 Welcome to the 403 of you who've joined us for tonight's webinar and all the viewers who are watching the podcast. MHPN wishes to acknowledge the traditional custodians of the lands across Australia upon which our webinar presenters and participants are located. We wish to pay respects to the elders past, present and future, for the memories, the traditions, the culture and the hopes of Indigenous Australia. My name is Katherine Bolland and I'll be facilitating tonight's very interesting session about internet gaming addiction and the effects on mental health. I'm a clinical psychologist in private practice in Sydney and I deal with families in high conflict and I can tell you that nothing in my clinical training prepared me for this tonight's topic, nothing in my personal life prepared me for it either and I'm the parent of three teenagers so I take a very active personal interest in the topic tonight as well. This evening we have the wonderful expertise of a range of professionals who are going to enlighten us on this topic. I'm certainly looking forward to it. Just a little note that we've noticed that some people who've registered might think that tonight's topic is about gambling. It is about video games that people play online as outlined in the case study. So you've had a chance to read our panellists bios and I am thrilled about the level and depth and breadth of expertise. I feel completely out of my depth with these excellent clinicians, researchers and I have to say gaming experts. So I think you're going to enjoy tonight's webinar. So I'd first like to go through and introduce our panellists to you. First of all I'd like to introduce Dr Sam Yong who's a GP. Hi Sam. Sam can you just tell me a little bit about in your youth general practice how often you come across kids or young people who are who you consider addicted to gaming. Yeah look I don't think it's as uncommon as we think. I've probably seen more of those kinds of patients as I work in a university clinic part-time and also tend to see younger patients. But it is something that I tend to ask about as well. I think it's more of something that is increasing in prevalence though certainly and I think it will continue to do so in the future. I certainly agree the last few years or anything to go by. Thanks for that Sam. I'd now like to introduce Vaz Strovopoulos who is a clinical psychologist and has an expertise in this area beyond anything I've seen before. Vaz are you undergoing any research in this area at the moment. Yes I'm investigating risk and protective factors related specifically to the gaming to the game context and I maintain collaborations with the UK, South Korea, Greece and the US. That's fantastic. I'm really looking forward to picking your brain. I'd now like to introduce Dr Kim Lee who is a psychiatrist. Kim I know that you've recently participated in a live debate with psychiatrist on whether internet gaming disorder should be included in the DSM-5. What was the verdict? The verdict was that the audience actually got to vote on their smartphone. So at the start people were saying yes it should be included, a majority and then at the end they still agreed that it should still be included in DSM-5 but actually the opposing team managed to shift quite a lot of the audience to say that we need more research in this area but certainly a very controversial diagnosis and we'll be not going anywhere and you can't soon. Yeah that's for sure. Alright I'd like to hear more about that in your presentation I think a bit Kim. Last but not least I'd like to introduce Dr John Hurley who's a mental health nurse and John I want to know a little bit about the context of your work at Headspace. What are some of the typical presentations of those kids with reported internet or gaming addiction? I think that's one of the most challenging aspects about this topic of discussion is that on reflection of the number of years of practice at Headspace increasingly I became aware there is not really any one typical presentation and that you actually do need to have a fair degree of curiosity and some skills to be able to explore with each young person as to whether there's a problem there or not. Well said. Alright thanks so much for that. I'm sure you all agree we've got a fantastic group of specialists here tonight. Just a couple of things I want to go through to make sure we have a great experience. First of all just basic ground rules to help ensure that everyone has the opportunity to get the most from the webinar. Some technical things that might help you if you're new to these platforms we've changed the platform somewhat. First of all if you'd like to access the chat box click open the chat tab on the bottom of your screen and the chat box will open in a separate window. You can also find supporting resources in the resource library tab on the bottom of your screen. If you would like some technical assistance there is a technical support FAQs tab to help with those issues and if you're still having difficulty there's a number to call if you need it. I'd also like at this point to give you a heads up but I will be encouraging you to give us some feedback at the end of tonight's webinar by completing the feedback survey which is really important for us in determining future webinars. So some pretty basic things and about being respectful to one another and the panellists please behave as you would in a face-to-face activity. We'll be trying to interact with you on the I will be trying to interact with you a little bit on the chat. There's been a lot of questions already submitted and I encourage you to ask the panellist questions through the chat and I will try to get through as many of those as possible. The other thing to let you know about is that we'll be going through each of the panellists will be giving their unique perspective on the case study and I'll talk about the case study in a little minute but each of the panellists will give a particular presentation tonight and then at the end of their presentations we'll be having a panel discussion which is where we'll have the opportunity to answer some of the questions that you want to put to these panellists. So what do we have to get out of tonight's presentation? So basically this webinar is going to give you the opportunity to recognise the clinical effects and harms to mental health related to internet gaming addiction. It will also increase your skills and understanding of managing internet gaming addiction and improve your awareness of evidence-based interventions. It will also identify strategies to engage specialist services when treating someone with internet gaming addiction. I think that most of you have had the opportunity to come across our case study with our 15-year-old Jack and I was shocked in reading this at how relevant and how real and how life-like this case study is. I'm looking forward to hearing our panellists' views about Jack and his situation and just on a little side note I'm also going to pick your brain's panellists about poor Jack's mum who I think has been coerced if I've read it correctly into actually delivering food to his room or otherwise he refuses to eat. But I think some of the questions we've already had tonight are about what are parents meant to do about these sorts of situations. So if you're aware of the case study that will help guide our presentation. So I'm going to turn over now to Dr Sam Yong who's going to give us the perspective from a GP. Thank you, Catherine. Yes, well my name is Sam and thank you for having me today. I just thought I would tell you a little bit about myself very quickly. But just in the top right-hand corner of this slide is just a picture of myself at the ripe old age of 17 and that's just me next to my computer which I spent a lot of time in front of. Actually in that year of my life I was a year 12 student and I recall that I checked how many hours I played on this online game called EverQuest and it