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European Psychiatry 23 (2008) 134e141 http://france.elsevier.com/direct/EURPSY/

Original article

Attention decit/hyperactivity disorder and video games: A comparative study of hyperactive and control children
phanie Bioulac*, Lisa Ar, Manuel P. Bouvard Ste
Centre Hospitalier Charles Perrens, Service universitaire de psychiatrie de lenfant et de ladolescent, 121, rue de la Be chade, 33076 Bordeaux cedex, France Received 30 January 2007; received in revised form 4 October 2007; accepted 4 November 2007

Abstract Introduction. e This study describes and compares the behavior of hyperactive and control children playing video games. Subjects and methods. e The sample consisted of 29 ADHD children and 21 controls aged between 6 and 16 years playing video games. We used the Child Behavior Checklist and the Problem Videogame Playing scale (PVP scale). This instrument gives objective measures of problem use, which can be considered as an indication of addictive videogame playing. We designed a questionnaire for the parents, eliciting qualitative information about their childs videogame playing. There were no signicant differences concerning frequency or duration of play between ADHD children and controls but differences were observed on the PVP scale. None of the controls scored above four whereas 10 hyperactive children answered afrmatively to ve or more questions. These children presented a greater intensity of the disorder than the other ADHD children. Conclusion. e While no differences concerning video game use were found, ADHD children exhibited more problems associated with videogame playing. It seems that a subgroup of ADHD children could be vulnerable to developing dependence upon video games. 2007 Elsevier Masson SAS. All rights reserved.
Keywords: Attention decit hyperactivity disorder; Video game; Children; Addiction

1. Introduction During recent decades, videogame playing has become one of the main leisure activities in children and adolescents. Grifths [31] found that 10% of children between 10 and 18 years played 1 h or more per day. In 1996, Buchman reported that 90% of children played 1 h or more per day at 9 years and the gure was 75% at 13 years (900 children aged 9e13) [11]. While other studies have conrmed the period of 1 h per day [17,23,24,54], the effect of video games on children and adolescents is not well understood. The initial studies focused on the negative effects of this activity [4,5,19]. Excessive videogame playing may be associated with various problems similar to those described in addiction such as preoccupation,

* Corresponding author. Tel.: 33 0556 561728; fax: 33 0556 561732. E-mail address: stephanie.bioulac@chu-bordeaux.fr (S. Bioulac). 0924-9338/$ - see front matter 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2007.11.002

tolerance, loss of control, withdrawal, family or school disruption, lies, disregard for physical or psychological consequences, and illegal acts [26]. It has been compared with pathological gambling and considered as a non-nancial form of gambling [31]. Grifths [34] used the term technological addictions, such addictions including addictions to the Internet and slot machines. They have been operationally dened as non-chemical (behavioral) addictions that involve excessive humanemachine interaction. Technological addictions can be viewed as a subset of behavioral addictions [37,41]. Grifths has operationally dened addictive behavior as any behavior that features all the core components of addiction. For this author any behavior (e.g. videogame playing) that fulls these six criteria (salience, tolerance, mood modication, withdrawal symptoms, conicts and relapse) is therefore operationally dened as an addiction. Some authors suggest the existence of videogame addiction, but to date this area has received little attention. Grifths

