Singapore experience in helping hidden

youth with gaming disorder

Ray Chua

Senior Psychologist

REACH West

National University Hospital, Singapore

Self Introduction

• 30+ years of gaming experience

• 10 years of experience working with gaming

addicts

• Led the counselling and research team at

TOUCH Cyber Wellness

• Leading the Cyber Health and Internet

Programme (CHIP) at REACH West, NUH

• Author of Virtual Realms Real Needs book

Improve mental health of children and

adolescents in schools and at-risk children in the community.

Provide training and support to

School Counsellors , General Practitioners (GP) and Voluntary Welfare Organisations (VWOs) in managing at-risk children and children with mental health conditions

Develop a mental health network for

children and adolescents (including at-risk children) in the community

Introduction to REACH

REACH Network

North - 2007

South - 2009

East - 2010West - 2011

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GPs

SPEDVWO

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REACH (West) Organization ChartProgram Director

A/Prof John Wong Chee Meng

Team Leader &

Senior Psychologist

Mr Ray Chua

Senior Assistant

Manager

Ms Jia Ning

REACH Doctors

Dr Tian Cheong Sing

Dr Celine Wong

Dr Teng Jia Ying

Child resident

Sr / Psychologists / Psychologist

Associates

Ms Yvonne Heng

Ms Nur Ashikin

Ms Goh Lishan

Ms Nona Ooi

Ms Sarah Lam

Mr Loy Xingqi

Ms Saratri Shanti Widiasri

Sr Occupational Therapist

Ms Stephanie Seow

Medical Social Worker

Ms Grace Ooi

Executive Assistant

Ms Shirley Cassandra Paul

Talk Outline

• Social withdrawal in Singapore

• Case vignette of youth with gaming

disorder and social withdrawal

• Case conceptualization and service

provision for the socially withdrawn

Unknown Singaporean Hikikomori

Source: kaizen60000.blogspot.com

Presentation of social withdrawal in SG

• School refusal

– Legal

• Singapore compulsory education act

– Compulsory primary school education

• Secondary schools have to account to Ministry of

Education for registered students who are not in

education, employment or training (NEET)

– Cultural

• Meritocratic society

• Education as a key driver of social mobility

Presentation of social withdrawal in SG

• Compulsory National Service (NS)

– Legal

• Compulsory for males aged 16.5-40 years under

the Enlistment Act

• NS defaulters are liable for jail term and fine

– Pre-enlistment medical screening

• Declare mental illness/psychiatric condition

• Review by psychiatrist

– Possibility of getting exempted from NS if

there is clinical documentation from

psychiatrist of severe house-boundness due

to psychiatric condition

Presentation of social withdrawal in SG

• Gaming disorder

– Usage location

• Home is the main location for gaming

• Fast broadband internet speeds

– Online purchase and download of games

– Parental concern over excessive time spent

on PC and mobile games

Pathological Video-Gaming among Singaporean Youth

• 2,998 primary and secondary school students

• 8.7% were classified as pathological gamers

• Pathological gamers are more likely to:

– Spend twice as much time playing (averaging 37

hours/week)

– Poorer social competence

– Decreasing time with family and friends in past year

because of games

– Neglecting self-care to play games

Choo, H., Gentile, D., Sim, T., Li, D. D., Khoo, A., & Liau, A.

(2010). Pathological video-gaming among Singaporean youth.

M, 16 year old Chinese Male

“Future seems like a fog”

Presentation

• Unusually quiet, perfectionistic personality

• Took a long time to respond to questions, often saying “I

don’t know how to say”

• Extreme dislike in learning Chinese, good results in

other subjects

• School late-coming started in Secondary 1 after

schoolmate commented that he was too quiet and weird

• Said he had no friends, felt lonely during recess

• Started to be absent from school and stopped going to

school completely from June 2017

• Stayed in his room, played games through the night,

slept during the day

• Little communication at home with family members

Service Provision

• Referred to REACH and diagnosed with gaming disorder

• Referred for psychotherapy and his parents referred to

community agency for family therapy

• Therapy sessions at home ended after 3 sessions in Aug

2017 as M felt that it was pointless to continue therapy

• Referred to Enhanced Step-Up programme with YMCA

Project Bridge. Youth worker was to explore alternative

education or vocational training options with M. Only

attended one session with youth worker.

