CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 22, Number 10, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2019.0085

Development of the Problematic Mobile Gaming

Questionnaire and Prevalence of Mobile Gaming Addiction
Among Adolescents in Taiwan

Yuan-Chien Pan, MS,1 Yu-Chuan Chiu, MD,2 and Yu-Hsuan Lin, MD, PhD3–6
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.

Abstract

Mobile gaming has gained popularity among adolescents, and an increase in problematic use has been reported.
The aims of this study are as follows: (a) develop a self-report questionnaire, the Problematic Mobile Gaming
Questionnaire (PMGQ); (b) establish a validated cutoff value using structured interviews; and (c) evaluate the
prevalence of mobile gaming addiction in adolescents. The PMGQ was built as a 12-item questionnaire rated on
a 4-point Likert scale to evaluate the symptoms of problematic mobile gaming (PMG). The construct validity of
the PMGQ was examined using exploratory factor analysis. Overall, 10,775 students with smartphones from
grade 4 to senior high school were recruited to complete the questionnaire. A total of 113 senior high school
students were interviewed using previously developed criteria for PMG to develop an optimal cutoff point
measuring sensitivity, specificity, and diagnostic accuracy. The cutoff point was determined using the Youden
index and optimal diagnostic accuracy. The PMGQ showed good internal consistency (Cronbach’s a = 0.92) and
adequate diagnostic efficiency (area under the receiver operating characteristic curve = 0.802). The items re-
vealed three factors of addiction: compulsion, tolerance, and withdrawal. For the PMGQ, a cutoff point of 29/30
demonstrated the most optimal Youden index and diagnostic accuracy. Demographic data showed that the
proportion of PMG was 19.1 percent among elementary school students, 20.5 percent among junior high school
students, and 19.0 percent among senior high school students. The PMGQ demonstrated appropriate validity
and accuracy in the assessment for PMG.

Keywords: problematic mobile gaming, mobile gaming addiction, Internet gaming disorder, smartphone addiction

Introduction approach.4–6 Another similar form of addiction, namely Internet

gaming disorder (IGD), is listed in the research criteria of the

A s smartphones become increasingly ubiquitous, smart-

phone overuse has emerged as a form of technological
addiction, which is becoming a crucial social issue. Accord-
ing to Griffiths,1 technology addiction is a type of behavioral
addiction that involves human–machine interactions and is
nonchemical in nature. Gambling disorder, the most well-
known form of behavioral addiction, is categorized under the
Substance-Related and Addictive Disorders section of the cur-
rent Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5), owing to similarities in symptomatol-
ogy, biological dysfunction,2 genetic liability,3 and treatment
DSM-5, indicating that this potential disorder requires further
research. Similarly, problematic mobile gaming (PMG) or
mobile gaming addiction also requires further research. The
availability of smartphones has led to extensive smartphone
penetration and has prompted researchers to investigate mobile
gaming addiction, a new form of IGD or smartphone addiction.
Engagement in mobile gaming has increased markedly.
Mobile devices, including smartphones and tablets, were
reported to be leading platforms for games in 2016. The most
popular mobile games are all online games played on
smartphones or tablets. The revenue generated by mobile

1
Department of Psychology, National Taiwan University, Taipei, Taiwan.
2
Department of Psychiatry, MacKay Memorial Hospital, Taipei, Taiwan.
3
Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan.
4
Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.
5
Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan.
6
Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan.

