DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY INVITED REVIEW

Internet gaming disorder in children and adolescents:

a systematic review
FRANK W PAULUS 1 | SUSANNE OHMANN 2 | ALEXANDER VON GONTARD 1 | CHRISTIAN POPOW 2
1 Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany. 2 Department of Child and Adolescent Psychiatry, Medical
University of Vienna, Vienna, Austria.
Correspondence to Frank W Paulus at Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421 Homburg, Germany. E-mail: [email protected]

This article is commented on by Mueller on page 636 of this issue.

PUBLICATION DATA AIM Internet gaming disorder (IGD) is a serious disorder leading to and maintaining pertinent
Accepted for publication 2nd February 2018. personal and social impairment. IGD has to be considered in view of heterogeneous and
Published online 6th April 2018. incomplete concepts. We therefore reviewed the scientific literature on IGD to provide an
overview focusing on definitions, symptoms, prevalence, and aetiology.
ABBREVIATIONS METHOD We systematically reviewed the databases ERIC, PsyARTICLES, PsycINFO,
IGD Internet gaming disorder PSYNDEX, and PubMed for the period January 1991 to August 2016, and additionally
MMORPG Massively multiplayer online identified secondary references.
role-playing game RESULTS The proposed definition in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition provides a good starting point for diagnosing IGD but entails some
disadvantages. Developing IGD requires several interacting internal factors such as deficient
self, mood and reward regulation, problems of decision-making, and external factors such as
deficient family background and social skills. In addition, specific game-related factors may
promote IGD. Summarizing aetiological knowledge, we suggest an integrated model of IGD
elucidating the interplay of internal and external factors.
INTERPRETATION So far, the concept of IGD and the pathways leading to it are not entirely
clear. In particular, long-term follow-up studies are missing. IGD should be understood as an
endangering disorder with a complex psychosocial background.

Games are an integrative part of human behaviour and The Diagnostic and Statistical Manual of Mental Disor-
experience. During the past two decades, the availability ders, Fifth Edition (DSM-5)9 conceptualizes ‘Internet gam-
and use of computer technology has dramatically increased ing disorder’ (IGD) in the chapter ‘Conditions for further
and changed the world of leisure activities. Use of the study’ (p.795), suggesting that this proposal is not yet
Internet and computer game playing have become common intended for clinical use but that research on this topic is
activities for children and adolescents, in addition to social encouraged. The essential feature of IGD is persistent and
and traditional mass media. Recent data from the USA recurrent participation in computer gaming for typically 8 to
suggest that 8- to 10-year-olds are busy 8 hours per day, 10 hours or more per day and at least 30 hours per week,
and adolescents more than 11 hours per day, with the typically in Internet-based group games (especially massively
recreational use of various electronic media (mobile multiplayer online role-playing games [MMORPG]).
phones, television and videos, computer use, music, print Since IGD has been defined only in 2013, previous liter-
media, Web pages, social media, not including telephone ature uses various terms for describing this clinical entity,
conversations and text messages). This covers more time such as Internet or computer addiction (see ‘Definition’).
than they spend in school or with friends.1,2 While IGD is typical for adolescents and young adults,
For most individuals, computer gaming is an enjoyable preschool and preadolescent children prefer non-Web-
and stimulating activity.3–5 Persons with various intra- and based games. Therefore, the American Psychiatric Associa-
interpersonal risk factors may, however, become attracted tion definition may not exactly fit for younger children and
to using computer gaming as a strategy to overcome indi- those playing offline.
vidual problems. Gaming and seeking for game-related Although IGD may be a serious disorder leading to sig-
pleasure may lead to neglecting ‘normal’ relationships, nificant impairment of personal and social functioning, the
school or work-related duties, and even basic physical definition, symptoms, prevalence, and aetiology have to be
needs. Computer gaming may thus be conceptualized as a seen in view of heterogeneous, incomplete, and changing
continuum from an enjoyable activity to pathological and concepts, and only a few available clinical studies of scien-
even addictive use.6–8 tific quality. We therefore decided to review the scientific

