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  • 1.
    Hellström, Charlotta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Adolescent Gaming and Gambling in Relation to Negative Social Consequences and Health2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The aims of the thesis were to study relationships between the effects of online gaming and gambling and negative social consequences and ill health among adolescents and to determine whether gaming and gambling activities occur together.

    The papers in this thesis used epidemiological methods to obtain self-report information from Swedish adolescents aged 13–18 years. Time spent in online gaming was associated with negative social consequences, and this relationship was explained by online gaming motives. Gaming for fun and social motives was associated with a reduced risk of negative social consequences, whereas gaming to escape problems, gain status, or meet demands from others was associated with an increased risk.

    Increased online gaming time on weekdays increased the probability of having depressive, musculoskeletal, or psychosomatic symptoms, and was related to online gaming motives. The probability of ill health was low in those who reported gaming for fun or social motives. Adolescents with symptoms of attention deficit hyperactivity disorder (ADHD) were more sensitive to gambling frequency and to developing a gambling problem. However, among those identified as susceptible, adolescents with ADHD were equally affected compared with other susceptible participants in terms of their gambling frequency.

    Boys had a higher probability than girls of participating in online gambling in association with online gaming. Having at least one parent born outside Scandinavia was associated with a higher probability of online gambling, especially among girls. The effect of alcohol use as a factor contributing to online gambling was greater among boys than among girls.

    The results of this thesis contribute new knowledge about sex differences in online gaming and gambling behaviours and add to the limited research on online gaming and online gambling behaviours among adolescent girls. Gaming motives may be helpful for identifying online gamers needing support to reduce their unhealthy gaming behaviour. Information about factors related to gaming and gambling problems may be of interest to clinicians in psychiatry, psychology and social work, as well as to policymakers, parents and teachers involved in adolescent health and development. Effect preventive strategies should consider the sex differences in gaming and gambling behaviour in adolescents.

    List of papers
    1. Influences of motives to play and time spent gaming on the negative consequences of adolescent online computer gaming
    Open this publication in new window or tab >>Influences of motives to play and time spent gaming on the negative consequences of adolescent online computer gaming
    2012 (English)In: Computers in human behavior, ISSN 0747-5632, E-ISSN 1873-7692, Vol. 28, no 4, p. 1379-1387Article in journal (Refereed) Published
    Abstract [en]

    In this study we examined the relation between gaming-time, motives to play, and negative consequences due to playing MMORPGs. A total of 7757 Swedish adolescents (3872 boys and 3885 girls) between 13 and 18 years of age completed a questionnaire during class hours. Results indicated that time spent on gaming was associated with negative consequences. This relation was further explained by motives to play. Gaming for fun and social motives were associated with a reduced risk whereas gaming to escape, to gain status, or due to demands from others were associated with an increased risk of negative consequences. Motives to play should be considered as a prime indicator for negative consequences, even more than time spent gaming. Implications of these findings for future research are discussed.

    Keywords
    Adolescent, Behaviour problems, Computer games, Consequences, Motivation, Videogames
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-178561 (URN)10.1016/j.chb.2012.02.023 (DOI)000304518000033 ()
    Available from: 2012-07-31 Created: 2012-07-31 Last updated: 2017-12-07Bibliographically approved
    2. Effects of adolescent online gaming time and motives on depressive, musculoskeletal, and psychosomatic symptoms
    Open this publication in new window or tab >>Effects of adolescent online gaming time and motives on depressive, musculoskeletal, and psychosomatic symptoms
    2015 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 120, no 4, p. 263-275Article in journal (Refereed) Published
    Abstract [en]

    Aim. To investigate whether adolescent online gaming time and the additive effect of gaming motives were associated with depressive, musculoskeletal, and psychosomatic symptoms. The hypothesis was that adolescents who engage in online gaming with escape motives and increased online gaming time have higher probability for depressive, musculoskeletal, and psychosomatic symptoms compared to adolescents with other online gaming motives and/or less online gaming time.