equated to about 1900 hours which is about two months and 22 days of time that I'd spent in front of that computer there just between January and August of that year. But it wasn't until I realised that I probably wasn't going to pass my year 12 exam or get into university that I decided to quit albeit for a temporary period of time. But certainly that is why this is a topic that's maybe a little bit of interest to myself and I think that the prevalence will continue to rise. We think that about two thirds of Australians actually play some form of video games pretty regularly and that the majority of households will have some sort of device that will enable people to play a computer game and the prevalence has been reported to be around five to six percent anyway here in Australia in terms of pathological video gaming tendencies. And this picture on the bottom left-hand side is probably not something that we haven't seen before. It's maybe a picture of what we see in the younger generation now engaging in technology at a very young age. And I think therefore these kinds of disorders not only internet gaming disorder but internet addictions and social media addictions will continue to rise over time. In terms of my general approach to this case but also just in any case and I know that Jack and his mother have already presented in this case. I think that half the issue is just identifying the fact that it is an issue in many young people. Many young people will present with other unrelated presentation things like viral infections or immunizations and often at that time in general practice we like to perform what we know as a head assessment which is just a general assessment to find out a bit about how life is going otherwise. And we tend to ask them about their home, their schooling, their general activities, whether or not there's any drugs involved, sexuality and depression and suicide also come to the fore. But I think it's a good time to also just ask what sort of interests they have and in general we do find that there is an increased prevalence of people who enjoy playing internet games and some people who will be addicted to such an activity. It's also a great opportunity to develop a bit of rapport, to engage patients and at this time I usually ask them what sort of video games they'll be playing, what sort of platforms they're using, whether that be on their computer or something like a PlayStation or an Xbox or an iPhone. I tend to ask them about how much they play and quantify their usage in terms of hours. I also like to find out a bit about what motivates them to play and what the addictive properties are, whether that be the problem solving, you know, I guess, properties of the game, the social aspects, the escape from reality or whether or not it's the measurable growth or the rewards that you can have it in very quick time. It's also a good opportunity to ask you about comorbid mental health problems like depression, anxiety or stress and using a DAS 21 can be very helpful in that sort of setting. And at that time, I also like to find out about whether or not there's any functional incapacity being caused in this scenario, whether that be relationships, financial school, work performance or social isolation. And that's something that I think we can already see in this case. In terms of managing such a patient where you might think that they might have a general addiction to internet game, I think it's really important to be non-judgmental and have an empathic approach in a case like this. I tend to acknowledge the merits of video gaming. And I guess I'm a bit biased, but I think that there are many. But in terms of general strategies, I think it's important to encourage social play, to play with friends or with family members. Some other things that parents can implement are to negotiate gaming as a reward for key responsibilities and trying to set a total gaming time per day. And I don't know that there is an exact number, but I think it is important to negotiate that between parent and child. I think one really important aspect is to move devices out of the bedroom into social areas and other activities to take their minds and to occupy them otherwise, whether that be exercise, co-curricular activities, other things like mindfulness. And I think it's very important to have the parents engaged in those activities as well. I know I spoke about the fact that technology is one of the problems of why we're seeing increased prevalence in such an addiction. But I think that using technology and the resources available can be a very useful tool to patients. I often refer people to a TEDx talk called escaping video game addiction. And a couple of podcasts as well, which I've listed there, the Game Critters podcast and the Psychology of Games podcast. In terms of referring on, I think it's also helpful to engage other specialties and use a multidisciplinary approach in this setting. And a refer to a psychologist would probably be the first port of call. And you could consider using a mental health care plan in general practice if they had other comorbid mental health disorders. As we spoke about this disorder is not listed on the DSM as of yet. We could consider cognitive behavioral therapy, and I'll leave others to discuss this a little bit further. There are of course addiction specialists. And now there's maybe an increase in interest in internet gaming as its own entity. I think you could also consider maybe getting some other people involved like the school counselor, and a referral to a psychiatrist in very difficult cases. But this concludes the end of my talk. And thank you very much. Wonderful. Thanks, Sam. I really enjoyed particularly watching the photo of you as a 17-year-old. I would love to pick your brains later about where you've gone on a personal journey with that. I'd now like to hand over to Vass, who's going to give us the clinical psychology perspective. Thank you. Thank you for inviting me here. My main aim based on Drac's case is to introduce six main points that define behavioral addictions and ITD. A case formulation conceptualization that embraces game-related factors and to expand the understanding around massively multiplayer online games as high risk internet applications. Every behavior that satisfies the following six points constitutes an addiction from an operational perspective. Tolerance, mood modification, salience, which means a specific frequency within a specific period of time, withdrawal symptoms, conflicts, and relapse. There's a continuum of social tolerance and acceptance of addictions, with substance abuse behaviors being less underdiagnosed and less socially tolerated, alcohol abuse somewhere in the middle, and behavioral addictions being potentially more socially tolerated and therefore more underdiagnosed. Time is necessary but not a sufficient criterion to define addictive use of the internet. The aim is the important criterion, why someone is there. If HEOC is there to moderate the way HEOC feels, then this constitutes a high risk factor. What triggers internet gaming disorder behaviors? A combination of individual and contextual factors that push the gamer into the world of the game, along with game-related factors that pull the gamer into the world of the game. Saying that I need to highlight that internet addiction behaviors and internet gaming disorder behaviors are primarily considered secondary symptoms which aim to emotionally regulate other primary symptoms such as depression and anxiety. However, they may eventually reinforce them. A drive for communication and socialization is what mainly use the gamers to aggressively use games, leading to loneliness and isolation. This is best conceptualized by the term internet paradox that defines how a communication medium can actually advance loneliness and isolation. Considering cyber relationships developed in the world of the games, such as Overwatch, these are best described by two