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Gaming Addiction, Gaming Engagement, and Psychological

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Gaming Addiction, Gaming Engagement,

and Psychological Health Complaints
Among Norwegian Adolescents
a b
Geir Scott Brunborg , Rune Aune Mentzoni , Ole Rogstad Melkevik
c b b b
, Torbjørn Torsheim , Oddrun Samdal , Jørn Hetland , Cecilie
b b
Schou Andreassen & StåLe Palleson
a
Norwegian Social Research , Oslo , Norway
b
Faculty of Psychology , University of Bergen , Bergen , Norway
c
The Norwegian Institute of Public Health , Oslo , Norway
Published online: 15 Feb 2013.

To cite this article: Geir Scott Brunborg , Rune Aune Mentzoni , Ole Rogstad Melkevik , Torbjørn
Torsheim , Oddrun Samdal , Jørn Hetland , Cecilie Schou Andreassen & StåLe Palleson (2013) Gaming
Addiction, Gaming Engagement, and Psychological Health Complaints Among Norwegian Adolescents,
Media Psychology, 16:1, 115-128, DOI: 10.1080/15213269.2012.756374

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 Media Psychology, 16:115–128, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1521-3269 print/1532-785X online
DOI: 10.1080/15213269.2012.756374

Gaming Addiction, Gaming Engagement, and

Psychological Health Complaints Among
Norwegian Adolescents

GEIR SCOTT BRUNBORG

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Norwegian Social Research, Oslo, Norway

RUNE AUNE MENTZONI

Faculty of Psychology, University of Bergen, Bergen, Norway

OLE ROGSTAD MELKEVIK

The Norwegian Institute of Public Health, Oslo, Norway

TORBJØRN TORSHEIM, ODDRUN SAMDAL, JØRN HETLAND,

CECILIE SCHOU ANDREASSEN, and STÅLE PALLESON
Faculty of Psychology, University of Bergen, Bergen, Norway

Distinguishing high engagement with games from gaming addic-

tion has been a challenge for researchers. We present evidence that
an established self-report instrument can be used to distinguish
addicted gamers from highly engaged gamers. The study used data
from the World Health Organization’s survey, Health Behaviour
in School-Aged Children. A nationally representative sample of
Norwegian eighth graders completed the Game Addiction Scale for
Adolescents. Respondents who endorsed all four of the core criteria
for addiction (relapse, withdrawal, conflict, and problems) were
categorized as addicted gamers. Respondents who endorsed two
or three of the core criteria were categorized as problem gamers.
Those who endorsed all three peripheral criteria (salience, toler-
ance, and mood modification), but not more than one of the
addiction criteria, were categorized as highly engaged gamers.
Controlling for gender and physical exercise, gaming addicts and
problem gamers had greater risk of feeling low, feeling irritable or
in a bad mood, feeling nervous, feeling tired and exhausted, and

Address correspondence to Geir Scott Brunborg, Norwegian Social Research, Munthes-

gate 29, Oslo 0260, Norway. E-mail: geir.s.brunborg@nova.no

115
 116 G. S. Brunborg et al.

feeling afraid. The highly engaged gamers did not have greater risk
of psychological health complaints. This suggests that it is possible
to distinguish addicted and problem gamers with psychological
health complaints from adolescents who are merely highly engaged
gamers.

Electronic game playing has emerged as one of the most popular forms of
recreational activities among adolescents in the Western world. Such games
can be played on a number of devices, including personal computers, game
consoles, and mobile telephones, at home or on the go, and alone or in
the company of others. According to one study, the majority of young
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adults (56.3%) play on a regular basis (Mentzoni et al., 2011). However,

a minority of gamers display problems associated with the activity (Choo
et al., 2010; Gentile, 2009; Gentile et al., 2011; Kuss & Griffiths, 2012; Lem-
mens, Valkenburg, & Peter, 2011b). Several terms have been proposed for
the state where gaming becomes problematic for adolescents, for example
gaming addition, video game addiction, pathological gaming, video game
dependence, and compulsive gaming. The term ‘‘gaming addiction’’ is used
here; gaming is used because it emphasizes that the object of addiction is the
gaming behavior, and addiction is used because it may be less ambiguous
compared to the above terms (O’Brien, 2010) and because it is commonly
used in the behavioral addictions literature (e.g., Andreassen, Torsheim,
Brunborg, & Pallesen, 2012; Charlton, 2002; Griffiths & Meredith, 2009; Kuss
& Griffiths, 2012; Lemmens, Valkenburg, & Peter, 2009). Gaming addiction is
not included as a formal diagnosis in the current Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev; DSM-IV-TR; American Psychi-
atric Association, 2000). However, a useful definition of gaming addiction is
‘‘the persistent inability to control excessive gaming habits despite associated
social or emotional problems’’ (Lemmens, Valkenburg, & Peter, 2011a, p. 38).
Compared to other nonchemical addictions, such as pathological gam-
bling, gaming addiction research lags behind in terms of theoretical models of
development, progression, and treatment. Rigorous theoretical frameworks
to specify causal and mediating factors that bring gaming addiction about are
lacking; however, some possible etiological factors such as male gender and
young age, certain personality traits (e.g., impulsivity), genetic vulnerability
(Griffiths, Kuss, & King, 2012), problematic cognitions (Sim, Gentile, Bricolo,
Serpelloni, & Gulamoydeen, 2010) as well as characteristics of the games
(e.g., reward; King, Delfabbro, & Griffiths, 2010) have been noted in the
literature. The few longitudinal studies that have been published so far
suggest that impulsivity, low social competence, loneliness, and low self-
esteem predict gaming addiction (Gentile et al., 2011; Lemmens et al., 2011b).
Recent research has suggested a division between gaming addiction
and high engagement with games. High engagement seems to relate to the
so-called peripheral addiction criteria (cognitive salience, tolerance, and eu-
 Gaming and Psychological Health Complaints 117

