Part 2 of a therapist training series on true digital natives. The first people in history born into an established, online, social structure. They are now coming of age and the rituals and unspoken social rules around family, friendship, and dating are changing in their wake.
Everything You Need
Tracy Markle, MA, LPC &
Dr. Brett Kennedy, Psy.D.
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Digital Media and Video Game Use
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In This Article
What is Online Addiction? Is it Even Real?
Yes, online addiction is real. Online addiction falls under the category of addictive behavior disorder. In 2018, World Health Organization (WHO) added gaming disorder to the category of behavioral disorder. WHO also created a new category of impulse control disorder called Compulsive Sexual Behavior Disorder (CSBD.) CSBD can include problematic pornography use and masturbation. You may have heard it referred to as pornography addiction.
It’s important to note that what most people call an “addiction,” such as drug addiction or addiction to alcohol, mental health professionals now officially term a “disorder.” In 2013, the American Psychiatric Association (APA) updated their diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and replaced the categories of substance abuse and substance dependence with a single category: substance use disorder. The DSM-5 addresses each specific substance as a separate use disorder. Alcohol abuse became alcohol use disorder, tobacco addiction became tobacco use disorder and so on.
While alcohol and tobacco addiction are substance use disorders, online addiction falls under the category of addictive behavior disorder. If you’re not familiar with behavioral addiction, that’s not surprising. Until recently, the mental health industry only recognized gambling disorder as a behavior disorder. But, in 2018, World Health Organization (WHO) voted to add gaming disorder to the category of behavioral disorder in their diagnostic manual International Classification of Diseases (ICD-11). The DSM-V also named internet gaming disorder as a condition for further study.
It’s interesting to note that the gambling industry also refers to itself as the gaming industry and that modern slot machines and video games both use persuasive design such as bright, colorful lights, engaging sound effects, and music to keep users playing.
In addition to recognizing gaming disorder as an addictive behavior, WHO also voted to create a new category of impulse control disorder in the ICD-11 called Compulsive Sexual Behavior Disorder (CSBD). According to WHO, CSBD is classified as an impulse control disorder and not a behavioral disorder because more research needs to be done. This classification opens the door for that research to begin. What does CSBD have to do with online addiction? CSBD is characterized by “a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior.” This behavior can include problematic pornography use and masturbation. (Sometimes called pornography addiction.) However, WHO stresses that distress over the behavior entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors, is not sufficient to diagnose CSBD.
Important Online Addiction Terms to Know
Online Addiction (also called Digital Media Addiction or Internet Addiction): is an umbrella term that can refer to an addiction to online video games, social media, online spending, surfing the internet (known as information overload), or online pornography. Only a small percentage of the population meets criteria for online addiction. This includes 8.5% of US children ages 8-181 and 13%-18% of US college students.2
Video Game Addiction: Termed "Gaming Disorder" by World Health Organization (WHO), is a pattern of “digital-gaming” or “video-gaming” characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences. The behavior pattern normally must be evident for at least 12 months and must be severe enough to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning
Compulsive Sexual Behavior Disorder (CSBD): A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior. Can include problematic pornography use (sometimes called pornography addiction.) The WHO ICD-11 recently included CSBD as an impulse-control disorder. The diagnostic criteria, however, are very similar to those for behavioral disorders such as gaming disorder. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behavior; and continued repetitive sexual behavior despite adverse consequences or deriving little or no satisfaction from it. The pattern should normally manifest over 6 months or more and cause marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet this requirement.
Digital Media Overuse: The use of digital media like video games, mobile apps or websites occurs on a spectrum. Healthy digital media use is on one end of the spectrum and addictive digital media use is on the other. In the middle is digital media overuse and that’s where the overwhelming majority of our clients fall. Digital media overuse is also more applicable to the larger population. The World Health Organization advises people who partake in gaming to be alert to the amount of time they spend on gaming activities, particularly when it’s to the exclusion of other daily activities or leads to changes in their physical or psychological health and social functioning. We further extend this advice to include any digital media use that you worry is becoming overuse for yourself or your child or loved one.