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[31] adapted a set of criteria from the DSM-III-R [2] to discriminate pathological gambling. Using this instrument, Grifths and Hunt [34] reported that 8% of their test subjects were addicted to computer games. In another study, Grifths [35] reported that one in ve adolescents was currently dependent at the time of the study (387 adolescents aged between 12 and 16 years). Fisher [20,21] adapted the criteria for pathological gambling in the DSM-IV [3] to create the DSM-IV-JV (J: Juvenile, V: arcade video game). In that study, 6% of the 460 subjects (aged 11e16 years) were found to be addicted. Other studies have reported similarities between computer videogame addiction and pathological gambling or substance dependence [12,27,35,48]. If it is accepted that videogame playing can be addictive, then it is appropriate to look for the neural foundation of this behavior. Dopaminergic neurotransmission (ventral striatum or nucleus accumbens) may be involved in the neural substrate of reinforcement [38]. Koepp et al. [40] have demonstrated an increase in the release of dopamine within the nucleus accumbens as a function of videogame playing. The same area is involved in drug addiction like cocaine [50]. Their results are in favor of a link between playing video game and dopamine release. It is now well known that attention decit/hyperactivity disorder (ADHD) is a risk factor for later substance use disorder (SUD) [16,52]. Additional psychiatric comorbidity, such as conduct disorder, increases this risk [6,8]. Higher rates of ADHD have been reported in adolescents with SUD relative to controls [13]. In a prospective study, Biederman et al. [7,8] found a similar rate of substance abuse in adolescents both with and without ADHD. However, between adolescence and adulthood, the rate of substance abuse increases substantially for individuals with ADHD. Adults with ADHD begin to abuse substances at an earlier age and abuse substances more often than their peers without ADHD [53]. Since ADHD is a risk factor for later SUD, could hyperactive children be more vulnerable to videogame addiction, if such a pathology exists? To our knowledge, this issue has received little attention. A recent study [14] reported that adolescents who play for more than 1 h on a console or Internet video game may have more intense symptoms of ADHD or inattention than those who do not. A signicant relationship between Internet use and ADHD has also been shown in elementary school children [56]. Most reported effects of video games centered on the alleged negative consequences. However, there are more and more references to the positive benets of video games in the literature [32,33]. Few studies have examined whether video games might be able to help in the treatment of children with impulsive and attentional difculties. For example, Kappes and Thompson [39] tried to reduce impulsivity in incarcerated adolescents by providing either biofeedback or experience with a video game. With the aid of a computer display, attention decit patients can learn to modulate brain waves associated with focusing [55]. Another study found that an action video game modied visual selective attention [30], which is impaired in ADHD.

In our work, we studied only videogame addiction and not Internet addiction. (Internet addiction is a broad term that covers a wide variety of behaviors and impulse control problems such as cybersex addiction, cyber-relationship addiction, net compulsions, information overload and computer game addiction [57].) The current study started from our clinical observation about ADHD children and adolescent behaviors. In fact, in our daily practice, many parents of hyperactive children have reported that their children spend considerable time playing video games while they are reluctant to engage in tasks that require sustained mental efforts. These children present attention difculties and often change their activities. They seem to be able to sustain their attention longer in front of video games than classical games. Such behaviors might be explained by examining cognitive regulation in ADHD children. Cognitive and motivational dysfunction in ADHD children causes changes in quality/quantity task engagement, and preference for immediate rewards and events over delayed ones [46]. Moreover, a tendency of stimulation-seeking in ADHD children has been reported. Videogame playing provides everchanging, multimodal stimuli and an immediate reward with a minimal delay. Videogame use may t the cognitive style of ADHD very well. These notions could explain why ADHD children spend considerable time playing video games. The relationship between ADHD and video games is unknown. Videogame playing has become one of the main leisure activities in children and adolescents and ADHD places a signicant burden on medical, nancial and educational resources. For these reasons, we decided to examine the relationship between ADHD and videogame use. The current exploratory study sought to describe and compare the behavior of hyperactive children playing video games vs. controls. Moreover, we hypothesized that hyperactive children would present a higher score on the Problem Videogame Playing scale than the controls. 2. Subjects and methods 2.1. Subjects The sample consisted of 50 children aged between 6 and 16 years playing a video game. The ADHD children were recruited among outpatients referred for a psychiatric examination to the Child and Adolescent Psychiatry Department, Bordeaux University Hospital. The controls were recruited among outpatients consulting a dental facility in the Bordeaux area. Controls were excluded if they had a pathological Tscore (>60) for attention problems on the Child Behavior Checklist [1,22]. Numerous studies of children in the general population or in clinical samples using behavior ratings such as the CBCL have conrmed the existence of a dimension of hyperactive behavior [10]. 2.2. Methods: assessment procedure Clinical diagnosis of ADHD was made by a psychiatrist using DSM-IV criteria after several interviews with the child

