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• Published: 10 December 2020

Effect of internet use and electronic game-play on academic performance of Australian children

• Md Irteja Islam 1 , 2 ,
• Raaj Kishore Biswas 3 &
• Rasheda Khanam 1  

Scientific Reports volume  10 , Article number:  21727 ( 2020 ) Cite this article

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This study examined the association of internet use, and electronic game-play with academic performance respectively on weekdays and weekends in Australian children. It also assessed whether addiction tendency to internet and game-play is associated with academic performance. Overall, 1704 children of 11–17-year-olds from young minds matter (YMM), a cross-sectional nationwide survey, were analysed. The generalized linear regression models adjusted for survey weights were applied to investigate the association between internet use, and electronic-gaming with academic performance (measured by NAPLAN–National standard score). About 70% of the sample spent > 2 h/day using the internet and nearly 30% played electronic-games for > 2 h/day. Internet users during weekdays (> 4 h/day) were less likely to get higher scores in reading and numeracy, and internet use on weekends (> 2–4 h/day) was positively associated with academic performance. In contrast, 16% of electronic gamers were more likely to get better reading scores on weekdays compared to those who did not. Addiction tendency to internet and electronic-gaming is found to be adversely associated with academic achievement. Further, results indicated the need for parental monitoring and/or self-regulation to limit the timing and duration of internet use/electronic-gaming to overcome the detrimental effects of internet use and electronic game-play on academic achievement.

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Introduction.

Over the past two decades, with the proliferation of high-tech devices (e.g. Smartphone, tablets and computers), both the internet and electronic games have become increasingly popular with people of all ages, but particularly with children and adolescents 1 , 2 , 3 . Recent estimates have shown that one in three under-18-year-olds across the world uses the Internet, and 75% of adolescents play electronic games daily in developed countries 4 , 5 , 6 . Studies in the United States reported that adolescents are occupied with over 11 h a day with modern electronic media such as computer/Internet and electronic games, which is more than they spend in school or with friends 7 , 8 . In Australia, it is reported that about 98% of children aged 15–17 years are among Internet users and 98% of adolescents play electronic games, which is significantly higher than the USA and Europe 9 , 10 , 11 , 12 .

In recent times, the Internet and electronic games have been regarded as important, not just for better results at school, but also for self-expression, sociability, creativity and entertainment for children and adolescents 13 , 14 . For instance, 88% of 12–17 year-olds in the USA considered the Internet as a useful mechanism for making progress in school 15 , and similarly, electronic gaming in children and adolescents may assist in developing skills such as decision-making, smart-thinking and coordination 3 , 15 .

On the other hand, evidence points to the fact that the use of the Internet and electronic games is found to have detrimental effects such as reduced sleeping time, behavioural problems (e.g. low self-esteem, anxiety, depression), attention problems and poor academic performance in adolescents 1 , 5 , 12 , 16 . In addition, excessive Internet usage and increased electronic gaming are found to be addictive and may cause serious functional impairment in the daily life of children and adolescents 1 , 12 , 13 , 16 . For example, the AU Kids Online survey 17 reported that 50% of Australian children were more likely to experience behavioural problems associated with Internet use compared to children from 25 European countries (29%) surveyed in the EU Kids Online study 18 , which is alarming 12 . These mixed results require an urgent need of understanding the effect of the Internet use and electronic gaming on the development of children and adolescents, particularly on their academic performance.

Despite many international studies and a smaller number in Australia 12 , several systematic limitations remain in the existing literature, particularly regarding the association of academic performance with the use of Internet and electronic games in children and adolescents 13 , 16 , 19 . First, the majority of the earlier studies have either relied on school grades or children’s self assessments—which contain an innate subjectivity by the assessor; and have not considered the standardized tests of academic performance 16 , 20 , 21 , 22 . Second, most previous studies have tested the hypothesis in the school-based settings instead of canvassing the whole community, and cannot therefore adjust for sociodemographic confounders 9 , 16 . Third, most studies have been typically limited to smaller sample sizes, which might have reduced the reliability of the results 9 , 16 , 23 .

By considering these issues, this study aimed to investigate the association of internet usage and electronic gaming on a standardized test of academic performance—NAPLAN (The National Assessment Program—Literacy and Numeracy) among Australian adolescents aged 11–17 years using nationally representative data from the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing—Young Minds Matter (YMM). It is hypothesized that the findings of this study will provide a population-wide, contextual view of excessive Internet use and electronic games played separately on weekdays and weekends by Australian adolescents, which may be beneficial for evidence-based policies.

Subject demographics

Respondents who attended gave NAPLAN in 2008 (N = 4) and 2009 (N = 29) were removed from the sample due to smaller sample size, as later years (2010–2015) had over 100 samples yearly. The NAPLAN scores from 2008 might not align with a survey conducted in 2013. Further missing cases were deleted with the assumption that data were missing at random for unbiased estimates, which is common for large-scale surveys 24 . From the initial survey of 2967 samples, 1704 adolescents were sampled for this study.

The sample characteristics were displayed in Table 1 . For example, distribution of daily average internet use was checked, showing that over 50% of the sampled adolescents spent 2–4 h on internet (Table 1 ). Although all respondents in the survey used internet, nearly 21% of them did not play any electronic games in a day and almost one in every three (33%) adolescents played electronic games beyond the recommended time of 2 h per day. Girls had more addictive tendency to internet/game-play in compare to boys.

The mean scores for the three NAPLAN tests scores (reading, writing and numeracy) ranged from 520 to 600. A gradual decline in average NAPLAN tests scores (reading, writing and numeracy) scores were observed for internet use over 4 h during weekdays, and over 3 h during weekends (Table 2 ). Table 2 also shows that adolescents who played no electronic games at all have better scores in writing compared to those who play electronic games. Moreover, Table 2 shows no particular pattern between time spent on gaming and NAPLAN reading and numeracy scores. Among the survey samples, 308 adolescents were below the national standard average.

Internet use and academic performance

Our results show that internet (non-academic use) use during weekdays, especially more than 4 h, is negatively associated with academic performance (Table 3 ). For internet use during weekdays, all three models showed a significant negative association between time spent on internet and NAPLAN reading and numeracy scores. For example, in Model 1, adolescents who spent over 4 h on internet during weekdays are 15% and 17% less likely to get higher reading and numeracy scores respectively compared to those who spend less than 2 h. Similar results were found in Model 2 and 3 (Table 3 ), when we adjusted other confounders. The variable addiction tendency to internet was found to be negatively associated with NAPLAN results. The adolescents who had internet addiction were 17% less and 14% less likely to score higher in reading and numeracy respectively than those without such problematic behaviour.

Internet use during weekends showed a positive association with academic performance (Table 4 ). For example, Model 1 in Table 4 shows that internet use during weekends was significant for reading, writing and national standard scores. Youths who spend around 2–4 h and over 4 h on the internet during weekends were 21% and 15% more likely to get a higher reading scores respectively compared to those who spend less than 2 h (Model 1, Table 4 ). Similarly, in model 3, where the internet addiction of adolescents was adjusted, adolescents who spent 2–4 h on internet were 1.59 times more likely to score above the national standard. All three models of Table 4 confirmed that adolescents who spent 2–4 h on the internet during weekends are more likely to achieve better reading and writing scores and be at or above national standard compared to those who used the internet for less than 2 h. Numeracy scores were unlikely to be affected by internet use. The results obtained from Model 3 should be treated as robust, as this is the most comprehensive model that accounts for unobserved characteristics. The addiction tendency to internet/game-play variable showed a negative association with academic performance, but this is only significant for numeracy scores.

Electronic gaming and academic performance

Time spent on electronic gaming during weekdays had no effect on the academic performance of writing and language but had significant association with reading scores (Model 2, Table 5 ). Model 2 of Table 5 shows that adolescents who spent 1–2 h on gaming during weekdays were 13% more likely to get higher reading scores compared to those who did not play at all. It was an interesting result that while electronic gaming during weekdays tended to show a positive effect on reading scores, internet use during weekdays showed a negative effect. Addiction tendency to internet/game-play had a negative effect; the adolescents who were addicted to the internet were 14% less likely to score more highly in reading than those without any such behaviour.

All three models from Table 6 confirm that time spent on electronic gaming over 2 h during weekends had a positive effect on readings scores. For example, the results of Model 3 (Table 6 ) showed that adolescents who spent more than 2 h on electronic gaming during weekdays were 16% more likely to have better reading scores compared to adolescents who did not play games at all. Playing electronic games during weekends was not found to be statistically significant for writing and numeracy scores and national standard scores, although the odds ratios were positive. The results from all tables confirm that addiction tendency to internet/gaming is negatively associated with academic performance, although the variable is not always statistically significant.

Building on past research on the effect of the internet use and electronic gaming in adolescents, this study examined whether Internet use and playing electronic games were associated with academic performance (i.e. reading, writing and numeracy) using a standardized test of academic performance (i.e. NAPLAN) in a nationally representative dataset in Australia. The findings of this study question the conventional belief 9 , 25 that academic performance is negatively associated with internet use and electronic games, particularly when the internet is used for non-academic purpose.

In the current hi-tech world, many developed countries (e.g. the USA, Canada and Australia) have recommended that 5–17 year-olds limit electronic media (e.g. internet, electronic games) to 2 h per day for entertainment purposes, with concerns about the possible negative consequences of excessive use of electronic media 14 , 26 . However, previous research has often reported that children and adolescents spent more than the recommended time 26 . The present study also found similar results, that is, that about 70% of the sampled adolescents aged 11–17 spent more than 2 h per day on the Internet and nearly 30% spent more than 2-h on electronic gaming in a day. This could be attributed to the increased availability of computers/smart-phones and the internet among under-18s 12 . For instance, 97% of Australian households with children aged less than 15 years accessed internet at home in 2016–2017 10 ; as a result, policymakers recommended that parents restrict access to screens (e.g. Internet and electronic games) in children’s bedrooms, monitor children using screens, share screen hours with their children, and to act as role models by reducing their own screen time 14 .

This research has drawn attention to the fact that the average time spent using the internet, which is often more than 4 h during weekdays tends to be negatively associated with academic performance, especially a lower reading and numeracy score, while internet use of more than 2 h during weekends is positively associated with academic performance, particularly having a better reading and writing score and above national standard score. By dividing internet use and gaming by weekdays and weekends, this study find an answer to the mixed evidence found in previous literature 9 . The results of this study clearly show that the non-academic use of internet during weekdays, particularly, spending more than 4 h on internet is harmful for academic performance, whereas, internet use on the weekends is likely to incur a positive effect on academic performance. This result is consistent with a USA study that reported that internet use is positively associated with improved reading skills and higher scores on standardized tests 13 , 27 . It is also reported in the literature that academic performance is better among moderate users of the internet compared to non-users or high level users 13 , 27 , which was in line with the findings of this study. This may be due to the fact that the internet is predominantly a text-based format in which the internet users need to type and read to access most websites effectively 13 . The results of this study indicated that internet use is not harmful to academic performance if it is used moderately, especially, if ensuring very limited use on weekdays. The results of this study further confirmed that timing (weekdays or weekends) of internet use is a factor that needs to be considered.

Regarding electronic gaming, interestingly, the study found that the average time of gaming either in weekdays or weekends is positively associated with academic performance especially for reading scores. These results contradicted previous literatures 1 , 13 , 19 , 27 that have reported negative correlation between electronic games and educational performance in high-school children. The results of this study were consistent with studies conducted in the USA, Europe and other countries that claimed a positive correlation between gaming and academic performance, especially in numeracy and reading skills 28 , 29 . This is may be due to the fact that the instructions for playing most of the electronic games are text-heavy and many electronic games require gamers to solve puzzles 9 , 30 . The literature also found that playing electronic games develops cognitive skills (e.g. mental rotation abilities, dexterity), which can be attributable to better academic achievement 31 , 32 .

Consistent with previous research findings 33 , 34 , 35 , 36 , the study also found that adolescents who had addiction tendency to internet usage and/or electronic gaming were less likely to achieve higher scores in reading and numeracy compared to those who had not problematic behaviour. Addiction tendency to Internet/gaming among adolescents was found to be negatively associated with overall academic performance compared to those who were not having addiction tendency, although the variables were not always statistically significant. This is mainly because adolescents’ skipped school and missed classes and tuitions, and provide less effort to do homework due to addictive internet usage and electronic gaming 19 , 35 . The results of this study indicated that parental monitoring and/ or self-regulation (by the users) regarding the timing and intensity of internet use/gaming are essential to outweigh any negative effect of internet use and gaming on academic performance.

Although the present study uses a large nationally representative sample and advances prior research on the academic performance among adolescents who reported using the internet and playing electronic games, the findings of this study also have some limitations that need to be addressed. Firstly, adolescents who reported on the internet use and electronic games relied on self-reported child data without any screening tests or any external validation and thus, results may be overestimated or underestimated. Second, the study primarily addresses the internet use and electronic games as distinct behaviours, as the YMM survey gathered information only on the amount of time spent on internet use and electronic gaming, and included only a few questions related to addiction due to resources and time constraints and did not provide enough information to medically diagnose internet/gaming addiction. Finally, the cross-sectional research design of the data outlawed evaluation of causality and temporality of the observed association of internet use and electronic gaming with the academic performance in adolescents.

