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Psychiatry & Psychology • J Korean Med Sci 2017; 32: 514-521

Comparison of QEEG Findings between Adolescents with
Attention Deficit Hyperactivity Disorder (ADHD) without
Comorbidity and ADHD Comorbid with Internet Gaming
Jeong Ha Park,* Ji Sun Hong,* Internet gaming disorder (IGD) is often comorbid with attention deficit hyperactivity
Doug Hyun Han, Kyoung Joon Min, disorder (ADHD). In this study, we compared the neurobiological differences between
Young Sik Lee, Baik Seok Kee, ADHD comorbid with IGD (ADHD+IGD group) and ADHD without comorbidity (ADHD-only
and Sun Mi Kim group) by analyzing quantitative electroencephalogram (QEEG) findings. We recruited 16
male ADHD+IGD, 15 male ADHD-only adolescent patients, and 15 male healthy controls
Department of Psychiatry, Chung-Ang University
Medical Center, Seoul, Korea (HC group). Participants were assessed using Young’s Internet Addiction Scale and ADHD
Rating Scale. Relative power and inter- and intra-hemispheric coherences of brain waves
*Jeong Ha Park and Ji Sun Hong contributed equally were measured using a digital electroencephalography (EEG) system. Compared to the
to this work.
ADHD-only group, the ADHD+IGD group showed lower relative delta power and greater
Received: 14 October 2016 relative beta power in temporal regions. The relative theta power in frontal regions were
Accepted: 26 November 2016 higher in ADHD-only group compared to HC group. Inter-hemispheric coherence values
for the theta band between F3–F4 and C3–C4 electrodes were higher in ADHD-only group
Address for Correspondence:
compared to HC group. Intra-hemispheric coherence values for the delta, theta, alpha,
Sun Mi Kim, MD
Department of Psychiatry, Chung-Ang University Medical and beta bands between P4–O2 electrodes and intra-hemispheric coherence values for the
Center, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea theta band between Fz–Cz and T4–T6 electrodes were higher in ADHD+IGD group
compared to ADHD-only group. Adolescents who show greater vulnerability to ADHD
Funding: This study was supported by a grant from the Korean
Health Technology R&D Project, Ministry of Health and Welfare,
seem to continuously play Internet games to unconsciously enhance attentional ability. In
Republic of Korea (A120013) and a grant from the Korea turn, relative beta power in attention deficit in ADHD+IGD group may become similar to
Creative Content Agency (R2014040055).
that in HC group. Repetitive activation of brain reward and working memory systems
during continuous gaming may result in an increase in neuronal connectivity within the
parieto-occipital and temporal regions for the ADHD+IGD group.

Keywords:  Internet Gaming Disorder; Attention Deficit Hyperactivity Disorder;
Quantitative Electroencephalogram; Spectral Analysis; Coherence Analysis

INTRODUCTION may disturb an individual’s daily life (6,7). Ha et al. (8) reported
high psychiatric IGD and ADHD comorbidity in Korean children.
Today, Internet access is available almost everywhere in daily   Quantitative electroencephalography (QEEG) has been wide-
life. Internet game playing is inextricably linked to Internet en- ly used to identify distinctive electrophysiological signatures as-
tertainment activities. Thus, excessive Internet game play has sociated with various psychiatric disorders (8). These measures
arisen as a meaningful issue influencing daily life (1,2). Due to are divided into 2 types. One is spectral analysis of absolute and
these concerns, the Diagnostic and Statistical Manual of Mental relative electroencephalography (EEG) signal power. This pro-
Disorders, Fifth Edition (DSM-5) defined losing control over In- vides information regarding amount of brain activity in differ-
ternet game playing as internet gaming disorder (IGD), a new ent frequency bands, including delta (0.5–3.5 Hz), theta (3.5–7.5
psychiatric disorder requiring further research, as explained in Hz), alpha (7.5–12.5 Hz), and beta (12.5–35 Hz). The other is co-
section III (3). herence analysis, which quantifies the inter-dependence or sta-
  A number of psychiatric comorbidities have been consistent- tistical correlation between different EEG channels to estimate
ly associated with IGD, such as attention deficit hyperactivity functional connectivity between different cortical areas in the
disorder (ADHD), major depressive disorder, and social anxiety time domain (9).