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and with his parents. Psychiatric comorbidity was also specied and divided in two categories: behavioral disorder (oppositional and deant disorder and conduct disorder) and emotional disorder (mood and anxiety disorders). The parents of hyperactive children completed the Conners parents rating scale [18]. The Conners parent rating scale (CPRS) is a popular clinical tool for obtaining parental reports of childhood behavior problems. This questionnaire-based instrument presents a standardized measurement of childrens behavior with a particular emphasis on hyperactivity. For both groups of children, we noted age and gender and collected behavioral data with the Child Behavior Checklist (CBCL) completed by the parents. The children lled in the Problem Videogame Playing (PVP) questionnaire to obtain the PVP score. The PVP scale is a nine-item self-administered questionnaire exploring preoccupation, tolerance, loss of control, withdrawal, escape, lies and deception, disregard for physical or psychological consequences and family/school disruption with dichotomous yes/no answers [47,48]. These dimensions are derived from the DSM-IV criteria for substance dependence and pathological gambling. The PVP gives objective measures of problem use, which can be considered as an indication of addictive videogame playing. In their study on 223 adolescents, Tejeiro et al. found a relationship between high PVP scores, as calculated by the number of afrmative answers, and the frequency and duration of play. They also found a positive correlation with high scores on the Severity of Dependence Scale, a self-administered scale designed to measure dependence on different types of drugs. We translated the PVP scale into French with the authorization of its authors. This questionnaire was developed for adolescents aged between 13 and 18 years. For the children we asked the parents to read the questionnaire with the children. None of the parents reported difculties for their children to answer questions. To further investigate videogame playing, we designed a questionnaire for the parents (Appendix 1), eliciting qualitative information about their childs videogame playing: frequency and duration of play, childs behavior (during play, when stopping playing, lies in order to play, missing meals because of playing, impact on schooling), and parents attitude (parental control). Written informed consent was obtained from the parents and children, respectively.

3. Results 3.1. Socio-demographic and clinical data Our total sample comprised 50 children, 29 ADHD subjects and 21 controls. The mean age and the sex ratio did not differ between the two groups (ADHD group: 25 boys/3 girls, mean age 10.8 years; control group: 18 boys/3 girls, mean age 12.1 years) (Table 1). There were signicant differences between the two groups regarding CBCL scores. The children with ADHD had higher T-scores on the following syndromes: anxious/depressed, social problems, thought problems, attention problems, aggressive behavior, internalizing and externalizing problems. They also had lower scores on the total competence (Table 1). Among the hyperactive children, seven (24%) had a behavioral disorder and six (21%) an associated emotional disorder, and 23 (79%) were receiving pharmacological treatment for ADHD. The mean hyperactivity index on the Conners parents rating scale was 68.9 (for ADHD children). 3.2. Commitment to video game The survey did not show any signicant differences concerning the frequency or duration of play between the two samples. Thirty eight percent of the control children played less than once a week whereas one third of the ADHD children played between one and three times a week (Fig. 1). Time per session was between 1 and 2 h for the majority of the sample (65% for ADHD and 50% for controls). The two groups did not differ with regard to the type of video game since they played both with action and reection games (adventure games, role playing games, logic games). Regarding videogame use according to the parents, hyperactive children were less likely than controls to stop playing of their own accord (59% ADHD vs. 90% controls; p 0.02). All

Table 1 Socio-demographic and Child Behavior Checklist (CBCL) data of the population Controls (N 21) Girls Boys Mean age (DS) CBCL Withdrawal Somatic plaints Anxious/depression Social problems Thought problems Attention problems Delinquent behavior Aggressive behavior Internalizing problems Externalizing problems Total score Total competence 3 18 12.1 (2.6) 53 56.7 54.9 53.05 52.85 55.45 54.4 52.35 52.15 47.9 50.2 45.15 ADHD children (N 29) 3 26 10.8(2.5) 55.16 56.4 63.48 64.32 57.88 68.64 59.76 65.04 60.2 62.56 64.92 34.91 > 0.05 > 0.05 0.02 0.002 0.03 < 0.0001 0.05 0.0003 0.01 0.0002 < 0.0001 0.004 p (ManneWhitney U test)

2.3. Statistical analysis We performed statistical analysis between ADHD children and controls. We used the Chi-square test for qualitative analysis (sex and parental questionnaire) (or the Fischer probability test when the size of the group was too small). The differences in demographic variables, CBCL dimensions and PVP scores between the ADHD children and controls were analyzed by using the Students t test or ManneWhitney U test. Statistical signicance was set at p < 0.05. Statistical analysis was performed with Statview 5.0.