models, the AAA, Anonymity Accessibility and Affordability among the players, and the AIS Model Anonymity Convenience and Escapism. Considering the games as high risk applications, MMOs, massively multiplayer online games, comprise a system of constant rewards and reinforcements along with online socialization. And when these two coexist with the constant evolution of a game character, then we have massively multiplayer online role-playing games which tend to be more addictive. In these games, players assume the role of a character and they control other character's actions and development. And a number of players can be concurrently present in the game while the game's persistent world continues to exist and evolve while the player is offline and away from the game. It's like sharing a collective dream. In the case of Overwatch, we have the two elements, online socialization and a constant system of rewards and challenges. Saying that I need to highlight, I need to illustrate that this is exactly the mechanism that the games use to maintain the attraction of the users, a progressively higher balance between the skills of the players and the demands of the game. In terms of our clinical formulation, case formulation, we usually have predisposing factors which constitute involved adaptation difficulties in someone's real life, which result to feelings of discomfort and distress that eventuate excessive gaming, that is perpetuated by access to gratification and relief. And if the gamer has a level of problem awareness and a motivation to change, then we do have protective factors. And these factors are equally distributed across the real and the virtual context and can be viewed either as risks or resources and risks, both static and dynamic. Finishing my presentation, I would simply like to say that in terms of our case formulation and our treatment plan, we need to involve elements related to the game context and the relationship between the gamer and his persona in the world of the game, as well as the relationship between the gamer and his online group. Thank you. Wow, Vas, you have got a depth of knowledge beyond anything I could possibly imagine. I'm still trying to get my head around the problem awareness and motivation to change. I'm thinking very much like an ignoramus parent here. How does one increase a young adolescent boy like Jack in our case study, his problem awareness or his motivation to change? And we might come back to that. But I'd like to hear next from Dr. Kim Lee, who's our psychiatrist, who's going to give us the point of view from psychiatry. Over to you, Kim. Thanks, Catherine. So on my journey through internet gaming disorder, at the start, I was like most of the people in the audience are games really that addictive. And I had to go overseas to clinics in Asia to really open my eyes up on what the problem was. And if you dig deeper into the game design, you'll find out that there are psychology 101 lessons that are being repeated in gaming and now smartphones. So I've got my rat ear in a skinner box. I've got this one from Ikea. But, you know, was able to train any rat to press the button continuously for a reward. And he did that by randomizing the reward. So the rat never knew when the next reward was going to come. Now, game designers have been doing this for decades and randomizing rewards to get players hooked. And you do a quick Google Search and Overwatch, even the Wikipedia link I put there for Overwatch. The game Overwatch has what's called loot boxes. So if you work hard at the game, you increase your level, you get a loot box a reward. And you don't know what's in that box. And that, for some people, is a real draw card to get them to keep grinding out, to keep pressing the button for the next level. And if you've maxed out on the loot boxes, you can actually spend money on Overwatch, what are they called, micro transactions. In the end, these fabulous games are designed for addiction, because addiction makes money and addictive games sell. And in Jack's gamers situation, it's hard to really say, oh, he's addicted to the loot boxes. But obviously there are other rewards that are very rewarding for him and brings him back. And one of those key things is that he's posting his videos online, getting comments through forums and his Facebook. And those little rewards that he's getting is big enough for him to overcome the bullying, which I think is probably an even bigger problem in this particular case. And that should be addressed as well. That's like you would in any other patient that comes to see you in your clinic. So as a child psychiatrist, I'm probably seeing one new case of internet gaming addiction in the camp setting. And these are usually children who are teenage boys or school refusing, refusing to leave their home, not functioning academically, socially, emotionally. And more and more I'm seeing girls who are presenting with difficulties getting off social media. And more recently, you've seen lots of whistleblowers, people like one of the founders of Facebook come out to say yes, Facebook is designed to be addictive. So what we've got now, ladies and gentlemen, is your smartphone is now designed to become your own skin evoke. So we are all giving away valuable data and information to the largest social experiment and operant conditioning laboratory in the world. And all the games now are designed to be online so they can collect that data. Now you can use that in your practice to your benefit by asking the child if they agree to log in to their Steam account and you can find out objectively how many gaming hours, just like what Sam mentioned when he was playing Year 12. And I see kids spending thousands of hours on one game in my clinic. So in terms of tips, very basic tips. Moving devices out of the bedroom. The Singaporean researchers found that if you had devices in the bedroom you're more like to become addicted. Schedule activities, no matter whether I go to Singapore, Korea or Japan. All those clinics there, the patients are handing in very detailed hour by hour programs of what they're doing in the day so that they know that they can still in that time with activities. And if there's an age classification, use it. The website Common Sense Media is a very good website to use if you're a parent or a clinician trying to find out more information. And abstinence is the aim because abstinence creates awareness. And the University of Adelaide, I'll just finish up now. The University of Adelaide with Glenda University did a recent study published this year that found that if you found gamers who are voluntarily wanting to quit, if you got them to stop gaming from Friday midday to Monday midday and gave their passwords to the study and were not able to access the gaming, they were able to shift their negative cognitions based on their gaming, their selfish theme and reduce their gaming hours one week later and one month later. Thanks. Wow, thanks so much, Kim. That is a fantastic and amazing study. I am going to tell my 16-year-old about it when I get home tonight. The Friday lunchtime was it? Friday lunchtime because weekends are probably the biggest time when you're going to spend time online. So it's a big chunk. Yeah, fantastic. All right, and last but not least again, I'd like to turn over to Dr John Hurley who's going to tell us about the perspective from a mental health nurse headspace. Over to you, John. Hi, that's three hard talks to follow. Thank you very much for that. This question would be the most common question that I have been asked at Headspace by both parents and by other clinicians because by some of my late life father and hence I have a teen-owned son and I've actually learnt a game. When I thought about answering that question, I kept a few things in my mind. One is that as the other speakers have so well outlined that games are made to be addictive. The second thing I kept in mind was that as a mental health profession or