© 2018 Mac Keith Press DOI: 10.1111/dmcn.13754 645

literature on IGD of the past two and a half decades to What this paper adds
provide an up-to-date overview on this disorder. • In representative samples of children and adolescents, on average, 2% are
affected by Internet gaming disorder (IGD).
METHOD • The mean prevalences (overall, clinical samples included) reach 5.5%.
This systematic review was conducted according to the • Definitions are heterogeneous and the relationship with substance-related
addictions is inconsistent.
structured Preferred Reporting Items for Systematic • Many aetiological factors are related to the development and maintenance
Reviews and Meta-Analyses (PRISMA) guidelines for sys- of IGD.
tematic reviews and meta-analyses.10 We searched the lit- • This review presents an integrated model of IGD, delineating the interplay
erature databases ERIC, PsycARTICLES, PsycINFO, of these factors.
PSYNDEX, and PubMed for articles published in English
between January 1991 and August 2016. We searched the gaming could be related to inefficient strategies of dealing
databases using the following terms: pathological gaming with life problems, poor time management, or other
[computer games OR video games OR online games OR underlying mental health problems. Interestingly, there is
Internet games] AND [abuse OR addiction OR compulsive no IGD Medical Subject Headings (MeSH) term available.
OR dependence OR dependency OR disorder OR effects There is also a debate about what amount of time spent
OR excessive OR habits OR misuse OR pathological OR with gaming indicates addiction because increased screen
problem OR problematic]. time relates to IGD.12,13 Griffiths and Meredith14 distin-
Applying the PRISMA guidelines for reviewing articles guished between excessive and addicted gamers depending
on IGD was beset by various problems: IGD is an expan- on the consequences of gaming because gaming may also
sive topic and includes subchapters such as definitions, have positive effects, enabling (virtual) social inclusion,
symptoms, consequences, aetiology, and related and risk increasing self-esteem and social acceptance, and structur-
factors. IGD terminology is inconsistent (see ‘Definition’) ing daily routine. Some authors related IGD symptoms to
and was only defined in 2013 in an amendment to the other disorders such as obsessive–compulsive disorder,
DSM-5.9 We therefore used the various search terms listed attention-deficit–hyperactivity disorder, or depression.15–17
above to retrieve a maximum number of related articles. For the first time, DSM-5 has clearly defined symptom
The aim of our review was to provide an overview on criteria for IGD,9 requiring five or more of the following
the concept and background of IGD. We initially retrieved nine diagnostic criteria during a 12-month period: (1) pre-
3682 articles. Checking the titles and abstracts for related- occupation with Internet games becomes the dominant
ness of the content, we excluded: (1) duplicates and articles activity in daily life; (2) withdrawal symptoms when remov-
with content not relevant to IGD, for example articles on ing the Internet (e.g. irritability, anxiety, or sadness, no
compulsive gambling or articles on the use of specific tech- physical signs of pharmacological withdrawal); (3) need to
nologies such as mobile phones; (2) articles referring only spend increasing amounts of time with Internet gaming
to adults (we only selected articles investigating children (tolerance); (4) lacking control of Internet gaming; (5) loss
and adolescents); (3) articles without reference to IGD. of interest in previous hobbies and entertainment; (6) con-
This reduced the number of relevant articles to 148 tinued excessive use despite knowledge of psychosocial
(4.0%). We additionally included 104 articles, books, and problems; (7) deception of family members, therapists, or
book chapters cited in the original literature or retrieved in others about the amount of Internet gaming; (8) escape
specific searches on subtopics. This summed up to a total from or relief of negative mood (e.g. feeling helpless,
number of 252 references in total. guilty, anxious); (9) loss of important aspects of life (e.g.
significant relationships, jobs, or educational/career oppor-
RESULTS tunities).
Definition The nosological classification of IGD9 is inconsistent
There are several terms and concepts for describing the (the first of the nine proposed criteria includes ‘Internet
pathological use of computer technology: IGD, Internet games’ only, but does not definitely exclude ‘non-Internet
addiction, technology-based addiction, pathological tech- based computerized games’ under the heading ‘Subtypes’,
nology use, pathological video gaming, pathological Inter- one page later) and still a matter of debate (e.g. Brunborg
net use, computer addiction, screen addiction, addictions et al.,18 M€uller et al.,19 W€ olfling et al.)20 DSM-5 excluded
to video games and online role-playing games, game various differential diagnoses, excessive use of social media,
overuse, video game addiction, smartphone addiction online consumption of sexual content, and excessive online
(http://www.helpguide.org/articles/addiction/smartphone- gambling, because these were considered to relate to
and-internet-addiction.htm.), cyber-relationship addiction, different pathologies. The forthcoming 11th Revision
net compulsions, information overload, excessive, problem, of the International Statistical Classification of Diseases
dependent, pathological, and addicted gamers. and Related Health Problems (ICD-11) will include online
The concept of IGD has been questioned11 because clin- or offline ‘gaming disorder’ (6C51)21 as a distinct nosologi-
ical data on symptoms of ‘true’ addiction are lacking, nega- cal entity after neglecting this disorder in previous
tive consequences may be overemphasized, and Internet editions.22

646 Developmental Medicine & Child Neurology 2018, 60: 645–659

 In addition, the DSM-5 definition of IGD excluded off- primarily exhibiting core symptoms, spend more time with
line and video gaming, probably because there is no suffi- gaming than those exhibiting only peripheral symptoms.
cient evidence for this type of gaming disorder as a Problematic use may lead to tolerance, an important
separate entity. It is not clear whether this restriction is symptom of addiction.8 Gunuc33 indicated that tolerance
justified because online and offline gaming share most fea- and time spent with gaming may play an important role in
tures, with the exception of direct social reinforcement developing addiction because screen time increases with
(team aspects) of online gaming. Furthermore, offline gam- addiction. Tolerance is not always a symptom of addictive
ing is more predominant in younger children,23 possibly behaviour, just as its absence does not exclude addiction. If
because Internet access may more easily be restricted in a gamer does not increase his gaming time (e.g. because of
this age group. With one exception,24 there are no data restricted access), psychological but not behavioural toler-
available on IGD in preschool children. ance may predominate.33 If tolerance develops, symptoms
The criteria for defining non-problematic, problematic, of withdrawal are likely to increase.33,48
and addictive use of computer games are diverse and prob- Craving and withdrawal are important symptoms of
ably best characterized as a continuum that considers vari- pathological gaming.49,50 Different conceptualizations of
ous dimensions such as severity of impairment, personality, withdrawal9,49 may explain why symptoms of craving and
cognitive distortions, psychopathology, and social function- withdrawal were not detected in some studies. Kaptsis
ing.25,26 et al.49 speculated that mild withdrawal symptoms may be
Considering problematic computer, online, or video overlooked because the environment of the gamers has
gaming as a behavioural addiction has led to significant adjusted to the addiction, or because symptoms had only
controversy. For classifying IGD, the recommendation is occurred in specific addictive subtypes. According to the
to differentiate between high engagement, addiction, gam- DSM-5 classification,9 withdrawal symptoms include sad-
ing enthusiasm, and problems related to excessive gaming. ness, irritability, and anxiety, whereas King et al.50 found
High engagement with gaming, contrary to game addic- patients being bored and driven for mental stimulation. A
tion, does not lead to negative consequences.18,27–32 recent article51 suggested that a better definition of with-
Pathological computer gaming and behavioural and sub- drawal symptoms and their duration is required.
stance-related addictions share similarities.33,34 Pathologi- Craving is not listed as a symptom of IGD in the DSM-
cal gamers share neurobiological correlates with 5. It might be considered an aspect of withdrawal.49
behavioural and substance-related addictions.8,35–39 An Related cues may activate specific brain regions and induce
important aspect in this debate relates to the definition of craving sensations.36,52 Dong et al.53 found craving and
addiction,40 which includes characteristic elements such as related changes in functional magnetic resonance imaging
salience, tolerance, withdrawal, relapse, mood modification, (MRI) in patients with IGD but not in subjects with
and tolerating negative consequences as key compo- recreational game use (RGU). Cue-induced craving is
nents.40,41 assumed to play an important role in maintaining addictive
behaviour and producing relapse.54
Symptoms Although cue-induced craving was much stronger in
IGD-related symptoms include excessive screen time, pre- Internet addicts, Niu et al.52 also described craving symp-
occupation with gaming, salience, tolerance, loss of con- toms in non-addicted Internet users.
trol, conflictuousness, mood imbalance, and relapse.8,42–44 Online gaming is a highly heterogeneous condition and
Conflictuousness means repeatedly having internal con- depends on a wide range of psychological factors. It is
flicts or conflicts with others in relation to the excessive important to understand gamers’ individual motives and
gaming activity.41 Mood imbalance (e.g. feelings of guilt, psychological factors to plan effective interventions. Bil-
depression) occurs as a consequence of losing control of lieux et al.55 described five subtypes of online gamer: two
gaming.45 Salience describes a condition where gaming has non-problematic and three problematic, as follows. (1)
become the most important activity in one’s life; and Regulated recreational gamers (non-problematic): ‘low
relapse refers to the tendency to refer to earlier gaming impulsivity traits, high self-esteem’. (2) Regulated social
patterns after periods of abstinence.46,47 role-players (non-problematic): ‘low levels of self-esteem,
When gamers are consistently engaged or preoccupied low impulsivity, and motivations related to social exchange
with thoughts about gaming, or crave gaming during absti- and role-playing’. (3) Unregulated achievers (problematic):
nence, they are about to lose control.47 King et al.46 ‘high scores on all impulsivity facets and primarily moti-
described symptoms of withdrawal, loss of control, and vated by achievement in the game’. (4) Unregulated esca-
conflictuousness as the core symptoms of pathological pers (problematic): ‘low achievement and high escapism,
gaming, and considered other symptoms as peripheral (i.e. poor self-esteem’. (5) Hard-core gamers (highly problem-
not essential for the diagnosis of IGD). Charlton and Dan- atic): ‘highest adverse consequences resulting from gaming
forth41 identified conflictuousness, symptoms of with- and high involvement in the game’.
drawal, relapse/reinstatement, and behavioural salience as Several studies56–59 investigated the validity of the DSM-
core symptoms; and cognitive salience, tolerance, and 5 criteria, showing that some of them were more suited
euphoria as peripheral symptoms. Addicted gamers, than others: ‘escape’ and ‘preoccupation’ were judged as