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40 35 30

137

30 ADHD Controls 25
ADHD Controls

Subjects ( )

20 15 10 5 0 0 1 2 3 4 5 6 7 8 9

Subjects ( )

25 20 15 10 5 0 <1/week 1-3/week >3/week Everyday

Number of affirmative responses

PVP: Problem videogame playing

Frequency (per week)

Fig. 1. Frequency of play in ADHD children and controls.

Fig. 3. Number of afrmative responses on the PVP scale.

control children stopped playing when their parents asked them to, whereas 66% of the ADHD children stopped playing ( p 0.01). Hyperactive children reacted more often than controls with reactions of refusal, tears, anger or violence when they had to stop playing (59% ADHD vs. 19% controls; p 0.008). In neither group did almost any parent report any negative impact on schooling, lies or missing of meals because of video games.

externalizing problems ( p 0.01) (Table 2). There were no signicant differences for the other CBCL dimensions. 4. Discussion The use of video games in children and adolescents with psychiatric disorders has received little attention. In our work, we did not nd any signicant differences concerning the frequency or the duration of play between ADHD children and controls, even if ADHD children seemed to play a little more often than the latter. This result is a little surprising. In fact, in most cases addiction is accompanied by greater frequency or duration of the addiction (as with gambling or alcohol). Some explanations might account for this. First, our cohort is rather small, so these ndings remain to be conrmed. Second, it is also rather young, so the subjects are perhaps at the beginning of the disorder. Third, videogame addiction is perhaps a vulnerability factor for other addictions and does not meet all the criteria of classical addictions. Moreover, parents could protect their children by limiting the duration of playing (at least at the beginning). On the contrary, there were differences in the behavior of the two populations when playing video games. According to the parents, hyperactive children were less likely than controls to stop playing of their own accord. ADHD children are known

3.3. Problem Videogame Playing (PVP) scores PVP scores (Fig. 2) indicated signicant differences between the ADHD children and controls. None of the controls scored above four whereas 10 hyperactive children (34% of the ADHD children) answered afrmatively to ve or more questions ( p 0. 002) (Fig. 3). We focused on this subgroup of ADHD children with high PVP scores and found signicant differences between them and the other hyperactive children. The subgroup had a higher hyperactivity index on the Conners parents rating scale (mean index 79 for ADHD with PVP score  5 vs. mean index 64.26 for ADHD with PVP score < 5; p 0.02). They also had higher scores on the following CBCL dimensions: delinquent behavior ( p 0.003), aggressive behavior ( p 0.02) and

70 60 50 40 30 20 10 0
Escape Lies Tolerance Relapse Preoccupation Loss of control Withdrawal Illegal acts

Subjects ( )

ADHD Controls

Table 2 Clinical data of subgroups of ADHD children ADHD children with PVP 5 (n 10) ADHD children with PVP score < 5 (n 19) 64.26 56.5 61.38 58.83 p (ManneWhitney U test)

Family /schooling disruption

Dimensions of PVP questionnaire

PVP: Problem videogame playing

Fig. 2. Afrmative responses on the PVP questionnaire in the two populations.

CPRS Delinquent behavior (CBCL) Aggressive behavior (CBCL) Externalizing problems (CBCL)

79 67.25 72.5 70.62

0.02 0.003 0.02 0.01

CPRS: Conners parents rating scale; CBCL: Child Behavior Checklist.