cross-hair professions we have over the years tended to pathologise as you could probably see I'm old enough to have been around in the time of the DSM3 then it was substantially thinner and contained things like homosexuality. So I wanted to be sort of alert that I wasn't pathologising something. This was reinforced by meeting many young people in my clinical room that use gaming to form friendships, fall in love, experience success, learn leadership, learn negotiation and expand their social skills and as well as meeting others who like our case study Jack clearly had some sort of profound problems around gaming. So as both clinician and academic what I did is I trotted out of Headspace and trotted into the literature of research and I did an in-depth literature review and what I found pretty well reflected what was in my clinical environment. What becomes immediately apparent on the left-hand side of the slide there you'll see all the benefits that the research indicates comes from gaming. They have friendships, youth identity, mental health literacy all sorts of advantages. And then on the next perspective when we have a look at the other research evidence we find that gaming is strongly associated with decreased psychosocial function and exacerbation of pre-existing mental health conditions. So even going to the evidence and the research itself wasn't necessarily clarifying what didn't come clear was that there was no defining diagnostic tool. There was no defining evidence-based clinical treatment and that's because there are very few clinical trials that are of a large number that are longitudinal. What also seemed to be apparent is that we need to be alert that the evidence suggests that perhaps we need to shift our gaze away from just gaming to wider internet applications because sometimes the addictions around what the internet supports such as gambling, sex or social interactions. One of the key things from the mental health nursing perspective or from any mental health perspective for that matter in terms of gaming is this question. The question of are they running away from something or are they not? This takes us back to this idea of pathologising something. Gaming is really really good fun and particularly if you read something called flow it's just a sheer joy. This is where your skills and the game sort of meld together and one hour or four hours feels like one hour. So I find in clinical practice a really useful thing to do as you would do with Jack is to explore the drivers for the game. Are they actually walking towards this game for sheer enjoyment much as what in my youth I walk towards cricket and would have spent thousands of hours doing that? Or are they in fact running away from something such as trauma, depression, parental abuse, social phobias, school bullying and using it as a refuge? I believe that once we can accept gaming as neither been intrinsically good or bad that we therefore will have more curiosity to be able to explore some possible answers to that. One of the things about engagement around gaming is that we now have emerging empirical evidence that the theoretical lines actually has a substantial positive impact on the impact on the outcomes of psychological treatments. Where we as where I come in is that I can use gaming as a tool rather than obstacle. I can situate the young person has been a teacher and an expert that they're accepted and that I'm not just simply another old person telling them how to live their life. Also being able to talk their language, the language of gaming, gives me some credibility to quite respectfully challenge perhaps the amount of hours they are spending on their games. Some useful things in terms of intervening. Now again I looked at the evidence and tried to find something within the literature that was giving me two things I really wanted to go back to the first question was how many hours should I let my child play. And I looked at scores and scores of articles and they most often talk about moderate extreme or small amounts of gaming but really didn't give hours in an empirical number. I sort of had a sense that it was around two hours a day seemed to be supporting some of those positive benefits of gaming and that beyond that seemed to be headed towards pathology but that's very rough. I found in my clinical practice that replacement rather than banning has been quite effective so by filling the day up with alternative activities there's less time to play and it also removes that confrontation. Finally it was around also intervening with a social capital and so social capital is about how young people use gaming and the internet add resources to their lives that they otherwise wouldn't have and that if we're asking young people to stop gaming we're asking to stop having friendships we're asking them to stop having excitement to stop having fun to stop having connectivity or key developmental aspects to teenagers. So we also need to be mindful of that. And I guess as a final message it would just be that for clinicians that we should really learn about gaming and be more literate about the languages and the type of games that are out there. Thank you. Thanks so much for that John that was fascinating. You're a braver man than I get venturing down the gaming with your sun path but it is a timely message for us all because I think as a clinician often feel and as a parent I feel dreadfully out of my depth with what is happening. We've had a lot of questions that I'm going to pull together and put to the panel and I encourage you to keep writing questions on the chat box and I'll try to get those questions to the panelists as I can although there are quite a lot of them. The elephant in the room in some way is that there are clear differences between what girls and boys or young men and young women are doing online and I guess I'd like to ask the panelists given that we're talking about internet gaming addiction why is this so much of a problem for teenage boys what's going on in the lives of boys that makes it a problem and what are the girls doing so I'll ask Sam to give his perspective on this first. Yeah sorry Catherine you just broke up there would you do that? Yeah I'm just saying what's with the boys what's going wrong with boys why is this a boy problem and you know obviously girls and boys are approaching online gaming quite differently I understand the prevalence rates are quite different I have three teenagers of different sexes in my house and I can tell you the boys are doing a lot of different things than my daughter why is that why boys? Yeah I think that's a really good question and I'm not sure that I would definitely know being a boy myself but I think a very large proportion of people who play video games are actually female I would agree with you that the majority of boys and I don't know I think it could be to do with the fact that it's competitive at times internet gaming and I think in general females are less competitive and have that desire to beat each other or win at something you know and I kind of think about the aspects of gaming that appeal to myself but it's also the fact that you also have very you see very quick rewards in games whether that be to achieve high school or to obtain loot boxes and you feel like you have very tangible rewards very quickly and that seems to be something of a lot of interest but also because it's a very easy way to socialize and I recall that even from a young age it was an easy way to meet people on the internet and to be friend people and to find an activity that you could potentially do with other people and get to know them at the same time and maybe that's something that boys have a little bit more difficulty doing finding something to occupy them with other young boys whether that you know and maybe that's why we're out in the yard maybe kicking a ball or throwing a ball or running around and girls are sitting around having a chat and socializing maybe in a