Review 647
less suited.56,57,59 ‘Deception’ in the study of Ko et al.57 Sex differences
was less suited for identifying IGD, whereas other stud- IGD may be observed up to five times more often in male
ies59,60 found the opposite. ‘Giving up other activities’ and children: IGD was diagnosed in 11.9% of the males and in
‘tolerance’,56,59 as well as ‘withdrawal’,59 and ‘loss of con- 2.9% of the females in a large US study.74 Only two stud-
trol’,56 were also debated. In addition, Ko et al.57 sug- ies75,76 reported no sex-related difference in addicted
gested ‘craving’ as a candidate criterion. Another topic of gamers.
controversy is the problem of a cut-off level because, so
far, there is no criterion standard for defining IGD.56,57,59 Age
The influence of age on IGD prevalence is not clear.
Consequences Unfortunately there are no studies available for younger
Problematic gaming may lead to several negative psychoso- children, with one exception.24 The highest prevalence of
cial consequences and mental health problems affecting IGD was found in adolescents;77 only one recent study
available time, work, education, family, partnership, identified more addicted adults than adolescents.30
friends, social life, psychosocial well-being, social compe-
tence, leisure activities, self-esteem, and loneliness.61–65 Aetiology
Professional and academic problems may include poor The aetiology of IGD is complex and not fully understood.
grades, academic failure, and financial problems.62,65 There IGD ‘can last for years and is not solely a symptom of
is a negative relationship between academic performance comorbid disorders’.13 There are internal and external fac-
and pathological gaming, affecting self-esteem and self- tors related to developing and maintaining the disorder. In
confidence.65 A minority of gamers reported that gaming addition, genetic, learning, motivational, game-related, and
resulted in an overall negative effect on quality of life.62 neurobiological aspects must be considered. It is unclear
Furthermore, Andreassen et al.66 emphasized the relation- whether psychiatric symptoms predispose for, or follow,
ship between psychiatric disorders such as anxiety and IGD because longitudinal studies are scarce.78
depression and gaming addiction. Messias et al.67 found a
higher risk of sadness, suicide ideation, and suicide plan- Internal factors
ning in heavy gamers involved with screen times of more Among the internal factors, deficient self-regulatory and
than 5 hours a day. Pathological media use may also decision-making abilities as a consequence of dysexecutive
reduce sleep duration and disrupt sleep patterns.62,68 IGD problems, mood and reward system dysregulation, and
is also associated with various somatic health and medical avoidant behaviour (escapism, deficient coping with
consequences, such as auditory hallucinations, enuresis, negative emotions), low self-esteem, poor self-efficacy, and
encopresis, wrist, neck, and elbow pain, tendosynovitis neurobiological factors may be involved.
(‘nintendinitis’), obesity, skin blisters, calluses, sore ten- Dysexecutive problems, deficient self-regulation, and decision-
dons, hand–arm vibration syndrome, and peripheral neu- making. Deficient inhibitory control, sensory–motor
ropathy.63,69 In addition, psychosocial and medical coordination, and executive control including self-control
consequences of IGD are similar in males and females.64 have been described in patients with IGD.37,79,80 Lower
To distinguish between causes and consequences, struc- functional connectivity of executive control networks
tural equation models have to be established on the basis along with impaired executive functions were described in
of longitudinal study data. Only a few studies have applied individuals with IGD.80 Compared with healthy individu-
such models, which mainly suffer from sample sizes that als, the anterior insula and the dorsolateral prefrontal cor-
are too small.70 tex are less activated during decision-making tasks in
patients with IGD.81,82 In addition, the volume of the
Prevalence striatum is increased in patients with IGD, which relates
Prevalence rates of IGD vary widely between studies from to impaired cognitive control.83,84 Decreased inhibition of
different countries, ranging from an estimated 0.6% in a impulsivity entails the disability to control compulsive
Norwegian survey71 up to an extreme of 50% in Korea.72 gaming despite serious negative consequences.85 Impaired
This may be caused by differences in assessing instruments, functioning of the amygdala, responsible for emotional
study population,8 and diagnostic criteria of IGD. Preva- control, may be associated with increased emphasis of
lence rates are highest in Eastern Asian countries and male emotions and immediate rewards, leading to excessive
adolescents aged 12 years to 20 years.9 The median preva- gaming without paying attention to negative long-term
lence rate for computer and IGD as calculated from consequences.85
Table I was 5.5%. Selecting the 10 population-based stud- Dysregulation of mood and reward system, avoidant
ies listed in Table I, we obtained a median prevalence of behaviour. Negative and depressed mood, stress, anxiety,
2.0%, which is close to the number of 1.6% of a recent and preference for immediate rewards86,87 are associated
European population-based study.19 with pathological gaming.63,88 Kwon89 hypothesized that
A recent review on 13 longitudinal epidemiological stud- IGD, such as drug abuse, may serve as a self-destructive
ies73 showed a moderate to high symptom stability over strategy for escaping unpleasant real-life problems. Li
2 years, and protective social factors. et al.90 suggested depression to mediate the relationship