662
 ASSESSMENT OF PROBLEMATIC MOBILE GAMING
games exceeded personal computer (PC) and console game
revenue for the first time in 2016.7 Therefore, we use mobile
games to represent online smartphone or tablet games. An
official survey by the Institute for Information Industry showed
that 58.7 percent (12.25 million) of people over the age of 12
years owned a smartphone in Taiwan in 2015. The top five
types of apps were those for games (53.7 percent), social
networking (27.8 percent), tools (27.7 percent), music (27.4
percent), and videos (24.4 percent).8 This report suggested that
mobile games are a crucial factor in the excessive use of, or the
addiction to, smartphones. Portability allows for shorter use
periods of gaming compared with the relatively long periods of
PC-based Internet gaming. The short use periods of smart-
phones result in distractions, which might lead to functional
impairment, which can culminate in incidents such as vehicle
crashes or near-crashes.9 A case report of tendon rupture as-
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.
sociated with excessive mobile gaming10 suggested that non-
pharmacological effects of mobile gaming such as pleasure
and excitement, similar to those of PC gaming, suppress pain
perception in pediatric patients11 and patients with burns.12
These effects can lead to compulsive–addictive behaviors.
Mobile gaming has been increasingly linked to adolescent
health problems. The close combination of gaming and so-
cial networking available on mobile phones may play a
crucial role in its addictive nature.13 Adolescent gamers can
readily share scores and achievements on social media and
receive immediate feedback. Inviting friends to join mobile
gaming sessions through social media is easier than for PC-
based online games. Although adolescents have potential to
build and enhance existing social relationships, they may
also have negative social experiences, such as bullying or
trolling behaviors.14 Furthermore, in a qualitative study in-
vestigating sleep deprivation for adolescents, boys were
more likely to report engaging in nighttime gaming on their
smartphones, which may negatively affect sleep quality.15
Self-report questionnaires have been developed to assess
smartphone addiction16–19 and IGD.20–22 The portability of
smartphones has resulted in rapid evolution of mobile gam-
ing. Mobile games have become a crucial factor in smart-
phone use and warrant a dedicated discussion. The elements
of game design are different between computer and mobile
gaming platforms. Gaming is platform specific; online
gaming is usually associated with PC games and requires a
higher investment of time and effort relative to mobile
games. The psychosocial effect of mobile games may be
different than that of nonmobile games. Related behaviors
and gaming contexts may also differ,23 which implies that
PMG may be a different concept than IGD. To our knowl-
edge, no questionnaire examines PMG. Among the scales for
smartphone addiction, only the Smartphone Addiction In-
ventory (SPAI) has a cutoff value that was determined by
clinical interviews with diagnostic criteria.24 This was also
the only diagnostic criterion of smartphone addiction for
clinical interviews.25 It is not feasible to conduct diagnostic
interviews for smartphone addiction in a large-scale epide-
miological study. It would be optimal to conduct a one-stage
investigation using a brief self-report instrument with high
diagnostic accuracy. The specific aims of this study were as
follows: (a) to develop the Problematic Mobile Gaming
Questionnaire (PMGQ) and its short form; (b) to establish a
cutoff value for the PMGQ to assess mobile gaming addic-
tion based on diagnostic criteria obtained by psychiatric in-
663
terview; and (c) to survey the prevalence of PMG among
students at elementary, junior, and senior high school levels.
Materials and Methods
Participants and procedure
We recruited 16,283 students from 169 schools (112 ele-
mentary, 39 junior high, and 18 senior high schools) in Tai-
wan. In total, 10,775 students (6,015 boys and 4,760 girls)
reported owning a smartphone. The students’ ages ranged from
10 to 18 (M = 13.06 years, standard deviation = 1.74) years.
After providing informed consent, all participants completed a
paper-and-pencil survey that collected demographic data,
characteristics of smartphone use, PMG data, and symptoms of
IGD. A total of 113 senior high students were further invited to
an interview session. The interviews were conducted indi-
vidually by two psychologists to validate and determine the
cutoff point of the PMGQ. The structured interview of PMG
was modified from the criteria of smartphone addiction.25
Measures
Problematic Mobile Gaming Questionnaire. The PMGQ
was built based on the SPAI considering the fact that the
definition of PMG or mobile gaming addiction is still a
controversial concept in the field of behavioral addiction.24
The 16 candidate items for the PMGQ were revised from the
SPAI. A total of 10 items overlapped with the short form
Smartphone Addiction Inventory (SPAI-SF). Additional
items were included with regard to the uniqueness of mobile
gaming and diagnostic characteristics of IGD in the DSM-5.
Participants were asked to rate items on a 4-point Likert scale
(1, strongly disagree; 2, somewhat disagree; 3, somewhat
agree; and 4, strongly agree).
Ten-Item Internet Gaming Disorder Test
The Ten-Item Internet Gaming Disorder Test (IGDT-10)
comprises 10 items and assesses levels of IGD.20 Each cri-
terion of IGD in the DSM-5 was operationalized using a
single item, except for the last criterion referring to func-
tional impairment, which was operationalized using two
items. Participants were asked to rate items on a 3-point
Likert scale (0, never; 1, sometimes; and 2, often). The items
of the IGDT-10 were recoded into a yes (1) or no (0) format
to resemble the dichotomous structure of IGD. The Cron-
bach’s alpha value of the scale was 0.68. The diagnosis of
IGD in the present sample was estimated using IGDT-10
with a cutoff threshold of 5.20
Proposed diagnostic criteria for PMG
The proposed criteria for PMG were modified from the
criteria of smartphone addiction25 and consisted of the fol-
lowing: (A) six symptom criteria; (B) four functional im-
pairment criteria; and (C) one exclusion criterion. Participants
who had three (or more) symptoms from criterion group A and
two (or more) functional impairment criteria, as assessed in
the structured interview, were defined as having PMG.25
Relevant features of PMG
To assess the relevant features of mobile gaming, all
participants reported (a) if they ever spent money on mobile
 664 PAN ET AL.