1Gentile, 2009 2Young, 201
Some Key Indicators of Online Addiction
- Experiencing serious impacts on social, academic or professional life because of screen use
- Experiencing strong and unpleasant reactions when the behavior is removed such as aggression or violence toward family members, committing self-harm, or committing property damage
- Unable to stop the behavior on their own despite being dealt negative consequences and despite speaking at length about how problematic the behavior is
There are more indicators of online addiction and it’s important to note that these behaviors usually must be observed for up to a year before a diagnosis of addiction can be made. When working with teens and children, we rarely use the word addiction because children and teenagers lack impulse control and are simply unable to limit their digital media use without the help of a parent or guardian to set boundaries.
How Persuasive Design Creates the Potential for Online Addiction
A term you’ll see while researching online addiction is persuasive design. It’s also sometimes called behavior design and is often used interchangeably with the term persuasive technology, although persuasive design was around long before the high-tech industry. But what exactly is it? A short definition of persuasive design is “an area of design practice that focuses on influencing human behavior through the characteristics of a product or service.”
To understand the importance of persuasive design in the high-tech industry, though, you must look at the investment Stanford University has made into it for nearly 30 years. Stanford University, located just six miles from Google headquarters in the heart of Silicon Valley, is well known for attracting great engineering minds who study and perform research there and then go on to found or work for legendary high-tech companies like Google and Instagram. They are less known, however, for their vast influence over the Silicon Valley business model of using behavioral psychology to craft irresistible products that people simply must have.
During the Cold War, the university brought in sponsored projects that urged researchers to monetize their work and forged strong relationships between the university community and private and government sectors. It was much later, in 1993, when a doctoral student in Communication named B.J. Fogg began studying the overlap between persuasion and computer technology. He became the first person to conduct experiments showing how computers could change people’s attitudes and behaviors. Fogg named this new field of study, “captology,” from an acronym of the words, “computers as persuasive technologies,” later shortening it simply to persuasive technology and currently calling it behavior design.
Stanford founded the Persuasive Technology Lab at Stanford University with Fogg as director and, in 2007, created a now infamous “Stanford Facebook class” that taught students to build basic Facebook apps, distribute them quickly, and worry about perfecting them later. Within just 10 weeks, the collective apps of all 75 students enrolled in the class had amassed more than 16 million users and generated about $1 million in ad revenue. One student who took the Stanford Facebook class wrote the following on the class blog:
I came to Stanford to study development, technology policy, innovation and entrepreneurship. Yes, I wanted to learn how Silicon Valley can be replicated and brought to other parts of the world including my home country Lithuania. I know many people have tried that without much of the luck, but I am young, fearless, highly motivated – I am gonna succeed.
Then I took Stanford Facebook Class. Let me tell a few words about it. The class was taught by a team of professors including top expert in the world on persuasive technology, previously successful entrepreneurs and high tech professionals.
We had people from Facebook coming to our class lab explaining the aspects how Facebook API works. People from Slide and Rock You (these companies have created 7 of 10 most popular applications on Facebook) would come to every second class and share their experience what it takes to create and market successful application. Then Google and Myspace guys would come to talk about their new project “Open Social”. Someone from top tier Silicon Valley venture capital business would give their advice how a “silly Facebook application” could be turned into a business that venture capitalists would be interested in. The students in the room were the most entrepreneurial ones that I met at Stanford. The experience is so rich that you can feel it only by being there.
Here is my point. It would impossible to replicate Stanford Facebook Class in any other part of the world. One simple class. And many people (including me) have a naive goal to replicate the entire Silicon Valley. It is good to dream, and I will keep on dreaming. But knowing your limits also helps.
Since then, Fogg has taught dozens of Silicon Valley titans a systematic process for designing products that change behavior using his own models and methods. Most notable is Fogg’s Behavior Model which states that Behavior = Motivation + Ability + Trigger. In 2017, Fogg changed the word “trigger” to “prompt” and the name of the lab was changed to the Behavior Design Lab as Fogg stated he was less focused solely on high-tech and more interested in using his findings to help create behavior change in all areas.
Through his research, Skinner discovered that he could best train rats to tap a lever by sometimes rewarding them with pellets. It was the sometimes part that was the key to turning a totally new behavior—tapping a lever—into a habit. After experimenting with four different reward schedules (giving rats pellets)—some predictable schedules, and some random ones—Skinner found that giving rats a random number of pellets after a random number of lever taps, otherwise known as a variable-ratio reward schedule, by far caused the rats to tap the lever at the highest, steadiest rates. Not only that, but the rats on the variable-ratio reward schedule were also the most resistant to stopping the conditioned behavior of lever tapping once the reward (pellets) stopped coming. Skinner posited that this persistent behavior from the rats who received pellets on a variable-ratio reward schedule was a result of their hope that the next tap might be the one that delivered a pellet.