648 Developmental Medicine & Child Neurology 2018, 60: 645–659

Table I: Prevalence of computer and Internet gaming disorder (IGD) across various countries

Prevalence
Country Study Investigation Age group Sex (M:F) Method(s) (%) Representative

Australia Thomas and Martin208 CGA 12–54y 42:58 YIAT 5.0 Y, students
Australia Thomas and Martin208 IA 12–54y 42:58 YDQ, 4.6 Y, students
DSM-IV-TR
Austria Batthyany et al.120 CGA 13–18y 54:46 CSVK-R 2.7 Y, students
China Cao et al.231 IA 12–18y 50:50 YDQ 2.4 Y, students
China Xu and Yuan232 Game addiction 13–18y DSM-IV 21.5 Y, students
China Cao et al.233 PIU 10–24y 51:49 YIAT 8.1 Y, students
Germany € sser et al.234
Gru Excessive computer 11–14y 54:46 CSVK, ICD-10, 9.3 Y, students
and VG playing DSM-IV-TR
Germany Gruesser et al.6 CGA Average 94:6 ICD-10 11.9 Y, students
21y 1mo
Germany Rehbein et al.29 VGD Average 51:49 VGDS 2.8 Y, students
15y 4mo
29
Germany Rehbein et al. VGD Average 51:49 KFN-CSAS 1.7 Y, students
15y 4mo
Germany Wo€ lfling et al. 235
CGA 13–18y ICD-10 7.5–8.4 Y, students
Germany M€uller et al.236 PIU 8–17y ? AICA-S 11.3 N, patients
Germany M€uller et al.165 IA 14–94y 48:52 AICA-S, CSV-S 2.1 Y
Germany Dreier et al.75 IGD 12–18y AICA-S 5.2 Y, students
Germany Paulus et al.24 CGA 4y 5mo–8y 50:50 YC-CGD 1.9 Y, children
2mo
Europe Mu€ ller et al.
19
IGD 14–17 47:53 AICA-S 1.6 Y
International Porter et al.114 Problem VG use 14–>40y 93:07 VGUQ 8.0 N, students
International Hussain et al.141 Online game 12–62y 77:23 DSM 3.6–44.5 N, gamers
addiction
Iran Zamani et al.237 CGA Grade 2 53:47 QACG 17.1 Y, students
students
the Netherlands van Rooij et al.34 Online VG addiction 13–16y 49:51 CIUS 1.5 Y, students
the Netherlands Haagsma et al.196 PGB 14–81y 50:50 GAS 1.3 Y
the Netherlands Lemmens et al.238 IGD 13–40y 50:50 IGD scales 5.5 Y
(DSM-5)
Norway Bakken et al.239 IA 16–74y 47:53 YDQ 1.0 Y
Norway Arnesen240 VGA 16–40y 44:56 DSM-IV-TR 0.6–4.0 Y
Norway Mentzoni et al.71 Problematic VG use 15–40y GASA 0.6 Y
Norway Wittek et al.241 VGD 16–74y 63:37 GASA 1.4 Y, gamers
Singapore Choo et al.242 Pathological VG 9–13y 73:27 DSM-IV 8.7 Y, students
Singapore Gentile et al.13 Pathological VG use 12–18y 73:27 DSM-IV-TR 9.0 Y, students
South Korea Hur72 IAD IAII and IAD 50.0 Y, students
South Korea Kim et al.243 IA 15–16y 35:65 YDQ 1.6 Y, students
South Korea Lee and Han244 Online game Grade 5 and Own, based 2.5 Y, students
addiction 6 students on YIAT
South Korea Park et al.245 IA 70:30 IAS 10.7 Y, students
South Korea Jeong and Kim246 IA 15–16y 53:47 IAT 2.2 Y, students
Spain Tejeiro Salguero and Mora n247 Problem VG playing 13–18y 54:46 PVP 9.9 Y, students
Spain Lopez-Fernandez et al.248 IGD 11–18y 53:47 PVP 7.7 Y
Taiwan Ko et al.249 IA Average 52:48 CIAS 7.5 Y, students
13y 7mo
250
Taiwan Wan and Chiou Online game 17–24y OAST 34 N
addiction
251
UK Fisher VGA 11–16y 48:52 DSM-IV 19.9 Y, students
UK Griffiths and Hunt252 Dependence on 12–16y 58:42 DSM-III-R 19.9 N
computer games
UK Lopez-Fernandez et al.248 IGD 11–18y 67:33 PVP 14.6 Y
USA Gentile74 Pathological VG use 8–18y 50:50 DSM-IV 8.5 Y

M, male; F, female; CGA, computer game addiction; YIAT, Young’s Internet Addiction Test; Y, yes; IA, Internet addiction; YDQ, Youth
Dependency Questionnaire; DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; CSVK-R,
Fragebogen zum Computerspielverhalten bei Kindern [Questionnaire for computer gaming behaviour in children]; PIU, problematic Inter-
net use; VG, video game; ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision; VGD, video
game dependency; VGDS, Videogame Dependency Scale; KFN-CSAS, Lower Saxony Research Institute of Criminology: Computer Game
Addiction Scale; AICA-S, Assessment for Internet and Computer Game Addiction; N, no; IA, Internet addiction; CSV-S, Scale for the Assess-
ment of Pathological Computer-Gaming; YC-CGD, Young Children – Computer Gaming Disorder Questionnaire; VGUQ, Video Game Use
Questionnaire; DSM, Diagnostic and Statistical Manual of Mental Disorders; QACG, Questionnaire of Addiction to Computer Games; CIUS,
Compulsive Internet Use Scale; PGB, problematic gaming behaviour; GAS, Gaming Addiction Scale; VGA, video game addiction; GASA,
Game Addiction Scale for Adolescents; IAD, Internet addiction disorder; IAII, Internet Addiction Impairment Index; IAS, Internet Addiction
Scale; IAT, Internet Addictions Test; PVP, Problem Video Game Playing scale; CIAS, Chen Internet Addiction Scale; OAST, Online gaming
Addiction Scale for Adolescents in Taiwan; DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised.