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to have difculties in organizing themselves and being compliant, although this is likely rather due to a clinical effect of their disorder. Moreover, PVP scores underlined signicant differences between the ADHD and control children, hence raising the question whether ADHD children have a greater tendency to be addicted to video games. On Grifths scale [31], a score of four or more criteria is considered as a sign of videogame dependence. In the DSM-IV-JV [20,21], if a person answered yes to four (or more) of the nine items, the person was deemed to be a videogame addict. Moreover, in the DSM-IV, the diagnosis of pathological gambling needs ve (or more) criteria to be met. In our study, none of the controls scored above four on the PVP scale whereas 10 hyperactive children answered afrmatively to ve or more questions. Yoo [56] suggested that ADHD symptoms are potentially important risk factors for Internet addiction and found that ADHD symptoms had signicant positive correlations with the degree of Internet addiction. In that study, the authors found that the ADHD group had higher Internet addiction scores compared with the nonADHD group, while no cut-off point was proposed for the PVP scale by Tejeiro [47,48]. If dependence is considered as a score of ve, all our dependent players were ADHD children. Along the same lines, we suggest that the severity of ADHD is signicantly positively correlated with the degree of videogame addiction. The 10 ADHD children represented 20% of the gamers. The same percentage was found in the study by Grifths [34] where one in ve adolescents was currently dependent upon computer games. In the future, videogame addiction might come to be regarded as being on a continuum with other kinds of addictions. The reward deciency theory is another theoretical assumption about the association between game addiction and ADHD [9]. It proposes that individuals who are less satised with natural rewards (pleasure drive for eating, love and reproduction) tend to adopt substances as a way to seek an enhanced stimulation of the reward pathway. Natural rewards involve the release of dopamine in the nucleus accumbens and frontal lobes. However, the same release of dopamine and production of pleasurable sensations can be produced by unnatural rewards such as alcohol, cocaine, amphetamine and other drugs, and by compulsive activities such as gambling, eating, sex, and risk-taking behaviors. Videogame addiction could serve as another relatively new kind of unnatural reward. Furthermore, impulsivity could be dened as a predisposition toward rapid, unplanned reactions to internal or external stimuli. Studies using rewardechoice paradigms have found that individuals with a history of substance abuse are more likely to choose an immediate reward. Similarly, studies measuring impulsivity in substance-dependent individuals have also supported a link between impulsivity and substance abuse. Impulsivity is one of the core symptoms of ADHD. This notion could explain why ADHD children are attracted to video games. A recent study showed that Internet-addicted subjects (screened with the Youngs Internet Addiction Scale) had various comorbid psychiatric disorders [36]. Twelve children and

12 adolescents were randomly selected for evaluation of the current psychiatric diagnoses. Seven children, but none of the adolescents, were diagnosed with ADHD. Consequently, they concluded that comorbidities differ with age. The authors did not conclude that Internet addiction is a cause or consequence of these disorders, but they suggested the possibility of age-specic comorbid psychiatric disorders in cases of Internet addiction. In our work, we did not study the age factor. However, future investigations could examine to what extent the results of PVP scores and other scales differ with age. Importantly, we studied videogame addiction and not Internet addiction. There may be differences between these two behaviors, and the age factor would need to be taken into account [44,45]. We then examined the subgroup of ADHD children with high PVP scores (group A) and found signicant differences between them and the other hyperactive children (group B). The intensity of disorder in group A was more severe, as shown by the hyperactivity index of the Conners parents rating scale. Group A exhibited behavioral characteristics different from those in group B. These results suggest an association between the level of ADHD symptoms and the severity of videogame addiction in children. Recent data suggest that the presence of ADHD symptoms, both in the inattention and hyperactivity-impulsivity domains, may be one of the important risk factors for Internet addiction [14,56]. Group A probably included ADHD children with a risk of developing videogame problems. Indeed, this subgroup might be vulnerable to developing dependence upon video games. 4.1. Limitations The present study has certain limitations. First our cohort was rather small; so it is difcult to compare the various subgroups. For this reason, the subgroup of ADHD children with high PVP scores and the other hyperactive children were not compared. Moreover, all subjects were recruited in an ADHD outpatient clinic, a setting where patients are likely to be more severely ill. Moreover, the study was descriptive and prospective, i.e. we sought to identify which behaviors or symptoms are a risk factor for videogame addiction or other addictive behaviors. For an exploratory study, we decided to keep the girls in the two groups. These results must be interpreted with caution because many children (45%) have another psychiatric diagnosis, so the differences found could be due to ADHD or to comorbid psychiatric problems. Finally, the focus is on videogame addiction, yet there are still no well-validated diagnostic criteria for this form of addiction. Further research into the area of videogame addiction is therefore required. 5. Conclusion Research into videogame addiction has received little attention. We did not nd any signicant differences between the ADHD children and controls concerning the use of video games (frequency and duration of play). However, ADHD children exhibited more problems associated with videogame playing. It

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seems that a subgroup of ADHD children (with a high PVP score) could be vulnerable to developing dependence upon video games. Since videogame playing will doubtlessly grow among the general population in the foreseeable future, wellvalidated diagnostic criteria are required for videogame addiction. Larger samples need to be investigated. Patient outcome should be explored as well as investigating whether such patients risk developing other addictive behaviors.