This study found that the average time spent on the internet on weekends and electronic gaming (both in weekdays and weekends) is positively associated with academic performance (measured by NAPLAN) of Australian adolescents. However, it confirmed a negative association between addiction tendency (internet use or electronic gaming) and academic performance; nonetheless, most of the adolescents used the internet and played electronic games more than the recommended 2-h limit per day. The study also revealed that further research is required on the development and implementation of interventions aimed at improving parental monitoring and fostering users’ self-regulation to restrict the daily usage of the internet and/or electronic games.

Data description

Young minds matter (YMM) was an Australian nationwide cross-sectional survey, on children aged 4–17 years conducted in 2013–2014 37 . Out of the initial 76,606 households approached, a total of 6,310 parents/caregivers (eligible household response rate 55%) of 4–17 year-old children completed a structured questionnaire via face to face interview and 2967 children aged 11–17 years (eligible children response rate 89%) completed a computer-based self-reported questionnaire privately at home 37 .

Area based sampling was used for the survey. A total of 225 Statistical Area 1 (defined by Australian Bureau of Statistics) areas were selected based on the 2011 Census of Population and Housing. They were stratified by state/territory and by metropolitan versus non-metropolitan (rural/regional) to ensure proportional representation of geographic areas across Australia 38 . However, a small number of samples were excluded, based on most remote areas, homeless children, institutional care and children living in households where interviews could not be conducted in English. The details of the survey and methodology used in the survey can be found in Lawrence et al. 37 .

Following informed consent (both written and verbal) from the primary carers (parents/caregivers), information on the National Assessment Program—Literacy and Numeracy (NAPLAN) of the children and adolescents were also added to the YMM dataset. The YMM survey is ethically approved by the Human Research Ethics Committee of the University of Western Australia and by the Australian Government Department of Health. In addition, the authors of this study obtained a written approval from Australian Data Archive (ADA) Dataverse to access the YMM dataset. All the researches were done in accordance with relevant ADA Dataverse guidelines and policy/regulations in using YMM datasets.

Outcome variables

The NAPLAN, conducted annually since 2008, is a nationwide standardized test of academic performance for all Australian students in Years 3, 5, 7 and 9 to assess their skills in reading, writing numeracy, grammar and spelling 39 , 40 . NAPLAN scores from 2010 to 2015, reported by YMM, were used as outcome variables in the models; while NAPLAN data of 2008 (N = 4) and 2009 (N = 29) were excluded for this study in order to reduce the time lag between YMM survey and the NAPLAN test. The NAPLAN gives point-in-time standardized scores, which provide the scope to compare children’s academic performance over time 40 , 41 . The NAPLAN tests are one component of the evaluation and grading phase of each school, and do not substitute for the comprehensive, consistent evaluations provided by teachers on the performance of each student 39 , 41 . All four domains—reading, writing, numeracy and language conventions (grammar and spelling) are in continuous scales in the dataset. The scores are given based on a series of tests; details can be found in 42 . The current study uses only reading, writing and numeracy scores to measure academic performance.

In this study, the National standard score is a combination of three variables: whether the student meets the national standard in reading, writing and numeracy. Based on national average score, a binary outcome variable is also generated. One category is ‘below standard’ if a child scores at least one standard deviation (one below scores) from the national standard in reading, writing and numeracy, and the rest is ‘at/above standard’.

Independent variables

Internet use and electronic gaming.

In the YMM survey, owing to the scope of the survey itself, an extensive set of questions about internet usage and electronic gaming could not be included. Internet usage omitted the time spent in academic purposes and/or related activities. Playing electronic games included playing games on a gaming console (e.g. PlayStation, Xbox, or similar console ) online or using a computer, or mobile phone, or a handled device 12 . The primary independent covariates were average internet use per day and average electronic game-play in hours per day. A combination of hours on weekdays and weekends was separately used in the models. These variables were based on a self-assessed questionnaire where the youths were asked questions regarding daily time spent on the Internet and electronic game-play, specifically on either weekends or weekdays. Since, internet use/game-play for a maximum of 2 h/day is recommended for children and adolescents aged between 5 and 17 years in many developed countries including Australia 14 , 26 ; therefore, to be consistent with the recommended time we preferred to categorize both the time variables of internet use and gaming into three groups with an interval of 2 h each. Internet use was categorized into three groups: (a) ≤ 2 h), (b) 2–4 h, and (c) > 4 h. Similar questions were asked for game-play h. The sample distribution for electronic game-play was skewed; therefore, this variable was categorized into three groups: (a) no game-play (0 h), (b) 1–2 h, and (c) > 2 h.

Other covariates

Family structure and several sociodemographic variables were used in the models to adjust for the differences in individual characteristics, parental inputs and tastes, household characteristics and place of residence. Individual characteristics included age (continuous) and sex of the child (boys, girls) and addiction tendency to internet use and/or game-play of the adolescent. Addiction tendency to internet/game-play was a binary independent variable. It was a combination of five behavioural questions relating to: whether the respondent avoided eating/sleeping due to internet use or game-play; feels bothered when s/he cannot access internet or play electronic games; keeps using internet or playing electronic games even when s/he is not really interested; spends less time with family/friends or on school works due to internet use or game-play; and unsuccessfully tries to spend less time on the internet or playing electronic games. There were four options for each question: never/almost never; not very often; fairly often; and very often. A binary covariate was simulated, where if any four out of five behaviours were reported as for example, fairly often or very often, then it was considered that the respondent had addictive tendency.

Household characteristics included household income (low, medium, high), family type (original, step, blended, sole parent/primary carer, other) 43 and remoteness (major cities, inner regional, outer regional, remote/very remote). Parental inputs and taste included education of primary carer (bachelor, diploma, year 10/11), primary carer’s likelihood of serious mental illness (K6 score -likely; not likely); primary carer’s smoking status (no, yes); and risk of alcoholic related harm by the primary carer (risky, none).

Statistical analysis

Descriptive statistics of the sample and distributions of the outcome variables were initially assessed. Based on these distributions, the categorization of outcome variables was conducted, as mentioned above. For formal analysis, generalized linear regression models (GLMs) 44 were used, adjusting for the survey weights, which allowed for generalization of the findings. As NAPLAN scores of three areas—reading, writing and numeracy—were continuous variables, linear models were fitted to daily average internet time and electronic game play time. The scores were standardized (mean = 0, SD = 1) for model fitness. The binary logistic model was fitted for the dichotomized national standard outcome variable. Separate models were estimated for internet and electronic gaming on weekends and weekdays.

We estimated three different models, where models varied based on covariates used to adjust the GLMs. Model 1 was adjusted for common sociodemographic factors including age and sex of the child, household income, education of primary carer’s and family type 43 . However, the results of this model did not account for some unobserved household characteristics (e.g. taste, preferences) that are unobserved to the researcher and are arguably correlated with potential outcomes. The effects of unobserved characteristics were reduced by using a comprehensive set of observable characteristics 45 , 46 that were available in YMM data. The issue of unobserved characteristics was addressed by estimating two additional models that include variables by including household characteristics such as parental taste, preference and inputs, and child characteristics in the model. In addition to the variables in Model 1, Model 2 included remoteness, primary carer’s mental health status, smoking status and risk of alcoholic related harm by the primary carer. Model 3 further included internet/game addiction of the adolescent in addition to all the covariates in Model 2. Model 3 was expected to account for a child’s level of unobserved characteristics as the children who were addicted to internet/games were different from others. The model will further show how academic performance is affected by internet/game addiction. The correlation among the variables ‘internet/game addiction’ and ‘internet use’ and ‘gaming’ (during weekdays and weekends) were also assessed, and they were less than 0.5. Multicollinearity was assessed using the variance inflation factor (VIF), which was under 5 for all models, suggesting no multicollinearity 47 .

p value below the threshold of 0.05 was considered the threshold of significance. All analysis was conducted in R (version 3.6.1). R-package survey (version 3.37) was used for modelling which is suited for complex survey samples 48 .

Data availability

The authors declare that they do not have permission to share dataset. However, the datasets of Young Minds Matter (YMM) survey data is available at the Australian Data Archive (ADA) Dataverse on request ( https://doi.org/10.4225/87/LCVEU3 ).

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Acknowledgements

The authors would like to thank the University of Western Australia, Roy Morgan Research, the Australian Government Department of Health for conducting the survey, and the Australian Data Archive for giving access to the YMM survey dataset. The authors also would like to thank Dr Barbara Harmes for proofreading the manuscript.

This research did not receive any specific Grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Md Irteja Islam & Rasheda Khanam

Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh

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Transport and Road Safety (TARS) Research Centre, School of Aviation, University of New South Wales, Sydney, NSW, 2052, Australia

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Islam, M.I., Biswas, R.K. & Khanam, R. Effect of internet use and electronic game-play on academic performance of Australian children. Sci Rep 10 , 21727 (2020). https://doi.org/10.1038/s41598-020-78916-9

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SYSTEMATIC REVIEW article

Massively multiplayer online games and well-being: a systematic literature review.

• 1 School of Health and Behavioural Sciences, University of the Sunshine Coast, Maroochydore, QLD, Australia
• 2 Institute of Health and Sports, Victoria University, Melbourne, VIC, Australia
• 3 School of Psychology, National and Kapodistrian University of Athens, Athens, Greece
• 4 Thompson Institute, University of the Sunshine Coast, Maroochydore, QLD, Australia

Background: Massively multiplayer online games (MMOs) evolve online, whilst engaging large numbers of participants who play concurrently. Their online socialization component is a primary reason for their high popularity. Interestingly, the adverse effects of MMOs have attracted significant attention compared to their potential benefits.

Methods: To address this deficit, employing PRISMA guidelines, this systematic review aimed to summarize empirical evidence regarding a range of interpersonal and intrapersonal MMO well-being outcomes for those older than 13.

Results: Three databases identified 18 relevant English language studies, 13 quantitative, 4 qualitative and 1 mixed method published between January 2012 and August 2020. A narrative synthesis methodology was employed, whilst validated tools appraised risk of bias and study quality.

Conclusions: A significant positive relationship between playing MMOs and social well-being was concluded, irrespective of one's age and/or their casual or immersed gaming patterns. This finding should be considered in the light of the limited: (a) game platforms investigated; (b) well-being constructs identified; and (c) research quality (i.e., modest). Nonetheless, conclusions are of relevance for game developers and health professionals, who should be cognizant of the significant MMOs-well-being association(s). Future research should focus on broadening the well-being constructs investigated, whilst enhancing the applied methodologies.

Introduction

Internet gaming is a popular activity enjoyed by people around the globe, and across ages and gender ( Internet World Stats, 2020 ). With the addition of Internet Gaming Disorder (IGD) in the 5th edition of the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-5; American Psychiatric Association, 2013 ) as a condition requiring further study, followed by the introduction of Gaming Disorder (GD) as a formal diagnostic classification in the 11th edition of the International Classification of Diseases (ICD-11; World Health Organization, 2019 ), research concerning the associated adverse effects of gaming has increased ( Kircaburun et al., 2020 ; Teng et al., 2020 ). Accordingly, a series of potentially harmful aspects of internet gaming, such as reduced social skills, aggression, reduced family connection, interruptions to one's work and education have been cited ( Pontes et al., 2020 ).

Despite such likely aversive connotations, the uptake of internet gaming continues to increase. Recent statistics suggest that 64% of adults in the United States (U.S.) are gamers, 59% of those being male, with the average age range situated between 34 to 45 ( Entertainment Software Association, 2020 ). Of note is that 65% of those gamers are playing with others online or in person and they spend an average of 6.6 h playing per week with others online. Similarly, a survey of 801 New Zealand households (2,225 individuals) revealed that two-thirds play video games, with 34 years being the average age ( Brand et al., 2019 ).

Such high levels of game involvement have been interwoven with high reports of potential well-being benefits in the U.S. sample, including 80% for mental stimulation, 63% for problem solving, 55% for connecting with friends, 79% for relaxation and stress relief, 57% for enjoyment, and 50% for accommodating family quality time ( Entertainment Software Association, 2020 ). Interestingly, 30% of U.S. gamers met a good friend, spouse, or significant other through gaming ( Entertainment Software Association, 2020 ). Thus, video gaming does offer benefits, especially for one's socialization; indeed, gaming can simultaneously engage multiple online players ( Pierre-Louis, 2020 ; Pontes et al., 2020 ).