disorders (4,5). ADHD seems to be a factor predicting loss of   Various studies have investigated QEEG features to discrimi-
self-control associated with excessive internet game play, which nate between ADHD and healthy controls (HCs). In ADHD, an

© 2017 The Korean Academy of Medical Sciences. pISSN 1011-8934
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considered to reflect problematic Internet use (22).19). In addition. One of the most replicated 3) Satisfied the criteria for IGD based on DSM-5 section III (3). Exclusion criteria for all groups were as follow: 1) K-ARS   Recently. K-ARS. ADHD-only group (15 male patients.  •  QEEG Findings of ADHD Comorbid with Internet Gaming Disorder increase in the absolute and relative power values of the theta able. or 7) A low IQ (Kore- and those with comorbid IGD. The theta/beta of ADHD-combined type. Greater absolute addition to ADHD. Children were also excluded ADHD+IGD group (16 male patients. or in power were seen in IGD participants (18. et al. items for assessing inattention and 9 items for assessing hyper- https://doi. we aimed to rean-Wechsler Adult Intelligence Scale IV score < 70). perinatal. spectral power of the al. 14. Clinician version (SCID-5-CV) (23).3. investigate whether ADHD comorbid with IGD (ADHD+IGD   HC group (mean age. there have been few studies to investi. spectral power value for the delta band in ADHD is commonly review of school reports for the past 12 months seeking behav- reported in ADHD (10-12). All patients visited the Department of Psy. 3) Severe medical illness.   The exclusion criterion for the ADHD-only group was YIAS tional connectivity deficits in ADHD patients in low-frequency score > 50. increased theta and decreased beta power. paroxysmal headaches or tics. in this study. and behavioral observations during the assessment.7) included 14 male partici- group) or ADHD without comorbidity (ADHD-only group) show­ pants between the ages of 13 and 19 years who were age matched ed any QEEG profile differences. ing. had no history of head injury or drug or alcohol abuse. each scored (22).org/10. In addition. A structured clinical interview was conducted by psychia.8) agreed to par- ticipate in this study. which   The inclusion criteria for the ADHD+IGD group were as fol- is summarized by the theta/beta ratio. and impulsive behaviors based on the SCID-5-CV (23). based psychiatric diagnosis including major depressive disor- decreased absolute beta power and increased absolute gamma der and anxiety disorder. Measures chiatry at Chung-Ang University Medical Center. All participants completed the Korean ADHD Rating Clinical symptom measures Scale (K-ARS) (20. psychostimulants during the last month. consciousness dis-   So far. or neonatal period. as well as Internet game playing patterns. and 2) Diagnosis of regions (14. The K-ARS tient Edition. and had not taken any prescribed medication for Study participants at least 90 days prior to evaluation.4 ± 1. nervous system diseases.19). searchers have discovered meaningful left-hemisphere func. 14. atic prenatal. 6) History of problem- ence analysis in IGD. To date. All participants Participants were assessed with YIAS.3346/jkms. All participants in the HC group were comorbidity.13).Park JH. Lastly. We wanted to identify neuro.7 ± 0. were of normal IQ. including theta and delta (16. Ko- between IGD and ADHD. 4) Past or current gamma power was significantly correlated with IGD symptom substance use disorders.32. head injury with cerebral symptoms. and hyperactivity. assessment for neurological soft signs. The HC physiological features supplying significant clues to the neuro. a result in QEEG spectral analysis (10-12). which indicates comorbid problematic game play- bands. EEG coherence findings in ADHD patients is an increase in the   Inclusion criteria for the ADHD-only group were as follow: 1) inter-hemispheric coherence of the theta band in entire brain Children and adolescents aged 10–17 years. on a 1 to 5 (“rarely” to “always”) scale. convulsions or history of convulsive gate QEEG findings to differentiate between ADHD adolescents disorders. inatten- ratio for clinical assessment in ADHD patients has been com. show­ MATERIALS AND METHODS ed evidence of adequate functioning at home/school for the past 2 years. despite the high comorbidity an-Wechsler Intelligence Scale for Children IV score < 70. YIAS scores above 50 were trists based on the Structured Clinical Interview for DSM-5. increased physical  515 .9) and if spike wave activity was present in the EEG.15). mean age.6 ± 1. and QEEG using a were screened through an interview assessing their attention. tive. re. neurobiological characteristics of IGD has not been order. which included hyperactive. 13. group consisted of children and adolescents from local schools physiological mechanism of IGD per se as well as IGD+ADHD and community groups. 5) Psychotropic medication including level (19). Otherwise. Compared to HCs. 2) Diagnosis cated QEEG finding in ADHD patients (10. with the ADHD+IGD group and ADHD-only group.2017.21) and Young’s Internet Addiction Scale (YIAS) The YIAS consists of 20 self-evaluating questions. 21-channel digital EEG system. is the most replicated problem and a medical history given by a parent or guardian. and prehensively investigated (12. HCs (12). reports from any other health profes- pha and beta bands is reduced in ADHD patients compared to sionals. studies have investigated IGD neurophysiological score < 18.514 http://jkms. In terms of intra-hemispheric coherence. Therefore.   free of neurological or medical disease/history. Pa. impulsivity. ioral/learning problems. commonly comorbid with IGD. low: 1) Children and adolescents aged 10–17 years. 2) A history or current episodes of any SCID-5-CV- features using QEEG spectral analysis (18. ADHD-combined type based on the SCID-5-CV (23). The interview included a description of the presenting band.13). especially in frontocentral regions.17). history of central well studied. is a scale for ADHD symptom severity composed of 18 items (9 incorporated information from as many sources as were avail. In addition. there have been few studies on QEEG coher. is the most widely repli.