Review 649
between actual–ideal self-discrepancy and escapism. On the accumbens. Dopamine levels that are too low or too high
other hand, escapism and game immersion are mediating are associated with impulsivity and risky decisions.104
factors between depression and problematic gaming, Excessive Internet and game use is associated with an over-
promoting IGD (https://bpistone.wordpress.com/2012/ all reward deficiency that is related to reduced dopaminer-
09/03/). gic activity, similar to that in drug abuse.8,79 Videogame
Self-esteem and self-efficacy. Low self-esteem was also found playing was found to induce dopamine releases similar to
to trigger pathological gaming behaviour.91 Excessive cocaine.79 Some authors have suggested an association
gamers are attracted to games because gaming stimulates between IGD and a dysfunction of the dopaminergic sys-
the experience of power and autonomy, and strengthens tem.79 Vousooghi et al.94 found a reduced number of D5
self-esteem. Furthermore, pathological gamers tend to dopamine receptors in computer game addicts compared
overvalue gaming rewards, activities, identities (avatars), or with healthy individuals.
items. This stimulates preoccupation with gaming and loss Hoeft et al.105 found sex differences when investigating
of interest in less attractive real-life activities. Avatars (sim- activation and connectivity of brain regions associated with
ulated identities in a game) may enhance the feelings of the mesocorticolimbic reward system.8 The higher risk of
empowerment and strength, and facilitate escape from gaming addiction for males could be related to these neu-
real-life problems.91 ronal differences.65
Neurobiology. Recent research describes neurobiological In summary, neurobiological and functional studies pro-
anomalies in pathological gamers such as altered grey mat- vide strong evidence for structural and functional brain
ter volume, functional connectivity, and activation in speci- changes in pathological gamers.
fic brain regions (especially the ventromedial prefrontal Personal risk factors. Personal risk factors include low self-
cortex) and neurobiological correlates to disorder-specific esteem,55,106–111 social isolation,108,109,111,112 decreased
behaviours and symptoms.92 It is not clear whether these interpersonal relationships and few or no friends in real
alterations are causes and risk factors for IGD or conse- life,113,114 impaired social functioning,13 limited other lei-
quences resulting from excessive gaming. The most com- sure or recreational activities,19,59 low educational or aca-
monly used methods (electroencephalography, positron demic achievement,18,19,115–118 and increased truancy, low
emission tomography, functional MRI, structural MRI commitment to school, and poor school or academic per-
[voxel-based morphometry, diffusion-tensor imaging]) were formance or unemployment.19,27,29,74,119–122
mainly applied in adults. Fr€olich et al.122 found no specific psychiatric disorders
Although pathological gaming is considered a beha- associated with computer game misuse or addiction. The
vioural addiction (e.g. Leeman and Potenza,38 Griffiths authors speculated that their results supported the idea of
et al.,63 Ong et al.,93 Vousooghi et al.),94 multiple similari- IGD as a distinct psychiatric entity. Hart et al.,123 in con-
ties have been described between addictive gaming and trast to Kim et al.,124 Rehbein et al.,29 and Subramaniam
other addictions such as substance dependency or patho- et al.,125 found no self-reported physical reactions or
logical gambling. For example, Fauth-B€ uhler and Mann95 increased stress levels in adolescent students with IGD.
found loss of sensitivity, increased reactivity to related Social factors such as poverty, social exclusion, poor par-
cues, increased impulsivity, and altered reward-based learn- ental competence and supervision, and inconsistent paren-
ing in addictive gamers and pathological gamblers com- tal behaviour play a role in developing IGD. Socio-cultural
pared with healthy individuals. influences such as gender roles, family structure, cultural
Impulsive behaviours are associated with deficits of fron- values, and personal beliefs should also be considered as
tostriatal networks, interhemispheric connectivity, and an related to IGD.126 Only one study reported multiple
altered structure of the insula.96,97 Dysfunction of the pre- comorbid conditions of IGD in younger children.127
frontal cortex and disrupted frontostriatal connectivity Individual factors such as sex, age, personality traits, and
indicate that the frontal lobe fails to regulate emotion-dri- various psychological factors may be related to an
ven urges.96,98 Gaming-related stimuli induce increased increased risk of developing and maintaining IGD.43,55,128
urges and provoke enhanced activation of frontolimbic and Sex. Males, independent of age, bear a higher
mesocorticolimbic reward systems in pathological risk8,19,43,74,107,129–131 of developing IGD, participating in
gamers.95,99 The same brain areas are also involved in cue- MMORPGs,132 and playing more violent games (e.g. Lem-
induced craving with other addictions.36,38,99,100 Moreover, mens et al.)133 They play more often for excitement and
the temporal homogeneity of the regional blood-oxygen- for making friends107 than females. Females engage in
level dependent signal in functional MRI, which presum- gaming for passing time, social networking, texting, online
ably indicates neural activity,101 was found to be increased shopping, but not for fighting or re-enacting negative emo-
in the posterior cingulate cortex in patients with IGD and tions.30,43,66,107,134–138 Wei et al.112 reported that female
with alcohol use disorder.102 gamers presented with shorter durations of online gaming
Substance-related and behavioural addictions affect the and shorter screen times. Social phobia also increases the
‘reward circuit’.38,79,103 The mesolimbic dopamine pathway risk of IGD,112 independent of sex.
is particularly important and includes dopaminergic neu- Age. Age shows an inversely U-shaped relationship to
rons from the ventral tegmental area to the nucleus IGD8,43,66,125,137,139 and correlates with the time spent