bit more of a mature fashion Yeah it's such a it's such an interesting area I think you know one of the other things I've noticed with my 16 year old son is he will 100% socialize on Friday and Saturday nights with online gaming not sure what my teenage daughter is doing would be considered socializing it's definitely using social media not internet gaming but and that's a whole another webinar topic about what girls are doing online I suppose Kim what do you think about this about the the vulnerabilities of boys in particular to gaming addiction? Sure I guess you've got to look at the Department of Health national statistics that came out a few years ago and they found that actually girls had more addictive problems with the internet and electronic gaming use so they that particular study they combined both internet and electronic games and although boys played more games girls were experiencing more typically controlling their internet use and although I see girls although I see girls playing games in my clinic generally it's all about marketing and money in the end and oh my webcams went up it's all about marketing and you know if you go in the playground on the earth well there's a lineup of boys playing British Bulldogs and the girls might be sitting around talking or playing a game that's safe for them and essentially the games at the moment they're designed in a way that is exciting and games that are violent are exciting and there are some theories that there's a strong link between ADHD and internet gaming problems and the exciting games are the violent games so that stimulates the child with ADHD and we know that there are more boys with ADHD and more and more in my practice I'm seeing children with autism suffering from difficulties using their iPad or electronic games that's actually one of the people on the chat was asking a little bit about autism spectrum disorders and gaming so I'm glad you touched on that Vaz what do you think about the gender difference here in prevalence rates or why how girls and boys approach gaming okay I have three points to highlight first from a research perspective we do know that those who present with internet gaming disorder symptoms tend to be more boys however when we have females presenting with IDD their symptoms are stronger are higher the clinical cases tend to be more severe that's the first point the second point has to do with the fact that in every form of addiction males tend to prevail and the common denominator when it comes to addictive behaviors is the lack of relationships is what we call you know it's the main addictive function one of the main addictive functions and when it comes to cyber relationships what has been suggested is that males are more prone to be addicted to them because from a social perspective are more limited than females in expressing their feelings either feelings of anger or feelings of abatement and proximity and the third point has to do with the fact that until now we haven't had what we call measurement invariant studies because there is the possibility that boys and girls address the same questionnaires that assess the prevalence in a different way so the same scores may indicate a different level of severity and the only study that has been published assessing that thing is an Italian study in 2017 there are more to come so it has been recommended that we need more measurement invariant studies to be to be sure about the extent of the difference of the prevalence between boys and girls but overall it's cyber relationships yeah right it's very interesting and just the male patterns of addiction in general you're reminding me of things that of course we know but it's it's just such a different way that girls and boys at pre adolescence and adolescence tend to approach these things all right I want to just turn our attention now to some other questions that are coming through and some of the people are asking us what are the particular risk factors that would make someone more vulnerable to online gaming addiction and can those risk factors be identified earlier in childhood so anyone want to anyone got a burning desire to sort of have a go at this one or have to direct you so I'm going to get you to answer it Sam yeah I mean that's that yeah you know in terms of risk factors for for gaming I'd say certainly social isolation is one because I think that there is that ease of socializing and engaging other people in such an activity and working towards a common goal I think that also uses a distraction so often you know people who actually have other things that they need to do whether it be students who need to do homework or people who need to work on something in particular will use it as a form of distracting themselves I think that's a big risk factor so you just interrupt Sam you mean procrastinating it's it's been a procrastination it is a form of procrastination and it's very easy it's very easily accessible as well nowadays it is so easy to log on and to click on to a game and then to engage yourself for a good one hour or two or more and I think that that is something that is that is why it's it's much more fun than homework let's face it of course of course all right John why do you think what what do you think the factors are that would be risk factors for for a particular child I think we've probably touched on all of us tonight that there's there's a lack of really clear undisputable evidence that's actually directing us towards this what seems to be a pattern or or themes emerging is that particularly in young people it's the young person who's a bit different the young person who perhaps because they're a bit different are being bullied at school or they feel judged by their peers and they feel disconnected from other young people who are also a bit different and so the gaming platforms tend to be a safe place for those kids who aren't the norm or who step a little bit outside of the norm and it's a safe environment for them to be in where for those of you I don't know how old we we all are in terms of when we all last walk through a high school playground they can be sometimes intimidating, rowdy, noisy places and these platforms are a safe refuge for those not to be judged yeah great all right Vance what do you think are there are there research is there any research into understanding what particular children are at risk of this what the personal interpersonal characteristics of those children are and yes there is research in terms of personality traits those who tend to be more introvert those who tend to be more open to experience and those who tend to be less agreeable appear to be at high risk those who suffer from from a comorbid form of psychopathology and they tend to use gaming as a maladaptive emotional regulation strategy but the important thing in terms of research is the emphasis on contextual factors so paradoxically it has been found that when we have more gamers in the same classroom then the game pattern is not addictive because they use the game as an extension of the socialization in reality just just can I just lay down again I just want to make sure I've understood it right so you're saying that if there are multiple players online it it becomes less addictive what has been found and it's very interesting is that when we have a higher percentage of gamers within the same classroom then the game itself becomes a mean of socialization it's like they do all the same thing and they they end up socializing through that it's it's a it's a form of social compliance a risk factor a main risk factor has to do with isolated player isolated gaming from someone's real contact and I would I would also highlight something which is very important there's a paradox with in the internet gaming disorder as a form of addiction while in general the prevalence of other forms of addiction tends to be higher in more individualistic and westernized cultures when it comes to internet gaming disorder