Multiplayer online games involve a broad genre of internet games, which entail participants playing with others in teams or competing within online virtual worlds ( Barnett and Coulson, 2010 ). A 2017 report of 1,234 Australian households (3,135 individuals) found 67% regularly played video games on computers, tablets, mobile phones, handheld devices, and gaming consoles, with 92% of those playing online with others ( Brand et al., 2017 ). When the “multiple-players” component allows the concurrent inclusion of large numbers (i.e., masses) of gamers, games are referred as massively multiplayer online games (MMOs; Stavropoulos et al., 2019 ). Such games employ the internet to simultaneously host millions of users globally. Participants tend to be organized in groups/teams/alliances competing with each other in the context of game worlds with progressively higher demands and challenges ( Adams et al., 2019 ). Massively multiplayer online role-playing games (MMORPG) expand on this format of play with the introduction of role-playing characteristics through the creation of an avatar. This involves the player establishing their own customizable character for their gameplay, providing an opportunity for gamers to experiment with their own identity in a safe environment ( Stavropoulos et al., 2020 ). Thus, MMORPGs constitute a distinct subgenre of MMOs.

A preponderance of recent research on MMOs has focused specifically on the negative effects of problematic gaming or IGD ( Kircaburun et al., 2020 ; Pontes et al., 2020 ). For instance, a systematic review conducted by Männikkö et al. (2017) focused on health-related outcomes of problematic gaming behavior. This review aligns with prior research that looked at the risk factors and adverse health outcomes of excessive internet usage, particularly among adolescents ( Lam, 2014 ; Goh et al., 2019 ). Despite these efforts, Sublette and Mullan (2012) suggested that the evidence regarding the negative health consequences of gaming is inconclusive (e.g., overall health, sleep, aggression). As Internet games, and especially MMOs, may be also played moderately, they can accommodate a series of beneficial effects for the users such as socialization, a sense of achievement, and positive emotion ( Halbrook et al., 2019 ; Zhonggen, 2019 ; Colder Carras et al., 2020 ). Accordingly, the systematic literature review of Scott and Porter-Armstrong (2013) aimed to offer a more balanced view of the whole range of the positive and the negative effects of participation in MMORPGs, including on the psychosocial well-being of adolescents and young adults. They studied six research articles, where both negative and positive outcomes were identified; for instance, they concluded that problematic/pathological gaming associated with the negative outcomes such as depression, disrupted sleep, and avoidance of unpleasant thoughts. However, they also suggested that the MMORPG context could often provide a refuge from real-world issues, where new friendships and cooperative play could provide enjoyment. Correspondingly, a review of videogame use and flourishing mental health employing Seligman's 2011 positive psychology model of well-being (i.e., positive emotion; engagement; relationships; meaning and purpose; and accomplishment) reported that moderate levels of play was associated with improved mood and emotional regulation, decreased stress and emotional distress, and relaxation. Decisively, Jones and colleagues ( Jones et al., 2014 ) asserted that “videogame research must move beyond a “good-bad” dichotomy and develop a more nuanced understanding about videogame play” (p. 7).

Despite the progress made, no systematic literature to date has synthesized the state of the empirical evidence considering the well-being influences of MMOs. This is important for three reasons: (a) MMOs have had significant advancements in the last 5 years, which may have radically altered their well-being potential (i.e., audio, visual, and augmented reality effects; Alha et al., 2019 ; Semanová, 2020 ); (b) the MMO players community has significantly expanded ( Statista, 2021 ) and; (c) growing empirical evidence has widened the available knowledge of the effects of multiplayer gaming ( Sourmelis et al., 2017 ; Cole et al., 2020 ). Consequently, this present systematic review will contribute to the niche research area referring to the MMOs and well-being association. To address this purpose, the notion of psychosocial well-being and its operationalization needs to be clarified. Scott and Porter-Armstrong (2013) conceived one's level of well-being as expressed through an individual's interpersonal and intrapersonal functioning. In that context, the complexity related to the assessment of one's well-being is acknowledged ( Burns, 2015 ; Linton et al., 2016 ). On that basis, this review utilized the six broad well-being themes as delineated by Linton et al. (2016) to inform the theoretical framework of synthesizing MMO well-being related effects and evidence. The six themes are: (a) mental well-being (e.g., a person's thoughts and emotions); (b) social well-being (e.g., interactions and relationships with others, social support); (c) activities and functioning (e.g., daily activities and behavior); (d) physical well-being (e.g., person's physical functioning and capacity); (e) spiritual well-being (e.g., connection to something greater, faith) and; (f) personal circumstances (e.g., environmental factors; Linton et al., 2016 ).

To enhance the utility of findings, the present review will focus on the most prevalent age range of MMO gamers. The entertainment software association reported that of those playing video games, 21% are under the age of 18 years, 38% between 18 and 34, 26% between 35 and 54 and 15% 55 and over ( Pierre-Louis, 2020 ). In addition, the currently most popular MMOs were identified and targeted. According to the entertainment software association, these involve World of Warcraft, RuneScape, and Guild Wars 2 among gamers older than 13 years ( BeStreamer, 2020 ; Entertainment Software Association, 2020 ). All the available empirical evidence derived by randomized, controlled trials, cross-sectional studies, and case studies with n > 1 that identified any MMOs linked well-being outcomes was included and examined across the six well-being domains identified (see Linton et al., 2016 ). Thus, all the range of interpersonal and intrapersonal well-being outcomes for MMO players over the age of 13 were considered. The ultimate aim of this review is to contribute to balancing the available knowledge surrounding the impact of the popular MMO genre, whilst concurrently illustrating directions for gamer-centered and beneficial future research and mental health practice initiatives.

Materials and Methods

This systematic review followed the methodology suggested in the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA; Moher et al., 2009 ; Shamseer et al., 2015 ). Research team discussion and perusal of related published reviews assisted the development of the initial research eligibility, search strategy, and related terms. Inclusion and exclusion criteria were further refined at the selection process stage, after exposure and familiarity with the research area; this review was limited to research obtained from database searches.

Eligibility Criteria

All research investigating massively multiplayer online gaming were eligible for review. The initial search eligibility criteria were (i) a publication date between 2012 to 2020; (ii) written in or translated into English language; and (iii) full-text, peer-reviewed primary research.

Information Sources and Search Strategy

Searches were conducted in August 2020 using online databases, JB searched PsycNET (APA), and PUBMED; whereas, LR searched Scopus (see Figure 1 ). In each case, the following search terms and protocol were used (massively multiplayer online OR multiplayer online OR MMORPG OR MMOG) to search abstracts and/or titles. Searches were limited by publication date, 2012 to the present. No specific terms for well-being outcomes were prescribed to ensure that the literature search remained expansive. Accordingly, potential well-being effects were assessed at the screening stage.

Figure 1 . PRISMA flow diagram for the present study.

Selection Process and Data Management

After the title search, abstracts were independently screened by two investigators (JB & LR) for positive outcome measures, fitting within the identified well-being parameters (i.e., Linton et al., 2016 ). Example terms included, but were not limited to, “well-being,” “quality of life,” “social support,” “belonging,” “positive affect,” and “cognitive ability.” Where abstracts contained insufficient/unclear information, the full-text was reviewed for accurate evaluation. The resultant items/studies/records were pooled, and duplicates were removed. The remaining, potentially relevant studies were divided equally between LR and JB, and the full studies were subsequently (and independently) assessed. Where uncertainty of inclusion was noted, articles were screened by the alternate investigator (i.e., JB or LR). Then, if uncertainty regarding inclusion still remained, investigator LK was the final arbitrator (see Figure 1 ).

This detailed screening process utilized the following inclusion criteria: (i) qualitative or quantitative research of any design; (ii) written in or translated into English language; (iii) a primary study aim was psychological well-being (or a component of psychological well-being; Linton et al., 2016 ); and (iv) it was clearly indicated that participants were aged 13 years or over [according to Entertainment Software Association (2020) age ranges of high gaming prevalence]. Studies were excluded if: (i) they were single case studies, reviews of any kind (e.g., systematic reviews or meta-analyses), dissertations or theses, or opinions or discussion papers; (ii) the focus was IGD, problematic gaming or addiction; (iii) they involved online gambling, sexual foci (e.g., cybersex), exergaming, or e-sports; (iv) the game was not generally available to the wider community or was an educational tool; (v) they focused on motivations for engaging in online gaming or on learning English language; or (vi) gaming was not played on computers. Once articles were pooled, each reviewer independently recorded the reasons for excluding the articles in a shared file.

Data Extraction Process

The final studies were summarized according to the following characteristics: (1) study design (e.g., cross-sectional survey); (2) sample characteristics (i.e., size, source of recruitment); (3) the specific MMORPG(s) emphasized; (4) variables (i.e., types of social capital, types of networks); (5) instruments for assessing key variables (e.g., time in game, social capital); (6) the type of analysis used; (7) main findings in relation to well-being (e.g., relationship between game and well-being or with belongingness); and (8) limitations. Investigators SR and LR each independently reviewed half of the studies, with joint discussion to resolve any uncertainties. Table 1 summarizes the reviewed studies.

Table 1 . Main characteristics of reviewed studies ( N = 18).

Data Analysis Procedures and Quality

Given the diversity of study objectives and well-being outcomes reviewed, meta-analysis was not plausible. Therefore, a narrative synthesis methodology was adopted, as it involves a textual summation and explanation of the data which was considered appropriate considering the focus of this review ( Greenhalgh et al., 2005 ; Popay et al., 2006 ). Following the goals of this review, the analysis aimed to identify the key positive or well-being outcomes of playing MMORPGs. Consequently, comparable studies/results were grouped together categorizing the data into themes (and subthemes) that drew on the six well-being themes identified by Linton et al. (2016) . A narrative account of these results is presented under relevant thematic headings, along with any pertinent moderating factors ( Greenhalgh et al., 2005 ).

Risk of bias and quality of evidence evaluations were undertaken using the Appraisal tool for Cross-Sectional Studies ( Downes et al., 2016 ) for the quantitative studies, and the Critical Appraisal Checklist for Qualitative Research ( Joanna Briggs Institute, 2020 ) for the studies that used a qualitative methodology. The Mixed Methods Appraisal Tool ( Hong et al., 2018 ) was used by JB and LR to conduct their independent appraisals of each study. These were then compared and discussed across each item/study/record to conclude agreement.

Study Selection

As per the flow of information and studies is shown in Figure 1 , a total of 1695 studies (PsycNET n = 524, PubMed n = 500, Scopus n = 671) were identified through the initial search. After abstracts were reviewed, 1,431 studies were excluded due to not being suitable for the present review. A further 64 studies were removed for duplication. A full-text review was done on the remaining 200 studies. Of these 182 studies were excluded due to age of participants ( n = 8), focus on IGD or addiction ( n = 32), focus on motivations/predictors of play ( n = 24), not being in English ( n = 4), not being primary research ( n = 30), focused on education ( n = 16), full-text unable to be accessed ( n = 4), not exclusively MMO ( n = 8), only measuring in-game behaviors ( n = 29), or not meeting well-being criteria ( n = 27). Following this screening process, 18 studies were included in the final narrative synthesis (see Figure 1 ).

Study Characteristics

The main characteristics, including the aims and purpose of each study, the well-being measures used, and the results of each of the final 18 studies are noted Table 1 . For those studies which reported the gender of their participants, males accounted for the majority, ranging from 65 to 100% [the latter being the case in the qualitative study of Gallup et al. (2016) ]. One study was equally represented gender-wise ( Cole et al., 2020 ) and one had slightly more females (51%) than males ( Doh and Whang, 2014 ). Participants were from North America, China, Korea, Greece, and Australia. For those studies that reported the game platform, World of Warcraft was the most common ( n = 10). Twelve studies measured time spent gaming with variable time measures, such as hours weekly, per week-day, and weekend. Averages of hours per week ranged from 11 to 36.7, while daily hours were estimated to vary between 2 and 5.

Risk of Bias and Quality of Studies

Quality of reporting, study design quality and risk of bias was assessed for each of the 13 cross-sectional studies. All the cross-sectional studies had a moderate level of risk of bias [studies: 1–4, 8–10, 12, 13, 15-18]. This included sample issues [studies, 1-4, 8-10, 12, 13, 15, 17, 18]. Only one study provided information to justify their sample size, and this was through pragmatic rather than statistical reasons ( Zhang and Kaufman, 2015 ). Although seven studies [studies, 1, 4, 8, 10, 12, 13, 17] had sample sizes over 300, sample size was deemed to be an issue of concern given the millions of MMOG players globally ( Internet World Stats, 2020 ). Sampling methods raised concerns regarding risk of bias and study design quality, as most studies relied on self-selection, and one MMOG was the primary data collection source [six studies used this MMOG alone (studies 2, 9, 11, 16–18), while four studies (studies 1, 4, 14, 15) included this MMOG], although conclusions were often made with reference to MMOGs as a whole. Only six studies [studies, 2, 3, 10, 13, 15, 16] acknowledged or raised concerns regarding response rates, but did not provide clear information on this or expected response rates due to the impossibility of determining sampling frames. Furthermore, due to participant self-selection, the majority of studies did not compare responders and non-responders. Of the two studies [4, 15] that did consider response bias, one ( Cole et al., 2020 ) found no difference between non-completers and completers, while the other ( Xanthopoulou and Papagiannidis, 2012 ) found differences on four demographic characteristics (age, gender, occupational, and marital status). Considering the quality of design, the majority of the 13 cross-sectional studies were deemed to fall into a fair category, with a major concern being the omission of whether ethical approval or participant consent was obtained [studies 2, 3, 8–10, 12, 13, 15] and only three studies reporting that there were no funding or other conflicts [studies 2, 12, 17].

The Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research was used to assess risk of bias for the qualitative studies ( Joanna Briggs Institute, 2020 ). Overall, the quality of these four studies [5, 6, 7, 11] was assessed as quite good. The JBI checklist highlighted two key concerns: adequate reporting of the positioning and of the research influence of the investigators. Only two of the four studies provided details as to the role or possible influence of the investigators on the research [studies 5, 7], and only one study [7] provided a statement showing the cultural and or theoretical perspective of the investigator.

Of the 18 studies, four were qualitative [5, 6, 7, 11] one was a mixed method design [14] and the others were all cross-sectional by design [1–4, 8–10, 12, 13, 15–18]. This led to all results showing exclusively correlational and/or regression links/effects, with unclear direction of causality regarding the MMO gaming and well-being experiences association. Only one study ( Xanthopoulou and Papagiannidis, 2012 ) was longitudinal in design with the second measurement being obtained 1 month after the first responses were collected, allowing for stronger predictive inference.

The well-being outcomes assessed in all the studies were operationalized similarly to authors' expectations aligning with the framework provided by Linton et al. (2016) . Two predominant types of positive outcomes were addressed by the included studies: social well-being and mental well-being. Additionally, one study ( Shen and Chen, 2015 ) [13] considered physical well-being. Several game attributes were considered as predictors across the studies reviewed. The most common attribute was the social aspect as examined by 15 studies [2–4, 6–14, 16–18]. This referred to modes of communication (e.g., in-game talk, game bulletin boards, online comms outside the game), “who” the gamers play with (e.g., real-world friends, on-line friends, family), and time spent gaming. The synthesized results are presented through the lenses of the 2 main well-being outcomes identified.

Social Well-Being

Of the 18 studies, 15 included some form of measurement of social well-being. O'Connor et al. (2015) [study 11] reported that participants of WoW game received social support from others within this gaming community. Gallup et al. (2016) [study 6] and Gallup et al. (2017) [study 7] found that using the online game environment was beneficial for secondary and tertiary students with an Autism Spectrum Disorder (ASD) diagnosis, to develop social connections as well as communication and relationship skills. This skill development also led to improved post-secondary education transitioning. Cole et al. (2020) [study 4] also looked at whether social support increased in the gaming environment, finding that more time spent in playing in guilds as related to higher levels of social support, and that this was correlated with cognitive-emotional outcomes. Additionally, they compared on-line and in-person social support and outcomes, finding differential effects. Cole et al. (2020) [study 4] concluded that MMOGs represent different social support environments, and as such, online worlds could be used as a new and different source of social support. These findings are echoed by Voulgari et al. (2014) [study 14], whose mixed methods research across more than 10 MMOGs found that gaming developed collaborative skills and social bonds additional to real-life relationships. Moreover, gaming constituted a part of the gamers' existing real-world social life.

Social capital effects investigated by the reviewed studies included bonding and bridging aspects. Bonding related social capital implies a deeper form of social support, experienced by those with whom one maintains emotional intimacy, such as their family and friends ( Meng et al., 2015 ) [study 10]. In the game context, bonding social capital refers to the support networks within a specific online gaming group or community, such as one's guild (i.e., group of in-game allies) or group within a particular game ( Claridge, 2020 ). Bridging social capital refers to the support, mainly by sharing information and resources, one may experience from broader and less intimate social groups they belong into, such as their social class, race, and religion ( Perry et al., 2018 ) [study 12]. Castillo (2019) [study 2] found greater bridging social capital experienced when gamers presented more motivated to form relationships with others, compared to gaming for competitive reasons. Moreover, Meng et al. (2015) [study 10] found that playing frequently in the online gaming environment with existing offline friends was positively correlated with both higher bridging and higher bonding social capital. This aligned with Kaye et al. (2017) findings, that playing with online and real-world friends, as well as online interactions in-game and outside, was positively related to both higher bridging and higher bonding social capital.

The study by Perry et al. (2018) [study 12] reported that harmonious passion for playing MMOGs helped build social capital; however, when this passion was obsessive, the outcomes were negative. Their study further found that playing with real-life friends was positively associated with higher bonding social capital experienced by gamers. Interestingly, playing with strangers, and possible new friends, was positively associated with increased bridging social capital. Choi (2019) [study 3] extended such findings by focusing on the link between a gamer's social interactions, avatar identification, and social capital. Higher avatar (i.e., in-game figure representing the gamer) identification was related to increased real-life social capital, with one's greater perception of in-game social interactions linked to higher levels of avatar identification and subsequently elevated social capital.

Three of the articles reviewed [Studies 16, 17, & 18] focused specifically on social well-being among older populations, with all participants exceeding 55 years. These studies by Zhang and Kaufman (2015) [study 16], Zhang and Kaufman (2016) [study 17], and Zhang and Kaufman (2017) [study 18] all looked at the social interactions of older adults in MMORPGs. It was found that enjoyment of relationships in the online game was positively related to both bridging and bonding social capital, and this was partly associated to a gamer's amount of game play, active participation in guilds, and their reported enjoyment of the game. The same three studies also suggested that gaming contributed to maintaining existing family and friend relationships, as well as the development of new meaningful friendships. One of the studies, did imply, however, that new online friends did not easily integrate into the older gamers' real lives ( Zhang and Kaufman, 2017 ) [study 18]. They explained that as the result of older adults' lesser need for large networks, as well as geographical limitations.

Lastly, one article looked at social well-being through the lens of marital satisfaction ( Ahlstrom et al., 2012 ) [study 1]. They reported that compared to couples where only one member is a gamer, couples who game together experience higher levels of marital satisfaction. Higher marital satisfaction was related to more time spent in in-game interaction and higher satisfaction of playing together. They supported that gaming is a leisure activity, where when only one person is immersed, disruption to marital harmony may be caused. Indeed, this was confirmed by both types of couples (e. g., only one gaming vs. both gaming), when considering their different or similar bedtimes and their arguments over the time spent in gaming compared to the time spent together.

Mental Well-Being

A smaller proportion of studies looked at the effects of MMOG on components of mental well-being such as self-esteem, depression, stress, general affect, and skill acquisition. Self-esteem was specifically identified in three articles [Studies 3, 4, & 8] and was related to social support received in the game and with positive gamer identities in an MMORPG ( Kaye et al., 2017 ; Choi, 2019 ; Cole et al., 2020 ). In their study investigating MMO involvement, gamer identity, and social capital, Kaye et al. (2017) [study 8] found that higher MMO involvement increased with higher bonding and bridging social capital and solidified gamers' identity, which in turn increased their self-esteem and decreased their loneliness. Similarly, Choi's 2019 [study 3] study into the effects of avatar self-identification indicated that perceptions of social support from MMORPG increased avatar identification alongside the gamers' real-life self-esteem. In their examination of a Compensatory Social Interaction Model, Cole et al. (2020) [study 2] investigated the associations between one's MMORPG guild play, social support, peer victimization, self-esteem, depression and stress. Gamers who engaged more in guild play, experienced higher levels of social support (compared to levels of peer victimization), which resulted in improved self-esteem, lower depression, and stress symptoms. Martončik and Lokša (2016) [study 9] directly looked at the social effects of WoW's (i.e., guild affiliation, communication used) on individual's mental well-being. Their study revealed that gamers perceived their level of loneliness as significantly lower in the online world than in the real world. Additionally, gaming with others already known to the player in their real-life decreased perceptions of real-world loneliness. Martončik and Lokša (2016) [study 9] also found that levels of anxiety were lower in the online world, when gamers perceived themselves as less lonely. Similarly, lower levels of loneliness and depression among gamers aged over 55 years were predicted by higher quality of guild play [study 18]. This suggested that for older adults, being an active member of an in-game guild, may improve their emotional well-being ( Zhang and Kaufman, 2017 ).

The mixed methods study by Voulgari et al. (2014) [study 14] contributed information across a combination of different social, cognitive, and emotional well-being outcomes of gaming. Their study found that playing MMOGs had positive impacts on gaining social skills and improving cognitive skills, as well as a positive affective impact. The cognitive skills they identified to have been improved included procedural knowledge and problem-solving skills. The acquisition of such cognitive and social skills was reported to be transferable into their offline world. The authors also reported that for some gamers, positive affective impacts, such as enjoyment and satisfaction, were the most important outcomes. In-game and work leadership skills were looked at by Xanthopoulou and Papagiannidis (2012) [study 15] in their examination on the effects of gaming on real-life employment. They found that in-game active learning was reflected in active learning at work, but only for high game performers. Moreover, transformational leadership was shown to spill over into a player's work life, although this appears to be enhanced by higher game performance.

In that line, Doh and Whang (2014) focused on the development of behavioral statements to establish the gaming environment as a different pathway to use in identity development. They reported that a player's motivation to participate in online gaming could progressively lead to an alternated identity. Lastly, Shen and Chen (2015) explored the effect of gaming related social capital into health-related outcomes. This study found that bonding and not bridging social capital occurring while playing online related to reduced health disruption in one's daily lives.

The increasing preference for MMO gaming for leisure and e-sport has led to a large body of research investigating the possible adverse outcomes related to their excessive usage ( Stavropoulos et al., 2019 , 2020 ). However, less is known about the possible benefits of moderate MMO gaming for one's individual psychosocial well-being. The aim of this review was two-fold: (a) to identify and summarize the empirical evidence for the potential interpersonal and intrapersonal positive well-being outcomes for non-excessive MMO players over the age of 13; and (b) to identify possible research priorities in relation to better understanding the beneficial effects of MMO gaming. Overall, a positive relationship between playing MMOs and social well-being was found.

This systematic review identified 18 studies that were published between 2012 and 2020, and which investigated the adaptive well-being outcomes of MMOG for adolescent and adult players. These studies examined two key aspects of psychosocial well-being, as defined by Linton et al. (2016) . Firstly, one's social well-being, encompassing individuals' connections with others—their interactions, their depth of relationships, and the social support their connections provided, was emphasized by the reviewed empirical evidence. This was the dominant topic of interest, while the gamers' mental well-being (e.g., individual psychological, emotional, and cognitive aspects) followed. In order to investigate these outcomes, gaming attributes such as gaming time, game performance, gamer identity, types of communication one is engaged in, type of co-players (e.g., online or offline friends, family, strangers), and guild membership were examined.

In that context, a commonly used measure of social well-being employed in the studies reviewed was social capital. The significant positive relationship found between MMOG engagement and bridging and bonding social capital in those studies appears promising. Specifically, reviewed findings in studies 2, 10, 12, and 16 suggest there is strong support for the notion that MMO gaming may foster one's social well-being in both virtual worlds and in their off-line lives ( Meng et al., 2015 ; Zhang and Kaufman, 2015 ; Perry et al., 2018 ; Castillo, 2019 ). Moreover, such evidence is strengthened by studies 1, 3, 4, 6, & 18, which utilized more discrete measures of social well-being, such as one's perceptions of social support, social interactions, and marital satisfaction, showing that MMO gaming bolstered these too ( Ahlstrom et al., 2012 ; Gallup et al., 2016 ; Zhang and Kaufman, 2017 ; Choi, 2019 ; Cole et al., 2020 ). These overall positive conclusive impacts on one's social well-being seem to be reasonably robust given (a) the diverse game attributes considered in these studies (e.g., time spent in play, gamer identity, frequency of play with different types of co-players, avatar identification); and (b) the diverse age and ethnicities of gamers that these impacts were found with-including a small and unique group of gamers with ASD. Moreover, the impacts of MMORPG on social well-being were apparent in both quantitative and qualitative research. Nevertheless, and in line with the current PRISMA systematic literature review's study eligibility criteria, it should be reiterated that the majority of the gamers in the studies reviewed were classified as non-problematic gamers, with study 5 actively excluding those who fit criteria for addiction (e.g., Doh and Whang, 2014 ). Similarly, reviewed studies 12 and 18 included gamers who could be classified as experienced and/or as heavy users, yet they had received no formal diagnosis ( Zhang and Kaufman, 2017 ; Perry et al., 2018 ). Thus, due to the wide range of time participants spent gaming, the findings are applicable to both the more casual and immersed gamer populations, solidifying the positive effects of MMO gaming on one's social well-being.

Further, the reviewed studies examined the mental well-being effects of one's MMO gaming. Self-esteem, loneliness, depression, and positive affect were the main psychological outcomes investigated, while studies 7 and 14 looked at cognitive skill acquisition ( Voulgari et al., 2014 ; Gallup et al., 2017 ). Overall, these studies found that gaming bolstered self-esteem, and reduced depression, stress, and loneliness, whilst fostering cognitive and social skills. However, these positive findings should be treated with some caution, as these variables were only considered in a handful of the studies and such revealed effects may be interwoven with one's concurrently experienced positive social well-being outcomes. More studies need to be conducted among MMO gamers, in which mental well-being outcomes are of primary focus, and social variables are controlled for.