650 Developmental Medicine & Child Neurology 2018, 60: 645–659

computer gaming.140,141 Older adolescents have the highest cites seven main online gaming motives: escape, coping,
probability of becoming game addicted.142 This may be fantasy, skill development, recreation, competition, and
related to a greater technology affinity of ‘digital natives’66 social.185
and to the developmental tasks of this age period (personal Cognitive performance. The relationship between cognitive
goals vs life optimization).143 Adolescents are especially performance and IGD is not clear. Hyun et al.131 found
vulnerable to the negative effects of IGD.133 no differences in cognitive performance between addicted
Personality traits. Personality traits are related to develop- and non-addicted gamers. Because of the cross-sectional
ing IGD,144,145 especially impulsivity,55,110,146–148 lower design of most clinical studies, the direction of causality is
self-control/self-regulation ability,124,146,149–151 sensation-, not clear. Park et al.186 found lower comprehension scores
stimulation-, and/or novelty-seeking,119,152,153 inclination resulting in lower social intelligence, and a negative rela-
to boredom,119 risky behaviour,154 hostility/animos- tionship between gaming activity and performance in
ity,119,155,156 and enhanced levels of aggres- attention tasks. The earlier IGD manifests and the longer
sion.19,83,110,124,146,153,154,157,158 it lasts, the lower the performance in attention tasks.
Gruesser et al.6 found only a weak association between
IGD and aggressive behaviour. Because of the cross-sec- External factors
tional design of most studies, a causal link between aggres- Several external factors promote and maintain IGD against
sive behaviour and IGD at present cannot be proved.133 better insight.187 Possible explanations between external
The contribution of the ‘Big Five’ personality traits factors and IGD are provided by learning theory (classical
(neuroticism, extraversion, openness to experience, agree- and operant conditioning, and gratifications theory)188 and
ableness, and conscientiousness)159 to developing and social–cognitive theory (model learning).189,190 External
maintaining IGD is not clear. Introversion, shyness, or low factors include familial, social, and game-related factors.
extraversion have been associated with IGD.116,160–168 Data Familial factors. Poor relationships with parents and peers
about trait empathy are inconsistent, ranging from are associated with IGD.45 Poor parental control and nega-
decreased empathy (e.g. Bartholow et al.)169 to no differ- tive role models, as well as a positive parental attitude
ences except for soft skills deficits.150,170 Other personality towards adolescent substance use, predict both substance
traits related to IGD are decreased conscientious- use and IGD.191,192 Particularly ignorant, oppressive, and
ness,128,160,164,165,167,168 decreased openness,167 agreeable- hostile parents, single parent families, and a broken home
ness, resourcefulness,128,150,161,171,172 irritability,110,146 and context increase the screen time of adolescents.193 In the
high neuroticism/low emotional stabil- Berlin Longitudinal Media Study, a controlled group study
ity.128,153,161,163,165,168,171–175 State and trait anxiety153,163 involving 1207 schoolchildren over a period of 4 years,
are characteristic of IGD. Narcissistic,124,176 avoidant, and ‘family violence’ and ‘poor parental care’ were identified as
schizoid interpersonal traits are also important for IGD.177 key risk factors of IGD.194
It must be stated that personality traits may change dur- Social factors. Team aspects are important motivational
ing individual development.178 Unfortunately, most studies factors for IGD; like-minded players may interact in real
investigating the relationship between personality traits life and in virtual environments. Communication and social
and IGD did not control for this age dependency. Future interaction are essential ingredients of many games, espe-
studies should therefore consider such effects. cially MMORPGs. Haagsma et al.195 reported that online
The preference of problematic game users for online social interaction strengthens meaningful feelings and self-
relationships is related to loneliness, deficient soft regulation, and reduces negative feelings such as loneliness
skills,30,64 and social inhibition.114 Being single bears a and boredom. Shy and isolated children find a safe and
higher risk for developing IGD.43 Caplan179 described that rewarding way of interacting with peers in the virtual
the relationship between loneliness and IGD could be mis- world. The avatar skin may provide a desirable appearance.
taken as social anxiety. In particular, MMORPGs create and provide a social envi-
Substance use disorder. Ong et al.93 found various personal- ronment that is built solely on gaming skills and availabil-
ity factors associated with adolescent substance use disor- ity on screen.
der and IGD. Substance use disorder was associated with a The virtual social environment enables the gamer to
higher risk of childhood adversity and delinquency,132 and interact with people having similar (gaming) interests. This
IGD more with traumatic childhood experiences.180 rather reinforces gaming instead of criticizing it.91 Virtual
Personal motives and preferences. Personal motives and pref- relationships thus become increasingly more important for
erences such as escapism,8,56,181,182 immersion, achieve- the gamer, and virtual rank and status increasingly satisfy
ment, and affiliation are related to IGD.55 Wan and otherwise deficient social needs and reinforce online pres-
Chiou183 described IGD effects as more related to relief ence.91,196 Moreover, the guild or clan may exert social
from dissatisfaction than to gaining satisfaction. Game pressure to attach gamers to the game and keep them
overuse may be related to three motivational factors: emo- active.45 Gamers will receive social rewards for gaming
tional regulation against dysphoria, escaping from real-life skills in the real peer group as well. Pathological gamers
problems, and developing personal relationships with other tend to overestimate gaming rewards, activities, virtual
gamers.184 The Motives for Online Gaming Questionnaire identities, or hard-earned ‘valuable’ items (weapons, life

