videogame, social media and tech dependence

Videogame, Social Media and Tech Dependence

(c)2021 Kenneth M. Woog, Psy. D.

1

Kenneth Woog, BS EEE, MBA, Psy.D.

Computer Addiction Treatment Program

of Southern California

computeraddictiontreatment.com

[email protected]

(949) 422-4120

Videogame, Social Media and Tech Dependence


2

Kenneth Woog, BS EEE, MBA, Psy.D.

Other affiliations:

Sentinel Gaming Systems, Partner

Pepperdine University GSEP, PRYDE

Program Director and Clinical Supervisor

Agenda


3

Problematic Videogame and Social Networking Research Brief Review of Worldwide Research

Review of the Science of Addiction

Proposed Simplified Model of Behavioral Addiction and Dependency Treatment targets

Gaming Disorder Treatment Protocol Also applicable to Social Networking Site Addiction

Case Studies

Questions

Dependency and Addiction are Different


4

Addiction is a very stigmatizing term that

patients may resent. It carries significant

negative implications that a patient has

poor moral character, is weak or lacking

self-control. It is also a term with specific

research, diagnostic and clinical uses.

Dependence is a less stigmatizing term.

Almost 100% of my clients admit to being

dependent but very few will admit to being

addicted.

These two different terms are often used

interchangeably.

Dependency and Addiction Definitions


5

NIDA Addiction Definition Behavioral Definition:

Covers both substance and behavioral addictions.

NIDA Dependence Definition: Withdrawal Proposed Psychological Dependence:

A state in which an organism functions

normally only in the presence of a drug or when

able to engage in a behavior that regulates

mood. Manifested as an emotional disturbance

when the drug is removed or the behavior is

restricted.

Dependency and Addiction are Different


6

Addiction is a state where the dopaminergic

reward pathways have been stimulated by a

substance or behavior to a degree that it

causes the organism to engage in the behavior

or use of the substance and is ultimately

unable to limit such behavior or substance

despite resulting negative consequences.

Psychological Dependence is the need to

intake a substance or engage in a behavior in

order to maintain an adaptive emotional state.

Symptoms of negative mood states will result

from discontinuance of the substance or

behavior.

Both Addiction and Dependency must be

addressed for effective treatment of

behavioral or substance use disorders.

Benefits of Gaming, Social Media and Tech


7

Video Gaming Benefits Hand/eye coordination, cognitive skills, increased

creativity, spatial visual skills, problem solving skills,

multitasking, leadership/teamwork, socializing

opportunities, learning strategies, improved mood

Social Media Benefits Develop/improve social skills, stay connected to friends

and family, learn about new cultural and societal ideas

and issues, increase creativity - share ideas with friends,

becoming better equipped to be active citizens in

society, improve mood

Technology Benefits Improve personal productivity and knowledge, learn new

skills, stay connected to the world, plus so many more…

Is Screen Time Beneficial?


8

Yes! But only to a point - then it is all downhill from there on


9

Problematic Video Gaming Vision problems, repetitive stress injuries, disordered

sleep/eating, anxiety, depression, social phobia, Gaming

Disorder, cognitive fatigue, academic failure, reduced

socialization, family/marital conflict, becoming

disconnected from the real world, isolation

Social Networking Problems Disordered sleeping, anxiety, depression, eating

disorders, addiction/dependency, FOMO, academic

failure, online bullying/harassment, damage to online

reputation, lowered self esteem, online misinformation,

online scams

Technology Costs Dependency on devices to deliver content, distracted

living, avoiding friends and family, 24/7 work availability

But is Too Much of a Good Thing a Disorder?

Yes: For Gaming Disorder

ICD-11 (2018)

Social Networking Addiction

no consensus

A Public Health Problem: The Research


10

Worldwide research however majority of research from China, Taiwan, South Korea

Gaming Addiction serious problem in China and South Korea

Two major areas of study: Gaming Addiction and Social Networking Addiction

SN Addiction research very limited and conflicting

24% of youth constantly on the internet

Estimates 25% of work internet use is social networking

No agreed upon definition or criteria as a mental illness

Gaming Addiction much better researched: prevalence: US/Europe 1.5%-8.2% of gamers in the US, higher in Asia

No high quality clinical treatment outcome studies

Technology 1981


13

1-2 phones

per household

Atari 2600 Console

IBM PC

Space Shuttle Launch

http://en.wikipedia.org/wiki/File:Ibm_pc_5150.jpg

40 Years Later: 2021


14

iPotty

PS5

Xbox Series X

Massive Video Gaming Industry


15

Forecasted $250B+ by 2023

Growing at 9-18% annually, huge growth in mobile gaming

63% increase in video game sales during pandemic

DFC Intelligence 2019

Video Gaming Goes Pro


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• $100s of Millions Committed to League Play • Fierce Competition Between Top Gaming Companies

• Streaming and television viewing income

• eSports Leagues Now at High School and Colleges • College Scholarships Now Available

Problem: Games played and amount of play (hours) put

players at risk of addiction and other health problems

• 16 y/o teen wins $3 million Fortnite Championship 2019!