Taken together, this review provides validation to game developers, educators, health professionals, and policy makers, that despite evidence regarding the adverse outcomes of excessive MMO gaming and problematic gaming behavior, there are important psychosocial benefits to be gained from moderate and adaptive gaming. This information is relevant to game developers as they should be encouraged to find ways to enhance social contact opportunities. Moreover, it is important that health professionals and educators are aware that MMO gaming is an avenue for social connection and support, similar to other real-world leisure and sporting pursuits. Pathologizing gaming could well undermine the identity, social, and psychological well-being of those who actively benefit by their moderate and adaptive gaming engagement.

Strengths and Limitations

The validity of these results is restricted due to the heterogeneity of methodologies used in the studies reviewed. Although qualitative and quantitative empirical evidence was included, most studies used a descriptive design to assess the self-reported effects of MMO gaming on well-being. Moreover, although many of the studies controlled for some covariates, such as demographic variables or gaming time, variables of interest were narrow, and other unmeasured variables might account for some of the observed effects. Additionally, although many of the predictor measures had solid theoretical bases, others have not been fully trialed (e.g., intensity of interaction, multimodal connectedness), contributing to possible validity issues. Furthermore, the value of the findings is impacted by a lack of generalizable results. For example, self-selection bias was reported by several studies, where heavy gamers or an overly well-educated sample was used, and some studies looked at specific populations (e.g., 55+ years, those with ASD; Zhang and Kaufman, 2015 ; Gallup et al., 2017 ) [See studies 7 & 16]. The sample of MMO games examined was also narrow, with WoW dominating. Finally, only a limited number of well-being constructs were examined by the 18 studies, thus the conclusions regarding well-being have limited generalizability/need to be treated with caution due to narrow constructs covered. Of note was a lack of variety in the well-being outcomes being studied. While social well-being is an important part of MMO gaming, little is known about other aspects of well-being such as mental well-being, spiritual well-being, and physical well-being. The fact that no randomized control trials have been undertaken to contribute to the research on well-being outcomes and MMO participation is an important omission in this field of study.

This review was limited to peer-reviewed studies published in three academic databases between 2012 and August 2020, at one particular point in time. Therefore, the review may be subject to English-language and publication bias, and the studies included may not be a representative sample. Relevant research may also have been missed due to including the use of selected search terms, and this review did not include non-peer-reviewed literature (e.g., theses, conference proceedings), which may have omitted important data. Finally, well-being is a broad concept, and other reviews may generate different empirical evidence dependent on the operationalizations followed.

Despite the noted review-level limitations, this study has several strengths. First, this review used rigorous methodology, following PRISMA guidelines and assessing quality and risk of bias using validated tools. Additionally, the inclusivity of study design has meant we have captured data through diverse approaches with similar outcomes. Finally, the broad search parameters with regards well-being ensured that we did not limit the construct to narrow conceptualizations of well-being outcomes related to MMO gaming.

This review has offered a valuable examination of the current research on the psychosocial benefits of multiplayer online gaming. It is important to note the number of reviewed studies that reported significant positive outcomes regarding social well-being. The major limitation of the review relates to the modest quality of research in the area, and the limited aspects of well-being investigated to date. While social well-being is an important part of MMO gaming, there is very little known about other aspects of well-being such as mental well-being, spiritual well-being, and physical well-being.

Recommendations for future research include broadening the well-being constructs that are investigated in relation to gaming. Clear and consistent operationalization of commonly used variables and measures and standardized demographic information would provide greater validity and comparability of results. Longitudinal research in which baseline measurements of well-being and other variables are taken to assess changes in this outcome, to determine causation and not merely correlational effects is also required. Finally, using a greater variety of gaming platforms, instead of mostly WoW, would provide increased robustness for positive well-being outcomes related to MMOGs.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author/s.

Author Contributions

LR and JB performed the bibliographic search, participated in the selection of included studies, resolved methodological doubts of possible studies, and helped in the all versions of this manuscript. LK-D and VS were senior authors and were involved in the review design and review aim, also the above processes conducted by LR and JB, and manuscript revision and submission. PM, AA, HS, JM, TD, and AW contributed in the interpretation of the results and the improvement of the manuscript. PM also contributed to mentoring in the PRISMA process. All authors contributed to the article and approved the submitted version.

VS has received the Australian Research Council, Discovery Early Career Researcher Award (DE210101107).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: MMOs, internet gaming, systematic literature review, PRISMA, well-being, massively multiplayer online

Citation: Raith L, Bignill J, Stavropoulos V, Millear P, Allen A, Stallman HM, Mason J, De Regt T, Wood A and Kannis-Dymand L (2021) Massively Multiplayer Online Games and Well-Being: A Systematic Literature Review. Front. Psychol. 12:698799. doi: 10.3389/fpsyg.2021.698799

Received: 22 April 2021; Accepted: 25 May 2021; Published: 30 June 2021.

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Copyright © 2021 Raith, Bignill, Stavropoulos, Millear, Allen, Stallman, Mason, De Regt, Wood and Kannis-Dymand. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Vasileios Stavropoulos, Vasileios.Stavropoulos@vu.edu.au

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

A study of experiencing flow through online games interaction exercise

• Published: 02 November 2023
• Volume 43 , pages 12522–12534, ( 2024 )

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• Danhong Zhu 1 ,
• Shaohua Huang 2 &
• Junwei Wang 3  

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The purpose of online games is to enjoy, and several teenagers find this type of online activity to be very enjoyable. Studies show that those with online gaming issues are more likely to display violent, depressed, and anxious behaviors. The primary cause of those disorders is their inability to control and control their own emotions, including their aggression, depression, stress, and other emotional states. This study quantitatively examines the effect of online game exercise interaction sustainability on flow experience, enhancing players’ flow experience by using online game exercise interaction as an explanatory variable. Even detrimental outcomes like bond slave, isolation, and indifference may result from the flow experience. For analysis, this study uses both quantitative research and a questionnaire. However, the length of online games had an inverted U-shaped modulator effect on how much flow experience was influenced by game interaction. Playing video games for an excessive amount of time can diminish the efficiency of game interaction and possibly have psychological effects including Internet bond slave, loneliness, and carelessness. The research summarizes the psychological factors influenced due to online games. The policy implications of this finding are that while acknowledging the positive impact of online game exercise interaction on traffic experience. The research focuses on the moderating effect of game duration and controlling gaming time to avoid the negative impact of online games on adolescents’ psychology.

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A large scale test of the gaming-enhancement hypothesis

Andrew k. przybylski.

1 Oxford Internet Institute, University of Oxford, Oxford, United Kingdom

John C. Wang

2 Nanyang Technological University, Singapore

Associated Data

The following information was supplied regarding data availability:

All study materials and data are available for download using the Open Science Framework: https://osf.io/je786/ .

A growing research literature suggests that regular electronic game play and game-based training programs may confer practically significant benefits to cognitive functioning. Most evidence supporting this idea, the gaming-enhancement hypothesis , has been collected in small-scale studies of university students and older adults. This research investigated the hypothesis in a general way with a large sample of 1,847 school-aged children. Our aim was to examine the relations between young people’s gaming experiences and an objective test of reasoning performance. Using a Bayesian hypothesis testing approach, evidence for the gaming-enhancement and null hypotheses were compared. Results provided no substantive evidence supporting the idea that having preference for or regularly playing commercially available games was positively associated with reasoning ability. Evidence ranged from equivocal to very strong in support for the null hypothesis over what was predicted. The discussion focuses on the value of Bayesian hypothesis testing for investigating electronic gaming effects, the importance of open science practices, and pre-registered designs to improve the quality of future work.

Introduction

Electronic games are now a ubiquitous form of entertainment and it is popularly believed that the time spent playing games might have positive benefits that extend outside of gaming contexts ( Lenhart et al., 2008 ; McGonigal, 2012 ). This general idea, the gaming-enhancement hypothesis , posits that electronic gaming contexts influence a range of perceptual and cognitive abilities because they present complex, dynamic, and demanding challenges. A recent representative study of British adults and young people suggests this idea is widely held; Nine in ten think brain-training games provide an effective way to improve focus, memory, and concentration, and as many as two thirds have tried using these games to improve their own cognitive abilities ( Clemence et al., 2013 ). This view is increasingly profitable and controversial ( Nuechterlein et al., 2016 ). Given the intense public and private interest and investment in games as a way of improving cognition and reasoning, is noteworthy that the scientific literature investigating the gaming-enhancement hypothesis, though promising, is still at an early stage.

A growing body of research suggests that common varieties of electronic gaming experience might enhance general cognitive skills and abilities. These studies show that those who opt to, or are assigned to, play a range of commercially available games show measurable differences in terms of their visual and spatial abilities ( Quaiser-Pohl, Geiser & Lehmann, 2006 ; Green & Bavelier, 2006 ), executive functioning, information processing ( Maillot, Perrot & Hartley, 2012 ), and performance at specialist skills such as laparoscopic surgery ( Rosser et al., 2007 ). In particular, action games ( Green & Bavelier, 2006 ), strategy games ( Basak et al., 2008 ), and multiplayer online games ( Whitlock, McLaughlin & Allaire, 2012 ), have been identified as having enhancing effects because they provide complex multi-tasking environments that require players to integrate a range of sensory inputs. Researchers argue these environments lead players to implement adaptive strategies to meet the varied demands of these virtual contexts ( Bavelier et al., 2012 ).

There is good reason to think that predispositions to engage specific kinds of games may relate to cognitive performance and reasoning more broadly. For example, in studying skill acquisition among strategy game players, researchers have reported evidence that differences in brain volume are correlated with speed and performance in gaming contexts ( Basak et al., 2011 ). Exploration and learning in online gaming contexts closely mirror their offline analogues. Those with pre-existing strengths tend to thrive at online gaming challenges initially, but those with low levels of starting ability quickly close the performance gap ( Stafford & Dewar, 2013 ). It is possible that such inclinations guide players to games that suit them. Findings from experimental and quasi-experimental studies suggest both preference and experience matter in terms of small to moderate effects across a wide range of cognitive performance indicators ( Powers et al., 2013 ).

Unfortunately, many of these studies have pronounced shortcomings that temper the broad promise of the gaming-enhancement hypothesis ( Van Ravenzwaaij et al., 2014 ). For example, most of the evidence supporting this view has been derived from small-scale surveys, intervention studies in university settings, or from samples of older adults. A recent review of this literature indicates a small yet consistent link between gaming and general reasoning ability (Cohen’s d  = 0.24), but the average sample size of studies examining the gaming-enhancement hypothesis is only 32 participants ( Powers et al., 2013 ). Perhaps as a consequence of such small samples, the effects sizes reportedly linking games to cognitive abilities vary widely as a function of the methods used and the research groups investigating them. For example, studies published in top-tier journals, while typically using very small samples, report substantially larger effects compared to the rest of the literature (e.g., Cohen’s d  = 0.85; Powers et al., 2013 ). Moreover, despite the fact that games are played by the overwhelming majority of young people ( Lenhart et al., 2015 ), fewer than one in ten studies of the gaming enhancement study have included participants under the age of 18. Childhood and adolescence see profound development in cognitive abilities, and though negative effects of games are fiercely debated ( Mills, 2014 ; Bell, Bishop & Przybylski, 2015 ), there is very little evidence concerning their possible positive effects in this cohort. Further, nearly all studies examining gaming effects do so by studying individual games or game types in isolation. So although there is reason to think that action ( Green & Bavelier, 2006 ), strategy ( Basak et al., 2011 ), and online game play ( Whitlock, McLaughlin & Allaire, 2012 ) could have positive effects it is not possible to know if attitudes, preferences, or engagement with games in general, or specific subtypes in particular, are driving the effects reported. Finally, there are a number of larger-scale intervention studies that show evidence that does not support or directly contradicts the gaming-enhancement hypothesis ( Chisholm et al., 2010 ; Kennedy et al., 2011 ). Given the nature of the existing evidence, research that systematically addresses these gaps in our knowledge is needed.

Present research

The aim of the present research was to evaluate the extent to which everyday electronic game engagement by young people relates to their general reasoning abilities. In particular, we were interested to test how personal preferences for specific types of games related to reasoning ability. In line with previous research, we hypothesized that those who gravitate towards action, online, and strategy games would show higher levels of cognitive performance on a test of deductive reasoning ability ( Basak et al., 2011 ). Our second goal was to test whether regular active engagement with action, online, and strategy games was linked to cognitive ability. In line with highly cited work in the area, we hypothesized that those playing these challenging games for more than five hours each week ( Green & Bavelier, 2006 ) would show higher levels of reasoning ability.