the prevalence tends to be higher in more collectivistic and less and less westernized countries like Korea or China and the way that this has been explained is the need of belonging so the gamers end up belonging in a social group and they they they they connect to it that strongly that they cannot disengage from the game so if someone doesn't have a group to belong in reality he or she is likely to substitute these these deficits online through the world of the game and this is possibly the most important risk factor that's absolutely fascinating I could spend a lot of time talking to you about this Kim what do you think what's your perspective about the you know individual risk factors yeah well in the Singaporean addiction clinic that I worked in we did a study on the data that we had coming through and the highest risk factor was Chrome orbit ADHD also a lot of children who had Chrome orbit major depression and we I think the one of the biggest biggest risk factors is parents buying these games and not really having a clue that these games could be addictive and you know the we're reaching a tipping point where people are waking up for this and realizing that hey there's something happening here and it's not quite right and you know last week we had Sean Parker one of the founder of the Facebook come out publicly and say yeah we program Facebook to be addictive and it's no wonder that Facebook is one of the top five largest companies in the world and we need to educate the public that there are risks involved in giving your child very young children games and games that are not age appropriate that's that's so true so I actually want to turn our attention a little bit to prevention and also some of the challenges we get not just with the young people who come into your practices or our practices but also their parents who might be be presenting with distress because of what is happening in the household as is the case in our case study I guess again coming from the position of a quite ignorant person about this do gamers actually know how much they are playing you all of you have talked a little bit about the importance of gamers becoming aware of how much they are online first of all do gamers actually know do parents know and how can we increase the awareness of this what seems to be a pretty important factor in increasing motivation for any treatment or intervention anyone can have a go at telling me this do gamers know how much they're gaming do problem gamblers know how much time they're spending in a casino well they usually know how much money they're spending at some point because there's a bank balance that if it goes down and I just one I don't know I really don't know do you know you I think I think there was a you know fantastic sort of description of going through how many hours that we played on something but do gamers actually look at stuff up I don't know I want to know well that's for some people they would look it up as a sort of sign of pride or you know dedication which is a great thing but you know what about another question how much time should you spend on your holiday going overseas because what I the way I see games is essentially another world and you're spending time in that world and you know we'd all love to spend you know months on end in Bali relaxing but there's a real world out there and it's back in Adelaide or back in Sydney or Melbourne and that's the truth of it if you want to let your child spend their time in a world that has no rules and people aren't accountable for what they do or what they say or bullying or how much money they spend on their grandparents credit card and yeah I mean these are all things that we got to wake up to mmm true all right Vast do gamers know how much they're playing and and how can we increase awareness of that okay I think there are two levels of awareness then they say the short time the on-time awareness while while while they are gaming which is not there because as John very widely said they are absorbed by the context of the game and the activity in the game due to online flow so they are not aware while they are playing while they are gaming but they have delayed awareness they know they have a healthy voice a reflective voice inside them and what I usually do when when I treat cases of ITD is to ask them whether there is a voice inside them that tells them that there is something wrong there and this healthy voice is the voice that we are live with and we aim to empower during therapy because there is a contradiction there is a discrepancy between what they know that it is right to be done and the way they actually act and and and and these discrepancy needs to be treated we need to empower the healthy part of the self which is there in a delayed way in a delayed time if I make sense that's that's absolutely makes sense all right some of our panelists are asking a little bit about parents and what some strategies are for parents so I'd like to ask every one of the panelists to help us out here and to tell us some practical strategies for parents about how to enforce shutoff times for the internet access or to empower parents managing this problem I think I facetiously said earlier that Jack's mother has somehow been complicit in bringing his dinner to his room because he refuses to eat otherwise but what can parents do I'm not sure that parents are going to be able to replicate that university study and take passwords of kids at lunchtime on Friday but could we have the panel's expertise on what practical strategies parents can do to help their kids over to anyone I think hi it's really important not to separate the child from the rest of the family system and at the same time from the other life tasks that an adolescent is facing we too often tend to try and treat people in isolation from their wider family system so I think part of it would be that there is no magic answer every young person I see is quite individual quite unique their circumstances and the parenting are quite individual and quite unique as well what does seem to work is open honest communication in terms of the parents and the children and have been non-confrontational when you look at one of the key developmental tasks of any adolescent is to differentiate themselves from their parents and so gaming becomes the focal point of what's actually normal developmental psychology but then it gets mired and murked up in this gaming issue so it's about one of the key things I do is get the parents in the room usually as many of the family members in the room as possible and that's not always easy with our funding systems and try and at least promote that open communication seems to be a common sort of theme all right other panelists what practical strategies can you give parents to help their kids gumtree who is that I said gumtree oh yeah tell us about that I often say to parents you know why don't you just put GTA 5 disc on gumtree and sometimes once I had this eight-year-old boy tell me I don't care if you sell that game I'm just going to get a cash invader and buy it for five dollars and you know these kids are savvy but you know it comes down to values and families and parents have to put their foot down at some stage and they look I understand you're really into this game but we actually value your time and we want you back in our lives and sometimes that sinks in sometimes it doesn't and if you need a professional to help you out with that then seek help I mean in our case study I noticed Jack is sort of sneaking his parent he seems to have eclipsed his parents in his technical skills his his you know obviously waiting till they've crashed out at night he's staying up at night he's doing it in these surreptitious ways I guess that would be pretty common for you know most of us who have teenage children do not have the technical skills that they have particularly once they hit higher adolescent years so how would you bring around a family like