phoria), whereas gaming addiction is characterized by fulfillment of the core

addiction criteria (conflict, withdrawal symptoms, relapse and reinstatement,
and behavioral salience; Charlton & Danforth, 2007; Ferguson, Coulson, &
Barnett, 2011; Skoric, Teo, & Neo, 2009). In this current study, we present
evidence that an already established self-report instrument (Lemmens et al.,
2009) can be used to distinguish addicted gamers from highly engaged
gamers. Also, we investigated whether engaged and addicted gamers differ
on several psychosocial variables, a finding that would further validate the
distinction between high engagement and gaming addiction.
Prevalence estimates of gaming addiction among adolescents vary greatly.
It has been reported to be 8.5% in the United States (Gentile, 2009), 8.7%
in Singapore (Choo et al., 2010), 4.9% in Connecticut (Desai, Krishnan-
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Sarin, Cavallo, & Potenza, 2010), between 1.9% and 2.3% in the Netherlands
(Lemmens et al., 2009), 0.2% in Germany (Festl, Scharkow, & Quandt, 2012),
and 0.9% in Norway (Frøyland, Hansen, Sletten, Torgersen, & Von Soest,
2010). The differences in estimated prevalence can probably be accounted
for by differences in the conceptualization of gaming addiction, assessment
methods, and sample characteristics (e.g., sampling techniques, age, and
response rates), as well as by country differences (Kuss & Griffiths, 2012).
Reworded DSM-IV-TR criteria for pathological gambling have been used
to measure the prevalence of gaming addiction (e.g., Choo et al., 2010;
Gentile, 2009; Tejeiro Salguero & Bersabé Morán, 2002). In line with the DSM-
IV-TR, polythetic scoring has also been used, whereby half or more of the
criteria need to be endorsed to be categorized as addicted. More conservative
estimates of gaming addiction have been obtained by using Lemmens et al.’s
(2009) Game Addiction Scale for Adolescents (GASA). This scale is based on
the six criteria (salience, tolerance, mood modification, withdrawal, relapse,
and conflict) for gaming addiction proposed by Griffiths (2005) in addition
to problems caused by excessive gaming. Prevalence estimates using the
GASA have been more conservative than those based on other assessment
approaches, as it has been used with a monothetic scoring procedure where
all of the criteria need to be endorsed (Lemmens et al., 2009; Mentzoni et al.,
2011).
Lemmens and colleagues (2009) presented evidence that the seven cri-
teria reflected different components of the same underlying concept. How-
ever, a developmental process has been suggested for behavioral addictions
whereby high engagement precedes addiction (Charlton, 2002). Charlton
and Danforth (2007) separated gaming addiction from high engagement by
factor analysis of gaming behavior items. They found evidence that addiction
involved conflict, behavioral salience, withdrawal, and relapse and rein-
statement. Engagement, on the other hand, involved tolerance, euphoria,
and cognitive salience. A recent meta-analysis of gaming addiction preva-
lence studies concluded that studies that used reworded DSM-criteria for
pathological gambling and polythetic scoring tended to overestimate the
prevalence because individuals who might be better regarded as highly
 118 G. S. Brunborg et al.

engaged with gaming were categorized as addicted (Ferguson et al., 2011).