Persuasive Design Terms to Know
Persuasive Design: According to the Interactive Design Foundation, persuasive design is an area of design practice that focuses on influencing human behavior through the characteristics of a product or service. Persuasive design is based on psychological and social theories and is often used in e-commerce (online shopping), organizational management (getting employees to adopt new behaviors), and public health (such as in ad campaigns that try to persuade people to wear medical masks when they go out.) However, designers also tend to use persuasive design in any field where they need to encourage long-term engagement through continued use of their platform. (Such platforms can include, but are not limited to video games, social media websites and apps, pornography websites, and news websites.)
Operant Conditioning: The process and study of teaching people or animals to adopt a new behavior by rewarding them for performing the behavior. By definition everything in a video game is operant conditioning because game designers must instruct users on how to progress through the game by using rewarding cues and prompts like exciting sounds, animations and messages. In this sense, operant conditioning is neither bad nor good. It’s just a term that psychologists use to describe the process of learning through reward.
Variable Ratio Reward Schedule: When operant conditioning rewards are delivered on an unknown schedule it’s called a variable ratio reward schedule. The variable ratio reward schedule is the most manipulative reward delivery schedule known to man and the basis of all addictions. It’s also the basis for many video game monetization strategies that use the principles of variable ratio reward schedule to elicit repeated in-game purchases from users.
User Experience (UX) — UX is the study of how a human user interacts with and experiences a particular product, system or service. UX is studied in great detail by some companies because a bad user experience usually results in a decline of use and therefore a decline in profits. According to the International Organization for Standardization (ISO), (a global network of national standards bodies), UX includes the emotions, beliefs, preferences, perceptions, comfort, behaviors, and accomplishments that result not only during and after, but even while anticipating use of a product system or service. ISO also notes that user experience is a consequence of brand image, presentation, functionality, system performance, interactive behavior, and assistive capabilities of a system, product or service. It also results from the user’s internal and physical state resulting from prior experiences, attitudes, skills, abilities and personality and from the context of use.
When Barbra lands on Pinterest, not only does she see the image she intended to find, but she is also served a multitude of other glittering objects. The images are related to what she is generally interested in — namely things to see on her upcoming trip to rural Pennsylvania — but there are other things that catch her eye as well. The exciting juxtaposition of relevant and irrelevant, tantalizing and plain, beautiful and common, sets her brain’s dopamine system aflutter wit the promise of reward. Now she’s spending more time on Pinterest, hunting for the next wonderful thing to find. Before she knows it, she’s spent 45 minutes scrolling.
3 Eyal, Nir. Hooked: How to Build Habit-Forming Products, (pp. 8-9). Penguin Publishing Group. Kindle Edition.
As the quote from Eyal’s book explains, video games and other digital media use variable-ratio reward schedules to zero in on the emotional part of a user’s brain and hijack the reasonable part of their brain, suppressing the areas of the brain associated with judgment and reason while activating the parts associated with wanting and desire. In other words, every time you earn a reward through a video game, get a like on Facebook or a happy face emoji on Snapchat, your brain releases dopamine. We call dopamine the “gimme more” neurotransmitter because every time your brain releases it in reaction to a behavior, the motivation to keep performing the behavior increases. Without intervention, this can lead to serious health consequences and addiction.
Why Kids and Teens are More Susceptible to Online Addiction
All children lack impulse control and their ability to regulate their emotions is not fully mature. This makes them especially vulnerable to variable-ratio reward systems. Additionally, a core set of mental health problems are often found to be coexisting with internet addiction or digital media overuse. For example, children with autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are more vulnerable than neurotypical children. This is because they find it more difficult to limit their time online. In the case of kids with ADHD, this is because they are naturally lower in dopamine. When they use highly rewarding applications like video games, their dopamine is triggered to release at a higher rate which leads to the child wanting more and more time gaming. Studies have shown that children with ASD prefer screen-based activities, especially video games, and are at greater risk for developing online addictions and for showing problematic symptoms at a lesser rate of exposure.