Advertising and Social Networking


17

Social Networking Has Become THE Dominant Marketing Industry

SmartInsights.com (2017)

Teenagers USA Screen Time 2015


18

Common Sense Media Survey (2015)

26% of teens in front of

a screen 8 hours/day

Media Consumption and Tech Has Helped Us Cope During the Pandemic but…


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• Dramatic increase in screen time for teens:

Video game Internet traffic up 75%

Online Zoom classes adds hours/day

• Less direct face time with friends

• Less sports, enrichment extracurricular

• Less life transition events/ceremonies

• Less travel, vacations

• Less “Real World” interactions

Result:

• Elevated depression, anxiety and

loneliness

• 150% Increase in suicidal ideation and

attempts

• Online media consumption all time high

• Increase in academic failure

Rock Center 20

Copyright© 2013 NBC Universal All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)

Video Game Definition


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“A game in which you press buttons to control and move images on a screen.” (Oxford 2019)

Video Game Technical Definition


22

Commonly provided in exchange for financial compensation, the application of these interventions is intended to facilitate the stimulation of the mesolimbic dopamine pathways of the brain to enhance motivation

for the repeated application of the interventions. (Woog 2021)

Behavioral interventions, often designed using principles of psychology, applied to individuals, often

in groups, through electronics means which may include visual images, sound and user interaction.

Video Games 2021


23

Sophisticated behavioral interventions Designed using principles of developmental, social and behavioral psychology

High user involvement through Powerful sensory stimulation

Social involvement through significant personal relationships

High user involvement is very valuable financially - billions of dollars at stake New business models require as much screen time as possible

Critical that users do not get satiated and change to different games Highly competitive industry

Many parents unable to monitor and or limit the delivery of these interventions Delivered through a variety of devices that are difficult for parents to manage:

Computers, laptops, tablets, game consoles, handheld gaming devices, cell phones

Parents may often give up trying

Excess use results in serious problems for users and their families Health problems, psychiatric and psychological problems, academic, career and social

problems including serious family conflict

Computer Addiction Research 1980s & 1990s


24

1980s - Anecdotal reports emerging

Computer Addiction? Shotton, 1989

Surveyed 127 teen/young adult males

Looked at all computing activities

Multi-user Dungeons and Dragons “…the MUD players hours were perhaps the most disruptive of their family lives than any other group”

1990s Self report surveys

Fisher, Griffiths - Prevalence: 6% , 20%

Problematic Gaming Research 2000s


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Worldwide Prevalence Research: 2.5-34%

2005, 2007 Germany Grusser 15+y/o (n>7000) 9.3-11.9%

2007 S. Korea. Lee & Han 5/6th graders (n=2584) 2.5%

2007 Taiwan. Wan & Chiou 17-24 y/o (n=416) 34%

2008 China. Xu & Yuan 13-18 y/o (n=623) 21.5%

2009 Austria. Battrhyany 13-18 y/o (n=1068) 2.7%

2009 Holland. Lemmens 12-18 y/o (721) 1.4-9.4%

2009 US. Gentile 8-18 y/o (1178) 8.5%

Nationwide Harris Poll Online survey

Criteria similar to pathological gambling

Problems correlated to 25 hrs./week of game play

2010 Australia. Thomas, Porter 14-54 y/o, 5-8%

Survey of Mental Health Professionals Exposure to Problematic Computer Use Woog (2004)

Post Card Mail Survey, postage paid 2003/2004

5000 MD, Psych, MFT (229 responses) across US

How many clients seen, what age groups?

Clinicians saw 3 clients/yr., avg, 0.66 (11-17)

What problematic uses seen (by age group)

How diagnosed? Successful treatment methods?

Did they know someone personally with these problems? >50%

26


Problematic Uses by Age Group Woog (2004)

Age 11-17 Age 18-25 Age 26+

Games 41% 18% 13%

Chat 34% 21% 19%

Sexual 25% 32% 54%

Online Relations 23% 28% 32%

Web Surfing 11% 12% 13%

Gambling 0% 4% 13%

Shopping 0% 4% 10%

Programming 0% 4% 3%


27

Reported Successful Treatment Methods Woog (2004)

Psychotherapy (CBT) - (45%)

Family / Marital Counseling (34%)

Behavior Therapy (33%)

Medication (32%) 11% respondents were psychiatrists

Abstinence (18%)

12 step programs, on-line, gameaholics anon (18%)

Controlled Use (moderation) (17%)

Parent Counseling (15%)

Social Skills Training (12%)

Addiction Counseling (11%)

Control / Monitoring Software - (8%)

28


"Do you believe computer/Internet addiction is a distinct disorder” Woog (2004)

% of respondents

No Yes Can be Don't Know

Treated prior 12 months 28 19 33 20

Not Treated 44 15 15 26

Responded “Yes” or “Can be” a distinct disorder:

Treated within past 12 months: 52%

Not treated within past 12 months: 30%

29


Iowa State University National Institute of Media and the Family

Survey of Video Game Play (2009)