Jack's where he's sneaking around doing this sort of stuff at night or behind the parents backs so to speak yeah I'm sorry oh sorry sorry go ahead sir yeah look I was just thinking about this scenario and I think it's a it's a very difficult one I think certainly you know one of the big things that that I promote in people who have this kind of problem would be to move any gaming devices such as the computer into areas where everyone is around like I think having them in the bedroom is definitely something that you know where where someone can gain guilt-free and not have to do it in front of their parents I think some of the other tips that I often will have the parents are you know trying to set a bit of an example we know that you know and I'm just as guilty as anyone we spend a lot of time on our phones on technology nowadays and I think children and adolescents are very perceptive of that and will follow those kinds of behaviors and I think it's very hard to tell an adolescent one thing but do another and so that's one thing I would definitely recommend is trying to decrease screen time for the adults and as well as a general tip and that's probably a better way to engage their children and to form sort of good social habits and other activities of interest as well Yeah that's true All right I want to move on to another area of interest that people have written in about and that is therapies and effective treatment so we might start with you Vass what are the evidence-based treatments for internet gaming addiction and how effective are they We don't have many how many studies published what we do know there's an an Asian study I don't remember the country which talks about reality therapy and specific questions about raising awareness there is there is the French approach which is not evidence-based published by Tisseron who says resurrect the avatar bring the gamer's persona into real life so what gives pleasure to the gamer inside the game needs to be to find a way to to to fit in the real world But hang on hang on just sorry I mean I am really speaking from an ignorant perspective what if the game what gives the gamer pleasure as sort of you know violent actions and some of the things that I worry about in gaming how does that work in this sort of therapy I think we need to we need to think of aggression as a form of of an acting out behavior and of course tension can be expressed in reality in more allowed or more elaborated ways but the gamer himself or herself needs to be able to leave part of his or her gaming life in his or her real life and this is this is probably the most important thing so who he is or who she is in the world of the game needs to be brought into into into reality according to Tisseron in France and the the other highlight which is a practiced by a center in the US called Restart which is famous for the treatment of internet addiction and internet gaming disorders has to do with group therapy so what they are saying basically is that individual treatment helps someone to address issues in his or her relationship with himself or herself but when it comes to internet gaming disorder which is basically caused by difficulties in relationships in real life we need group therapy and progressively tightened boundaries so initially the gamer themselves the gamers themselves are not able to activate the level of control that they would like to have had in their lives and they need external boundaries progressively they establish a level of control and they need to grow relationship wise and they need groups so it's a necessity when it comes to internet gaming disorder cases group therapy is a necessity when we facilitate groups of gamers it's very different to other forms of addictions because they tend not to speak not to talk and the easiest way to start them talk is through introducing their online personas through their nicknames within the group therapy you get them talking yes this is the initial stage practice both in France in Italy polyclinical gemaliant increase often this is what we do but unfortunately these three countries lack into evidence-based approaches you need to publish more yeah that's what you're saying it's such a it seems so relevant to what you're talking about and such a really need to get the empirical studies involved in that yeah absolutely great that's so helpful Kim what do you think about effective treatments? I can tell you that there are many ineffective treatments such as Chinese boot camps and right yeah they're quite sort of paramilitary boot camps what do they actually do what do what do they I tried to go there but they're very quite the Chinese about letting you in to the country and but there are some interesting things being done in Korea they're doing things like transcranial direct stimulation those kinds of things and is there any evidence for that any evidence? in terms of randomized control trials no but you know gamers are actually using these techniques and buying them off eBay and enhancing their brains by using these machines themselves but in terms of actual I think it comes back down to abstinence no matter which country I go to and in Singapore they found that a reduction in gaming time improved your depressed symptoms improved your actual mental health and yeah I mean the old abstinence thing I mean is there any Sam is there any any effective medication people are oh it's sort of quite interested in that the other the other thing I was going to say with in terms of this case in terms of Jack Gamer's case is that he's quite motivated to become a professional and he needs to be a bit more realistic about that and I'd have a sit down and and chat with him about the chance with him becoming an Olympic athlete is actually higher than him becoming an E-Force athlete and E-Force is essentially a billion dollar industry marketed by the actual companies themselves to glamorize gaming and make this seem like a professional thing and the weird thing is that everyone's jumping on it you got Harvard colleges sponsoring teams we've got Adelaide Crows who lost the grand final this year sponsoring an E-Sports team spending six diggers some because they know that there's a big money in this and we've got to wake up to the fact that you know the other day I met an Olympic athlete an actual Olympic athlete and they actually take some days off the rest the weird thing about gaming is is that kids and gamers adults they can spend huge amounts of time and not feel fatigued they can they have a huge appetite for time spent online and that's within the game design the game design never makes you feel full yeah it's the perfect storm perfect skinner box as you know as we've as we've heard yeah all right I'm I'm conscious of time and what I want to do is spend the next couple of minutes five minutes or so just coming back to each of our panelists and get them to give their sort of key messages about internet gaming addiction where they think this is going and what the sort of key messages for clinicians parents or gamers themselves dealing with this issue ah so we'll go back in order I'll start with you Sam what are the key messages you think you'd like our participants to go away with tonight yeah look I think from a general practice point of view I think trying to increase awareness in general practice and trying to at least ask about the issue identify the fact that it's an issue is something that would be a good start and you know certainly I think the prevalence will increase as the younger population is exposed to increasing levels of internet and technology and also increasing awareness of this disorder as well I think in terms of just you know key management strategies you know I definitely am a big advocate of moving moving these devices out into social areas trying to restrict use and trying to I guess come to a negotiation about trying to spend a limited time per day but also replacing you know that activity with other interests and