When it comes to young children, we don’t diagnose online addiction because we view it as more of an impulse control issue because children lack cognitive control, seek reward over risk, and cannot easily control their online use.
Pornography addiction is a fairly well-known concept, but lesser known is the fact that online pornography use is common among middle-school and high-school age groups. It's the least talked about form of digital media addiction and digital media overuse for kids with many parents being unaware that their children are engaging with pornography. This is an area in which our co-founder Dr. Brett Kennedy specializes. If you have questions about it, you can contact him here.
Information is power and for many people, acquiring relevant information about topics of interest is a highly stimulating reward. As we learned earlier, when our brain feels rewarded it releases dopamine, the “gimme more” neurotransmitter, inspiring us to repeat the behavior. Online platforms like YouTube, Netflix and Google News design suggestion algorithms to provide us with the content we seek to obtain that next dopamine hit. It’s for this reason that many of us struggle with spending inordinate amounts of time on the internet reading the news, engaging in chat rooms or streaming videos. It’s so common that the term “binge-watching” was recently coined to describe the phenomenon.
One-click ordering, subscribe and save deals, “free” shipping memberships, and same-day delivery are just some of the innovations the internet has brought to the modern shopping experience. While these services can add tremendous value to our lives, especially during a global pandemic, they can also make compulsive spending way too easy. Compulsive spending online occurs on many platforms. It can take the form of spending too much money on Amazon or Ebay or even trading stocks. For middle-school and high-school age groups, where we see more problems with compulsive spending is in video games as more and more video games require in-game purchases to advance or continue in the game. In some of the more extreme cases, we have seen young people get a hold of their parents’ credit cards and spend thousands of dollars. So, one of our recommendations is: Don’t give your child your credit card if they are playing games online.
Today, half of the 7 billion people living on earth use at least one social media platform with Facebook and YouTube being the most popular. With such global popularity, it’s no wonder that most people who use the internet will have an issue with social media at one time or another. As Stanford Behavior Design Lab Director B.J. Fogg said in the course description for his famous “Facebook Class” at Stanford University, “Today’s Facebook experience has so many elements of persuasion, so we’ve decided to dive in deep.” In addition to the persuasive design used on social media platforms to keep users checking their phones for a little dopamine hit in the form of a like or comment, there is a growing body of research correlating social media use with increased symptoms of anxiety and depression.
Checklist: Avoid Online Addiction by Monitoring These Items
8 Ways to Move Away from Online Addiction &
Towards Healthy Digital Media Use
Third-Party Apps for Monitoring or Limiting Screen Use
- RescueTime: A time-management app that provides insights into how you spend your time and offers distraction blocking features.
- Net Nanny: Parental control software and website blocker. Allows you to monitor your family’s digital habits as well as manage screen time.
- CovenantEyes: App focused on helping you quit using pornography.
- Gamplay Time Tracker Game time monitoring app that keeps track of your sessions by recording statistical data and compiling charts for a better assessment of your time spent playing video games
- Famisafe Lets parents control screen time, track real-time location and detect inappropriate content on kids’ devices.
- Circle Parental Controls Set healthy time limits and filter content across every device
- Safe Surfer Mobile app to manage devices and filter an extensive range of categorized online content.
- Qustodio Parental control app designed to help you supervise, manage, and protect your child’s device use on the go
- Screentime Parental control app for Android and iOS that allows you to set time limits as well as set tasks for your children.
- AppDetox (Android only) Mobile app that allows you to set your own rules for your app usage in order to detox from digital media overuse and stop procrastinating.
- Offtime Decide the duration of your disconnection and this app will take care of everything. Your phone will still not disturb you even if you restart it.
- Antisocial Monitor and compare your own phone usage or monitor usage and control another phone.
- Apple’s Screen Time With Screen Time, you can access real-time reports about how much time you spend on your iPhone, iPad, or iPod touch, and set limits for what you want to manage.
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Teen Suicide Study Identifies Gaps in Adult Digital Literacy as a Risk Factor Written by Dr. Brett Kennedy, Psy, D. Suicide is the number two cause of death for 10-
Part 1 of our therapist training series on true digital natives. Because therapists and all adults have a learning curve to overcome if we are to provide, at the very least, culturally competent services for young people. Ideally, we can achieve cultural humility and partner with true digital natives to understand how technology is forever changing our template for human relations.