Nationwide Harris Poll Online survey, Gentile et al. (2009)

Sample of 1178 youth 8-18 years of age

11 Questions Similar to Criteria for Pathological Gambling:

Negative Consequences of Play

Avoiding important academic, occupational or social responsibilities

Problematic behaviors as a result of play

8.5% of respondents met 6 or more criteria

Male : Female 4:1

Problematic use correlated to 25+ hours/week of play

30


Make Love, not Warcraft - Southpark

Copyright© 2007 Paramount Pictures All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)

31


1. Attempts at Controlling Excesses

Child Abuses Computer

Parents remove

keyboard/mouse/power cord/router

or install/use parental control software

Child’s obtains hardware or

defeats parental

controls/software

Period of escalating

anger, poor school

performance, sleep

issues

Child challenged to find covert

solution to bypass control.

Highly reinforcing for both

Child and Parent!

Technology divide a parental

vulnerability!

Repeated

cycles

damage

relationship

Options:

1. Play BTPG for months/years

2. Parents give up

3. Remove computer from home

4. Seek professional tx

“Beat the Parents Game!”

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2. Abstinence / Relapse Cycle


Parents remove computer

from home

Child’s attitude improves

Parents return computer to home


anger, poor school

performance, sleep

issues. Deprivation

effects if child addicted.

Period of child

working to get

computer back

Repeated

cycles

damage

relationship

Options:

1. Give up

2. Remove computer long term

3. Seek professional tx

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3. Parent-Child Power Struggle


Parent demands child’s

performance improves as

condition to return computer

Child demands computer

as condition for school

improvement or attendance

OR shuts down, sleeps

excessively in apparent

“depression”


anger, poor school

performance, sleep

issues. Parents finally

have had enough!

Sometimes this is

encouraged by mental

health professionals.

Period of parents

and child locked

in power struggle

Parent removes computer Longer term

cycle

Options:

1. Give up

2. Seek (new) professional Tx

3. Send child away for Tx

34


“Harm Reduction” Treatment Model - 2007

Addict Completes Daily

Responsibilities

Addict is frustrated or angry about

limits. Has extra free time to

pursue other activities.

Total gaming/media time

reduced

Addict learns to accept feelings

of frustration, cravings, while

accruing significant real-life

rewards

Addict Uses Computer with limits

until time runs out

Repeated daily

cycles + real world

rewards =

Harm Reduction

Gaming / Media use not allowed

until after responsibilities are

completed.

• Behavior Therapy:

• Computer use contingent on meeting other daily responsibilities (i.e. homework). Reduce gaming /media rewards through reduction of game play or media time

• Taper down use limits to reduce chance of serious abreaction, depression, self-harm

• PC Moderator was helpful to enforce limits, reduce conflict: minimize “Beat the Parents” game

• Apply as long as possible, limits removed and Addict reassessed

• Individual Psychotherapy / Family Counseling

• Limited or no participation by younger clients

35


Harm Reduction Clinical Observations

Adults not allowed to play videogames as a child can still face issues as an adult.

Problematic use resumed after periods of forced abstinence - sometimes even worse! – Deprivation effect.

Psychotherapy in the absence of behavioral intervention showed poorer outcomes. Poor engagement.

Brief behavioral intervention did not show lasting treatment effects

Premature conclusion of “successful” treatment problematic

Consistent application of the behavioral intervention, even in the absence of psychotherapy resulted in a reduced motivation for play for some clients, and these effects seem to persist long term.

Why? What were the processes that resulted in these treatment effects?


36

Problematic Gaming Research 2010-2019 Brain Imaging: Videogame Play and Addiction


37

Copyright© 2013 NBC Universal All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)

Problematic Gaming Research 2010- Brain Imaging: Videogame Play and Addiction


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Striatal Dopamine confirmed reward center involvement

Structural / behavioral differences found

Game Players of Difference Game Genres

Positive changes observed showing improved functioning in logic or puzzle games

Negative changes observed in action based role-playing games. Problem solving relying on repetitive visual cues (memory)

Gaming Addicts vs. Controls

Negative changes linked to deficits in impulse control, behavioral inhibition, attentional capabilities, and cognitive functioning

Differences in observed activation to presented cues

Problematic Gaming Research 2010-2019

• CBT Models of Internet Addiction and Gaming Disorder Emerging


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• CBT Treatment Methods Proposed Based on These Models

• Methods followed those of substance abuse treatment

• Poor Outcome Study Quality

• Small sample sizes, lack of experimental controls

• Limited specificity of use: Internet Addiction vs. Gaming Addiction

• High dropout rates

• Consensus building for diagnostic criteria for distinct disorder

Gaming Disorder ICD-11 (6C51) (2018)

Gaming disorder is characterized by a pattern of persistent or recurrent gaming

behaviour (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the

internet) or offline, manifested by:

1. impaired control over gaming (e.g., onset, frequency, intensity, duration,

termination, context);

2. increasing priority given to gaming to the extent that gaming takes precedence

over other life interests and daily activities; and

3. continuation or escalation of gaming despite the occurrence of negative

consequences.