The meta-analysis also concluded that studies that required the endorsement
of Charlton and Danforth’s (2007) criteria for addiction provided more precise
estimates.
Previous studies have investigated associations between gaming addic-
tion and psychological health complaints. For instance, one study found that
problem gamers (who endorsed four or more of the seven criteria on the
GASA scale) had higher levels of anxiety and depression, as well as lower
life satisfaction compared to non-problem gamers (Mentzoni et al., 2011). In
another study, gaming addicts reported greater frequency of sleep problems
and several somatic complaints related to physical strain compared to non-
addicts (Choo et al., 2010). This study used reworded DSM-IV-TR criteria
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for pathological gambling with a polythetic scoring. Hence, the pathological

category may have included individuals who only show high engagement
with games.
Several studies have addressed this issue by differentiating between
gaming addiction and gaming engagement. First, one study found that a
group classified as gaming addicts played twice as many hours per week
compared to a group classified as highly engaged gamers (Charlton & Dan-
forth, 2007). In another study, gaming addiction scores, but not gaming en-
gagement scores, were negatively associated with emotional stability (Charl-
ton & Danforth, 2010). Gaming addiction scores, but not gaming engagement
scores, have also been found to be negatively related to scholastic achieve-
ment (Skoric et al., 2009). This accumulated evidence suggests that gaming
addiction and gaming engagement are qualitatively different constructs and
should, therefore, be treated as such.
Previous research has indicated an association between gaming addic-
tion and psychological health complaints. However, it has to a very lim-
ited degree differentiated between gaming addiction and high engagement.
Therefore, the current study investigated if addicted gamers and highly en-
gaged gamers were at greater risk of subjective psychological complaints
compared to other adolescents. Possible confounding factors known to be re-
lated to subjective psychological health complaints were adjusted for. These
were gender and physical exercise (Callaghan, 2004). We expected that
gaming addicts, but not highly engaged gamers, would have greater risk
of psychological health complaints compared to other adolescents.

METHODS

Sample and Procedure

The current study used data from the World Health Organization survey
Health Behavior in School-Aged Children (HBSC ) 2009/10 (Currie et al.,
 Gaming and Psychological Health Complaints 119

2009). A nationally representative sample of Norwegian eighth graders was

selected by means of a clustered sampling procedure where school class was
the sampling unit. In total, 1,320 eighth graders (688 girls, 632 boys) with a
mean age of 13.6 (SD D 0.32) years participated. Surveys were administered
by class teachers according to a standardized protocol. Participation was
voluntary, and participants were informed that anonymity and confidentiality
were ensured. For more information concerning the HBSC study, confer
Currie, NicGabhainn, Godeau, and The International HBSC Network Coor-
dinating Committee (2009), Roberts et al. (2009), and www.hbsc.org.

Measures
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GAME ADDICTION SCALE FOR ADOLESCENTS (GASA)

The 7-item version of the GASA (Lemmens et al., 2009) was used. The scale
was made to reflect Griffiths’ (2005) six components of addiction (salience,
tolerance, mood modification, relapse, withdrawal, and conflict) and also
problems caused by excessive gaming. Respondents indicated their responses
on a 5-point scale (1 D never, 2 D almost never, 3 D sometimes, 4 D often,
and 5 D very often). Internal consistency (Cronbach’s alpha) for the scale in
the current study was .85. As suggested by Lemmens et al. (2009), each item
was regarded as endorsed if the response was 3 (sometimes) or higher.
Four groups were constructed based on the responses on the GASA
scale. In accordance with Charlton and Danforth (2007), respondents who
endorsed all four items tapping core addiction criteria (relapse, withdrawal,
conflict, and problems) were categorized as addicted gamers (n D 56). The
respondents who endorsed two or three core criteria were categorized as
problem gamers (n D 170). The respondents who endorsed all the three
items tapping gaming engagement (salience, tolerance, and mood modifi-
cation), but who fulfilled none or one of the core addiction criteria were
categorized as highly engaged gamers (n D 65). The remaining adolescents
comprised a non-addicted/non-problem/non-highly engaged contrast group
(n D 1029).

TIME SPENT GAMING

Time spent gaming was measured using the following item: ‘‘How many
hours a day do you usually spend playing PC-games or video games (Playsta-
tion, Xbox, GameCube, etc.) in your spare time?’’ Respondents answered this
question separately for weekdays and weekends. The response categories
were: 0 D not at all, 0.5 D about half an hour a day, 1 D about 1 hour
a day, 2 D about 2 hours a day, 3 D about 3 hours a day, 4 D about
4 hours a day, 5 D about 5 hours a day, 6 D about 6 hours a day, 7 D
about 7 hours a day, and 8 D about 8 hours or more a day. The responses
for weekdays were multiplied by five, and the responses for weekends were
 120 G. S. Brunborg et al.

multiplied by two, and these values were subsequently added together. The
responses ranged from 0 to 49 hours per week.

PSYCHOLOGICAL HEALTH COMPLAINTS

Six items from the Health Behavior in School-Aged Children Symptom Check-
list (Haugland & Wold, 2001) were used. These were feeling low, being
irritable or in a bad mood, feeling nervous, difficulties sleeping, tired and
exhausted, and afraid. Participants were asked: ‘‘In the last 6 months: how
often have you experienced the following : : : ?’’ Each complaint was rated
on a five-point frequency scale: 1 D about every day, 2 D more than once a
week, 3 D about every week, 4 D about every month, or 5 D rarely or never.
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The checklist has demonstrated satisfactory test-retest reliabilities ranging

from .60 to .70 for single items (Haugland & Wold, 2001). The scores for the
complaints were recoded into dichotomous variables. Scores 1 (about every
day) and 2 (more than once a week) were recoded to 1, denoting regular
complaints, whereas scores 3 (about every week), 4 (about every month),
and 5 (rarely or never) were recoded to 0.