Appendix 1. Parents videogame questionnaire (Who is answering the questionnaire: father/mother/both parents) Date: / /200 .
1. Has your child played video games Yes No during the last 12 months? 2. How often does your child play video games? Less than once a week Yes No Once to three times a week Yes No More than three times a week Yes No Every day Yes No 3. What are the names of the three most used video games? d d d 4. What does your child play video games on? (several answers are possible) Playstation on the TV Yes No Portable playstation (e.g. Game Yes No Boy.) Video games on computer Yes No Video games online Yes No Arcade video games Yes No 5. How long does your child play video games? Less than 1 h Yes No 1e2 h Yes No 2e3 h Yes No More than 3 h Yes No 6. At home, does your child have free Yes No access to video games? 7. Have you decided on the Yes No conditions of use of the video games? If afrmative, please specify which conditions? (several answers are possible) Time in week Yes No Time in day Yes No Maximal playing time Yes No Type of game Yes No Conditions before playing (specify): ............................... ............................... ............................... 8. Does your child respect the conditions of playing video games? Never Yes No Rarely Yes No Often Yes No Always Yes No 9. Does your child stop playing video games of his/her own accord? Never Yes No Rarely Yes No Often Yes No Always Yes No

10. Does your child stop playing video games when you ask him/her to? Never Yes No Rarely Yes No Often Yes No Always Yes No 11. Do you need to get angry to make him/her stop playing video games? Never Yes No Rarely Yes No Often Yes No Always Yes No 12. How does he/she react when you make him/her stop playing video games? (several answers are possible) Indifference Yes No Agreement Yes No Refusal Yes No Anger Yes No Tears Yes No Violence Yes No Others: ........................... .............................. 13. What is your childs behavior during videogame playing? (several answers are possible) Stays calm Yes No Restless Yes No Quiet Yes No Comments, screams Yes No Happy Yes No Worried, sad Yes No Others: .......................... ............................... 14. How does he/she react when losing on video games? (several answers are possible) Calm Yes No Restless Yes No Angry Yes No Sad, cries Yes No Breaks the videogame equipment Yes No Hurts himself or others around Yes No Others: .......................... ............................... 15. Has your child missed meals because of playing video games? Never Yes No Rarely Yes No Often Yes No Always Yes No 16. Has your child already lied in order to play video games? Never Yes No Rarely Yes No Often Yes No Always Yes No Comments: ........................ .............................. 17. When not playing video games, does your child read/talk about video games? Never Yes No Rarely Yes No Often Yes No Always Yes No 18. Is his/her behavior different when Yes No he/she does not play video games for several days? If afrmative, please specify (several answers are possible) Calm Yes No Restless Yes No Angry Yes No Sad Yes No