    Method. An anonymous and voluntary questionnaire was completed during class hours by 7,757 Swedish adolescents aged 13-18 years. The questionnaire included demographic background, gaming habits, and depressive, musculoskeletal, and psychosomatic symptoms.Results. It was found that increased online gaming time during weekdays increased the probability of having depressive, musculoskeletal, and psychosomatic symptoms. However, these relations with time spent gaming were further explained by online gaming motives. Weekday online gaming for more than five hours a day, in combination with escape motives, was associated with an increased probability of depressive symptoms (odds ratio (OR) 4.614, 95% CI 3.230-6.590), musculoskeletal symptoms (OR 2.494, 95% CI 1.598-3.892), and psychosomatic symptoms (OR 4.437, 95% CI 2.966-6.637). The probability of ill health decreased when gaming was for fun or had social motives.

    Conclusion. Excessive gaming time and escape motives were found to be associated with increased probability of ill health among adolescents. Gaming motives may identify gamers in need of support to reduce unhealthy gaming behaviour as well as identify individuals at risk for ill health.

    Keywords
    Adolescent; computer games; depression; health; musculoskeletal symptoms; psychosomatic symptoms
    National Category
    Medical and Health Sciences Psychology
    Research subject
    Family Medicine
    Identifiers
    urn:nbn:se:uu:diva-261153 (URN)10.3109/03009734.2015.1049724 (DOI)000365684900006 ()26072677 (PubMedID)
    Available from: 2015-08-31 Created: 2015-08-31 Last updated: 2017-12-04Bibliographically approved
    3. Gambling frequency and symptoms of attention-deficit hyperactivity disorder in relation to problem gambling among Swedish adolescents: A population-based study
    Open this publication in new window or tab >>Gambling frequency and symptoms of attention-deficit hyperactivity disorder in relation to problem gambling among Swedish adolescents: A population-based study
    Show others...
    2017 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 22, no 2, p. 119-126Article in journal (Refereed) Published
    Abstract [en]

    Aim: To investigate the associations between gambling frequency, attention-deficit hyperactivity disorder (ADHD) symptoms, and problem gambling among adolescent boys and girls. One hypothesis was that adolescents with increased ADHD symptoms have a higher frequency of gambling compared to adolescents with fewer ADHD symptoms.

    Method: A population-based sample of adolescents (aged 15–18 years) completed a questionnaire on demographics, gambling habits, ADHD symptoms, and problematic gambling; 1412 adolescents (from 4440 sampled) with gambling experience were included in the final sample.

    Results: A zero-inflated negative binomial regression analysis revealed that increased ADHD symptoms, higher gambling frequency, and higher age were associated with lower odds for being non-susceptible to gambling problems. Moreover, gambling frequency interacted with ADHD symptoms in predicting probability of being non-susceptible to gambling problems. However, when analysing those already susceptible to problem gambling, ADHD symptoms did not modify the effect of gambling frequency on the expected magnitude of gambling problems. In susceptible individuals, problem gambling increased with both increased ADHD symptoms and increased gambling frequency, but the level of problems due to gambling frequency did not change depending on the ADHD symptom level. There was an interaction effect between sex and gambling frequency in relation to gambling problems.

    Conclusions: Adolescents with ADHD symptoms seem to be more sensitive to gambling, in terms of being susceptible to developing gambling problems. However, once susceptible, adolescents with ADHD symptoms are affected by gambling frequency similarly to other susceptible participants.