Review 651
energy, treasures, etc.). Overestimating such features may Complex models
be another reason for losing interest in real-life activities.91 Considering the complex aetiology of IGD, various models
Wan and Chiou183 found no relationship between expe- of the disorder have been developed. These models include
riencing a ‘flow state’ and excessive gaming, whereas Hull behavioural, psychopathological, and social aspects with
et al.197 highlighted the experience of a flow state as various weights. Cognitive–behavioural dimensions144,214
‘heightened levels of a sense of time being altered during include maladaptive cognitions and thoughts going along
play’, and that pursuing this ‘high’ was a risk factor for with negative self-value, self-doubts, and poor self-efficacy.
IGD. These deficits will promote and maintain pathological
Game-related factors. Structural characteristics of specific Internet use. Defence mechanisms used by pathological
game genres will promote a pathological gaming beha- gamers are ‘stonewalling’, minimizing, blaming (e.g. stress),
viour:198 game ‘immersion’ and increased weekly and holi- excusing, rationalizing, and attacking.214 Strong emotions
day screen time;13,118,164,199–201 strong gaming urges;201,202 such as feelings of excitement when winning or finishing a
non-age-appropriate shooter games or games with forbid- game, powerfulness, relief (escaping from real-world prob-
den content (forbidden fruit hypothesis);19,203,204 (over-) lems), and friendships with ‘electronic friends’ will pro-
involvement in social networks;199 and becoming familiar mote excessive gaming behaviour. Some models were
with specific game characteristics (mental constructs devel- empirically evaluated.196
oped during regular participation).205,206 Haagsma et al.195 proposed and evaluated a cognitive
Internet and role-playing games possess more addictive behavioural model of IGD. The key features of this model
potential than offline games because of their inherent relate to preferences of social interaction, deficits in mood
social reinforcements.195,207,208 In particular, MMORPGs and self-regulation, ruminations, and compulsive aspects.
include addiction-promoting features that attach gamers to The first three factors explained 79% of the variance in
the game;45,209 for example, a never-ending design, the their model. In another publication,215 the authors exam-
possibility of acquiring power, glory, and attractive items ined the model of planned behaviour theory, and found cli-
such as invincible armament, their hierarchical social orga- ents’ perceived lack of control over gaming as the main
nization (e.g. in guilds), and a regular membership fee,210 factor for predicting IGD.
rewards and punishments (earning scores, reaching levels), Dong and Potenza103 proposed a cognitive–behavioural
narrative elements (e.g. an interactive story), realistic model of IGD. Because of an increased reward sensitivity
graphical quality, and fast loading times.209 Another and decreased lack of considering losses,8,216,217 as well as
method to increase game involvement is monetarization: deficient response inhibition218,219 and executive control,80
the obligation to purchase items in ‘free-to-play’ (initially the authors speculated that deficient cognitive control in
cost-free) games.75 Kuss et al.198 found specific motivation, association with enhanced reward seeking would lead to
especially ‘escapism’, and ‘mechanics’, a subcomponent of increased gaming. Gamers exhibit deficiencies in impulse
achievement, but not total screen time to predict control, attentional capabilities,220–222 overall cognitive
MMORPG addiction. MMORPG addiction in college stu- functioning,8,223 and impaired risk perception,224 favouring
dents was predicted by five critical factors: curiosity, role risky decisions because they strive for immediate positive
playing, belonging, obligation, and reward.211 rewards and neglect negative long-term consequences for
Gaming equipment and permanent Internet access influ- social or work domains in real life.225
enced adolescents’ IGD rates: possessing a PlayStation but The multi-disciplinary aetio-pathogenetic model of Dre-
not their own personal computer, Game Boy, television, or ier et al.226 and M€ uller et al.227 includes psychological (e.g.
a powerful Internet access in their own room promoted dysfunctional beliefs), social (e.g. familial dysfunctions,
game addiction.74,122,199 social insecurity), and neurobiological (e.g. neurotransmitter
Additional aspects. Beranuy et al.45 identified three factors dysregulations, dysfunctions of the reward system) IGD-
involved in motivating gamers: entertainment, escapism, promoting factors. Game-related (e.g. success, competition,
and virtual friendships. With increasing screen time, exploration), environmental (e.g. availability, accessibility,
MMORPG gamers start to lose control and narrow their popularity), and personal characteristics (e.g. impulsivity,
behavioural focus. Griffiths and Beranuy,212 investigating negative self-concept, neuroticism), motivational states (e.g.
subjective deficiencies in MMOPRG gamers, found lack of escapism, compensation, coping), and specific game features
real friends, difficulties in relationships, and problems with (e.g. reward, curiosity, obligation) help to maintain IGD
physical appearance as key motivational factors for gaming. within vicious circles despite negative consequences.
Furthermore, the use of non-age-appropriate games or Another complex bio-psycho-social process model, the
games with forbidden content (‘forbidden fruit hypothe- Interaction of Person-Affect-Cognition-Execution (I-
sis’),19,203,204 involvement in social networks,199 and Inter- PACE) model,228 integrates psychological and neurobio-
net access at home213 as well as psychopathological logical aspects of IGD. In short, a person defined by their
comorbidities such as attention-deficit–hyperactivity disor- core characteristics (influenced by numerous biological,
der, depression, social anxiety, autism, etc. and other addi- motivational, and social protective and risk-increasing fac-
tional risk factors will promote IGD. tors) decides to use a certain application in response to

652 Developmental Medicine & Child Neurology 2018, 60: 645–659

 Internal factors
Structural brain deficits (PFC, amygdala, connectivity,
dopaminergic/serotonergic system)

EDF ( ⇐ ADHD)

⇓ self-regulation (impulsivity), ⇓ self-control, ⇓ decision-

making, ⇓ mood regulation

⇓ self-worth, depression, ?OCD

IGD

External factors

Social factors (positive/negative experiences, balance

needs – satisfaction)

Game-related factors (rewards)

Parental influences (example, control, neurobiology)

Figure 1: An integrated model of Internet gaming disorder (IGD). PFC, prefrontal cortex; EDF, executive dysfunction; ADHD, attention-deficit–hyperactiv-
ity disorder; OCD, obsessive–compulsive disorder.

Gaming addiction

>>> time spent

loss of control

Withdrawing
from
social activities
Pathological
gaming Withdrawal
symptoms
>>time spent
Stopping Continuing
Gaming fun increasingly gaming
difficult despite negative
Fun & pleasure experiences &
Self-control disadvantages
Personal maintained
learning effects Caught in vicious
Parental control? circle, poor
Social learning alternatives
Game-related
factors
Self-deficiency,
Personality? depression

Social reward? All or nothing

thinking, low
frustration
tolerance

Personality
Negative social
experiences

Figure 2: The pathway of gaming fun, pathological gaming, and gaming addiction.

their actual situation and their affective and cognitive affective responses under aspects of gratification and the
responses. Internet gaming disorder (IGD) then develops specific neurobiological conditions of diminished executive
as a result of the described personal characteristics and control, despite negative consequences in daily life.