8) was higher than cal systems. no significant differences in mean K-ARS score between the Intra-hemispheric coherence for each frequency band was also ADHD+IGD group and ADHD-only group. Fp2–F8. IGD = internet gaming disorder. Finally.5 (5.9 ± 7.5–3. P4–O2. ADHD-only group.5 Hz).5–7. T4. n = 15) HC (C. T5–T6.. Pz. C4– Spectral analysis for relative power by band https://doi. Inter-hemispheric coherences the ADHD+IGD group (mean ± SD. The mean YIAS score in the ADHD+IGD group was performed with NeuroSpeed software (Alpha Trace Medi. USA) Electrode impedance was maintained below 5 kΩ. Two additional elec. et al.7 (0. and HC facts removed were extracted from raw data.5 ± 5. P < 0.5 Hz). Demographic characteristics of the study population Variables ADHD+IGD (I.4 ± 11. All analyses were bandpass filtered from 0. pling frequency was 256 Hz. SD = standard deviation.9 (7.6 ± 2.7) 1.3346/jkms. F = 55. and A2 was the reference electrode.6 ± 7.9) 13.46. evaluated between the following 18 pairs: Fp1–F3. RESULTS EEG data processing First. mon 14. Data were differences.05.8) 26. < 0. When at least 1 group showed statistically significant system (Grass-Telefactor. T3–T4.3. Cz. The relative power values of the delta band in temporal regions were significantly greater in the ADHD-only group compared Statistical analysis to the ADHD+IGD group (F = 4. IL. Bold font indicates statistically significant group differences.6 (1. C3– P3. P = 0. EEG recording lasted for enrolled. values (relative power values. F7.3) 30. F3. F3–C3. The Bon- acquired from 19 electrodes placed on the scalp based on the ferroni correction was used for these post hoc analyses. EEG amplifiers were ues. correlation analyses were conducted to assess associations be- C3.3) 55.100 I=A=C Duration of illness. P < 0.9) 7.1) 4. F4–C4.44. Data sam. 61. T3–T5.5–12. P3–P4.001). theta (3. 0.8) 18.66. P value) Post hoc Age 14.32. epileptic discharges and other abnormal findings were Demographic characteristics evaluated by a neurologist.9) 2.5–35.7) 7. alpha (7. T6–O2.2017. Relative power was calculated for that in the ADHD-only group (26.39. There were Fp2. F = 55.005 I=A>C YIAS 61. F4. RI. C3–C4. inter-hemispheric coherence val- trode. and Cz–Pz. International 10/20 system: Fp1. 0. ADHD = attention deficit hyperactivity disorder.5 to 46 Hz. Fp1–F7. ANOVA = analysis of variance. 10 minutes.8) 14.6) .1 ± 17.3. T4–T6. 516   http://jkms. Park JH. Table 2). and intra-hemispheric coherence values).202 I=A=C Years of education 8. Participants sat on a University Hospital Institutional Review Board (C2014159).4 (1. T5. For analyses. F7–F8. 6.9 (17. with a 60 Hz notch filter. formed consent was submitted by all subjects when they were main awake during EEG acquisition. ADHD-only = ADHD without comorbidity group.39.1 (17. only group (30. and the applicable participants were There were no significant differences in age or education years excluded.   All EEG acquisitions were conducted by 1 technician in an Ethics statement electrically shielded EEG room in the Department of Neurology The present study protocol was approved by the Chung-Ang at Chung-Ang University Medical Center. YIAS score. and K-ARS score for the three groups often”) (20.  •  QEEG Findings of ADHD Comorbid with Internet Gaming Disorder activity) scored by interviewees as 0 to 3 (“never or rarely” to “very illness duration. Chicago. Mean K-ARS scores for beta (12.4 (11. In- comfortable chair with closed eyes and were instructed to re. < 0.3 (1. F3–F4. T6. P4.0 Hz) bandwidths. HC = healthy control group.3.94.21). between the ADHD+IGD group.3) and ADHD- for each frequency band between right and left hemisphere ho.514 . C4. USA). and group (18. F8–T4.and intra-hemispheric frequency band co- EEG measurement herence between groups were also analyzed with a one-way EEG data was collected using a 21-channel CMXL-P230 EEG ANOVA.7 (12.001) (Table 1).0 software (SPSS Inc. education years. P3–O1. K-ARS = Korean ADHD Rating Scale.7) 13. performed with SPSS 23. Data are pre- sented as mean (SD). Austria). (mean ± standard deviation [SD]. tween each clinical scale score (YIAS and K-ARS) and QEEG trodes were placed on the ear lobes: A1 was the ground elec. The rela- Demographic characteristics including age. YIAS = Young’s Internet Addiction Scale.001 I=A>C Demographic and clinical characteristics were analyzed using ANOVA and independent t-test. and statistical significance was set at P < 0. West Warwick. were analyzed using one-way analysis of variance (ANOVA). Fp2. Differences in inter. P3.6 (0. n = 14) Statistics (F. T3. and O2.8) and that in the HC delta (0. O1.5 Hz). pairwise comparisons were conducted. Post hoc comparisons were carried out using Bonferroni correction. tive power values of the theta band in frontal regions were signi­ Table 1. n = 16) ADHD-only (A. F8. 32.1) were significantly higher than for the mologous sites were calculated for the following 8 pairs: Fp1– HC group (4.6 (2. F7–T3. ADHD+IGD = ADHD comorbid with IGD group. Fz.5 (1. Fz–Cz.3) 55. 0. T5–O1.001 I>A=C K-ARS 32. EEG data analysis group (Table 1).6 (7. and O1–O2. Fp2–F4. 300-second EEG data periods with arti.94.

ried out using Bonferroni correction.047 2.050 Post hoc I=A=C A>I I=A=C I=A=C I=A=C Theta ADHD+IGD 13. P value 1.012 A > C Intra-hemispheric coherence values of the delta band between Iinter-hemispheric coherence values were ANOVA.25) 24.48 (5. Intra-hemispheric coherence values of the theta band be.400 0.004) between Fz–Cz electrodes.27) 21.83.39. 1). Coherence analysis   In the ADHD+IGD group.07 (7. HC = healthy control group.034 Post hoc I=A=C A<I=C I=A=C I=A=C I=A=C Relative power values were analyzed using ANOVA.33) 20.004).09.67 (3.75 (3.39. Theta band inter-hemispheric coherence between F3–F4 (F = 5. P = 0.67 (3.62 (5. 0. P value hoc ence for any EEG frequency band in each group.46.3346/jkms.34 (4.574 1.80) 19.40) 14. +IGD = ADHD comorbid with IGD group.94.06.49 (2.45 (  517 .043 2. P = 0. Bold font indicates statistically significant group differences. P < 0.33) 23.59 (5.12 (4.28.79 (3.26 (3.05 (4.23 (5.81 (3. P = 0. 0.15.20) 22. 0.51 (4.018 Fig.59) 23. P = 0. F4–C4 electrodes were higher in the ADHD+IGD group com- pared to HC group (F = 6.111) 4. The relative power values of the beta band electrodes.42) 17. or alpha power Intra-hemispheric coherence values of the theta band between differences between the 3 groups in the whole brain.94 (3.51.03 (2.64) 19. theta.060) 5.32 (2. Table 2.864 Post hoc I=A=C I=A=C I=A=C I=A=C I=A=C Beta ADHD+IGD 21.089 Post hoc A>C I=A=C I=A=C I=A=C I=A=C Alpha ADHD+IGD 13.3.233 6.78) ADHD-only 15.85 (4.50 (3.65 (3. Relative power comparisons for EEG frequency bands between ADHD+IGD (I) and ADHD-only (A) and HC (C) groups Variables Frontal Temporal Central Parietal Occipital Delta ADHD+IGD 25. EEG = electroencephalography.87 (3. In the ADHD-only group.26) 19.06 (6.14) HC 13. In addition.17 (3.86) 24.001.93 (4.107) 0. YIAS score was positively correlat- Inter-hemispheric coherence ed with intra-hemispheric theta coherence (Pearson’s r = 0.24) ADHD-only 28. 