Data source

The present study utilized data collected in the first year of the Effects of Digital Gaming on Children and Teenagers in Singapore (EDGCTS) project. This dataset has been used in numerous previous publications focusing on the effects of gaming on motivation, dysregulated behavior, and interpersonal aggression in young people ( Wan & Chiou, 2006 ; Gentile et al., 2009 ; Wang, Liu & Khoo, 2009 ; Chen et al., 2009 ; Choo et al., 2010 ; Gentile et al., 2011 ; Wang et al., 2011 ; Li, Liau & Khoo, 2011 ; Chng et al., 2014 ; Prot et al., 2014 ; Gentile et al., 2014 ; Busching et al., 2015 ; Eichenbaum & Kattner, 2015 ; Chng et al., 2015 ; Liau et al., 2015b ; Choo et al., 2015 ; Liau et al., 2015a ). A subsample of data from the EDGCTS project was used for the present study because it included self-reports of game play and an objective test of participants’ reasoning abilities. Neither of these variables has been the focus of previously published studies, and a complete list of publications based on the EDGCTS dataset can be found on the Open Science Framework (osf.io/je786).

Participants, ethics, and data

Ethical clearance for data collection was granted through the Institutional Review Board of Nanyang Technological University in Singapore. Because of the combined length of the EDGCTS testing protocol, data collection was conducted over a four-day period to reduce participant burden and minimize sequence effects. The research was deemed low risk and consent was obtained from parents through liaison teachers. Participants were informed that involvement in the project was voluntary and that they could withdraw at any time. Ethical review for this secondary data analysis was conducted by the research ethics committee at the University of Oxford (SSH/OII/C1A-16-063).

In the first wave of the EDGCTS, quantitative data were collected from a total of 3,034 respondents. Gender information was present for 3,012 participants (99.3% of all cases), age data were available for 2,813 participants (92.7%), 2,135 participants provided the name of at least one electronic game they played (70.4%), and a total of 2,647 participants completed the reasoning test (87.2%). In sum, a total of 1,847 participants (60.9% of all cases), provided valid data and were included in subsequent analyses. These 1,847 participants ranged in age from 8 to 16 years ( M  = 10.97, SD = 1.99); 430 of these identified as female and 1,417 identified as male. The self-report materials, datasets, source code, and analysis code used in this study are available from the Open Science Framework (osf.io/je786).

Outcome variable

Reasoning ability.

Participants’ deductive reasoning ability was assessed using the 60-item Raven’s Standard Progressive Matrices Plus (RPM) task ( Raven, Raven & Court, 2003 ). The RPM, a widely used non-verbal test of reasoning ability, measures deductive intelligence by prompting takers to identify the key missing visual element that completes patterns shown in a series of increasingly complex 2 × 2, 2 × 3, 3 × 3, 4 × 4, and 6 × 6, matrices. This assessment was used because it has been well validated across a range of demographic and cross-cultural cohorts ( Raven, 2000 ). Because our participants were school-aged children, they completed the version of this multiple-choice test designed for group administration in educational settings for students between the ages of 8 and 16 years. Participants got a median of 29 of 60 matrices ( SD = 4.44) correct and age-adjusted reasoning scores were created for each participant in line with best-practices ( Savage-McGlynn, 2012 ). To this end, participants were segregated by age and their raw performance scores were transformed into z -scores such that their performance was standardized with respect to other children their age.

Explanatory variables

Participants’ electronic gaming was assessed through a series of questions asking about the games they frequently played. Participants were requested to provide the names of up to three games they played as well as an estimate of the amount of time they spend playing each. A total of 446 (24.1%) participants named a single game, 485 (26.3%) participants named two games, and 916 (49.6%) named three games. The titles of named games were content coded to mark if they belonged to one of the three game categories of interest: action games (e.g., Call of Duty, Halo), multiplayer online games (e.g., Maple Story, World of Warcraft), or strategy games (e.g., SimCity, StarCraft).

Game preference

Preference scores were created for each participant using the game names provided through self-report. If one or more of a participant’s named games belonged to the action, online, or strategy types, they were marked as expressing a preference for this kind of game (coded 1); if not, they were counted as not having a preference for this game type (coded 0). This meant three preference scores, one for each game type, were computed for each participant.

Regular play

Data from game preference scores and participants’ self-reported play behavior were used to determine if participants were regular players of specific game types. Scores were created for participants by combing information about the kinds of games they expressed preferences for and their self-reported amounts of weekly play. Amounts of weekly play were computed summing participant estimates of weekday engagement, multiplied by five, and estimates of weekend day engagement multiplied by two. Codes for game types were then used to create one game engagement score for each type of game. In line with the approach prescribed in previous research ( Green & Bavelier, 2006 ), participants were considered regular active players of a game type if they invested five or more hours in a given game type in a week (coded 1), and were coded 0 if they did not spend any time playing this game type in a typical week. Table 1 presents summary statistics for participant game preferences and proportions of active players of each game type.

Preliminary analyses

Zero-order bivariate correlations between observed variables are presented in Table 2 . Because 36 correlations were conducted, we adjusted our p value threshold for rejecting the null hypothesis from 0.05 to 0.0014 ( Holm, 1979 ). Analyses indicated that older participants were more likely to report higher levels of engagement with games as compared to younger ones ( r s = .130–.278). Similarly, female participants were less likely to engage action and strategy games ( r s = .128–.217). Gender was not significantly related to online game play nor was it related to age-adjusted reasoning ability (all p s > 0.0014). Because gender was not associated with our target outcome, which was centered on age, neither age nor gender were considered as covariates in hypothesis testing.

Game preference and reasoning ability

In line with meta-analytic evidence a series of one-sided Bayesian independent samples t -tests were used to quantify evidence for the game-enhancement hypothesis ( Rouder et al., 2012 ; Powers et al., 2013 ; Morey, Romeijn & Rouder, 2016 ), that specified preference for action, online, and strategy games would be related to better deductive reasoning ability. Table 3 presents a summary of these results and observed means using a Cauchy prior of 0.24, effect size for quasi-experiments on measures of reasoning and intelligence, and a second prior effect size for the enhancement hypothesis as reported in top-tier journals (Cohen’s d of 0.85; Powers et al., 2013 ). Results provided very strong support for the null hypothesis over the alternative for action games (BF 10 = 0.06; M 0  = 0.02, SD 0  = 1.00, M 1  =  − 0.12, SD 1 = 0.97) and equivocal support for alternative hypothesis for those who preferred strategy games (BF 10 = 1.45; M 0  =  − 0.02, SD 0  = 1.02, M 1  = 0.08, SD 1 = 0.93), or online multiplayer games (BF 10 = 2.815; M 0  =  − 0.5, SD 0  = 1.04, M 1  = 0.05, SD 1 = 0.95). In examining the robustness of these Bayes factors it is clear that evidence for effects larger than the average in the literature are also not supported. Results derived using the larger effect sizes reported in top-tier journals for the enhancement effect, d  = 0.85, appeared less likely as evidence was 1.25 and 57.01 times more likely to have been observed under the null hypothesis than under the gaming-enhancement hypothesis (see Table 3 ). Figure 1A – 1C , present relative evidence for the gaming enhancement hypothesis for effect sizes ranging from a 0.0 to 1.5. Taken together with the focused hypothesis tests, these results indicated participants’ preferences for these specific types of games were not reliably linked to their deductive reasoning ability in these data.

BF 01 denotes evidence favoring the Null hypothesis. BF 10 denotes evidence favoring the alternative hypothesis.

Note. Equal variances are assumed. (A) through (C) represent game preference, and (D) through (F) represent regular game play. (A) Action games. (B) Strategy games. (C) Online games (D) Action games. (E) Strategy games. (F) Online Games.

Regular game play and reasoning ability

To examine the relations between regular action, strategy, or online game play and reasoning ability, three additional Bayesian hypothesis tests were conducted following the procedure used for game preferences. These models evaluated the relative evidence for the null hypothesis as well as the gaming-enhancement hypothesis that postulates that playing these games for more than five hours each week would be associated with players’ reasoning abilities. Results provided moderate support for the null over the alternative hypothesis for action games (BF 10 = 0.12; M 0  = 0.02, SD 0  = 1.00, M 1  =  − 0.07, SD 1  = 0.99), equivocal evidence for strategy games (BF 10 = 1.120; M 0  =  − 0.023, SD 0  = 1.02, M 1  = 0.08, SD 1 = 0.90), and equivocal to moderate evidence for the null over the alternative hypothesis for multiplayer online games (BF 10 = 0.34; M 0  =  − 0.4, SD 0  = 1.04, M 1  = 0.01, SD 1 = 0.97). Robustness checks using effect size for the gaming enhancement hypothesis as reported in top-tier journals ( d  = 0.85; Powers et al., 2013 ) indicated evidence against the this hypothesis. Data were between 2.45 and 29.15 times more likely to be observed under the null hypothesis. Figure 1D – 1F present relative evidence for the gaming enhancement hypothesis for effect sizes ranging from of 0.0 to 1.5. Taken together with the previous results, these findings suggest it is unlikely that regular active play of these games is systematically related to higher levels of general reasoning abilities.

The promise that electronic games might positively influence human cognition is one that generates intense public, corporate, and scientific interest. The present research drew on a large sample of school-aged children and considered both their electronic gaming and cognitive performance to test of the gaming-enhancement hypothesis. Of central interest was the nature of the potential relations between children’s self-reported preferences and gaming habits, and performance on a widely used test of deductive reasoning ability. Contrary to our expectations, the results did not provide substantial evidence in support of the idea that the complex and interactive experiences provided by commercially available games generalize to functioning outside of gaming contexts. In most cases, the evidence was in favor of the null hypothesis over this account.

We hypothesized that those who express preferences for action, strategy, and multiplayer online games, modes of play would show modestly higher levels of cognitive performance as seen in previous smaller-scale studies ( Basak et al., 2011 ). In contrast to what was expected, we found equivocal to very strong evidence favoring the null hypothesis over this prediction. Second, we hypothesized that regular engagement with games—playing five or more hours a week of action, strategy, and multiplayer online games—would be linked with better reasoning ability. Results from our analyses did not support this prediction. Evidence for regular strategy game players were equivocal, but ranged from moderately to strongly in favor of the null for these types of games. Taken together, our findings disconfirmed the gaming-enhancement hypothesis, especially in terms of the larger effects reported in top-tier journals.

Our approach carries a number of strengths that should inform future studies of gaming effects. First, evidence from this study relied on data provided by more than 1,800 young people, a sample over 50 times larger than the average for studies examining gaming and cognition ( Powers et al., 2013 ). If research is to sort out the cognitive dynamics of play, larger and more robust sampling is needed. Second, the Bayesian hypothesis testing approach we adopted used open source software (JASP; JASP Team, 2016 ) and allowed our study to quantify evidence for the both the null hypothesis as well as a plausible alternative based on the existing literature. Although the analysis plan for this study was not registered before the data were known, the framework provides valuable empirical data that researchers can use as the basis, or prior, to inform their own pre-registered designs. Finally, if indeed scholars are increasingly skeptical of corporate attempts to sell games based on their purported upsides (e.g.,  Allaire et al., 2014 ), this vigor should be extended to all scientific inquiry in this area, for example by making the materials, data, source and analysis code openly available. Future research making both positive and negative claims regarding the effects of gaming on young people should do likewise.

Limitations and future directions

The present study presents a number of limitations that suggest promising avenues for future work. First, because the data under study were cross-sectional they capture an easy to interpret pattern of results that represent a snapshot in time. The data structure did so at the expense of being able to draw causal inferences, and a complementary approach would examine long-term salutary effects on cognition, ideally as a function of experimental manipulations of game exposure. Second, data regarding participants’ game preferences and regular play were collected through self-report. Research indicates that some participants, and young people in particular, provide exaggerated data when it comes to taboo activities such as sexual habits and drug use ( Robinson-Cimpian, 2014 ). It is possible that the average levels of engagement reported by our participants disguised interesting patterns of engagement which merit inquiry. For example, infrequent periods of high engagement (e.g., binge-playing) might have its own special relations with reasoning abilities. If so, an experience-sampling based approach would be needed to assess both between- and within-person variability with respect to the relation between gaming and reasoning ability. Finally, the present study only used a single assessment of general cognitive abilities, the Ravens Progressive Matrices task ( Raven, 2000 ). There are many other facets to intelligence and executive control that might be more sensitive to influence by regular electronic gaming. Measures of naïve reasoning ( Masson, Bub & Lalonde, 2011 ), short and long-term memory ( Melby-Lervåg & Hulme, 2013 ), audio processing ( Liu & Holt, 2011 ) might be more liable to be influenced by gaming. If the gaming-enhancement hypothesis is not broadly accurate, it may find empirical support under conditions where these alternative aspects of intelligence and reasoning abilities are under study.

