Gaming: The good, the bad, and the ESSENCE

[Posted on 13 April, 2022, by Dejan Stevanovic]

Twenty years ago, I had a friend whom I was the only friend. Although never assessed, I am sure now that he had marked autistic traits, if not complete autism spectrum disorder (ASD). He enjoyed playing multiple video games (in the rest of the text used only games), mainly strategic team sport or social games, for hours and hours daily. He would sometimes engage in a game just because he had to, and occasionally, he would lose control over his gaming and forget to eat or go to bed the whole night. Interestingly, he had never given priority to gaming to the extent that it would interfere with his fixed daily routines or studying. I also remember that he would sometimes be so in a game that he could think of playing the game in his mind. He would recommend that I should play games if sad or upset or lonely, since he coped this way with these emotions.

The gaming continuum

Most children and adolescents and some adults play games. The potential tendency of game playing is to oscillate between the “bright” side of an entertaining leisure hobby, a beneficial and skills’ developing and improving activity and adaptive behavior, to the “dark” side of addictive behavior. Playing games, even violent shooter ones, may have cognitive, motivational, emotional, and social benefits across all age groups (e.g., Granic et al., 2014) and help maintain good mental health and well-being or be an e-sport (i.e., adaptive game use). The “dark” extreme is hazardous gaming, recognized under the factors influencing health status, referring to a pattern of gaming that increases the risk of harmful physical or mental health consequences to the individual or others around (World Health Organization [WHO], 2019). Even worst, gaming disorder (GD) has been introduced as a mental disorder due to addictive behaviors, with three core symptom domains: impaired control over gaming behaviors, increasing priority given to gaming behaviours to the extent that gaming takes precedence over other interests and activities, and continuation or escalation of gaming behaviors despite negative consequences (WHO, 2019).  

From ESSENCE to disordered gaming and vice versa

Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCE), as an umbrella term for neurodevelopmental difficulties/disorders (NDDs) with a variety of symptoms in cognitive, emotional, behavioral, motor, and social developmental domain, potentially aligns with the gaming continuum, especially its “dark” side. The association between NDDs and gaming behaviors has become evident, although of an unclear direction. A recent review found that subclinical autistic-like traits and clinical populations with ASD have significantly higher levels of disordered gaming than typically developing peers (Murray et al., 2021). Interestingly, autistic symptoms did not correlate with GD, indicating that the severity may not exhibit GD symptomology. Two recent reviews also found a consistent positive association between attention deficit hyperactivity disorder (ADHD) and GD (Dullur et al., 2021), with ADHD being the most likely of all mental disorders linked with problematic gaming (Männikkö et al., 2020). It was also implicated that ADHD may be a predisposing factor for developing problematic gaming behaviors, with limited support for the causation. A bidirectional link is also suspected that problematic and disordered gaming may also worsen symptoms associated with NDD, especially in ADHD (e.g., Shuai et al., 2021). In my view, ESSENCE conditions, but at least ASD an ADHD, and disordered gaming lay on a trans-syndromal psychopathlogical frameswork of symptom dimensions and the clusters of aspects of behaviors, functioning, psychological traits, social factors, and environmental exposures, as well as user preferences (van Os et al., 2019). Thus, I think there is the co-occurrence of many symptom dimensions and clusters at different levels, with the manifestations being contextual, beyond simple causal or bidirectional links between NDDs and disordered gaming.

From adaptive gaming to improved ESSENCE

Although playing games can improve brain health is not new, only recently have games been taken seriously as a digital intervention for ESSENCE conditions. Likely impacting some neurobiological and neuropsychological aspects, adaptive and serious games may help treat ESSENCE conditions through various processes such as cognitive remediation, physiotherapy, occupational therapy, or the development of social and communication skills (Griffiths, 2019). For example, action games could improve reading abilities and visual-to-auditory attentional shifting in some children with dyslexia (Franceschini et al., 2017), although not replicated later (e.g., Łuniewska et al., 2018). More structurally applied serious games are designed to educate, train, or change behaviors and the evidence points to them as effective interventions in reducing ADHD symptoms, besides other mental health problems (Dewhirst et al., 2022), or for facilitating the learning process of youngsters with intellectual disabilities (De Boeck et al., 2012). Adaptive gaming has gone even further and EndeavorRx is the first FDA-authorized game treatment for 8-12-year-aged with ADHD (https://www.endeavorrx.com/).  

One size does not fit all

Besides the current implications that underlying NDDs may lead to disordered gaming, disordered gaming may worsen underlying NDDs or may cause NDD-like symptoms, and that adaptive gaming use may improve NDDs, as well as that NDD innervations can treat GD (e.g., methylphenidate in Han et al., 2009), not everyone with NDDs will lose or profit equally from gaming. For example, the review mentioned above found that the strength of the association between GD and ADHD is highly variable (Dullur et al., 2021), meaning that different factors are operating in-between, like time effects, development, treatment, and many others (Paulus et al., 2018). Or, not all children with dyslexia would improve significantly reading abilities with action games, since the findings were not replicated across the studies (e.g., Franceschini et al., 2017; Łuniewska et al., 2018). A possible explanation could be that NDDs are highly heterogenous conditions in terms of symptoms, severity, course, and outcome, with gaming effects or GD being heterogenous, too (Ballou & Zendle, 2022), besides being on the common trans-syndromal psychopathological framework. For example, a boy with ASD and ADHD is at risk for developing disordered gaming if games are played long enough, with sufficient intensity, and contextual factors present (i.e., absence of parental supervision). Still, some aspects of his attention difficulties, social skills, and impulsivity could be improved with gaming. More than in any other situation and ever before, a personalised approach is inevitable to separate problematic and adaptive gaming and NDD symptoms and to diagnose and intervene in GD and NDDs or to consider gaming as a digital intervention for ESSENCE conditions.

ESSENCE and gaming share something in common, some psycho-neuro-biological substrate likely, that allows them to co-exist closely and be treated similarly or even use gaming as an NDD intervention. For me, gaming has more benefits than harms in ASD and ADHD and we should advocate for it. Still, we have to go further and likely to the symptom level rather than the disorder/syndrome level to disentangle the good from the bad when researching and practicing problematic and adaptive gaming and ESSENCE. Returning to my friend from the beginning, he would unlikely be diagnosed with GD since not all three criteria would be met. Still, hazardous gaming and adaptive gaming were likely taking turns in at least a neurodiverse individual.

The author does not have any conflict of interest to disclose.

[This is a blog. The purpose of the blog is to provide information and raise awareness concerning important issues. All views and opinions expressed are those of the writer and not necessarily shared by the GNC.]