games; (b) the average time (hours per week) spent on In-
ternet gaming during weekdays and weekend days; (c) body–
mass index (BMI); and (d) whether they had myopia.
Statistical analysis
The construct validity of the PMGQ was examined by
exploratory factor analysis (EFA) using the maximum like-
lihood estimation method and oblique promax rotation. EFA
was conducted using the sample of senior high students
(n = 1,455, which was regarded as an appropriate sample
size). A receiver operating characteristic (ROC) analysis was
conducted to examine the diagnostic ability of the PMGQ.
The area under the ROC curve (AUC) was used to measure
the diagnostic efficacy of the PMGQ. The diagnostic accu-
racy indicated the percentage of all correct decisions.
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.
loading; these factors are not listed in Table 1. We selected
items with highest factor loading in each factor and main-
tained the proportion of items in the original three-factor
model of the PMGQ to construct a short form of the PMGQ,
termed PMGQ-SF. The total scores of the PMGQ and
PMGQ-SF ranged from 12 to 48 and 4 to 16, respectively.
The PMGQ and PMGQ-SF demonstrated good internal
consistency (Cronbach’s a = 0.92 and 0.79, respectively).
Determination of cutoff point
A structured interview based on proposed diagnostic cri-
teria for PMG was used as the gold standard for diagnosis.
Table 2 shows the ROC analysis for the PMGQ. The AUC
was 0.802, indicating the high diagnostic value of the
PMGQ. A cutoff point of 29/30 was optimal for discrimi-