    Keywords
    Adolescent, attention-deficit hyperactivity disorder symptoms, gambling, problem gambling, Problem Gambling Severity Index
    National Category
    Medical and Health Sciences Public Health, Global Health, Social Medicine and Epidemiology
    Research subject
    Family Medicine
    Identifiers
    urn:nbn:se:uu:diva-261154 (URN)10.1080/03009734.2017.1294636 (DOI)000401756500008 ()28436719 (PubMedID)
    Available from: 2015-08-31 Created: 2015-08-31 Last updated: 2018-09-14Bibliographically approved
    4. Online computer gaming among adolescent girls is associated with higher probability for online gambling
    Open this publication in new window or tab >>Online computer gaming among adolescent girls is associated with higher probability for online gambling
    Show others...
    (English)Article in journal (Refereed) Submitted
    National Category
    Public Health, Global Health, Social Medicine and Epidemiology
    Research subject
    Family Medicine
    Identifiers
    urn:nbn:se:uu:diva-261155 (URN)
    Available from: 2015-08-31 Created: 2015-08-31 Last updated: 2015-10-01
  • 2.
    Hellström, Charlotta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Online gaming in relation to negative consequences and ill health among adolescents2013Licentiate thesis, comprehensive summary (Other academic)
    List of papers
    1. Influences of motives to play and time spent gaming on the negative consequences of adolescent online computer gaming
    Open this publication in new window or tab >>Influences of motives to play and time spent gaming on the negative consequences of adolescent online computer gaming
    2012 (English)In: Computers in human behavior, ISSN 0747-5632, E-ISSN 1873-7692, Vol. 28, no 4, p. 1379-1387Article in journal (Refereed) Published
    Abstract [en]

    In this study we examined the relation between gaming-time, motives to play, and negative consequences due to playing MMORPGs. A total of 7757 Swedish adolescents (3872 boys and 3885 girls) between 13 and 18 years of age completed a questionnaire during class hours. Results indicated that time spent on gaming was associated with negative consequences. This relation was further explained by motives to play. Gaming for fun and social motives were associated with a reduced risk whereas gaming to escape, to gain status, or due to demands from others were associated with an increased risk of negative consequences. Motives to play should be considered as a prime indicator for negative consequences, even more than time spent gaming. Implications of these findings for future research are discussed.

    Keywords
    Adolescent, Behaviour problems, Computer games, Consequences, Motivation, Videogames
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-178561 (URN)10.1016/j.chb.2012.02.023 (DOI)000304518000033 ()
    Available from: 2012-07-31 Created: 2012-07-31 Last updated: 2017-12-07Bibliographically approved
    2. Motives for playing and online gaming time in relation to depression, musculoskeletal symptoms and psychosomatic symptoms: a populationbased cross-sectional study of Swedish adolescents
    Open this publication in new window or tab >>Motives for playing and online gaming time in relation to depression, musculoskeletal symptoms and psychosomatic symptoms: a populationbased cross-sectional study of Swedish adolescents
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Objective: Playing online computer games is one of the most common leisure activities among adolescents. However, frequent computer-related activities have been suggested to be a new health risk factor associated with psychosomatic and physical complaints. The present study examined online gaming time and motives for playing, in relation to depression, musculoskeletal symptoms and psychosomatic symptoms. Methods: A total of 7,757 Swedish adolescents aged 13–18 years completed a voluntary, anonymous questionnaire during class hours that included questions about demographic background, depressive symptoms, musculoskeletal symptoms, psychosomatic symptoms and gaming habits. Results: Increased gaming time on weekdays elevated the odds for depression, musculoskeletal symptoms and psychosomatic symptoms. However, the effects of time spent gaming were further explained by motives for playing. Gaming on weekdays for more than five hours a day, in combination with escape motives, revealed the highest odds for depression symptoms (OR = 5.335, p < 0.001), musculoskeletal symptoms (OR = 2.614, p < 0.001), and psychosomatic symptoms (OR = 4.814, p < 0.001). The increases in odds for depression symptoms, musculoskeletal symptoms and psychosomatic symptoms were less obvious among weekend gamers. Conclusion: Motives for playing was the dominant factor in relation to depression, musculoskeletal symptoms and psychosomatic symptoms, whereas the time factor was of less importance. Online gaming motives may identify problem gamers in need of intervention to reduce their unhealthy gaming behaviour. Further research on health issues in relation to online gaming should consider the combined effects of time spent gaming and gaming motives.

    Keywords
    adolescent; computer games; depression; health; musculoskeletal symptoms; psychosomatic symptoms
    National Category
    Medical and Health Sciences
    Research subject
    Family Medicine
    Identifiers
    urn:nbn:se:uu:diva-210295 (URN)
    Note

    Opublicerat manuscript. Ingår som delarbete2 i Licentiatexamination.