PHYSICAL EXERCISE

Physical exercise was assessed by the following item: ‘‘How many hours a
week do you participate in sports or exercise so vigorously that you become
short of breath and/or sweaty?’’ Responses were provided by selecting one
of the following response alternatives: none, about 1/2 hour, about 1 hour,
about 2–3 hours, about 4–6 hours, or 7 hours or more. The item has been
found to have acceptable test-retest reliability and validity (Booth, Okely,
Chey, & Bauman, 2001). Responses were rescaled into a continuous variable
in terms of hours per week where 0 D none, 0.5 D about 1/2 hour, 1 D
about 1 hour, 2.5 D about 2–3 hours, 5 D about 4–6 hours, and 7 D 7 hours
or more.

Statistics
To avoid estimation bias from the clustered sampling procedure, the analysis
was conducted using the cluster command in STATA, with school as the
primary sampling unit. This procedure produces standard errors that account
for the dependence between observations from members of the same cluster.
If not accounted for, dependence between observations tends to inflate the
type I error rate of conventional tests (Gelman & Hill, 2007). The differences
between the addicted gamers, the problem gamers, the highly engaged
gamers, and the contrast group in risk of psychological health complaints
was analyzed by modified Poisson regression with robust standard errors,
which has been proposed as an alternative to logistic regression because
it provides estimates of relative risk rather than odds ratio (Zou, 2004). The
 Gaming and Psychological Health Complaints 121

analyses were computed separately for each psychological health complaint,

and the blockwise entry of independent variables was identical. In the first
block, only the gaming groups were included and the contrast group com-
prised the reference category. In the second block, gender and physical
exercise were added in order to adjust for the effect of these possible
confounders.

RESULTS

Prevalence
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The proportion of respondents who endorsed all four items tapping the core
addiction criteria was used to estimate the prevalence of gaming addiction.
The estimated prevalence of gaming addiction was 4.2% (95% CI: 3.0–5.4).
The estimated prevalence for girls was 2.2% (95% CI: 1.1–3.3). For boys, the
prevalence was 6.5% (95% CI: 4.7–8.3).
In order to allow comparison with previous studies (Festl et al., 2012;
Mentzoni et al., 2011), we also estimated the prevalence of gaming ad-
diction using Lemmens and colleagues’ (2009) monothetic and polythetic
approaches. The monothetic approach involves endorsement of all the seven
criteria in the GASA. The estimated prevalence using this approach was 3.9%
(95% CI: 2.7–5.1). For girls it was 1.8% (95% CI: 0.7–3.0), and for boys it was
6.1% (95% CI: 4.4–7.8). The polythetic approach to scoring requires four
or more endorsed criteria. Using this approach, the estimated prevalence
of problematic gaming in the current study was 16.1% (95% CI: 14.1–18.2).
The estimated prevalence for girls was 7.0% (95% CI: 5.3–8.9). For boys, the
prevalence was 26.3% (95% CI: 22.7–29.9).

Time Spent Gaming

The mean time spent gaming per week was 10:00 hours (95% CI: 9:18–
10:48). For girls, it was 5:00 hours (95% CI: 4:12–5:54), and for boys it was
15:42 hours (95% CI: 14:42–16:36). The proportion who played video games
(more than zero hours per week) was 70.9% (95% CI: 68.2–73.4%). For girls
it was 51.7% (95% CI: 47.7–55.7), and for boys it was 92.2% (95% CI: 90.0–
94.0).
For the addicted gamers, the mean time spent gaming per week was
24:01 hours (95% CI: 19:11–28:52). This was significantly more compared to
the contrast group (7:16 hours [95% CI: 6:40–7:52], t D 11.64, p < .001) and
the problem gamers (18:09 hours [95% CI: 16:01–20:16], t D 2.51, p < .05).
However, it was not significantly different from the mean time spent gaming
per week among the highly engaged gamers (19:31 hours [95% CI: 16:31–
22:31] t D 1.66, p D .10).
 122 G. S. Brunborg et al.