0. 0.81) 16.34 (3.99) 21. ADHD+IGD = ADHD comorbid with IGD group.003) HC = healthy control group.86 (6.62) 23. HD-only group compared to the HC group (F = 6.17) 19.94) 23.22.20 (3.24. and HC (C) groups group (Table 3.96. P < in temporal regions were significantly lower in the ADHD-only 0.12 (3. 0.53 (4.723 3. 0.63.91 (1.413 (0.76. 0.006 A > C Intra-hemispheric coherence C3–C4 0.03 (2. 0.043 3.84) F.  •  QEEG Findings of ADHD Comorbid with Internet Gaming Disorder ficantly higher in the ADHD-only group compared to HC group electrodes. 0.045 3. P = 0. 0. 0.347 0.11) 21.129) 0.049 3. P = 0.68) 23. 0. 0.02 (4.38) 23. Fig.06) 25.723 0.48 (3.505 (0. 0. et al.63 (3.08) 19.72) 22.31) 16.09.001) (F = 3. SD = standard deviation. ANOVA = analysis of variance.22 (3.57.81) 24. P = 0.08) F.10) 20. 0.68) HC 20.33. Post hoc comparisons were carried out using Bonferroni correction.21) 14.034 3.079 4.556. cates statistically significant group differences. 0.32.44 (5. P value 3.98) F. Post Variables ADHD+IGD ADHD-only HC F.495 (0. P = 0. https://doi. 0.563 (0.34.047 3.68. Bold font indi- pared to the ADHD-only group (F = 8.034). 0.96.94) F. and of the beta band between P4–O2 (F = 9.80) 21.83 (4.21) 22. Theta coherence F3–F4 0. SD = standard deviation. ADHD-only (A). P < 0. IGD = internet gaming disorder.02) 23.88) 19.94.56) 16.06 (4.79 (2. 0. P = 0. P = 0.Park JH.44 (4.06) HC 29.04) 17. P value 2. 0.39 (3.60 (5.40.006) and C3–C4 electrodes (F = 4.45) 23.09 (2. ADHD 2).68 (3. Intra- 6.68. Post hoc comparisons were car- P4–O2 electrodes were higher for the ADHD+IGD group com.441 (0.012) was sig- nificantly higher in the ADHD-only group compared to the HC Table 3.375 (0.002).76 (2.27 (3.56. ANOVA = analysis of variance.68.19) 13. IGD = internet gaming disorder.35) 19.90) 20.95 (3.103) 0. ADHD-only = ADHD without comorbidity group.35) 18.29) ADHD-only 14.002 3. Data are presented as mean (SD). ADHD = attention deficit hyperactivity disorder.025).62) 15.2017. the relative power value of the beta hemispheric coherence values of the theta band between Fz– band in the temporal area was positively correlated with K-ARS Cz electrodes were higher in the ADHD+IGD group and AD- score in the ADHD+IGD group (Pearson’s r = 0.25) 23.169) 0.04 (5.74 (1.36 (2.677.42) HC 12.37 (2. P value 0. 0.39. There were no significant associations between YIAS and K-ARS scores and inter-hemispheric coher. ADHD = attention deficit hyperactivity disorder.27) 16.61) 21.005).86.16 (2.86.49 (3.001) and T4–T6 (F = 6. ADHD-only = ADHD without comorbidity group.29.94.05 (3. There were no significant relative delta.33) 24.52) 18.001) electrodes were significantly higher in the ADHD+IGD group compared to the ADHD+IGD group and HC group (F = group compared to the ADHD-only group and HC group.55 (4. Inter-hemispheric coherence differences among ADHD+IGD (I).14) ADHD-only 19.07 (2.30 (3. of the alpha band between P4–O2 (F = 12. Data are presented as mean (SD).30.48.30) 16. tween P4–O2 (F = 10.514 http://jkms.90) 18.11) 20.45) 13. Table 4.