The behaviour pattern is of sufficient severity to result in significant impairment

in personal, family, social, educational, occupational or other important areas of

functioning.

The pattern of gaming behaviour may be continuous or episodic and recurrent.

The gaming behaviour and other features are normally evident over a period of at

least 12 months in order for a diagnosis to be assigned, although the required duration

may be shortened if all diagnostic requirements are met and symptoms are severe.


40

Gaming Disorder: ICD-11 (2018)

World Health Organization

Addiction Disorders Restructured

to Include Behavioral Addictions

Disorders due to substance use +

Disorders due to addictive behaviors

Moved Gambling Disorder

Added Gaming Disorder

“gambling” changed to “gaming”

Online vs. offline dropped

Once and for all!

Severity not defined

Not Implemented until 1/1/2022 US perhaps not until 2025 or 2027


41

What is Social Media?


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Websites and applications that enable users to create and share content or to participate in social

networking. (Oxford 2021)

Social Media Technical Definition


43

Providers of these interventions are often compensated by selling access to these individuals via advertising. The application of these interventions is intended to

facilitate the stimulation of the mesolimbic dopamine pathways of the brain to enhance motivation for the

repeated application of the interventions. (Woog 2021)

Behavioral interventions, often designed using principles of psychology, applied to individuals, often

in groups, through electronics means which may include visual images, sound and user interaction.

Social Dilemma


44

Social Media/Networking Research


45

1980’s – No research Chat and messaging in infancy

1990’s – 2009 “Internet Addiction” Captured essence of many different applications of Social

Networking

Emerging awareness of problems related to Social Media

FOMO, body image issues

2010’s – Social Networking Site (SNS) Addiction 2011 – First published literature review of SNS Addiction

Prevalence surveys conflicting, poor sampling: 1-2% US adults

2020’s - Hopefully better research Growing excess use of social networking

Hooked on Facebook:

The Role of Social Anxiety and Need for Social

Assurance in Problematic Use of Facebook Roselyn J. Lee-Won, PhD, Leo Herzog, BA, and Sung Gwan Park, PhD (2015)


46

Cyberbullying, Depression, and Problem Alcohol

Use in Female College Students: A Multisite Study Ellen M. Selkie, MD, MPH, Rajitha Kota, MPH, Ya-Fen Chan, PhD,

and Megan Moreno, MD, MSEd, MPH (2015)

Exploring the Role of Parents and Peers in Young Adolescents’

Risk Taking on Social Networking Sites Wonsun Shin, PhD, and Nurzali Ismail, ME (2014)

Instagram #Instasad?: Exploring Associations Among

Instagram Use, Depressive Symptoms, Negative

Social Comparison, and Strangers Followed Katerina Lup, MA, Leora Trub, PhD, and Lisa Rosenthal, PhD (2015)

Social Media Research


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The Facebook Experiment: Quitting Facebook Leads to Higher Levels of

Well-Being. Tromholt M., Cyberpsychology, behavior and social networking, 19(11), 661–666.

https://doi.org/10.1089/cyber.2016.0259 (2016)

Prolonged Mobile Phone Use Is Associated with Poor Academic

Performance in Adolescents. Xianchen Liu, MD, PhD,1 Yachen Luo, MS,2 Zhen-Zhen Liu,

MD,3 Yanyun Yang, PhD,2 Jianghong Liu, PhD,4 and Cun-Xian Jia, PhD (2020)

Social Media Research

https://doi.org/10.1089/cyber.2016.0259

https://doi.org/10.1089/cyber.2016.0259

Summary of SNS Addiction Andreassen, C.S. Online Social Network Site Addiction: A Comprehensive Review.

Curr Addict Rep 2, 175–184 (2015).


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Bergen Facebook Addiction Scale


49

1. You spend a lot of time thinking about Facebook or planning how to use it.

2. You feel an urge to use Facebook more and more.

3. You use Facebook in order to forget about personal problems.

4. You have tried to cut down on the use of Facebook without success.

5. You become restless or troubled if you are prohibited from using Facebook.

6. You use Facebook so much that it has had a negative impact on your job/studies.

Captures essence of addiction and dependency

Research Summary 2021

Gaming and Social Networking problematic uses distinct but significant overlap Gaming Disorder has been researched more and longer

Gaming contains a Social Networking component

Social Networking integrating gaming applications

Both predict increased Depression and Anxiety (males)

Gaming Disorder is a defined Mental Disorder China/South Korea (15%), US – likely >3%

Negative life outcomes correlate to >25 hours /week

Social Networking excesses lead to problems: Elevated risk of depression, anxiety, body image issues, cyber bullying

and lowered self-esteem

Social Networking Addiction Research Limited Obviously problematic uses, limited prevalence research

Insufficient research to support it as a mental disorder

Dependency symptoms clearing observed


50

We Need a Simplified Model


52

Informs assessment Assessment focused on causes (i.e. excess use), reinforced

problematic behavior and current client functioning

Informs treatment Interventions apply to specific processes and deficits

Educates client and families Externalizes the problem and its causes. Addiction result is normal.