The cutoff point for the PMGQ was optimized for diag- nating cases of PMG from diagnostic negatives. Table 3
nosis when the score was accompanied by the highest shows the ROC analysis for the PMGQ-SF. The AUC was
Youden index and optimal diagnostic accuracy. Participants 0.736, indicating that the PMGQ-SF had acceptable diag-
were further classified into a PMG group and non-PMG nostic efficiency. A cutoff point of 9/10 was best for dis-
group according to the cutoff point of the PMGQ. Demo- criminating cases of PMG from diagnostic negatives.
graphic data and relevant characteristics of mobile gaming Furthermore, we conducted an exploratory analysis
were further compared between these two groups by using (n = 6,996) to determine the cutoff point of the PMGQ based
the chi-squared test or t test. A one-way analysis of variance on the diagnosis of IGD as the gold standard. The results
compared the group differences in terms of relevant features revealed that an AUC of 0.854 and a cutoff point of 29/30
of PMG among students with three levels of education. were still optimal for distinguishing between cases of IGD
and diagnostic negatives.
Results
Factor analysis of the PMGQ and development Demographic data and relevant characteristics of PMG
of the short form PMGQ
All participants were divided into three groups as follows:
Table 1 shows the PMGQ and results of the EFA. Results (a) fourth to sixth grade, (b) junior high school, and (c) senior
revealed that the PMGQ contained three potential factors, high school. Each group was further classified into a PMG
namely compulsion, tolerance, and withdrawal. We deleted group and a non-PMG group with a cutoff point of 29/30 in
four items because of apparent cross-loading and low factor the PMGQ. Overall, the proportion of people with PMG was
Table 1. Factor Loading of the Problematic Mobile Gaming Questionnaire
Factor 1, Factor 2, Factor 3,
compulsion tolerance withdrawal
(1) I have often experienced dry/sore eyes, muscle aches, or other physical 0.751 -0.092 0.060
discomforts from playing mobile games for a long duration.a
(2) I often do not plan on playing mobile games, but cannot resist picking up 0.692 0.052 -0.012
my phone to play (swipe).a
(3) I have a habit of playing mobile games before going to sleep and therefore 0.689 -0.059 0.077
reducing sleep time or sleep quality.
(4) Mobile games have had a negative impact on my academic performance or 0.670 0.034 0.084
occupation.
(5) Despite the negative consequence of mobile games, I have not decreased 0.600 0.171 -0.062
playing mobile games.
(6) I have attempted to reduce my mobile gaming, but did not succeed. 0.580 0.173 0.007
(7) Compared to 3 months ago, I am averaging more time every week playing -0.074 0.852 0.084
mobile games.a
(8) I find that I am spending more time playing mobile games. 0.082 0.850 -0.047
(9) I have been told multiple times that I am spending more time playing 0.117 0.530 0.150
mobile games.
(10) If I cannot play a mobile game, I feel restless and irritable.a 0.014 -0.002 0.905
(11) If I have a period of not playing mobile games, I start to feel -0.004 0.100 0.814
uncomfortable.
(12) I had an experience where I was playing a mobile game while 0.216 0.025 0.427
simultaneously walking, crossing the street, riding a motorcycle, or
driving and almost had a dangerous accident.
Bold indicates values most closely related to their given factors.
a
The items of the Problematic Mobile Gaming Questionnaire-Short Form.
 ASSESSMENT OF PROBLEMATIC MOBILE GAMING 665

Table 2. Sensitivity, Specificity, Positive cation levels. A significant difference in BMI was noted
Predictive Rate, Negative Predictive Rate, between the PMG and non-PMG groups among elementary
Diagnostic Accuracy, and Youden Index school and junior high students, but not senior high students.
of Cutoff Points in the Problematic Mobile The proportion of children with myopia or severe myopia
Gaming Questionnaire Between Diagnostic was not significantly different between the PMG and non-
Positive and Negative Groups (N = 98)
PMG groups.
Youden Regarding students who played both PC-based and
Cutoff Sensitivity Specificity PPR NPR DA index mobile-based online games (n = 6,996), Figure 1 shows the
point (%) (%) (%) (%) (%) (%) proportion of those with positive diagnoses of IGD and
PMG. The results demonstrated that 77.8 percent of students
26 88.2 43.8 45.5 87.5 59.2 32.0 with possible IGD also met the PMG criteria (determined
27 82.4 50.0 46.7 84.2 61.2 32.4 using the PMGQ). However, only 12.6 percent of students
28 76.5 59.4 50.0 82.6 65.3 35.8
who met the PMG criteria also met the IGD criteria. Our data
29 70.6 68.8 54.5 81.5 69.4 39.3
30 67.6 82.8 67.6 82.8 77.6 50.5 showed that students with IGD also have high probability of
31 47.1 89.1 69.6 76.0 74.5 36.1 having a diagnosis of PMG, but not vice versa.
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.