Addiction, High Engagement, and Psychological Health Complaints

The prevalence of all the psychological health complaints for the addicted
group, the problem gamer group, the highly engaged group, and the contrast
group are presented in Table 1. Table 1 also shows the gender distributions
and the mean scores for physical exercise.
The results of the hierarchical regression models predicting psycho-
logical health complaints are presented in Table 2. Before controlling for
gender and physical exercise (Model 1), the addicted gamers and the prob-
lem gamers had greater risk of feeling irritable or in a bad mood, feeling
nervous, having trouble sleeping, being tired and exhausted, and feeling
afraid compared to the contrast group. Adjusting for the effects of gender
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and physical exercise (Model 2) did not have an effect on these relationships.
However, both the addicted gamers and the problem gamers had higher risk
of feeling low in Model 2 compared to the contrast group.
In order to compare the addicted gamers to the highly engaged gamers
and problem gamers, the analyses was repeated with the addicted gamers as
the reference category. Compared to the addicted gamers, the highly engaged
gamers had significantly lower risk of feeling irritable or in a bad mood (RR D
0.53 [95% CI: 0.31–0.90], p < .05) feeling nervous (RR D 0.31 [95% CI: 0.14–
0.66], p < .01), and being tired and exhausted (RR D 0.49 [95% CI: 0.30–
0.84], p < .01). The highly engaged gamers did not differ in risk of feeling
low, having trouble sleeping, and feeling afraid, from the addicted gamers.
Compared to the addicted gamers, the problem gamers had significantly
lower risk of feeling irritable or in a bad mood (RR D 0.53 [95% CI: 0.31–0.90],
p < .01), feeling nervous (0.42 [95% CI: 0.26–0.67], p < .001), being tired and
exhausted (0.64 [95% CI: 0.45–0.91], p < .05), and feeling afraid (0.51 [95%
CI: 0.27–1.00], p < .05). The problem gamers did not have significantly lower
risk of feeling low and having trouble sleeping, compared to the addicted
gamers.

TABLE 1 Prevalence (%) of Subjective Psychological Complaints Among Gaming Addicts,

Problem Gamers and Highly Engaged Gamers (N D 1320)

Addicted Problem gamers Highly engaged Contrast group

(n D 56) (n D 170) (n D 65) (n D 1029)

Dependent variables
Feeling low 20.0 (9.1–30.9)a 18.0 (11.5–24.5)a 10.8 (2.9–18.6)a 12.5 (10.4–14.6)a
Irritability or bad mood 47.3 (31.6–63.0) 26.3 (18.6–34.1)a 23.1 (12.2–34.0)ab 16.8 (14.6–19.1)b
Nervous 38.2 (24.4–50.9) 17.3 (10.5–24.0)a 10.8 (3.0–18.5)ab 10.8 (9.0–12.7)b
Trouble sleeping 29.1 (17.0–41.2)a 32.1 (24.9–39.4)a 13.8 (5.0–22.7)b 17.6 (15.0–20.2)b
Tired and exhausted 47.3 (33.7–60.8)a 34.3 (25.8–42.9)ab 24.6 (13.8–35.4)bc 19.9 (16.9–22.8)c
Afraid 16.4 (6.8–26.0)a 10.1 (5.9–14.4)ab 1.5 ( 0.2–4.7)bc 3.1 (2.0–4.3)c
Control variables
Gender (female) 26.8 (17.1–36.4)a 32.9 (25.9–39.9)a 16.9 (7.2–26.7)a 58.9 (55.9–61.9)
Physical exercise (M, SD) 2.62 (18.86–3.37)a 2.93 (2.62–3.24)a 3.30 (2.59–4.00)ab 3.61 (3.43–3.78)b

Note. The contrast group comprises non-addicted/non-problem/non-highly engaged adolescents. With 95% confi-
dence intervals in parentheses. Groups differ at p < .05 by chi-square (or t test) if they do not share a letter in
their superscripts.
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TABLE 2 Hierarchical Regression Predicting Subjective Psychological Complaints (N D 1320)

Irritability or Trouble Tired and

Feeling low bad mood Nervous sleeping exhausted Afraid

Model 1 RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI)

Contrast group 1.00 1.00 1.00 1.00 1.00 1.00

Highly engaged 0.86 (0.42–1.77) 1.37 (0.86–2.18) 0.99 (0.48–2.05) 0.79 (0.42–1.46) 1.24 (0.80–1.93) 0.49 (0.68–3.53)
gamers
Problem gamers 1.44 (1.00–2.07) 1.57 (1.17–2.09)** 1.59 (1.09–2.32)* 1.82 (1.41–2.36)*** 1.73 (1.36–2.20)*** 3.22 (1.83–5.67)***
Addicted gamers 1.60 (0.92–2.78) 2.81 (2.06–3.82)*** 3.52 (2.41–5.15)*** 1.65 (1.07–2.55)* 2.38 (1.75–3.23)*** 5.21 (2.62–10.36)***

Model 2 RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI) RR (95% CI)