P < 0. < 0. and HC (C) groups Variables ADHD+IGD ADHD-only HC F.596 (0.535.001 I>A=C Beta coherence P4–O2 0.76.723 (0.077) 0. solid line).163) 0. P = 0. P < 0.150) 0. < 0.636. P value Post hoc Delta coherence P4–O2 0. < 0.001) and T4–T6 (F = a6. P = 0. SD = standard deviation. P = 0.726 ( 12.139) 0.06. group YIAS scores were positively correlated with intra-hemi- spheric delta coherence (Pearson’s r = 0.514 . ADHD-only (A).001) between P4– O2 electrodes.493 (0.167) 0. P < 0.005 I>C P4–O2 0.012) were significantly higher in the (see Table 4).670 (0. = healthy control.001.003 I>A=C Alpha coherence P4–O2 0. for theta between P4–O2 (Pearson’s r = 0.097) 0.364 (0.023) electrodes. for the alpha band between P4–O2 (F = 12. Data are presented as mean (SD).509 (0.688 ( https://doi.709 (0. F7 F4 F8 F3 Fz Fp1 Fp2 T4 F7 T3 C3 C4 F3 F4 F8 Cz Fz A2 A1 P3 Pz P4 T6 T5 T4 T3 C3 C4 Cz A2 A1 O1 O2 P3 Pz P4 T6 T5 Fig.  •  QEEG Findings of ADHD Comorbid with Internet Gaming Disorder YIAS score was positively correlated with intra-hemispheric beta for alpha (Pearson’s r = 0. ADHD+IGD = ADHD comorbid with IGD group.468.410 (0. 0.608 (0.524 (0. Table 4. P = 0. P = 0.09.39. 0.86.138) 10.008) between P4–O2 electrodes.067) 0. Fp1 Fp2 P = 0.159) 6.047) between P4– trodes. ADHD+IGD = attention deficit hyperactivity disorder comorbid with internet gaming ADHD-only = attention deficit hyperactivity disorder without comorbidity. 0. HC = healthy disorder.001 I>A Theta coherence Fz–Cz 0.504 (0. Bold font indicates statistically significant group differences. ANOVA = analysis of variance.39.  518   http://jkms.534 (0.077) 0. Post hoc comparisons were carried out using Bonferroni correction. ADHD = attention deficit hyperactivity disorder.63.3346/jkms.001) electrodes were significantly higher Inter-hemispheric coherence values for the theta band between F3–F4 (F = 5. Interhemispheric coherence comparisons between ADHD-only and HC groups.003) electrodes.2017.29.76. IGD = internet gaming disorder.109) 0. Intra-hemispheric coherence values for the delta band between P4–O2 electrodes were higher in the ADHD+IGD group compared to the ADHD-only group (F = 8.001 I>A=C The intra-hemispheric coherence values were analyzed using ANOVA. HC control.579 (0.095) 0. HC = healthy control group.006) and C3–C4 electrodes (F = 4. Lastly. 2. ADHD-only = attention deficit hyperactivity disorder without comorbidity. P = 0. and for the Fig. P = 0.570 (0. both ADHD+IGD group and ADHD-only O2 electrodes.144) 8.09. 0.546. 1.200) 6.3. Intra-hemispheric coherence comparisons among ADHD+IGD (I).722 (0.001 I>A=C T4–T6 0. beta band between P4–O2 (F = 9.63.096) 0.125) 9.543 (0. Intra-hemispheric theta band coherence values be- tween P4–O2 (F = 10.490 (0. Intra-hemispheric coherence comparisons between ADHD+IGD and ADHD- O1 O2 only groups.002) between P4–O2 elec- coherence values (Pearson’s r = 0.162) 6.001) electrodes.600 (0. ADHD-only = ADHD without comorbidity group.004 I=A>C F4–C4 0.519. P = in the ADHD+IGD group compared to the ADHD-only and HC groups (dotted lines) 0. Park JH.156) 0.94. ADHD-only compared to HC group (see Table 3).001) and T4–T6 (Pearson’s r = 0. and for beta (Pearson’s r = 0.121) 0.406. P < 0.754 (0. et al.