32 41.2 95.3 82.4 75.3 76.5 36.5

33 41.2 98.4 93.3 75.9 78.6 39.6 Discussion
34 38.2 100.0 100.0 75.3 78.6 38.2
This is the first study to develop a self-report questionnaire
Note: AUC = 0.802.
AUC, area under the receiver operating characteristic curve; DA, on PMG. Based on the high reliability of diagnostic inter-
diagnostic accuracy; NPR, negative predictive rate; PPR, positive views, we provided a cutoff point for mobile gaming ad-
predictive rate. diction for the PMGQ. The cutoff point of 29/30 indicates
that if half of the items were assessed as somewhat agree, the
19.1 percent (53.1 percent boys) among elementary students, assessment would indicate addiction. Similarly, the cutoff
20.5 percent (58.4 percent boys) among junior high students, point of 9/10 in the PMGQ-SF demonstrated the same clin-
and 19.0 percent (57.3 percent boys) among senior high ical implication. Our results show that the cutoff point can
students. Among the elementary students, 23.3 percent boys distinguish heavy smartphone users by their time spent on
and 14.3 percent girls met the criteria for PMG. For junior smartphone use as well as the money they spent on mobile
high students, the proportion of PMG was 21.0 percent for gaming. Because whether smartphone addiction constitutes a
boys and 19.7 percent for girls. For senior high students, 22.3 diagnostic entity is still a topic of debate, the PMGQ with
percent of boys and 14.6 percent of girls met the criteria for cutoff points may be used as a screening tool to identify users
PMG. potentially at risk of such addictions in adolescence.
Table 4 shows the group comparisons of demographic data Our findings demonstrated differences based on age and
and relevant characteristics of PMG. Significant gender sex in PMG. Boys showed more PMG tendencies than girls
differences were noted between the PMG and non-PMG did in the elementary and senior high school groups, whereas
groups among elementary and senior high school students, no gender difference was noted in the junior high school
but not among junior high school students. Those in the PMG students. The proportion of girls with PMG was 19.7 percent,
group spent significantly more money on mobile gaming, 14.3 percent, and 14.6 percent at the junior high, elementary,
significantly more time engaging in Internet gaming per and senior high school levels, respectively. The proportion of
week, and scored significantly higher on both the PMGQ and boys with PMG was similar in the three groups (23.3 percent,
IGDT-10 in all three subsamples. The proportion of students 21.0 percent, and 22.3 percent in elementary, junior high,
who met the IGD diagnostic criteria was significantly higher and senior high school levels, respectively). Studies have
in the PMG group than in the non-PMG group in all edu- suggested that males are more addicted to Internet use than
females, while the pattern is reversed for smartphone use,
possibly because females are more inclined toward social
Table 3. Sensitivity, Specificity, Positive interaction facilitated by smartphones.26 In recent years,
Predictive Rate, Negative Predictive Rate, however, the numbers of female and male mobile gamers
Diagnostic Accuracy, and Youden Index have been close, which is different from male-dominated,
of Cutoff Points in the Problematic Mobile online PC gaming.27 The close combination of gaming and
Gaming Questionnaire-Short Form Between social networking available on smartphones may play a
Diagnostic Positive and Negative Groups (N = 98) crucial role in its addictive nature.13 For example, mobile
Youden game players can easily share scores or achievements on
Cutoff Sensitivity Specificity PPR NPR DA index social media and receive immediate feedback. They are also
point (%) (%) (%) (%) (%) (%) more easily able to invite their friends to join mobile gaming
platforms through social media than for PC-based online
8 100.0 21.9 40.5 100.0 49.0 21.9 games. The increasing prevalence of PMG in female junior
9 88.2 40.6 44.1 86.7 57.1 28.9 high school students implies that social interactions in
10 61.8 67.2 50.0 76.8 65.3 29.0 gaming may attract female adolescents.
11 38.2 89.1 65.0 73.1 71.4 27.3 The PMG group had higher IGD-10 scores and spent more
12 26.5 98.4 90.0 71.6 73.5 24.9 time engaging in online gaming than the non-PMG group.
13 11.8 98.4 80.0 67.7 68.4 10.2
Among students who played both online PC games and
Note: AUC = 0.736. mobile games, there was an overlap of 12.6 percent in those
 Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.