    Available from: 2013-11-04 Created: 2013-11-04 Last updated: 2013-11-14Bibliographically approved
  • 3.
    Hellström, Charlotta
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Nilsson, Kent
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Leppert, Jerzy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Åslund, Cecilia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Effects of adolescent online gaming time and motives on depressive, musculoskeletal, and psychosomatic symptoms2015In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 120, no 4, p. 263-275Article in journal (Refereed)
    Abstract [en]

    Aim. To investigate whether adolescent online gaming time and the additive effect of gaming motives were associated with depressive, musculoskeletal, and psychosomatic symptoms. The hypothesis was that adolescents who engage in online gaming with escape motives and increased online gaming time have higher probability for depressive, musculoskeletal, and psychosomatic symptoms compared to adolescents with other online gaming motives and/or less online gaming time.

    Method. An anonymous and voluntary questionnaire was completed during class hours by 7,757 Swedish adolescents aged 13-18 years. The questionnaire included demographic background, gaming habits, and depressive, musculoskeletal, and psychosomatic symptoms.Results. It was found that increased online gaming time during weekdays increased the probability of having depressive, musculoskeletal, and psychosomatic symptoms. However, these relations with time spent gaming were further explained by online gaming motives. Weekday online gaming for more than five hours a day, in combination with escape motives, was associated with an increased probability of depressive symptoms (odds ratio (OR) 4.614, 95% CI 3.230-6.590), musculoskeletal symptoms (OR 2.494, 95% CI 1.598-3.892), and psychosomatic symptoms (OR 4.437, 95% CI 2.966-6.637). The probability of ill health decreased when gaming was for fun or had social motives.

    Conclusion. Excessive gaming time and escape motives were found to be associated with increased probability of ill health among adolescents. Gaming motives may identify gamers in need of support to reduce unhealthy gaming behaviour as well as identify individuals at risk for ill health.

  • 4.
    Hellström, Charlotta
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Nilsson, Kent W.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Leppert, Jerzy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Aslund, Cecilia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Influences of motives to play and time spent gaming on the negative consequences of adolescent online computer gaming2012In: Computers in human behavior, ISSN 0747-5632, E-ISSN 1873-7692, Vol. 28, no 4, p. 1379-1387Article in journal (Refereed)
    Abstract [en]

    In this study we examined the relation between gaming-time, motives to play, and negative consequences due to playing MMORPGs. A total of 7757 Swedish adolescents (3872 boys and 3885 girls) between 13 and 18 years of age completed a questionnaire during class hours. Results indicated that time spent on gaming was associated with negative consequences. This relation was further explained by motives to play. Gaming for fun and social motives were associated with a reduced risk whereas gaming to escape, to gain status, or due to demands from others were associated with an increased risk of negative consequences. Motives to play should be considered as a prime indicator for negative consequences, even more than time spent gaming. Implications of these findings for future research are discussed.

  • 5.
    Hellström, Charlotta
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. School of Health, Care and Social Welfare, Mälardalen University.
    Wagner, Philippe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Nillson, Kent W.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Leppert, Jerzy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Aslund, Cecilia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Gambling frequency and symptoms of attention-deficit hyperactivity disorder in relation to problem gambling among Swedish adolescents: A population-based study2017In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 22, no 2, p. 119-126Article in journal (Refereed)
    Abstract [en]

    Aim: To investigate the associations between gambling frequency, attention-deficit hyperactivity disorder (ADHD) symptoms, and problem gambling among adolescent boys and girls. One hypothesis was that adolescents with increased ADHD symptoms have a higher frequency of gambling compared to adolescents with fewer ADHD symptoms.

    Method: A population-based sample of adolescents (aged 15–18 years) completed a questionnaire on demographics, gambling habits, ADHD symptoms, and problematic gambling; 1412 adolescents (from 4440 sampled) with gambling experience were included in the final sample.