Lack of ability to limit use IS the disorder, not a moral failing

Rationale for interventions that non-professionals can understand Explains why certain parenting interventions not helpful Increases empathy for client struggling with the disorder Helps create realistic expectations for treatment and outcome Helps define the “end” of treatment

Integrates both Addiction and Dependency Understandable and acceptable

(c)2021 Kenneth M. Woog, Psy. D. 53

The Science of Addiction

56

Sufficient Activation Results in Addiction


What is Addiction?


57

Excess reward pathway activation

Altered brain wiring associating the addicting substance or behavior with pleasure

The amount of the brain wiring makes it dominant

Cues in environment trigger reward pathway involvement

Brain changes that result in behavioral deficits:

Behavioral inhibition, impulsivity

Decision making difficulties

The bad news: The brain wiring does not go away

Learning theory

The good news: New wiring can mediate old wiring

Structural Changes and Dependency


58

Video to follow discusses cocaine but applies equally to all addictive substances or behaviors

Real-life Rewards Fade to Gray


59

The Secret Life of the Brain © 2001 PBS All rights reserved Reproduced under Fair Use (Title 17: Chapter 1 § 107)

Range of Pleasure Perception Narrows (conceptual)


60

Recall /Anticipate

Pleasurable Event

Video Gaming

Academic/Occupational

Sports, Exercise

What is Dependence?


61

• The negative feelings

associated with withdrawal

are thought to come from

two sources:

• Diminished activation in

the reward circuitry of the

basal ganglia and

• Activation of the brain's

stress systems in the

extended amygdala.

• Dependence is experiencing withdrawal symptoms, (negative

feelings) upon discontinuing an addictive substance or behavior

Problematic Adolescent Internet Use Research 2014


62

Depressive Symptoms and Problematic Internet Use Among Adolescents: Analysis of the Longitudinal Relationships from the

Cognitive–Behavioral Model Manuel Gamez-Guadix, PhD (2014)

Negative outcomes at an academic, family or social level due to problematic internet use predicted increase in depression symptoms 1 year later

Depressive symptoms at time 1 predicted problematic internet use with negative outcomes one year later

Simplified Dependency Model


63


64

Dependency Model Treatment Targets

Simplified Addiction Model


65

After sufficient play, reward

pathway is hijacked and

structural brain changes

lead to reduced coping and

self regulation functioning

Addiction Model Treatment Targets


66

Decrease consumption levels,

Increase competing activities:

Sports, academics, off-line

socializing, family involvement

Decrease rewards directly via

reduced use (loot, ranking, likes),

punish use through less desired

contingencies. Reduced use time

over extended period to restore

structural deficits

Limit access (strongly enforced) to

(ERP), Mindfulness based

cognitive psychotherapy.

Medications an option to reduce

craving, mood disturbance and

impulsivity

Premack Principle (aka Grandma’s Rule)


67

Contingency Established

Less Preferred Activity (Homework)

Videogame play causes

Homework behavior to increase

BUT as importantly in this case

Motivation for Videogame Play is reduced

To increase the frequency

of a less preferred activity,

a more preferred activity is

made contingent upon the

occurrence of the less

preferred activity.

But less known relationship:

This contingency will also

decrease the frequency of

the more preferred activity.

More Preferred Activity (Videogame Play)

+

-

Unified Gaming* Disorder Treatment Model


68

1. Physical activity, diet, sleep, hygiene,

other leisure activities, psychotherapy,

family counseling, medication

2. Counseling / coaching - identify

enrichment activities (occupational,

educational, social, spiritual, recreational

etc.), establish daily schedule

3. Restrict access to gaming until end of day,

contingent on other activities and responsibilities

and for a reduced amount of time, tapering down

as needed for safety and efficacy

4. Game play daily but with reduced

rewards as a consequence of reduced

play. No play when it needs to be zero.

5. Scheduled wind down after play ends,

psychoeducation, psychotherapy to deal

with urges and impulses.

Interventions Outcome

External Cues

* Substitute any addicting substance or behavior

ERP

Treatment Protocol Overview

Intake Assessment (2 hour session) Initial Sessions (2-6 sessions)

ACT psychotherapy as skills building, coaching, self-help guidance Ongoing assessment Refer out for medication evaluation or adjunctive psychotherapy Agree upon usage limits/goals Socialize to individual and family psychotherapy

Establish Weekly Schedule and Behavioral Contracting (2-4 sessions) Work out issues with behavioral contracting, monitor progress Ongoing Individual and family therapy

Follow up Sessions (6-12 sessions) Taper sessions down to 30 min, then every other week, etc.

Termination Session Maintain behavioral plan past termination Follow up sessions as needed


73

How to Classify and Code Diagnosis ?