Closing remarks

The promise that popular games can enhance cognitive skills is an alluring one. Our findings suggest there is no relation between interest in, or regular play of, electronic games and general reasoning ability. As such, we advise that future research examining the potential influences of gaming contexts on players should pre-register their analysis plans or follow the registered reports process (e.g.,  Chambers, 2013 ; Elson, Przybylski & Krämer, 2015 ). Such steps would go a long way to reduce researcher degrees of freedom which might, along with publication bias, affect conclusions drawn about the effects of gaming and cognitive enhancement ( Feynman, 1974 ; Gelman & Loken, 2013 ; Nissen et al., 2016 ). While the research presented here might be further informed by additional work conducted to these standards, our findings above offer an early exploration of the gaming-enhancement hypothesis which is well-powered and guided by open-science.

Funding Statement

This research was partially funded by a John Fell Fund Grant (CZD08320) through the University of Oxford to Dr. Przbylski, and a joint grant awarded by the Ministry of Education, Singapore and the Media Development Authority f (EPI/06AK) to Professor Wang. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Additional Information and Declarations

The authors declare there are no competing interests.

Andrew K. Przybylski conceived and designed the experiments, performed the experiments, analyzed the data, contributed reagents/materials/analysis tools, wrote the paper, prepared figures and/or tables, reviewed drafts of the paper.

John C. Wang conceived and designed the experiments, performed the experiments, contributed reagents/materials/analysis tools, wrote the paper, reviewed drafts of the paper.

The following information was supplied relating to ethical approvals (i.e., approving body and any reference numbers):

Ethical clearance for the Effects of Digital Gaming on Children and Teenagers in Singapore project (EDGCTS) was sought and granted through the Institutional Review Board of Nanyang Technological University in Singapore. The Research and Ethics Committee at the Oxford Internet Institute conducted ethical review for secondary data analysis on the EDGCTS dataset (SSH/OII/C1A-16-063).

• Open access
• Published: 16 August 2022

Relationship between time spent playing internet gaming apps and behavioral problems, sleep problems, alexithymia, and emotion dysregulations in children: a multicentre study

• Gellan K. Ahmed 1 ,
• Alaa A. Abdalla 2 ,
• Ali M. Mohamed 3 ,
• Lobna A. Mohamed 4 &
• Hala A. Shamaa 5  

Child and Adolescent Psychiatry and Mental Health volume  16 , Article number:  67 ( 2022 ) Cite this article

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Internet gaming addiction (IGA) is a serious condition that can significantly impact personal and social functioning. Many studies of IGA have been conducted in adolescents and young adults, but there are limited data available in children. We investigated the time spent using internet gaming apps in children and its association with behavioral problems, sleep problems, alexithymia, and emotional regulation.

The research populations (N = 564) were categorized based on the number of hours spent using online gaming applications. The Strengths and Difficulties Questionnaire, the Children's Sleep Habits Questionnaire Abbreviated, the Children's Alexithymia Measure (CAM), and the Clinical Evaluation of Emotional Regulation–9 were used to assess all participants.

Compared to other groups, children who used internet gaming applications for more than 6 h had a higher proportion of abnormal responses on the emotional symptoms and hyperactivity scales. Children who used internet gaming applications for more than 6 h had the poorest sleep quality (75%), while children who used internet gaming applications for 1–2 h had the best (36.7%). Participants who used internet gaming apps for 1–2 h had significantly lower mean total scores on the emotional regulation scale and total CAM, whereas those using internet gaming apps for more than 6 h had the highest mean scores in the CAM.

Conclusions

Excessive use of internet gaming apps during childhood may be associated with hyperactivity, peer problems, high socioeconomic level, alexithymia concerns, shorter daytime sleep duration, and a delayed morning wake-up.

Games play a critical role in the integration of human behavior and experience. Computer technology has drastically risen in availability and use over the previous two decades, reshaping the leisure world. Beyond social and conventional media, today's young people use the internet and play computer games [ 1 ]. In 2018, the International Classification of Diseases (ICD-11) proposed that gaming disorder (GD) should be classified as a disease [ 2 ]. Impaired control over gaming, giving gaming a higher priority, and continuing or increasing gaming despite experiencing negative effects are the three symptoms that must be present for GD to meet the diagnostic criteria of (ICD-11) [ 2 ]. Thus, the American Academy of Pediatrics recommends that children limit their screen time to 1 to 2 h per day [ 3 ]. Similarly, the Canadian Society for Exercise Physiology recommends that children aged 5 to 17 spend no more than 2 h per day on recreational screens [ 4 ].

Different rates of IGD have been reported in young people due to different measurement tools and cultural backgrounds. In Europe, for example, the prevalence was 1.2–1.6% [ 5 , 6 ], whereas in Asia, it ranged from 1.6–18.4% [ 7 , 8 , 9 ]. In Egypt, the prevalence of IGD among adolescents was 9.7% [ 10 ]. However, more research based on more extensive samples should be undertaken to validate those figures [ 11 ].

Excessive video gaming has also been linked to attention problems, poor academic performance [ 12 ], anxiety, depressive symptoms, deterioration of interpersonal relationships, family conflicts, youth violence or crime [ 13 ], low self-esteem, and dissatisfaction with daily life [ 14 ].

Sleep deprivation may result from increased screen time [ 15 , 16 ]. Delayed bedtimes and late waking times may exacerbate rhythm desynchronization and have a negative effect on academic performance [ 16 ]. Psychological stimulation (i.e., an elevated mood caused by social media use) [ 17 ], light-emitting screens [ 18 ], and decreased sleep duration are all possible causes of disturbed sleep [ 19 ]. Players from various time zones frequently participate in multiplayer games [ 20 ]. As a result, some gamers may delay logging off or may wake up during the night to continue gaming [ 5 ], resulting in inconsistent or chaotic sleep–wake patterns and sleep deprivation. Furthermore, online gaming is associated with increased sleep latency and decreased total rapid eye movement sleep [ 21 ].

Gaming and the pursuit of game-related pleasure can cause the neglect of “regular or normal” relationships, school or work-related obligations, and even basic physical requirements. Playing games can thus be viewed as a progression from pleasurable leisure to a problematic and even compulsive habit [ 22 , 23 , 24 ]. This can be explained by alexithymia. Alexithymia is characterised by difficulties describing and expressing emotions. Other fundamental characteristics of alexithymia include an externally oriented cognitive style, a constrained imagination, and a lack of empathy [ 25 , 26 ]. Individuals with alexithymia face significant challenges in forming friendships and typically have low social functioning because of these constraints [ 27 ]. The concept that people with alexithymia attempt to manage their emotions through compulsive [ 28 ] or impulsive [ 29 ] actions has been associated to addictive illnesses. A previous study found that regular gamers exhibited higher levels of alexithymia than irregular gamers [ 30 ]. Gaetan et al. proposed that, because alexithymia typically displays with a flat emotional profile and the virtual environment facilitates emotion regulation, online gaming may serve as an attempt to control these characteristics in adolescents with alexithymia [ 31 ].In addition, previous research found that adolescents with IGA exhibited more comorbid psychiatric disorders and difficulties expressing emotions, indicating the adoption of avoidance strategies [ 10 ].

Furthermore, children and teenagers are thought to use video games as a maladaptive coping mechanism to deal with negative emotions [ 32 ]. In this regard, children with limited social skills, the internet in general, and video games, are likely to be preferred over real-life interactions [ 33 , 34 ]. As a result, emotion avoidance and dysregulation can occur.

Although there have been some studies on problematic internet use and online gaming they have focused mostly on adolescents and young adults, with limited data on children. One reason is that most diagnostic tools are self-administered by patients and can only be done by adolescents. In contrast, there are no parent-administered versions of the GD screen scales that can be utilised with children. Indeed, the diagnostic criteria for GD rely on subjective diagnostic criteria, such as loss of control and continuing or increasing gaming despite suffering negative consequences, which are difficult to assess in children. In order to avoid these problems in the present study we measured the number of hours spent playing online games and asked whether there was any relationship to behavioral problems, sleep problems, alexithymia, and emotional regulation.

Study design, and population

This was a cross-sectional study between February and November of 2021. To cover the various sociodemographic variables, 564 participants ranging in age from 6 to 14 years old were enrolled in three Egyptian cities: Assiut (Upper Egypt), Cairo (central), and Ismailia (lower Egypt). In each city, we choose 3 schools: one governmental school, one private school and one model governmental school (governmental with language modified curriculum). All the schools in the study covered all educational grades (i.e. primary, elementary and secondary school), had the largest number of students in each city, and had an official website. An online link was published on school websites with the agreement of the school's manager to find parents who were willing to participate and evaluate their children. the link consisted of three sections to be answered by parents. The first two sections included information about the student such as age, gender, play on online gaming apps and other information such as a history of substance abuse, psychiatric disorders, or medical conditions (to identify their eligibility for study). The third section included information about the study aims with an option to decline or accept our invitation to join the study. Parents who agreed to our request had their children evaluated at local Child and Adolescent Clinics. Children with an IQ of less than 70 or a history of substance abuse, psychiatric disorders, or medical conditions were not eligible.

About 50 requests to participate were excluded because the online information, such as medical history, was unclear. A total of 680 requests were approved of whom 564 participants eventually entered the study.

The research population (N = 564) was categorized based on the number of hours used for online gaming applications. Group 1: use internet gaming applications for 1–2 h, Group 2: use internet gaming applications for 3–4 h, Group 3: use internet gaming applications for 5–6 while Group 4: uses internet gaming apps for more than 6 h.

The evaluation was done in Arabic by trained psychiatrists and psychologists who interviewed parents about their children. Regarding psychiatric interviews and scores of scales of this study, children who had problems reported to the parent to schedule an appointment with a psychiatric counsellor at school for further evaluation and treatment.

Demographic data

The information was collected from parents regarding sociodemographic status and the child’s clinical, and medical histories. Information included: age, gender, birth order, number of children, speech delay, motor development, family history of psychiatric problems, previous medical conditions, the number of devices used to access internet gaming apps, and the number of hours spent on internet gaming.

The Strengths and Difficulties Questionnaire (SDQ) parent version parent [ 35 ]

This consists of 25 questionnaires used to screen for behavioral problems in children aged 4–17 years. It was categorized into five subscales: emotional symptoms, conduct problems, hyperactivity/inattention symptoms, peer relationship problems, and prosocial behavior. The total difficulty score is calculated by adding the first four numbers. Research on the reliability of the SDQ has produced mixed results. However, most studies report internal consistency of the total difficulties score and the subscales scores with a Cronbach α above 0.70 [ 36 , 37 ].

Socioeconomic scale

The educational level of the parents and mothers, their occupation, total family income, and the family's lifestyle were included in this study. Based on their total (raw) score, which is calculated using an equation based on these four characteristics, individuals in a sample are classified as high, middle, or low class. Cronbach’s alphas of SEC is 0.89 [ 38 ].

The Children’s Alexithymia Measure (CAM) [ 39 ]

The Children’s Alexithymia Measure (CAM) is intended to be completed by a parent. The CAM comprises 14 components rated in a range of 0 to 3. Total scores can vary from 0 to 42, with higher numbers indicating more alexithymia.The internal consistency of CAM is coefficient alpha = 0.92 [ 39 ]

The Children's Sleep Habits Questionnaire Abbreviated (CSHQ-A) [ 40 ]

In this study, the Children's Sleep Habits Questionnaire (CSHQ-A) was used to assess sleeping difficulties. These questionnaires were collected retrospectively, with parents recalling sleep patterns, disturbances, or activities from the previous week (e.g., bedtime, sleep behavior, waking during the night, morning wake up). A CSHQ-A score of more than 30 was considered abnormal and indicative of sleep difficulties. It has sensitivity 89.2% and specificity 44.6% [ 41 ].

The Clinical Evaluation of Emotional Regulation–9

This consists of nine questions derived from Swanson Nolan and Pelham (SNAP-IV) items and applied to a factor of emotional dysregulation. It is used to evaluate emotional regulation and answered by parent. Previously, these items were graded on a 0 to 3 Likert scale, with the extremes of not at all and very much serving as anchors. The highest accuracy for identifying children and adolescents with current significant emotional regulation problems is a score of 4 or higher. The Cronbach’s alphas of the nine retained items were 0.80 [ 42 ].

Statistical analysis

SPSS was used for statistical analysis (version 26). The data was described using frequencies and percentages. To investigate categorical variables, the chi-squared test was performed. If there were statistically significant differences in mean values between more than two groups, the ANOVA test was used. Linear regression was performed to investigate potential risk variables for increased use of internet gaming apps. A p-value of less than 0.05 was considered statistically significant.

Demographic characteristics

The research populations (N = 564) were categorized into four groups based on the number of hours used by online gaming application participants. Group 1 uses internet gaming applications for 1–2 h (N = 244), Group 2 uses internet gaming applications for 3–4 h (N = 120), Group 3 uses internet gaming applications for 5–6 (N = 92) while Group 4 uses internet gaming apps for more than 6 h (N = 32).