theta band inter-hemispheric coher. In fact. ing Internet gaming is sent to parietal association areas. where cognitive memory pro- adolescents. cess. There. Visual information from the occipital cortex dur- Internet game play to enhance attentional ability. consis- study. ADHD-only group.32. tal and central regions.3346/jkms. alpha. and HC group by coherence reduction seems to be complexity and competition analyzing relative power and inter-hemispheric and intra-hemi. This is thought to reflect widespread trodes was higher in the ADHD+IGD group compared to the ADHD deficits in hemispheric specialization (14). which is reflected etal regions. The dorsolateral prefrontal cortex and temporoparietal junc- HD-only group. ADHD+IGD and HC groups. rela. Internet video game playing might be a means of self-med.3. actions between inter-hemispheric neurons. which play main roles in working memory.  •  QEEG Findings of ADHD Comorbid with Internet Gaming Disorder DISCUSSION (14) have suggested that density increase in short neuronal fi- bers during normal brain maturation might result in coherence In this study. In addition. This the ADHD-only group compared to the HC group in this study. A recent spheric coherence to find whether IGD comorbidity with ADHD fMRI study has reported that atypical default mode network con- was distinguishable from pure ADHD and cognitively healthy nectivity in ADHD patients. between neurons during maturational processes (14). and beta band intra-hemi- mission similar to methylphenidate stimulation in ADHD. In this study.514 http://jkms. et al. includ- tive beta power in attention deficit was similar to that in healthy ing the parieto-occipital junction. study.   Intra-hemispheric theta band coherence in temporal elec- tire brain regions (14. However. decrease between right and left hemispheres. In addition to the increase medial frontal and right parahippocampal areas in response to in theta/beta ratio (15). spheric coherence in the ADHD+IGD group might be associat- in this study. with delta. several functional neuroimaging cognitive and attentional tasks. particularly in system (34. In the same context. In a previous QEEG study. relative beta power in temporal regions was posi. ed inter-hemispheric coherence in theta bands throughout en. an increase in relative theta and petitions and interactions between inter-hemispheric neurons. are significant- ferent between the ADHD+IGD group and HC group in this ly stimulated by gaming cues (34). As stated above in the inter-hemispheric coherence https://doi. During this pro- ence values in frontal and central regions were significantly great. 36).32).24. Increased right medial parieto-occipital intra-hemi- ication in IGD patients with attentional problems (31). differences in QEEG features were evaluated be. delta power as well as theta/beta ratio has been commonly re.2017. theta.   A previous functional neuroimaging study has reported that ported (9). ly group. in contrast to the AD. IGD severity was positively correlated with reactivity in right er has been also reported (11. a decrease in relative alpha and beta pow. Therefore. ly higher in the ADHD+IGD group compared to the ADHD-on-  519 . theta. which was correlated with behavioral and cogni.35). there studies have suggested that Internet gaming stimulates cortico- was no significant difference in relative beta power between the striatal-limbic circuitry in participants with or without IGD (34. HC group. in a decrease in theta band inter-hemispheric coherence in fron- tive symptom improvement (30). In turn. eo game playing might stimulate synaptic dopaminergic trans. including both greater and lesser adolescents. the medial parieto-occipital junction plays a central role er in the ADHD-only group compared to the HC group in this in visuomotor information processing (38). one of gaming can increase intra-hemispheric coherence in the right the most common findings is that ADHD children show increas­ medial parieto-occipital area. which spheric coherence in parieto-occipital regions were significant- could result in attentional capacity enhancement (31). In addition. ed with a continuous gaming stimulus. these results indicate that repetitive activation   Beta activity increase tends to reflect brain cortical activity of the brain dopaminergic reward system and working memory enhancement (29). It has been suggested that vid.28) have been interpreted as corti.25). the ADHD+IGD group values in temporal regions compared to ADHD-only group. ADHD+IGD group showed lower rel. suggests that continuous game playing induces complex com-   In previous ADHD studies. The reason for tween ADHD+IGD group.Park JH. sponse to gaming cues related to the brain dopaminergic reward cal hypoarousal during information processing. a decrease in beta activity (26) and an gaming cues (34). IGD tively correlated with ADHD symptoms severity in the ADHD+ symptom severity evaluated by YIAS was positively correlated IGD group. These regions showed high reactivity in re- increase in delta activity (27. and beta band intra-hemispheric co-   Taken together. Barry et al. might indicate failure of the maturation- ative delta band power and greater relative beta band power al processes (33). tion. relative theta power was not significantly dif.   