The possibility that the next edition of the World Health Organization's (WHO's) standard for health data and trends will cite a “gaming disorder” for the first time is not sitting well with a group of researchers. One of the co-authors of a published debate paper that questions the move thinks strong opposition to the proposed classification's inclusion in the 11th edition of the International Classification of Diseases (ICD-11) has surprised WHO leaders, but he believes the organization remains committed to the move.
“It sounds like the WHO is determined to make it happen,” says Christopher J. Ferguson, PhD, a Stetson University professor of psychology who has researched topics related to video game participation for around a decade. Ferguson and more than a dozen colleagues internationally co-authored the paper published in the Journal of Behavioral Addictions, stating that the research basis for a gaming disorder is sparse and that those who advocate it are wrongly applying substance use criteria to gaming participation.
“In the variation they have now in the ICD-11, they didn't even bother with listing symptoms,” says Ferguson. “They don't even delineate boundaries.”
The ICD is the global health information standard for morbidity and mortality statistics and is used to determine reimbursement and resource allocation for about 70% of the world's health expenditures. ICD-11 is expected to be finalized in 2018.
Tendency to pathologize
The proposed description for gaming disorder does offer some sense of the parameters that the WHO envisions. It opens with:
“Gaming disorder is manifested by a persistent or recurrent gaming behavior (i.e., 'digital gaming' or 'video-gaming') characterized by an impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities and continuation of gaming despite the occurrence of negative consequences.”
It goes on to state that a pattern of gaming and accompanying negative consequences should be evident for at least 12 months for a diagnosis to be assigned, although this can be shortened in cases where symptoms are severe.
In their paper criticizing the proposal, Ferguson and his co-authors cited two main areas of concern. First, they wrote that there is a lack of consensus in the research regarding patterns of gaming. Sound clinical studies have been scarce to this point, they stated, and there has been evidence of inflated prevalence estimates due to misleading responses among some survey participants.
The lack of a firm consensus is responsible in part for the delay to render a final decision on whether “Internet gaming disorder” should be listed as a disorder in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-5 cites Internet gaming disorder as a proposed diagnosis for further study.
Second, the paper's authors wrote that the application of substance use and gambling criteria to gaming behaviors does not take into account the lack of evidence of physiological withdrawal in problematic gaming behavior.
“Applying symptoms reminiscent of substance use disorders to gaming behaviors too often pathologizes thoughts, feelings and behavior that may be normal and unproblematic in people who regularly play video games,” they wrote.
'Moral panic' theory
Ferguson theorizes that much of the concern about video gaming behavior is generational, and fits the model of a “moral panic” theory in which new technology tends to breed exaggerated fears.
Parents talk of children being transformed into addicts who are no longer interested in school or activities and only want to sit in their basement and play video games. “They say things like, 'My kid would be fascinated with math if he weren't playing video games,'” says Ferguson.
While he understands that young people are capable of escaping into video games for six to hours straight (“I've got a 13-year-old myself; you don't have to convince me”), he does not see that as different from any other pursuit that someone can overdo, from exercise to music. But that does not necessarily elevate all of these potentially problematic behaviors to a status warranting an addiction construct being applied to each, he says.
In that respect, opposition to the gaming disorder concept resembles the recent questioning of the sex addiction construct by some educators and researchers. A moral component exists with both, as some see the efforts to establish a diagnostic category as an attempt to pathologize behaviors that some individuals find distasteful or morally wrong.
Ferguson says he has heard indirectly that some of the WHO's interest in gaming disorder stems from leaders in countries that want to see the behaviors pathologized so that people can be coerced into treatment.
The authors of the debate paper—to which the WHO has not formally responded—believe the inclusion of gaming disorder in ICD-11 could have damaging consequences for young people. “We expect that inclusion of gaming disorder in ICD-11 will cause significant stigma to the millions of children and adolescents who play video games as part of a normal, healthy life,” they wrote. “Raising concerns around the dangers of video gaming is known to add tension to the parent-child relationship, which exacerbates conflict in the family and can perpetuate violence against children.”