other activities that you can perform as a family and I think those are some good strategies to have it's also important to involve others as I said I think someone you know you asked about medication therapy and certainly to date I'm not aware of any successful cases of medications being used for this disorder in isolation and I'm not sure that I've found any evidence that that would be useful okay yeah thanks Sam that's that's incredibly helpful all right Vass I might ask you to just give us your summation of the key messages for our participants tonight okay I will start from the last medication what we do know is that we have what we call cross-addictive behaviors so if someone has a tendency to behave addictively this tendency can transform from one form of addiction into another and what is officially recommended with clients who present with behavioral addiction symptoms including in entertaining disorder is not to be medicated very easily because they can it is likely for them to develop a form of legal substance related addiction based on their medication that's the first thing the second point is a rather optimistic point research wise what we do know about excessive gaming is that it tends from longitudinal studies between 16 and 18 is that it tends to drop over time during that time so it could be a developmental trajectory between 16 and 18 so it so it picks at 16 and then by the time a young person is 18 it sort of dropped off a little yes and it's quite similar to Sam's case very interestingly so it could be a developmental trajectory related to differentiation needs from the parents that will dissipate over time and the other thing that we do know is that it tends to be more intensive the first year of involvement of a gamer with a game and it tends to dissipate after so for parents and families don't be they should be less worried if the symptoms present to be intense between before the age of 18 and after the first year of involvement with an internet game if they maintain medication wise they need to be very very cautious both practitioners and parents and different wise relationships we need to work with decreasing push factors so have more inviting relationships in real life and decreasing pull factors relationships within the world of the game an important thing is for all of us to ask the gamers who are they in the world of the game what is the feeling of the meaning that they have within the game team and to compare that with who they are in reality and how much they feel they matter about their social groups in real life right great okay thanks Vass Kim what just a couple of key highlights for you that you'd like our participants to come home with yeah I guess being the psychiatrist on the panel I should probably comment on medication whether I would prescribe Jack Gamer medication probably not I think we need to address some of the face-to-face bullying in the school which I often get involved in in Adelaide we've had quite a significant stint of cyberbullying happening in schools in my area seeing widely publicized actually and the Kali Ryan Foundation are making legal sort of changes to the law where to ban cyberbullies from social media which is an amazing step forward have I prescribed medications for kids in similar situations for Jack Gamer I mean if he was socially anxious about going to school had the pressure symptoms that he thought life was not worth living and actually one of the key factors to look out for is people who actually don't actually enjoy playing the game anymore right because the facts of that love-hate relationship the dopamine the same thing doesn't give you that same level of enjoyment anymore and if you're playing this game grinding it out just for the pure thing that's habitual then you might you know consider some medications and the only thing for other sort of people who can prescribe in the forum is just to be mindful that if you are starting an SSRI serotonin type antidepressant it can increase impulsivity and you find them compulsively spending money or things like that so they're the kind of things you want to watch out for so you know the usual go low go slow kind of yeah and psychological therapy right great excellent messages all right John what are your take home messages for our participants in echoing some of what Vas was saying I think there's the first message is don't panic a lot of this over time does most certainly improve as terms of the intervention we have a very powerful one which is the way that we relate with the person involved in the therapeutic alliance within that and we can use that as a platform to help to guide them towards building a life that's actually more reflective of their wider needs than just their gaming needs alone and that's about building their self-awareness about what else they might want from their loss both now and going into the future and very often particularly young adolescents don't know that and so some patients some patients and some hang in their time very important very important when parenting adolescents in general I would say wouldn't you John it is it is hang in there hang in there and make sure they know that you as a parent are on their team that you're on their side they're definitely using a quick fix that for sure absolutely not and that means that sometimes the parents need support for sure possibly more so than the young person I think that's actually a really really good point John I think that's certainly true in the you know the clinical practice I've seen so great great ideas there I have so appreciated that and I guess that brings us to the end of our webinar this evening and coming what's really struck me is so important in fearing a lot about internet gaming as it really comes back to the very basic things that clinicians know we were hearing tonight about the importance of interpersonal relations about the parent-child dynamics about getting the games out of the bedroom and into social situations and the incredibly interesting work that Vas is telling us about about the drawing from the person's experiences as a gamer into they're bringing that into their real life so the very basic things we know about human psychology and psychiatry are as relevant here even though for those of you like me who don't know much about internet gaming those issues are still the same so I'd like to first of all thank you all for your participation in tonight's webinar and for those of you who are very active on the chat room I'd like you to invite you to join future MHPN webinars and just as a bit of a teaser for what's coming up in 2018 we'll be continuing the BPT Bipolar Disorders series in February and have topics in 2018 that will cover prostate cancer oppositional defiant disorder impulse control disorder as well as better access to telehealth webinar and what I'd also like to encourage you to complete the feedback survey before you log out so if you click on the feedback survey tab at the bottom of your screen it will open the survey to also let you know you will get a certificate of attendance within four weeks and every participant will be sent a link will be sent a link to the online resources which are associated with this webinar again within four weeks and what I'd also like you to do is remember that MHPN supports the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners share tips and resources and build local referral pathways and engage in professional development activities so if you're interested in setting up your own network or special interest group or joining an existing one you can contact MHPN or indicate your interest on the exit survey so again please fill out the survey and before I close I'd like to acknowledge the consumers and carers who've lived with mental illnesses in the past and those who continue to live with mental illness in the present once more thank you to everyone for your participation this evening and thank you to our panelists good evening