    Results: A zero-inflated negative binomial regression analysis revealed that increased ADHD symptoms, higher gambling frequency, and higher age were associated with lower odds for being non-susceptible to gambling problems. Moreover, gambling frequency interacted with ADHD symptoms in predicting probability of being non-susceptible to gambling problems. However, when analysing those already susceptible to problem gambling, ADHD symptoms did not modify the effect of gambling frequency on the expected magnitude of gambling problems. In susceptible individuals, problem gambling increased with both increased ADHD symptoms and increased gambling frequency, but the level of problems due to gambling frequency did not change depending on the ADHD symptom level. There was an interaction effect between sex and gambling frequency in relation to gambling problems.

    Conclusions: Adolescents with ADHD symptoms seem to be more sensitive to gambling, in terms of being susceptible to developing gambling problems. However, once susceptible, adolescents with ADHD symptoms are affected by gambling frequency similarly to other susceptible participants.

  • 6.
    Hellström, Charlotta
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Åslund, Cecilia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Motives for playing and online gaming time in relation to depression, musculoskeletal symptoms and psychosomatic symptoms: a populationbased cross-sectional study of Swedish adolescentsManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: Playing online computer games is one of the most common leisure activities among adolescents. However, frequent computer-related activities have been suggested to be a new health risk factor associated with psychosomatic and physical complaints. The present study examined online gaming time and motives for playing, in relation to depression, musculoskeletal symptoms and psychosomatic symptoms. Methods: A total of 7,757 Swedish adolescents aged 13–18 years completed a voluntary, anonymous questionnaire during class hours that included questions about demographic background, depressive symptoms, musculoskeletal symptoms, psychosomatic symptoms and gaming habits. Results: Increased gaming time on weekdays elevated the odds for depression, musculoskeletal symptoms and psychosomatic symptoms. However, the effects of time spent gaming were further explained by motives for playing. Gaming on weekdays for more than five hours a day, in combination with escape motives, revealed the highest odds for depression symptoms (OR = 5.335, p < 0.001), musculoskeletal symptoms (OR = 2.614, p < 0.001), and psychosomatic symptoms (OR = 4.814, p < 0.001). The increases in odds for depression symptoms, musculoskeletal symptoms and psychosomatic symptoms were less obvious among weekend gamers. Conclusion: Motives for playing was the dominant factor in relation to depression, musculoskeletal symptoms and psychosomatic symptoms, whereas the time factor was of less importance. Online gaming motives may identify problem gamers in need of intervention to reduce their unhealthy gaming behaviour. Further research on health issues in relation to online gaming should consider the combined effects of time spent gaming and gaming motives.

  • 7.
    Vadlin, Sofia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Åslund, Cecilia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Hellström, Charlotta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Nilsson, Kent W.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Associations between problematic gaming and psychiatric symptoms among adolescents in two samples2016In: Addictive Behaviours, ISSN 0306-4603, E-ISSN 1873-6327, Vol. 61, p. 8-15Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to investigate associations between problematic gaming and psychiatric symptoms among adolescents. Data from adolescents in the SALVe cohort, including adolescents in Vastmanland who were born in 1997 and 1999 (N = 1868; 1034 girls), and data from consecutive adolescent psychiatric outpatients in Vastmanland (N = 242; 169 girls) were analyzed. Adolescents self-rated on the Gaming Addiction Identification Test (GAIT), Adult ADHD Self-Report Scale Adolescent version (ASRS-A), Depression Self-Rating Scale Adolescent version (DSRS-A), Spence Children's Anxiety Scale (SCAS), and psychotic-like experiences (PLEs). Multivariable logistic regression analyses were performed, and adjusted for sex, age, study population, school bullying, family maltreatment, and interactions by sex, with two-way interactions between psychiatric measurements. Boys had higher self-rated problematic gaming in both samples, whereas girls self-rated higher in all psychiatric domains. Boys had more than eight times the probability, odds ratio (OR), of having problematic gaming. Symptoms of ADHD, depression and anxiety were associated with ORs of 2.43 (95% CI 1.44-4.11), 2.47 (95% CI 1.44-4.25), and 2.06 (95% CI 1.27-333), respectively, in relation to coexisting problematic gaming. Problematic gaming was associated with psychiatric symptoms in adolescents; when problematic gaming is considered, the probability of coexisting psychiatric symptoms should also be considered, and vice versa.

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