140 Appendix 1 (continued )

S. Bioulac et al. / European Psychiatry 23 (2008) 134e141 and prosocial behavior: a meta-analytic review of the scientic literature. Psychological Science Sep 2001;12(5):353e9. Anderson CA, Dill KE. Video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. Journal of Personality and Social Psychology 2000;78:772e90. August G, Stewart M, Holmes C. A four-year follow-up of hyperactive boys with and without conduct disorder. British Journal of Psychiatry 1983;143:192e8. Biederman J, Wilens T, Mick E, Milberger S, Spencer T, Faraone S. Psychoactive substance use disorder in adults with attention decit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. American Journal of Psychiatry 1995;152:1652e8. Biederman J, Wilens T, Mick E, Faraone S, Weber W, Curtis S, et al. Is ADHD a risk factor for psychoactive substance use disorder: ndings from a four-year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry 1997;36(1):21e9. Blum K, Braverman ER, Holder JM, Lubar JF, Monastra VJ, Miller D, et al. Reward deciency syndrome: a biogenetic model for the diagnosis and treatment of impulsive, addictive and compulsive behaviors. Journal of Psychoactive Drugs Nov 2000;32(Suppl. ieiv):1e112 [Review]. Boyle M, Offord D, Racine Y, Szatmari P, Fleming J, Sanford M. Identifying thresholds for classifying childhood psychiatric disorder: issues and prospects. Journal of the American Academy of Child and Adolescent Psychiatry 1996;35:1440e8. Buchman DD, Funk JB. Video and computer games in the 90s: childrens time commitment and game preference. Children Today 1996;24(1):12e5. Carlton PL, Manowitz P, McBride H, Nora R, Swartzburg M, Goldstein L. Attention decit disorder and pathological gambling. Journal of Clinical Psychiatry 1987;48:487e8. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. American Journal of Psychiatry 2003;160:1041e52. Chan PA, Rabinowitz T. A cross-sectional analysis of video games and attention decit hyperactivity disorder symptoms in adolescents. Annals of General Psychiatry 2006:5e16. Childcoat H, Breslau N. Pathways from ADHD to early drug use. Journal of the American Academy of Child and Adolescent Psychiatry 1999; 38(11):1347e54. Christakis DA, Ebel BE, Rivara TP, Zimmerman FJ. Television, video, and computer game usage in children under 11 years of age. Journal of Pediatrics 2004;145(5):652e6. Conners CK. Rating scales in ADHD: use in assessment and treatment monitoring. Journal of Clinical Psychiatry 1988;59:24e30. Dill K, Dill J. Video game violence: a review of the empirical literature. Aggression and Violent Behavior 1998;3:407e28. Fisher S. Identifying video game addiction in children and adolescents. Addictive Behaviors 1994;19(5):545e53. Fischer S. The amusement arcade as a social space for adolescents: an empirical study. Journal of Adolescence 1995;18:71e86. Fombonne E, Chehdan F, Carradec AM, Achard S, Navarro N, Reis S. Le Child Behavior Checklist: un instrument pour la recherche en psychiatrie de lenfant. Psychiatry and Psychobiology 1988;3:409e18. Funk JB. Reevaluating the impact of video games. Clinical Pediatrics 1993;32(2):86e90. Gentile DA, Lynch PJ, Linder JR, Walsh DA. The effects of violent video game habits on adolescent hostility, aggressive behaviors, and school performance. Journal of Adolescence 2004;27:5e22. Goodman A. Addiction: denition and implications. British Journal of Addiction 1990;85:1403e8. Goudriaan AE, Oosterlaan J, De Beurs E, Van den Brink W. Pathological gambling: a comprehensive review of biobehavioral ndings. Neuroscience and Biobehavioral Reviews 2004;24:123e41. Green CS, Bavelier D. Action video game modies visual selective attention. Nature May 2003;423:534e7. Grifths MD. Amusement machine playing in childhood and adolescence: a comparative analysis of video games and fruit machines. Journal of Adolescence 1991;14:53e73.

Happy Yes No Other comments: ...................... ............................. 19. Do you think your childs Yes No behavior signicantly disturbs family relationships because of playing video games (e.g. conict with parents, with brother/sister, withdrawal.)? Specify: ......................... ............................. .............................. Yes No 20. Do you think your childs behavior signicantly disturbs his/ her schooling because of playing video games? Specify: ......................... ............................. ............................. 21. After playing video games, has Yes No your child complained about somatic problems (e.g. headache, eyestrain, abdominal pain, back pain)? Specify: ......................... ............................. ............................. 22. Do you think your child has Yes No a problem with videogame playing? 23. Do you think your child plays Yes No video games too much? 24. If you think your child plays Yes No video games too much, are you worried about it? 25. Do other members of the family Yes No play video games? Please specify (several answers are possible) Brother/sister Yes No Mother Yes No Father Yes No Comments: ........................ ............................. ............................. Yes No 26. If your child is taking medication for ADHD, do you think his/her behavior regarding video games has been modied by the treatment? Specify the name of medication and the changes you have noticed: ............................. ............................. .............................

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