Taken together. cessing and motor activity are integrated (37). showed no theta band inter-hemispheric coherence differenc- ative theta power in frontal regions was significantly higher in es in frontal and central regions compared to the HC group. In this study. in this study.   In this study. alpha. In addition. delta. these results cautiously suggest that greater herence in parieto-occipital regions in the ADHD+IGD group vulnerability to attention difficulties seems to be correlated with in this study. methylphenidate system during gaming induce complex competitions and inter- treatment resulted in an increase in beta power in centro-pari. functional connectivity. Rel. tent activation of visuospatial working memory during Internet   In spite of the inconsistent results of previous studies. In the present

2. 122: https://doi. 4. Park cuit including connectivity between the dorsolateral prefrontal Young Sik Lee  http://orcid. Schreppel T. Aldemir S.  9. Kuss DJ. Formal anal. Alba G. Ploskova E. Curr Pharm Des not by clinicians. 1. Weinstein A. Writing . Bresnahan SM. Anderson JS.3346/jkms. Kim SM. Hall JR.2017. Third. Herrmann MJ. Curr Psychiatry Rep 2012. Griffiths MD. Hong JS. Barry RJ. Addict Biol Forthcoming 2015. American Psychiatric Association. Pereda E. Cho IH. 116: Hong JS. ORCID 23: 440-55. Diagnostic and Statistical Manual of EEG scalp electrode might reflect summed brain activity from Mental Disorders: DSM-5. although there has been solid evidence & editing: Han DH. González A. Kim SM. which is reflected in an increase in inter-hemispheric coherence in those regions. Billieux J. Eur Psychiatry 2008. 520   http://jkms. temperament and character in university students. Schou Andreassen C. Shin D. ric Association. A meta-analysis of quantitative EEG power associat- ed with attention-deficit hyperactivity disorder. morbidity in ADHD patients. Han DH. Clarke AR. Griffiths MD. Writing . Bae S. 30: 252-62.32. Karila L. Evren C. McCarthy R. Selikowitz M. Coskun KS. Clin Neurophysiol 2011. tinuous game play might induce complex competitions and in. 7. Ha JH. Selikowitz M. 16: 272-8. Snyder SM. Funding acquisition: Kim SM. Kim SM. J Clin Neurophysiol 2006. pared to ADHD-only group is an IGD state or trait marker. Bioulac S. First. Chin B. 13. The relationship between addictive use of social media was quite small. Weizman A. Barry RJ. sample size zoni   In summary. Jacob C. Heine M. the ADHD+IGD group and ADHD-only group tionship of Internet addiction severity with depression. J Neural Transm (Vienna) executive function activation during Internet gaming can cause an increase in neuronal connectivity among the parieto-occipi. video games: a comparative study of hyperactive and control children. fronto-central and temporal regions. Increased EEG power density in alpha and tion: Park JH. Washington. John- stone SJ. Rushby JA. Psychol Addict Behav 2016.  •  QEEG Findings of ADHD Comorbid with Internet Gaming Disorder section. Méndez LD. Kim SM. Baik Seok Kee  http://orcid. 12. SM. Yildirim FG. Specificity of quantitative EEG analysis in adults The authors have no potential conflicts of interest to disclose. Barry RJ. Kim JH. of their correlation with real neuronal activity. Behavioural differences between EEG-defined subgroups of chil- Conceptualization: Park JH. Clarke AR. McCarthy R. Dalbudak E. 67: 821-6. Min KJ. Lauer P. Brain connectivity who have greater vulnerability to attention difficulties seem to and psychiatric comorbidity in adolescents with Internet gaming disor- continuously play Internet games as a subconscious means to der. 112: 133- 44. and alex- showed QEEG profile differences providing clues to understand ithymia. Internet game play stimulates the working memory cir. which is reflect. enhance attentional ability.original draft: Park JH. and video games and symptoms of psychiatric disorders: a large-scale tablish whether altered connectivity in ADHD+IGD group com. Kuss DJ. Selikowitz M. Emerging association between addictive gam- ed by a decrease in inter-hemispheric theta band coherence in ing and attention-deficit/hyperactivity disorder. Attention deficit/hyperactivity disorder and dopaminergic reward and working memory systems during con. Park JH. McCarthy tion-deficit/hyperactivity disorder: a comparative study of two DSM-IV Ji Sun Hong  http://orcid. repetitive visuospatial working memory and Sun Mi Kim  http://orcid. Min KJ. Maz-   There are possible limitations in this study. with attention deficit hyperactivity disorder. 20: 4026-52. Barry RJ. Demetrovics Z. Clarke AR. ysis: Han DH. Kim SM. Hong JS. Second. review of epidemiological research for the last decade.40). cross-sectional study.3. Psychiatric comorbidity working memory and executive function activation during con- assessed in Korean children and adolescents who screen positive for In- tinuous Internet gaming might cause an increase in neuronal ternet addiction. Pallesen S. Billieux J. et al. Heckel LD. repetitive visuospatial 14: 590-7. Koehler 15. Rela-   In conclusion. Clin Neurophysiol 2002. Kim 97-104. 5th ed. 23: 134-41. Ugurlu H.: American Psychiat- various cortical regions beneath the electrode (39. 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