123
Contrast group 1.00 1.00 1.00 1.00 1.00 1.00
Highly engaged 1.25 (0.56–2.76) 1.56 (0.95–2.55) 1.40 (0.66–2.95) 0.93 (0.50–1.74) 1.47 (0.92–2.36) 1.11 (0.16–7.87)
gamers
Problem gamers 1.69 (1.18–2.43)** 1.56 (1.16–2.11)** 1.91 (1.32–2.77)** 1.95 (1.49–2.54)*** 1.89 (1.47–2.44)*** 4.29 (2.42–7.61)***
Addicted gamers 2.13 (1.25–3.63)** 2.93 (2.16–3.98)*** 4.59 (3.06–6.88)*** 1.90 (1.21–2.99)** 2.95 (2.16–4.03)*** 8.33 (4.53–15.32)***
Gender:
Boys 1.00 1.00 1.00 1.00 1.00 1.00
Girls 3.02 (2.16–4.23)*** 1.53 (1.20–1.94)** 2.01 (1.47–2.75)*** 1.42 (1.13–1.80)** 1.57 (1.26–1.95)*** 5.12 (2.70–9.70)***
Physical exercise 0.90 (0.84–0.97)** 0.89 (0.84–0.93)*** 0.96 (0.90–1.03) 1.00 (0.95–1.05) 0.98 (0.94–1.03) 0.82 (0.72–0.93)**

Note. The contrast group comprises non-addicted and non-highly engaged adolescents.
RR D Risk ratio.
*p < .05, **p < .01, ***p < .001.
 124 G. S. Brunborg et al.

DISCUSSION

The estimated prevalence of gaming addiction among Norwegian eighth

graders was 4.2%. Our prevalence estimate was lower than estimates based
on reworded DSM-IV-TR criteria for pathological gambling used with poly-
thetic scoring (8.7% in Singapore and 8.5% in the United States; Choo et al.,
2010; Gentile, 2009), but closer to what Ferguson et al. (2011) regarded as the
most precise prevalence estimate in their meta-analysis of the prevalence of
gaming addiction, which was 3.1%. Our estimate was still higher: However,
the reason for this is probably the young age of the sample, as the frequency
of gaming has been reported to drop after age 13 (Gentile, 2009; Melkevik,
Torsheim, Iannotti, & Wold, 2010). In addition, it may be explained by
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country differences.
The results showed that adolescents who were addicted to gaming and
the less severe problem gamer group both had greater risk of feeling low,
feeling irritable or in a bad mood, feeling nervous, being tired and exhausted,
and feeling afraid. This is in line with findings from previous studies (Charlton
& Danforth, 2010; Choo et al., 2010; Gentile et al., 2011; Mentzoni et al.,
2011) and suggests that gaming addiction is associated with a wide range
of negative outcomes. Adolescents who were highly engaged with gaming,
on the other hand, did not have increased risk of any of the psychological
complaints. This is in accordance with previous findings suggesting that high
engagement seems to be unrelated to health (Charlton & Danforth, 2010).
Hence, the results met our expectation that addicted gamers and problem
gamers, but not highly engaged gamers, had greater risk of psychological
health complaints compared to other adolescents. Direct comparison also
showed that highly engaged gamers had significantly lower risk of feeling
irritable or in a bad mood, feeling nervous, and being tired and exhausted
compared to the addicted gamers. However, there were no differences be-
tween the two groups in terms of risk of feeling low, having trouble sleeping,
and feeling afraid. This suggests that what separates addicted gamers from
highly engaged gamers is that the addicted gamers are more irritable, more
nervous, and more tired, but that they may not be distinguished in terms of
symptoms of depression, sleep problems, and frightfulness.
Both addicted gamers and problem gamers had greater risk of psycho-
logical health complaints compared to the contrast group. However, direct
comparisons showed that the addicted gamers had significantly greater risk of
feeling irritable or in a bad mood, feeling nervous, being tired and exhausted,
and feeling afraid compared to the problem gamers. This suggests that the
problem gaming category can be used to distinguish gamers with a somewhat
lower magnitude of problems from other adolescents, but that using the
addiction category makes this distinction clearer.
As in previous studies, we found differences in gender distribution for
the gaming groups and in the prevalence of psychological health complaints,
 Gaming and Psychological Health Complaints 125

and we found that physical exercise was negatively associated with psy-
chological health complaints (e.g., Callaghan, 2004). However, our analyses
showed that these relationships could not account for the higher risk of psy-
chological health complains among addicted gamers and problem gamers.
The results from the current study suggest that gaming addiction is
associated with psychological health complaints, but that strong engage-
ment with games is not. This is in line with findings reported by Charlton
and Danforth (2007), Ferguson and colleagues (2011), as well as by Skoric
and colleagues (2009), and supports the growing notion that addiction and
engagement are qualitatively different phenomena. However, the addicted
gamers and the problem gamers in our study did not spent more time gaming
compared to the highly engaged gamers. This finding is not in line with
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the results of Charlton and Danforth’s (2007) study. A possible explanation