Table 4. Comparison Between Problematic Mobile Gaming and Nonproblematic Mobile Gaming Groups According to the Cutoff Point
of 29/30 in the Problematic Mobile Gaming Questionnaire
Fourth to sixth grade Junior high school Senior high school
(N = 4,948) (N = 4,372) (N = 1,455)
PMG Non-PMG PMG Non-PMG PMG Non-PMG
(N = 946) (N = 4,002) (N = 898) (N = 3,474) (N = 277) (N = 1,178)
n % n % v2 P n % n % v2 p n % n % v2 p
Gender 64.366 <0.001 1.165 0.280 13.693 <0.001
Male 613 64.8 2,014 50.3 539 60.0 2,016 58.0 186 67.1 647 54.9

666
Female 333 35.2 1,988 49.7 359 40.0 1,458 42.0 91 32.9 531 45.1
Spend money on mobile 202 21.4 345 8.6 126.147 <0.001 326 36.3 628 18.1 138.943 <0.001 117 42.2 364 30.9 13.028 <0.001
gaming
Myopia 336 35.5 1,443 36.1 0.097 0.756 449 50.0 1,786 51.4 0.568 0.451 177 63.9 769 65.3 0.188 0.664
M SD M SD t P M SD M SD t p M SD M SD t p
Time spent on Internet gaming 29.39 15.12 20.53 11.15 16.96 <0.001 33.13 14.43 23.12 11.16 19.34 <0.001 30.94 14.00 23.13 10.46 8.72 <0.001
(hours per week)
BMI 19.78 5.38 19.00 4.87 4.12 <0.001 20.39 4.76 20.03 4.31 2.09 0.037 21.35 4.90 21.21 4.35 0.44 0.658
PMGQ 35.24 5.22 19.39 5.59 82.80 <0.001 34.77 4.57 20.10 5.50 82.11 <0.001 34.47 4.30 20.85 5.48 44.83 <0.001
IGDT-10 2.06 2.62 0.45 1.04 15.40 <0.001 1.49 2.34 0.36 0.88 11.97 <0.001 0.98 1.97 0.37 0.89 4.35 <0.001
BMI, body–mass index; IGDT-10, Ten-Item Internet Gaming Disorder Test; PMG, problematic mobile gaming; PMGQ, Problematic Mobile Gaming Questionnaire; SD, standard deviation.
 ASSESSMENT OF PROBLEMATIC MOBILE GAMING
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.
FIG. 1. The proportion of diagnostic positive group of
IGD and PMG in students who played both computer-based
and mobile-based online games. IGD, Internet gaming dis-
order; PMG, problematic mobile gaming.
with IGD and PMG. Our findings demonstrate that PMG and
IGD are not the same, and this result is consistent with studies
demonstrating an approximate overlap of 25 percent between
Internet and smartphone addiction.18,28 Diagnostic standards
of PMG and IGD are different, and no standard PMG diag-
nosis is agreed on internationally. However, the identical
optimal cutoff point of 29/30 is based on both PMG and IGD
criteria, which provides robust evidence that PMG is more
prevalent than IGD. In addition, the trends of PMG and IGD
were similar among adolescents in different age groups. Junior
and senior high school students were more likely to have PMG
and IGD than elementary students. The rapid increase in the
prevalence of smartphones and mobile games may have re-
sulted in PMG being more prevalent than IGD. The portable
nature of smartphones makes mobile games not only more
readily engaging for the general population but also more
accepted as a medium for social interaction in adolescents.
The PMGQ demonstrated the three-factor structure of
PMG. These factors, namely compulsion, tolerance, and
withdrawal, are the fundamental symptoms of substance-
related and addictive disorders in the DSM-5. The first fac-
tor, compulsion, explains the highest variance in the PMGQ
(54.4 percent), and the fact that these six items comprise half
of the PMGQ may suggest that compulsion is a core symp-
tom of smartphone addiction.29 The first two items with
highest factor loadings, playing mobile games for a long
duration and cannot resist swiping, resulted in excessive,
frequent, and short-period use. Considerable time spent
playing mobile and PC-based Internet games indicates