No Current Gaming Disorder Diagnosis or ICD Code

We can use:

Diagnosis ICD-10 Adult

Other impulse disorders F63.89, Impulse disorder, unspecified F63.9

Diagnosis ICD-10 Children/Adolescents

F98.9 Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence

Other mood, developmental or behavioral disorders

2025 or 2027 - Gaming Disorder ICD-11 (6C51) Will still need to use ICD or behavioral codes for SNS Addiction


74

Intake Assessment

Assess the problem – questionnaires, interviews (2 hours)

Include parents/significant others if possible/necessary

Identify the negative impact on health, academic, occupational and social domains (Motivational Interviewing)

Identify the impact on the family/couple

Assess for related mental health issues Depression, anxiety, system, developmental delays, other

Identify the amount and times of play AND pseudo-play

5 15 25 35 45 55 65

hrs/week

Not addicted Likely Addicted Very Likely Addicted

Serious Impairment Little Impairment from gaming


76

Intake Assessment (continued)

Brief psycho-education

Science of Addiction, game culture, treatment methods

Practical advice - “Never pull plug on game play”

Discuss goals for treatment

Ask both parents/spouse and addict separately:

“What do you think is a reasonable amount of time?”

“What important responsibilities have suffered as a result of gaming?”

Abstinence or moderation?

Negotiate to starting point - how much and when each day

Discuss reasonable expectations for parents/significant others

Develop a simplified treatment plan

Educate client and family, seek buy-in from client

Contract for specific number of sessions

Limited emphasis on broadcasting a DSM or ICD diagnosis


77

Three Interventions Elements


78

Acceptance and Commitment Therapy


80

Individual-Focused ACT Treatment with Parental Participation Suitable for clients aged 13 (depending on maturity) to 35 Parent(s) attends initial assessment and sessions

Some private sessions with client or parents ACT Model explained as tool to deal with dependency

Normalized - everyone faces this just in different ways Specific issues targeted – parents often willing to share their issues

Initial sessions focus on skills building, later on results May evolve to individual work with client or parent

Between Session Assignments Involve Family Everyone reading “The Happiness Trap” or “Acceptance and

Commitment Therapy in 7 Weeks” watching assigned videos, doing Yoga or guided meditation together as family

Dinner discussions Shared experiences to bring parents/child

together

Acceptance and Commitment Therapy


81

• Benefits: • Improved client attendance and participation • Improved compliance with between-session assignments • Daily in-home monitoring of client’s involvement • Engenders hope and involvement for parents,

improving willingness to continue in treatment • ACT work with parents reduces codependency

• They gain skills, understanding, empathy from the sessions • Regular weekly treatment outcome assessment

• Risks, Challenges • Unwillingness of parents to participate

• Fix my kid or they are an adult! • Parental burnout, schedule conflicts • Parental psychopathology • Excess family or marital conflict

Behavioral Therapy

Identify academic, career, social/relational values and set long/short term goals

Define the activities and milestones in support of goals

Make gaming/media consumption contingent on completing activities in support of client’s goals. Currently using Sentinel Gaming System if needed.

Reduce rewards of gaming/media consumption by reducing time spent

Increase motivation for pursuing goals by linking them to tangible rewards

Client Uses

Computer/Games

Client has frustration about

limits. Now has extra free time

to pursue other activities.

Reduce amount of ALL

media time according to

agreed upon “safe” limits

on a daily basis.

Client learns to have

feelings of frustration

cravings, while accruing

significant real-life rewards

Use is limited each day

Repeated daily

cycles + real

world rewards

= dependency

broken


82

What is a Safe Level? What is not safe…


5 15 25 35 45 55 65 hrs/week

Not dependent Likely dependent Dependent

Serious Impairment Little Impairment Modest Impairment Mild Impairment

• No single number - varies individual to individual

• Genetic/individual variability, life circumstances

• Impairment above 15 hours/week • Time includes all related activities – Twitch, YouTube, Discord

• Significant impairment found at 25 hours/week

• Safe does not mean appropriate for lifestyle / commitments • College, high school students, athletes, parent, spouse

• Never binge for more than 5 hours in any one day!

83

How Much Screen Time is Appropriate?


84

Pre-school age children

Parents and technology Many parents use technology

as a parent helper.

Elementary, Middle School, High School

No guidance from WHO or AAP on amount of time Lifestyle balance, AAP has Media Time Calculator (Hint: just leftover

time)

Guidance on limits to video gaming + other technology screen time*

Gentile et al. (2009), 25+ hrs./week significantly problematic 8 -18 y/o

6-7 (Elementary) <1 hr./day, maximum 6 hrs./week

8-11 (Elementary) <1.5 hrs./day, maximum 9 hrs./week

12-13 (Middle School) <2 hrs./day, maximum 12 hrs. /week

14-18 (High School) < 2.5 hrs./day 15 hrs. /week

Screen time recommendations

0-1 y/o 2-4 y/o 5-18 y/o

0 <1 N/A

0-2 2-5 y/o 6-18 y/o

0 <1 “Balance”

Life Balance Worksheet


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What does the number 168 represent?