for this discrepancy in findings is that time spent playing in the current
study covered all games, whereas Charlton and Danforth (2007) focused
only on one particular game. Hence, it is possible that their respondents
also spent time playing other games. Different instruments were used in the
two studies, which may also explain the discrepancy. Charlton and Danforth
(2007) state that ‘‘: : : in general one would expect addicts to perform an
activity for a greater amount of time than those who are highly engaged
: : : ’’ (p. 1541). However, our finding points to the possibility that among
adolescents who spend a large amount of time gaming, it is possible to
distinguish between those who do not have psychological problems, and
those who have problems or are addicted and who, consequently, may
suffer in terms of psychological ill health. The current study holds potentially
important information for adolescents, parents, schools, and policymakers.
In addition, our findings have several theoretical implications. Firstly, they
validate the distinction between engaged and addicted gamers. Second, they
implicate that more research on assessment and operationalizations of video
game behavior is warranted. Third, our findings highlight the dire need
for theoretical development to explain and predict game-related behaviors
that are associated with good, neutral, and negative outcomes, respectively.
It should in this regard be noted that although much research focus on
the negative aspects of gaming addiction, several studies also attest to the
potential health improving aspects of video game use (Primack et al., 2012).
Future longitudinal studies should investigate which factors predict healthy
and engaged play and which factors predict unhealthy and addicted play.
There are strengths and limitations about the study that should be
mentioned. The use of a large representative sample of Norwegian eighth
graders allowed estimation of the prevalence of gaming addiction in the
population of Norwegian eighth graders, but may be restricted to this par-
ticular age group. The interpretation of our findings is limited by the use
of cross-sectional design. We are precluded from drawing inferences about
directionality and causality. It is possible that gaming addiction precedes
 126 G. S. Brunborg et al.

psychological health complaints, and it is possible that psychological health

complaints precede gaming addiction. Both types of directionality have been
found in a previous longitudinal study (Lemmens et al., 2011b). More stud-
ies using longitudinal design, as well as experimental studies, are required
in order to come closer to establishing the direction of causality. All the
information used in the current study was based on self-report, which in
itself may be regarded as a limitation, as the common method bias by this
may have influenced the findings (Podsakoff, MacKenzie, Lee, & Podsakoff,
2003). More objective methods, such as electronic registration of game play,
clinical assessment of gaming addiction, and the use of objective indicators
of psychological health (e.g., cortisol profiles) would be an asset to future
research.
Downloaded by [Universitetsbiblioteket i Bergen] at 13:22 24 March 2015

In summary, the current study showed that the prevalence of gaming ad-
diction was 4.2% among a nationally representative sample of eighth graders
in Norway. The study also showed that the risk of several psychological
health complaints was greater for gaming addicts and problem gamers com-
pared to adolescents without problems and with high engagement. Further-
more, these findings could not be better accounted for by gender differences
or differences in physical exercise as these were included as control variables.
The current study supports the growing notion that gaming addiction and
strong engagement with games are qualitatively different phenomena.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of men-

tal disorders (4th ed., text rev.). Washington, DC: Author.
Andreassen, C. S., Torsheim, T., Brunborg, G. S., & Pallesen, S. (2012). Development
of a Facebook addiction scale. Psychological Reports, 110, 501–517.
Booth, M. L., Okely, A. D., Chey, T., & Bauman, A. (2001). The reliability and validity
of the physical activity questions in the WHO health behaviour in schoolchildren
(HBSC) survey: A population study. British Journal of Sports Medicine, 35, 263–
267.
Callaghan, P. (2004). Exercise: A neglected intervention in mental health care. Jour-
nal of Psychiatric and Mental Health Nursing, 11, 476–483.
Charlton, J. P. (2002). A factor-analytic investigation of computer ‘‘addiction’’ and
engagement. British Journal of Psychology, 93, 329–344.
Charlton, J. P., & Danforth, I. D. W. (2007). Distinguishing addiction and high
engagement in the context of online game playing. Computers in Human
Behavior, 23, 1531–1548.
Charlton, J. P., & Danforth, I. D. W. (2010). Validating the distinction between com-
puter addiction and engagement: Online playing and personality. Behaviour &
Information Technology, 29, 601–613.
Choo, H., Gentile, D. A., Sim, T., Li, D., Khoo, A., & Liau, A. K. (2010). Patholog-
ical video-gaming among Singaporian youth. Annals of Academy of Medicine
Singapore, 39, 822–829.
 Gaming and Psychological Health Complaints 127

Currie, C. E., NicGabhainn, S., Godeau, E., & The International HBSC Network
Coordinating Committee. (2009). The health behaviour in school-aged children:
WHO collaborative cross-national (HBSC) study: Origins, concept, history and
development 1982–2008. International Journal of Public Health, 54, 131–139.
Desai, R. A., Krishnan-Sarin, S., Cavallo, D., & Potenza, M. N. (2010). Video-gaming
among high school students: Health correlates, gender differences, and prob-
lematic gaming. Pediatrics, 126, e1414–e1424.
Ferguson, C. J., Coulson, M., & Barnett, J. (2011). A meta-analysis of pathological
gaming prevalence and comorbidity with mental health, academic and social
problems. Journal of Psychiatric Research, 45, 1573–1578.
Festl, R., Scharkow, M., & Quandt, T. (2012). Problematic computer game use among
adolescents, younger and older adults. Addiction.
Frøyland, L. R., Hansen, M., Sletten, M. A., Torgersen, L., & Von Soest, T. (2010).
Downloaded by [Universitetsbiblioteket i Bergen] at 13:22 24 March 2015

