potential harms of Internet gaming, manage impulse control, identify triggers of Internet binge behaviour and use cognitive restructuring to challenge and modify cognitive distortions and rationalisations to justify excessive Internet use. The programme also helps develop self-identity, interpersonal communication skills and alternative emotion management strategies.
There are support communities for Internet gamers such as StopGaming-Reddit as well as www.gamequitters.com, and in Australia, www.GameAware.com.au developed by Andrew Kinch.
From our clinical experience, we would suggest adding components to conventional game-quitting programmes, such as expanding the person’s social network to include autistic friends and psychological treatment of anxiety and depression that accommodates the characteristics and experiences of autistic teenagers and young adults.
Parents must consider removing gaming devices from the person’s bedroom, not gaming first thing in the morning, and having a game-free day each week for all family members. We recommend a gradual reduction in the total amount of gaming each day, first establishing the accurate real-time spent engaged in gaming and reducing that time by perhaps 15 minutes each day for a week or more, then another 15-minute reduction to reach a goal of a total of two hours a day.
There will need to be careful consideration of activities to replace gaming, such as reading, watching movies and artistic activities, time with friends and new social activities such as Dungeons and Dragons, an autism support group, being with pets, adventure sports and geocaching, martial arts and online and college courses which may include game design.
Where to Now?
We recommend our online course Succeeding with Autistic Teenagers, which includes a section on gaming addiction for autistic adolescents, the psychological, emotional and physical changes for autistic teenagers, self-identity, issues such as managing a meltdown and sleep, friendship, sexuality and gender identity and preparation for employment.
References
APA (2022) Diagnostic and Statistical Manual of Mental Disorders-5 Text Revision. American Psychiatric Association
Clarke and Adams( 2020) Research in ASD 72
Craig et al. (2021) Research in ASD 82, 101726
Hirota, McElroy, and So (2021) Journal of Autism and Developmental Disorders 51, 2764-2772.
Murray et al. (2022) Journal of Autism and Developmental Disorders 52, 2762-2769