The number of hours in a week

Where we spend our 168 matters

This is how we get back in the

game of life

Behavioral Treatment

Behavioral Contracting

Create a weekly schedule

Use gaming/social media time as reward for participation in completing daily activities. Parents provide accountability

Younger clients start with parental controls

Older Clients allow initial attempt at self regulation

Add sports, extracurricular, social activities fill gaps


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Parental Control Challenge 2021


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• Parents not tech-savvy

• Too Many Devices To Track!! • Some you may not

know they have

• 24/7 Content Access

• Many Ways to Connect • Cell Data, WIFI

• Downloadable content

• Device Controls Not That Secure

• Many Ways to Bypass – Google it!

• More “Beat the Parents Game”! • Its fun and they often win!

• Good controls in the hands of non-tech parents

• Internet/Gaming Cafes, Coffee Shops with

WIFI Hotspots

Simplify Media/Gaming Device Availability 93

Consolidate client’s gaming/media use to one device

Other user’s computers/tablets/smartphones in home must be secured (password protected, locked away)

Client’s other computers must be removed These allows secretive use and use in bed, bathroom, etc.

Other media devices except smartphone must be removed

No more Tablets, Ipods (except Nano)

Additional gaming consoles or handheld system must be removed

If possible move computer system into a common area Install/configure limit setting tool (parental control) on System

Agreement that use would not start until certain time

Set to agreed upon daily limits If user cannot self-limit, then they meet the definition of addict

For adults: allow attempt to self regulate smartphone first

If unsuccessful then they must give up the device


Sentinel Gaming System - Designed for the Prevention and Treatment of Videogame Addiction


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High Performance Gaming Desktop PC Windows 10 OS, VR, 4K ready Plays PC, XBOX One*, PS4/5* Games &

Your Phone (Android)

Designed for behavioral treatment protocol Automate behavioral contingencies, Gradual tapering down use automatically Tools to monitor and encourage productive computer time Web based controls can be operated from anywhere with internet View current status or modify settings/limits in real time Usage monitored (when, how long and even view screen images)

Settings for when, how long and how users can operate system Gaming Mode, Study Mode, No Video Modes, GamePlay+

Users may remain System Administrator of the computer system Highly Secure – Tamper and hack resistant Began field testing in 2015 with videogame addicted clients Presented to clients as last resort, the “threat” alone has motivated

some clients!

*Running a Windows 10 app and you

must have the console and games

Mobile Device Parental Controls


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Carrier Based Best Option Cannot be defeated by child (except jailbreak) Some carriers not useful if WIFI available

Data based applications for voice, text, Social Media

Free or monthly fees (varies by carrier) Change carriers if necessary

Application Based Installed app Android “Uninstall protection” prevents removing app

Factory Reset Protection – Android Lolipop+

Apple products provide remote notification of uninstall Features and support vary by product

Be careful … child may get prepaid phone Always be on the lookout for contraband devices

Bottom Line: If you can’t manage it, get rid of it!

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Case Studies Representing the Treatment

Model Presented

Sampling of Clients of 2005 - 2019

Some details modified to ensure confidentiality


Case Study - 17 years old 99

17 y/o male WOW Addiction

Declining / failing grades in high school

Therapist recommended parents remove computer from home until client attended school reliably for two weeks and brought grades up

Parent: “2 weeks of attending school and doing h/w, get computer back”

Child: “Give me back computer or I won’t go to school

30 days later… still not in school

Setup PC Moderator with computer time allowed for attending school, even part day

1 hour school= 1/2 hour computer time

Back in school full time within 1 week

Limits set to daily (2 hours) and weekend (5 hours) use and contingent on doing h/w each weekday


Case Study – 25 years old 100

Had been attending local university for a long time, completed all the credits to graduate but his GPA was below 2.0. Had retaken so many classes could only take 400 level courses to bring up GPA. Parents brought him for treatment for videogame addiction.

Had started new school term with 2 classes, parents worried this would be his last and not graduate. Client claimed he could regulate on his own.

Had done a few family sessions, then parents not willing to participate and continued with individual sessions. Was open, honest and participated in therapy. Recommended Sentinel early on but was refused by client and parents.

Despite client’s self report of good school performance, at midterm, client had an F and a D+ in his courses.

All agreed to Sentinel and behavior plan of studying 8 hours/day and getting 3 hours of gaming time. Parents could not support the behavioral plan, so I did it myself.

Client ended term with an A and B in his classes.


Video Gaming Addiction Treatment Cases Sample of those presented at 2019 Southwestern School for Behavioral Health Studies

Age Referral Behav. Tx Ind. Tx Family Tx Current Status

25 College suspension Sentinel yes as needed ongoing, successful college term

22 College suspension self no no failed recent college term

22 College suspension Sentinel yes 1/month ongoing, successful college term

31 No school, no work Sentinel no 1/week successful college term, employed, moved out

20 College suspension self no as needed failed college, returning to cc college

27 Unemployed, gaming self yes as needed employed, gaming 5-10 hrs./week

16 Declining academics self no 3 sessions schoolwork improved, refused Sentinel

23 College suspension abstinence yes 10 sessions working full time, no gaming, returning college

23 College suspension Sentinel no 1/week working, successful college term, stopped gaming

27 Unemployed, gaming self no 1/month part time employment, gaming >35 hrs/week

23 Failing college Sentinel yes 1/week successful college term

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Chris Revisited


107

Credits / References / Resources 108

Andreassen, C.S. Online Social Network Site Addiction: A Comprehensive Review. Curr Addict Rep 2, 175–184 (2015). https://doi.org/10.1007/s40429-015-0056-9

Cash, H. (2012). Internet Addiction: A Brief Summary of Research and Practice. Current Psychiatry Reviews. Vol .8, No. 4.