Innocent Fun? Gambling and gaming among Norwegian adolescents. Oslo:

NOVA.
Gelman, A., & Hill, J. (2007). Data analysis using regression and multilevel/hier-
archical models. New York, NY: Cambridge University Press.
Gentile, D. A. (2009). Pathological video game use among youth ages 8 to 18.
Psychological Science, 20, 594–602.
Gentile, D. A., Choo, H., Liau, A., Sim, T., Li, D. D., Fung, D., & Khoo, A. (2011).
Pathological video game use among youths: A two-year longitudinal study.
Pediatrics, 127, E319–E329.
Griffiths, M. D. (2005). A ‘‘components’’ model of addiction with a biopsychosocial
framework. Journal of Substance Abuse, 10, 191–197.
Griffiths, M. D., Kuss, D. J., & King, D. L. (2012). Video game addiction: Past, present,
future. Current Psychiatry Reviews, 8, 308–318.
Griffiths, M. D., & Meredith, A. (2009). Videogame addiction and its treatment.
Journal of Contemporary Psychotherapy, 39, 247–253.
Haugland, S., & Wold, B. (2001). Subjective health complaints in adolescence—
Reliability and validity of survery methods. Journal of Adolescence, 24, 611–
624.
King, D., Delbrabbro, P., & Griffiths, M. (2010). Video game structural characteristics:
A new psychological taxonomy. International Journal of Mental Health and
Addiction, 8, 90–106.
Kuss, D. J., & Griffiths, M. D. (2012). Internet gaming addiction: A systematic review
of empirical research. International Journal of Mental Health and Addiction,
10, 278–296.
Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2009). Development and validation
of a game addiction scale for adolescents. Media Psychology, 12, 77–95.
Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2011a). The effects of pathological
gaming on aggressive behavior. Journal of Youth and Adolescence, 40, 38–47.
Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2011b). Psychosocial causes and
consequences of pathological gaming. Computers in Human Behavior, 27, 144–
152.
Melkevik, O., Torsheim, T., Iannotti, R. J., & Wold, B. (2010). Is spending time
in screen-based sedentary behaviors associated with less physical activity: A
cross national investigation. International Journal of Behavioral Nutrition and
Physical Activity, 7, 1–10.
 128 G. S. Brunborg et al.

Mentzoni, R. A., Brunborg, G. S., Molde, H., Myrseth, H., Skouverøe, K. J. M., Het-
land, J., & Pallesen, S. (2011). Problematic video game use: Estimated prevalence
and associations with mental and physical health. Cyberpsychology, Behavior,
and Social Networking, 14, 591–596.
O’Brien, C. (2010). Addiction and dependence in DSM-V. Addiction, 106, 866–867.
Podsakoff, P. M., MacKenzie, S. B., Lee, J. Y., & Podsakoff, N. (2003). Common
method biases in behavioral research: A critical review of the literature and
recommended remedies. Journal of Applied Psychology, 88, 879–903.
Primack, B. A., Carroll, M. V., McNamara, M., Klem, M. L., King, B., Rich, M., Chan,
C. W., & Nayak, S. (2012). Role of video games in improving health-related
outcomes. A systematic review. American Journal of Preventing Medicine, 42,
630–638.
Roberts, C., Freeman, J., Samdal, O., Schnohr, C. W., de Looze, M. E., Gabhainn,
Downloaded by [Universitetsbiblioteket i Bergen] at 13:22 24 March 2015

S. N., et al. (2009). The health behaviour in school-aged children (HBSC) study:
Methodological developments and current tensions. International Journal of
Public Health, 54, 140–150.
Sim, T., Gentile, D. A., Bricolo, F., Serpelloni, G., & Gulamoydeen, F. (2012). A
conceptual review of research on the pathological use of computers, video
games, and the Internet. International Journal of Mental Health and Addiction,
10, 748–769.
Skoric, M. M., Teo, L. L. C., & Neo, R. L. (2009). Children and video games: Addiction,
engagement and scholastic achievement. Cyberpsychology & Behavior, 12, 567–
572.
Tejeiro Salguero, R. A., & Bersabé Morán, R. M. (2002). Measuring problem video
game playing in adolescents. Addiction, 97, 1601–1606.
Zou, G. (2004). A modified Poisson regression approach to prospective studies with
binary data. American Journal of Epidemiology, 159, 702–706.

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