The sociodemographic characteristics of the study groups are illustrated in Table 1 . There was a significant difference between groups regarding age, gender, number and order of siblings in families, motor and speech development delays, socioeconomic status, and the number of devices used to access internet gaming apps. Participants who used internet gaming applications for 1–2 h and those who used internet gaming applications for 3–4 h were the youngest (8.43 ± 2.47, 8.7 ± 2.8, respectively) while participants who used internet gaming applications for 5–6 h and those who used internet gaming applications for more than 6 h were the oldest (9.6 ± 2.51, 9 ± 3.09, respectively)( see Figure 1 ). There was a higher proportion of males (58.9%) than females (41.1%). The majority of the participants were first-born and had only one sibling. The percentage delay in speech and motor development, as well as the number of devices used to access internet gaming apps, increased with increased hours of use until it reached 6 h, after which the percentage decreased. In terms of socioeconomic level, the group that used internet gaming applications for more than 6 h had the lowest mean socioeconomic score. In all groups, the middle socioeconomic level had the highest proportion, followed by the lower socioeconomic level.

The Strengths and Difficulties Questionnaire (SDQ) scale

There was a significant statistical difference between the groups studied on all SDQ subscales. In comparison to other groups, children who used internet gaming applications for more than 6 h had a higher proportion of abnormal responses on the emotional symptoms and hyperactivity scales (see Table 2 ).

In comparison to the other groups, children who used internet gaming applications for 1–2 h had the lowest percentage prosocial scale.

Participants who used internet gaming apps for more than 6 h all scored abnormally on the total difficulties scale, but none scored abnormally on the prosocial scale. This group also had the lowest percentage of abnormal responses in the conduct subscale and peer problems.

The Children's Sleep Habits Questionnaire

Table 3 displays the results of the Children's Sleep Habits Questionnaire. There were significant differences in the total bedtime subscale and total morning wake-up scores. Children who used internet gaming applications for more than 6 h had the highest scores in all subscales as well as the total score in the Children's Sleep Habits Questionnaire, while children who used internet gaming applications for 1–2 h had the lowest scores. There was the highest percentage of poor sleep quality (75%) in children who used internet gaming applications for more than 6 h and the lowest percentage in children who used internet gaming applications for 1–2 h (36.7%).

There was a significant difference between groups in terms of night-time and daytime sleep duration, as well as total sleep duration per hour. Participants who used internet gaming applications for more than 6 h had a longer night-time sleep duration per hour (9.2 ± 1.6) and a shorter daytime sleep duration per minute (8.7 ± 13.6).

The Children's Alexithymia Measure (CAM) Scores and the Clinical Evaluation of Emotional Regulation–9

The total score of the Clinical Evaluation of Emotional Regulation–9 and total CAM was lowest in participants who used internet gaming apps for 1–2 h; the highest CAM score occurred in children who used internet gaming apps for more than 6 h (See Table 4 ).

Identification of Possible Risk Factors for the Increased Number of Internet Gaming Apps Used by Children

Table 5 shows the results of univariate linear the regression analysis evaluating the multiple risk factors affecting participants' use of internet gaming apps. Participants with high emotion dysregulation score (p = 0.025), shorter sleep duration (day and night) (p = 0.021), and a delay in morning wake-up (p = 0.005) were more likely to use internet gaming apps. Using internet gaming apps, on the other hand, was associated with a higher number of devices (p = 0.0001), emotional problems (p = 0.002), conduct problems (p = 0.001), hyperactivity difficulties (p = 0.015), peer problems (p = 0.04) and the total difficulties (p = 0.001). Controlling for gender led to the same results (see Additional file 1 : table S6 and S7). An increased number of devices and shorter sleep duration (day and night) were associated with more intensive use of internet gaming apps in both genders. (see Additional file 1 : table S8 and S9).

Among the numerous factors related to problematic online gaming, time spent playing online games has been one of the most controversial [ 43 ]. However, most international scientific communities recommend less than 2 h per day as a total screen time for children under 17 years old. Here we investigated the time spent using internet gaming apps in children and its association with behavior problems, sleep problems, alexithymia, and emotional regulation.

In the current study, there was a significant difference between groups in terms of age, gender, order of birth, number of siblings in families, motor and speech development delay, and the number of devices used to access internet gaming apps. Participants in groups 3 and 4, who used internet gaming applications for 5–6 h or more than 6 h, were older than those who used them for 1–2 or 3–4 h. This finding was consistent with a 2-year follow-up study in South Korea, which found that individuals at high risk for IGD were more likely to be older children and spend longer times gaming per day [ 43 ]. This could be due to more exposure to the internet in older children who use it for online studying and communication, particularly after the COVID-19 pandemic.

All groups had a higher proportion of boys than girls. A large US study found that problematic internet gaming occurs up to five times more frequently in male children (11.9%) than in females (2.9%)[ 12 ], and an Australian study of internet use and electronic gaming by children and adolescents found that only 5.3% of boys did not play electronic games compared to 24.8% of girls [ 44 ]. Males have 2.5 times more GD than females, according to a global systematic review [ 45 ]. This discrepancy may be caused by the popularity of online games for social networking and other associated activities among females [ 46 ], whereas fighting and action games are more popular among boys and may be more engaging when played in a group of peers.

Most participants were first-born and had one sibling with a middle socioeconomic status. Our finding is consistent with previous research conducted among Egyptian university students [ 47 ], however it contradicts a study conducted in China, where family structure was unimportant [ 48 ]. These disparities could be attributed to factors such as participant age, cultural variations, and sociodemographic factors. Our results in Egypt could be related to the fact that the children's parents are preoccupied with raising a new child, the children may exhibit more extreme behaviours to get their parents' attention, and the first child's feelings of sibling jealousy contributed to the rise in internet gaming app use.

There was a substantial statistical difference between the groups in all SDQ subscales. In Group 4, who used internet gaming applications for more than 6 h, abnormal responses in the emotional symptom scale and the hyperactivity scale were higher than in the other groups. In addition, they had abnormal responses in the total difficulties scale, while none of them had an abnormal response in the prosocial scale. This group also had the highest percentage of abnormal responses in the conduct subscale and peer problems.

This finding was consistent with a survey on the mental health and wellbeing of children and adolescents aged 4–17 years in Australia, where Rikkers and his colleagues investigated the association of internet use and electronic gaming with emotional and behavioral problems. They used the Kessler 10 Psychological Distress Scale (K10) for younger children and the Strengths and Difficulties Questionnaire (SDQ) for older children and adolescents. They found that children who spent more daily time at the weekend playing online games scored high on both K10 and SDQ [ 44 ].

Additionally, Italian research on school-aged children found that ADHD patients with IGD presented with more severe symptoms. A binary logistic regression showed that IGD was correlated with the degree of inattention. This may be because the main characteristics of IGD are similar to those of ADHD, including the impulsive urge for quick gratification and the tendency for sensation-seeking activities. This link may be useful in the treatment and management of IGD via ADHD treatment and management techniques [ 49 ].

Another review investigating IGD in children found that predisposing comorbidities and health-related consequences, in addition to poor relationships with parents and peers, were commonly observed in children with IGD [ 1 ]. Additionally, adolescents in Singapore [ 50 ] and Germany [ 51 ] were found to have longitudinal correlations between emotional problems and the prevalence of IGD. Korean schoolchildren also showed a stronger correlation between IGD and emotional disorders with follow-up for one year, which was found to be 2.8 times higher than in participants without emotional problems [ 52 ]. IGD may result from attempts to utilize online games to self-regulate, escape, or ease unpleasant emotions [ 53 ].

The present study also found that participants who used internet gaming apps for 1–2 h had significantly lower mean total scores on the Clinical Evaluation of Emotional Regulation–9 and total CAM. The group of children who used internet gaming apps for more than 6 h had the highest mean of CAM. Furthermore, participants with high score of emotion dysregulation were more likely to spend increased time on online gaming apps. A study that was conducted on middle and high school-aged French adolescents revealed that regular online gamers, who played significantly more hours than irregular gamers, regulated their emotions more than irregular gamers did. They also felt more intensely. But regular gamers displayed emotions less than irregular players. Also, frequent gamers had higher alexithymia levels than irregular gamers [ 54 ].

Online addictive behaviours may have an impact on how emotions are regulated by strengthening control of emotions, obtaining online social validation, and compensating for disadvantages in the real life [ 55 ]. It has been hypothesized that excessive online behaviours are indicators of a range of diseases, including depression [ 56 ]. Playing an excessive number of online hours may thus be a technique to treat pre-existing depressed psychopathology, which itself might subsequently provoke additional symptomatology. Therefore, integrating therapy to handle children's emotional problems may have additional advantages for preventing IGD in children and adolescents [ 57 ].

The total bedtime subscale and total morning wake-up scores were significantly different between groups, with children who used internet gaming applications for more than 6 h scoring highest in all subscales as well as the total score in the Children's Sleep Habits Questionnaire. For example, children who used internet gaming applications for more than 6 h had the worst sleep quality (75%). Furthermore, those who used internet gaming applications for more than 6 h had longer night-time sleep duration per hour and a shorter daytime sleep duration per minute. Also, participants with shorter sleep duration (day and night) and delay in morning wake up more likely to use internet gaming apps.

Our findings matched those of a systematic review of seven studies on the relationship between internet gaming and sleep problems which found that problematic or addictive gaming, particularly massively multiplayer online role-playing games, is associated with sleep problems, including poorer sleep quality and shorter sleep duration [ 58 ]. Another systematic review discussed the association between screen time and sleep patterns among school-aged children and adolescents. It found associations between screen time and reduced sleep quality, longer sleep onset latency, delayed bedtime, shorter total sleep time and increased daytime tiredness. In addition, 86% of studies found an association between video game use and abnormal sleep patterns [ 59 ]. The proposed mechanisms for sleep disturbance included displacement of sleep time, psychological stimulation, light exposure, and increased physiological alertness [ 17 ].

Several limitations must be considered when interpreting our findings. First, this study did not assess scholastic achievement in children who use internet gaming applications excessively. Second, the cross-sectional research design of the current study may limit the ability to draw causal conclusions between video gaming addiction and related characteristics. Thirdly, more information about the nature and content of games, as well as player types was needed to conduct a more thorough investigation of IGA's impact on psychiatric issues. Finally, possible negative feelings of parents about their children’s internet gaming app usage may bias answers to the questionnaires.

An increased number of hours pent using internet gaming applications was associated with more psychiatric problems, sleep disturbance, alexithymia, and emotion dysregulation. Excessive use of internet gaming apps made children more susceptible to hyperactivity and peer problems. Participants with excessive use of internet gaming apps were more likely to have a high socioeconomic status, high alexithymia issues, shorter daytime sleep duration, and a morning wake-up delay.

Distribution of age groups amoung studied groups

Availability of data and materials

All data generated or analyzed during this study are available from corresponded on request.

Abbreviations

Internet gaming disorder

The International Classification of Diseases-11th revision

The Children's Sleep Habits Questionnaire Abbreviated

The strengths and difficulties questionnaire

The Children’s Alexithymia Measure

Swanson Nolan and Pelham

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Acknowledgements

The authors would like to thank the Mental Health Research Network of Egypt (collaboration between psychiatrists, psychologists, and public health) that offered a meeting, training, and joining research groups for mental health across Egyptian universities. Also, we are grateful to Dr. John Rothwell (Head of Sobell Research Department of Motor Neuroscience and movement Disorders, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK) for revision of the English style and comments on the manuscript. He is not included as a contributing author.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt

Gellan K. Ahmed

Department of Neurology and Psychiatry, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Alaa A. Abdalla

Ministry of Education, Cairo, Egypt

Ali M. Mohamed

Department of Neurology and Psychiatry, Alexandria University, Alexandria, Egypt

Lobna A. Mohamed

General Secretariat of Mental Health and Addiction Treatment, Demira Mental Health Hospital, Dakahlya, Egypt

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GA, AA and AM recruited participants, analysis, and interpreted data, and were the contributors in writing the manuscript. LM and HS revised data interpretation, read and approved the final manuscript. All authors read and approved the final manuscript.

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The study received ethical approval from Assiut University, Faculty of Medicine's institutional review board (IRB). This research was registered as a clinical trial. To participate in the study, the parents signed informed consent on behalf of their children. They were assured that their information would be kept private, and that data would be made available in an anonymized form. All procedures performed in this study were in accordance with the ethical standard of the institution and/or national research committee, with the 1964 Helsinki Declaration and its later amendments.

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Additional file 1:.

Table S6. univariate linear Regression model between hours of internet gaming apps and other parameters in male. Table S7. Univariate linear Regression model between hours of internet gaming apps and other parameters in female. Table S8. Multi linear Regression model between hours of internet gaming apps and other parameters in male. Table S9. Multi linear Regression model between hours of internet gaming apps and other parameters in female

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Ahmed, G.K., Abdalla, A.A., Mohamed, A.M. et al. Relationship between time spent playing internet gaming apps and behavioral problems, sleep problems, alexithymia, and emotion dysregulations in children: a multicentre study. Child Adolesc Psychiatry Ment Health 16 , 67 (2022). https://doi.org/10.1186/s13034-022-00502-w

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Received : 25 May 2022

Accepted : 29 July 2022

Published : 16 August 2022

DOI : https://doi.org/10.1186/s13034-022-00502-w

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