DSM-5 (2013) American Psychiatric Association

DFC Intelligence (2019) Worldwide Video Game Market Forecasts

Dong, G. et al (2014) A cognitive-behavioral model of Internet gaming disorder: Theoretical underpinnings and clinical implications. Journal of Psychiatric Research. Nov;58: 7–11.

Gamez-Guadix, M. (2014) Depressive Symptoms and Problematic Internet Use Among Adolescents: Analysis of the Longitudinal Relationships from the Cognitive–Behavioral Model. Cyberpsychol ology Behavior and Social Networking Nov;17(11):714-9. doi: 10.1089/cyber.2014.0226.

Griffiths, M. (2012) Video Game Addiction: Past, Present and Future. Current Psychiatry Reviews. Vol 8, No. 4.

Kuss, D. J., & Griffiths, M. D. (2017). Social Networking Sites and Addiction: Ten Lessons Learned. International journal of environmental research and public health, 14(3), 311. https://doi.org/10.3390/ijerph14030311

Harris, R. (2009). ACT Made Simple: An Easy-To-Read Primer on Acceptance and Commitment Therapy. Oakland, CA: New Harbinger


Credits / References / Resources

King, Daniel & Delfabbro, Paul. (2018). Internet Gaming Disorder: Theory, Assessment, Prevention, and Treatment (1st Edition). 10.1016/C2016-0-04107-4.

NBC News.com Rock Center (2012) Tangled Web. retrieved from: http://www.nbcnews.com/video/rock-center/49754151#49754151

NIDA (2007) The Science of Addiction. Retrieved from: http://www.nida.nih.gov/scienceofaddiction/

Palaus, Marc et al. (2017) Neural Basis of Video Gaming: A Systematic Review. Frontiers in Human Neuroscience Vol 11

Southpark - Comedy Central, Season 10, “Make Love, Not Warcraft”

Substance Abuse and Mental Health Services Administration (US); Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet]. Washington (DC): US Department of Health and Human Services; 2016 Nov. CHAPTER 2, THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424849/

Thompson, C. (2020) Schools confront ‘off the rails’ numbers of failing grades. Associated Press. https://apnews.com/article/distance-learning-coronavirus-pandemic-oregon-7fde612c3dbfd2e21fab9673ca49ad89\


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http://www.nida.nih.gov/scienceofaddiction/

https://apnews.com/article/distance-learning-coronavirus-pandemic-oregon-7fde612c3dbfd2e21fab9673ca49ad89











Credits / References / Resources

Tromholt M. (2016). The Facebook Experiment: Quitting Facebook Leads to Higher Levels of Well-Being. Cyberpsychology, behavior and social networking, 19(11), 661–666. https://doi.org/10.1089/cyber.2016.0259

Wölfling, Klaus, et al. (2019). Efficacy of Short-term Treatment of Internet and Computer Game Addiction. A Randomized Clinical Trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.1676.

World Health Organization (2018), Gaming Disorder http://www.who.int/features/qa/gaming-disorder/en/

Woog, K. (2004) A survey of mental health professionals clinical exposure to problematic computer use. http://www.pcmoderator.com/research.pdf

Woog, K. (2016). Proposed gaming addiction behavioral treatment method. Addicta: The Turkish Journal on Addictions, 3, 271–279.

Young, Kimberly et al. (2010) Internet Addiction: A Handbook and Guide to Evaluation and Treatment. Hoboken NJ: John Wiley & Sons


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http://www.pcmoderator.com/research.pdf

http://www.pcmoderator.com/research.pdf

Longest Running Dedicated Technology Addiction Treatment Programs in US


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David Greenfield, Ph.D. - The Center for Internet and Technology Addiction West Hartford, CT 06119 860-561-8727 Hillarie Cash, Ph.D. - Internet/Computer Addiction Services, reStart Redmond, WA. 98052, (425) 861-5504 Kenneth Woog, Psy.D. - Computer Addiction Treatment Program Lake Forest, Ca 92630, (949) 422-4120 Kimberly Young, Ph.D. - Center for Internet Addiction Recovery Bradford, PA 16701 814-451-2405

Questions? 112

“With technology we are bringing boredom to the brink

of extinction. Satisfying this with the immediate

gratification of media consumption may have tragic

consequences for mankind” (c)2021 Kenneth M. Woog, Psy. D.

videogame, social media and tech dependence

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