Review 653
DISCUSSION prevalence of 5.5% (Table I) and a median of 2.0% for
Many IGD-affected adolescents will endanger their health, population-based studies that seems more accurate. Male
fail academically, and may become isolated and depressive. adolescents usually manifest higher prevalences than
Reviewing the scientific literature, the evidence of a diag- females.206 Most studies cited in our review investigated
nostic entity of IGD and the pathways to the disorder are adolescents. Only a few individual studies1,13,74,87,118 and
not entirely clear. In particular, long-term follow-up stud- one review article230 included data on children. To the
ies are still lacking. There is some evidence that IGD does best of our knowledge, there is only one study available
not affect anyone but that multiple, often interacting per- investigating IGD in preschool children.24
sonal, familial, and environmental risk factors and comor- Predisposing comorbidities and health-related conse-
bid conditions will contribute towards developing and quences are commonly observed in IGD.20,29,71,184 Causal
maintaining the disorder. associations cannot be analysed because IGD and comor-
Because the paucity of available high-quality, long-term bid disorders such as attention-deficit–hyperactivity disor-
studies impeded us in analysing available studies accord- der, depression, or social anxiety share common
ing to the PRISMA guidelines,10 we can only provide a aetiologies, and may interact. Longitudinal studies that
systematic review on IGD, summarizing the available could resolve this question are lacking. Low parental com-
evidence. petence, personality traits, and problems of self-esteem or
The DSM-5 tentative definition of IGD9 is a good start- social skills may contribute to developing and maintaining
ing point for collecting diagnostic evidence, tolerance, loss IGD.
of control, giving up other interests, and excessive use Summarizing aetiological knowledge, we suggest an inte-
despite clear-cut psychosocial and health-related problems, grated model of IGD (Fig. 1) that delineates the interplay
representing the most stringent criteria. There are, however, of external and internal factors. External and internal fac-
weaknesses of the DSM-5 definition; it excludes other dif- tors are interrelated with each other and with IGD. IGD
ferential diagnoses, and alternative media and content, and may aggravate existing deficits and vice versa; poor social
has the problem of defining ‘hazardous’ screen times.18–20 relations will motivate for gaming, and spending increasing
Developing IGD requires several complex interacting time with gaming will aggravate poor relationships, thus
internal and external factors.103,196 Among these, problems further reinforcing IGD.
of self-regulation and decision-making, dysregulation of Gaming reinforces itself by multiple mechanisms, as
mood, and reward systems are based on neurobiological explained in the section on ‘External factors’. The pathway
deficits that may also explain sex differences.65 Among the towards addiction is characterized by a change of emphasis
external factors, familial deficits, including intrafamilial from fun, through losing control, to obsession. Figure 2
violence and poor parental care, and deficient social skills summarizes this development.
may increase the risk of developing IGD, especially of In conclusion, we have reviewed the current literature
becoming addicted to MMORPGs195 or action real-time for characterizing IGD as a complex, endangering disorder
strategy (shooter) games such as Multiplayer Online Battle with an intricate psychosocial background, and many per-
Arena.229 Finally, several game-related personally and sonal, neurobiological, familial, social, and game-inherent
socially reinforcing factors, as well as steadily improving IGD-promoting factors.
technical performance, will promote IGD.207,208,211
The wide range in IGD prevalence rates relates to dif- A CK N O W L E D G E M E N T S
ferent definitions of IGD, regional differences, and differ- The authors have stated that they had no interests that might be
ent methods of assessment. We found a median IGD perceived as posing a conflict or bias.

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Review 659
 DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY INVITED REVIEW

RESUMEN
~
TRASTORNO DEL JUEGO EN INTERNET EN NINOS  SISTEMATICA
Y ADOLESCENTES: UNA REVISION 

OBJETIVO El trastorno del juego por Internet (IGD, siglas en ingles) es un trastorno grave que provoca y mantiene un deterioro
personal y social relevante. El IGD ha sido considerado en vista de conceptos heteroge neos e incompletos. Por lo tanto, nosotros
revisamos la literatura cientıfica sobre el IGD para proporcionar una visio  n general enfocada en sus definiciones, sıntomas,
prevalencia y etiologıa.
METODO Se revisaron sistematicamente las bases de datos ERIC, PsyARTICLES, PsycINFO, PSYNDEX y PubMed en el perıodo
desde enero del 1991 a agosto del 2016, y adicionalmente se identificaron referencias secundarias.
RESULTADOS La definicio n propuesta en el Manual Diagno stico y Estadıstico de los Trastornos Mentales, Quinta Edicio n
proporciona un buen punto de partida para diagnosticar el IGD, pero conlleva algunas desventajas. El desarrollo del IGD requiere
de varios factores internos que interactu  n del estado de a
 an, tales como deficiencias en el yo la regulacio nimo y las recompensas,
problemas en la toma de decisiones y factores externos, tales como antecedentes de familias deficientes y las habilidades
sociales. Adema  s, factores especıficos relacionados con el juego pueden promover el IGD. Resumiendo, el conocimiento
 gico, sugerimos un modelo integrado del IGD dilucidando la interaccio
etiolo  n de factores internos y externos.
INTERPRETACION  Hasta ahora, el concepto del IGD y las vıas que conducen a el no son del todo claras. En particular, faltan
estudios de seguimiento a largo plazo. El IGD debe entenderse como un peligro de trastorno con un fondo psicosocial complejo.

RESUMO
~ SISTEMATICA
ß AS E ADOLESCENTES: UMA REVISAO
DESORDEM DO JOGO DE INTERNET EM CRIANC 

OBJETIVO A desordem do jogo de internet (DJI) e uma desordem seria causando e mantendo dificuldades pessoais e sociais. A
DJI tem sido considerada em vista de conceitos heteroge ^ neos e incompletos. Portanto, revisamos a literature cientıfica sobre DJI
para fornecer uma visa ~ es, sintomas, prevale
~ o geral com foco em definicßo ^ ncia e etiologia.
METODO Revisamos sistematicamente as bases de dados ERIC, PsyARTICLES, PsycINFO, PSYNDEX, e PubMed para o perıodo de
janeiro de 1991 a agosto de 2016, e adicionalmente identificamos refere ^ncias secunda  rias.
RESULTADOS A definicßa~o proposta pelo Manual Diagno stico e Estatıstico de Desordens Mentais, quinta edicßa~o, fornece um bom
ponto de partida para diagnosticar DJI, mas traz algumas desvantagens. Desenvolver DJI requer a interacßa ~ o de va rios fatores
internos como eu deficiente, regulacßa ~o de humor e recompensa, problemas com tomada de deciso ~ es, e fatores externos como
suporte familiar e habilidades sociais deficientes. Adicionalmente, fatores especıficos relacionados aos jogos podem levar a DJI.
Sintetizando o conhecimento etiolo  gico, sugerimos um modelo integrado de DJI para elucidar a relacßa ~ o entre fatores internos e
externos.
INTERPRETAC ~ Ate o momento, o conceito de DJI e as vias levando a ela na~o sa~o inteiramente claros. Em particular, faltam
ß AO
estudos com acompanhamento de longo prazo. A DJI deve ser entendida como uma desordem perigosa, com complexas bases
psicossociais.