By Professor Tony Attwood and Dr. Michelle Garnett
Internet gaming has become very popular and is enjoyed as a means of social interaction, often with friends after school, with gaming experiences often being the currency of conversations for adolescents and young adults. Gaming is also a means of stress relief and relaxation, improving cognitive skills in games that require strategic thinking and problem-solving and a popular way of achieving competitive success and self-esteem. However, there can be concerns regarding the frequency and duration of internet gaming. Excessive gaming can lead to, reduced real-life interactions to develop friendship abilities, physical health issues, sleep disturbance, neglecting responsibilities and reduced engagement in family activities
Systematic reviews of the research literature on autism and internet gaming have confirmed that autistic children, adolescents, and adults are at greater risk of problematic video gaming than their nonautistic peers (Craig et al., 2021; Kervin et al., 2021). These 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 according to DSM-5-TR (APA, 2022) but greater than nonautistic peers and paediatric guidelines. Autistic children also play more internet games than their non-autistic siblings and spend more time playing them than other extracurricular activities.
Perhaps unsurprisingly, parents, partners, and professionals’ express concerns about the amount of gaming time and the feelings generated by being online or deprived of going online. 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 due to fear that their amount of gaming time would be reduced. This frequently leads to family conflicts.
When is internet gaming a concern?
A working group of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, APA, 2022) reviewed 240 research articles on internet gaming and confirmed behavioural similarities between internet gaming, gambling disorder and substance use disorders. The DSM-5-TR describes individuals with a formal diagnosis of Internet Gaming Disorder as sitting at a computer and engaging in gaming activities for 8-10 hours or more each day and at least 30 hours per week.
Excessive gaming time is associated with a lower quality of life, sleep deprivation, anxiety, and depression (Kuss et al., 2021), as well as reduced academic performance and real-life social relationships. There are also concerns about a lack of exercise, access to sunlight and obesity. Excessive internet gaming affects both mental and physical health.
Japan was the first country to describe extreme social withdrawal and isolation within one’s home, often staying in one’s bedroom, and not participating in social, academic or work activities. The Japanese term Hikikomari describes self-imposed social isolation that lasts longer than six months. This profile has been confirmed in other countries, with a recognition that the recluse is usually engaged in internet and social media activities. Thus, Hikikomori is not another term for agoraphobia, a fear of leaving home but creating a lifestyle to maximise internet gaming opportunities.
One recent research study found the characteristics of Hikikomori occurred in around one-third of a sample of autistic people (Brosnan & Gavin, 2023). The theoretical link between Hikikomori, autism and internet gaming disorder was reviewed by Dell’Osso et al. (2023) and confirmed. Parents may be concerned that internet gaming may evolve into their child becoming a hermit, rarely coming out of their bedroom to socialise face-to-face with family members and friends.
Emotion Regulation and Internet Gaming
Our clinical experience is that engaging in internet gaming provides high excitement and enjoyment for someone who may be depressed and have little to enjoy and look forward to, as described by an autistic adolescent who said Life is boring and empty without the internet. When asked about their most enjoyable experiences, autistic adolescents and adults may reply with ‘access to technology and gaming’ (Clarke & Adams, 2020). The enjoyment is greater than interpersonal experiences with family and friends. Internet gaming may act as a thought blocker, a means of escape from anxious or depressed thinking, and a means of alleviating loneliness and a lack of social engagement by connecting with fellow gamers.
Two studies have confirmed that gaming addiction has a mediating effect on emotion regulation and school connectedness. In these studies, autistic traits were related to decreased emotion regulation, which was related to lower school connectedness, lower school grades, and increased internet gaming addiction (Hirota et al., 2021; Liu et al., 2017).
ADHD, Autism and Internet Gaming
Current research indicates that between 40-70% of autistic individuals have ADHD (Rong et al., 2021). ADHD is associated with an almost constant desire for immediate stimulation, such as novelty-seeking and risk-taking. The instant gratification offered in gaming can be reinforcing to a person with ADHD to a level that is beyond what their daily life, when off the screen, can offer them. A study of over 4,000 gamers confirmed that autism and ADHD predicted the severity of internet gaming (Concerto et al., 2021). Other research has shown that ADHD medications can reduce internet gaming disorder symptoms (Weinstein & Weizman, 2012), an outcome we have observed clinically.
Recommendations for Internet Game Use
The American Academy of Child and Adolescent Psychiatry (2015) has the following recommendations for internet game use.
- Avoiding video games in preschool-aged children
- Checking the Electronic Software Ratings Board ratings to select appropriate games – in terms of content and level of development
- Playing video games with children to share the experience and discuss the game’s content
- Setting clear rules about game content and playing time, both in and outside the home
- Monitoring online interactions and warning children about the potential dangers of Internet contact while playing games online
- Allowing video game playing only in public areas of the home, not in the child’s bedroom
- Remembering that you are a role model for your children, including which video games you play and how long you play them
- Enforcing total screen time limits
- Ensuring video games are only played after homework and chores are done
- Encourage participation in other activities, particularly physical activities
Our clinical experience is that some of these recommendations will be a challenge for the parents of an autistic child or adolescent, such as game playing in public areas of the home. Having people nearby can distract or interrupt the focus and concentration of an autistic person when gaming. Being a role model may be difficult for some autistic parents who have their own problems reducing gaming time. The recommendations also require parents to be assertive and consistent and to resist the autistic child’s ability to thwart the recommendations. However, the recommendations are wise and based on the collective wisdom of child and adolescent psychiatrists and clinical psychologists.
Training on Autism and Internet Gaming
Michelle and Tony have prepared a webcast on Addiction and Autism, including internet gaming and substance addiction. During this event we will be sharing our clinical experience regarding autism and internet gaming, and substance use and explaining the important recent research in these areas.
The event was created for parents and carers, autistic adolescents and adults, and health and educational professionals.
APA (2022) Diagnostic and Statistical Manual of Mental Disorders-5 Text Revision. American Psychiatric Association
Brosnan and Gavin (2023) PLoS ONE 18 e0281833
Clarke and Adams (2020). Research in ASD 72
Concerto et al. (2021) Brain Sciences 11, 774
Craig et al. (2021) Research in ASD 82, 101726
Dell’Osso et al (2023) Brain Science 13, 1116
Hirota, McElroy, and So (2021) Journal of Autism and Developmental Disorders 51
Kervin et al. (2021) Research in Developmental Disabilities 117
Kuss et al. (2021) Computers in Human Behaviour 115
Liu et al. (2017) Research in Developmental Disabilities 68
Murray et al. (2022). Journal of Autism and Developmental Disorders 52, 2762-2769
Rong et al. (2021). Research in Autism Spectrum Disorders, 83
Sussman et al. (2018). Child and Adolescent Psychiatric Clinics of North America 27
Weinstein and Weizman (2012) Curr. Psychiatry Rep 14