Challenges

• Lack of motivation to engage in psychotherapy

• M’s father not keen for M to see the psychiatrist

• Parents blaming school for not protecting M from school

bullies

• M’s difficulties in self-expression

• M’s parents expecting M to verbalize his difficulties to them

Guiding him through the fog

• School teachers did a home visit in March 2018 to bring

him test papers and chinese new year goodies. M told

teacher that he was keen to seek help through medication.

• Expressed that he would like to do better but he does not

know how and does not feel like it.

• Dr appointment made for him in 3 weeks time. Did not

attend as he was crying at home before appointment.

• Appointment postponed to Apr 2018. M was diagnosed as

having mixed anxiety and depressive symptoms and

prescribed medication.

• Referred to see REACH to resume psychotherapy.

Guiding him through the fog

• Saw M for 7 sessions of psychotherapy in 2018

• Felt that he was unmotivated, unproductive and has

serious problem with procrastination

• Goal for therapy was to find motivation in life

• Employed cognitive behavioural approach in therapy

• Sharing of case formulation to help him understand his

difficulties

– How his anxiety and perfectionistic personality traits led to

avoidance of important tasks and instead engaging in

procrastination activities like gaming

• Engaged in exposure therapy to address anxiety

• Taught M adaptive coping strategies in preparation for

return to school

Case formulation

Predisposing

Factors

Precipitating

Factors

Perpetuating

Factors

Protective

Factors

Shy

temperament

Perfectionistic

personality

traits

Poor verbal

expression

abilities

Bullying and

ostracization in

secondary

school

Use of

avoidance

Low motivation

during periods

of low mood

Black and white

thinking

High self-

expectations

Negative belief

that help from

family means

that he is

incapable

Supportive

school

Supportive

parents and

friends

Seeing light beyond the fog

• Returned to school in Jan 2019

• REACH wrote a memo to school recommending for him to

be dropped from Express to Normal stream to reduce

academic stress. He will take his GCE N levels exams this

year.

• Motivated and engaged at the beginning and wanted to

take two subjects at Express level

• Recurrence of late-coming and absenteeism from school

towards middle of the year

• Told psychiatrist that the reason was that he was lazy

• Doctor felt that it is likely to be avoidance due to increasing

pressure to perform academically. Medication dosage was

increased.

Case reflections

• Continued outreach from school and extended

family was instrumental

• Working with the socially withdrawn takes time

• Case conceptualization is key in helping them

understand their difficulties and in planning for

interventions

Case Conceptualization

• Consider biological, psychological and social

(and spiritual) factors

• Avoid bias of conceptualizing through the lens of

your profession or training

Biological factors

• Physical health problems

– eg, diabetes, eczema

• Mental health disorders

– Psychotic disorders (eg, schizophrenia)

– Anxiety disorders (eg, social anxiety)

– Mood disorders (eg, depression)

– Development disorders (eg, autism)

– Personality disorders (eg, paranoid, schizoid)

– Stress related disorders (eg, PTSD)

Psychological factors

• Early childhood experiences or adverse

childhood events

• Self esteem/image

• Personality

• Procrastination

• Social competence

Social factors

• Societal and family expectations

• Family dynamics

• Parenting styles

• Relationships

• School issues

Service Provision - Outreach

• Be familiar with the typical activities of the

socially withdrawn

– Gaming

– Social media

– Drama shows

– Anime/manga

Service Provision - Outreach

• Physical outreach

– Build rapport through their interests

– Playing games with them

• Virtual outreach

– Gaming worlds, guilds/clans

– Social media

– Online forums

Service Provision - Interventions

• Biological factors

– Medical treatment

– Medication

• Psychological factors

– Psychotherapy

– Case management

• Social factors

– Parenting training

– Family therapy

– School interventions

Summary

• There are the socially withdrawn in every society

but they may present to services under various

forms

• Complex biological, psychological, and social

factors might underlie the social withdrawal

• Services for the socially withdrawn should

ideally assess clients using the biological,

psychological and social framework in order to

provide them with appropriate interventions