problematic use or addiction. Frequent and short-period
smartphone use interferes with the daily routine and thus
results in everyday functional impairment, which can simi-
larly be observed in all substance and behavioral addic-
tions.30 In addition, the cannot resist swiping question is
regarded as a central component of behavior addic-
tion.25These two items are fundamental for investigating the
nature of PMG and are preserved in the 4-item PMGQ-SF.
The factor, tolerance, which explains the second highest
variance in the PMGQ (8.1 percent), elucidates the different
roles of tolerance in PMG and smartphone addiction. There
are several arguments against the value of tolerance in the
667
assessment of smartphone addiction. The tolerance factor has
the most unstable structure with the lowest eigenvalue and
fewest items in both the SPAI19,24 and Smartphone Addic-
tion Scale.28 Previous clinical interviews revealed that tol-
erance had the lowest interrater reliability among all 12 of
the candidate criteria.30 Evidence suggests that tolerance
criteria have no bearing on smartphone addiction.25,27 In
addition, smartphones are rapidly becoming prevalent in
everyday life. Thus, an increase in the use of smartphones,
which could be viewed as the manifestation of tolerance,
may not necessarily be pathological; however, increased
mobile gaming may still be fundamental to this form of
addiction. These items that investigate the increased preva-
lence of mobile gaming are still valuable with respect to the
time course of PMG and relapse prevention beyond toler-
ance. The portability of smartphones might result in rela-
tively infrequent withdrawal symptoms related to mobile
gaming. The first two withdrawal-related items of the PMGQ
describe emotional states, namely restlessness, irritability,
and distress. Such descriptions are consistent with the find-
ings in a recent systematic review on IGD, which showed the
presence of emotional, but not physical, withdrawal symp-
toms.31 Both emotional and physical withdrawal symptoms
occur upon abrupt substance cessation.
No significant differences in BMI were noted between the
PMG and non-PMG groups of senior high school students.
The BMI-related difference in elementary school and junior
high school students was not clinically significant and the
average BMI was within the normal range. A cross-sectional
study in 2004 showed that the association between a high
level of mobile phone use and adolescent BMI was depen-
dent on different activities.32 Mobile gaming was associated
with increased BMI, whereas other activities were not.
Adolescent BMI was also associated with television viewing
and Internet usage.32 It is conceivable that sedentary activi-
ties increase BMI. However, with the evolution of smart-
phones, mobile gaming is no longer necessarily sedentary.
For example, the most popular mobile game worldwide in
summer 2016, Pokémon GO, was associated with a short-
term increase in daily physical activity.33–36 This related
survey was performed from August to October 2016, and
Pokémon GO had been the most frequently downloaded
game during this period.37 Players with PMG, despite
spending longer time playing sedentary, PC-based Internet
games, did not have an increased BMI possibly due to rel-
atively higher physical activities.
The proportion of children with myopia was not signifi-
cantly different between the PMG and non-PMG groups.
Viewing digital screens for long durations and at short dis-
tances are well-known risk factors of myopia in adolescents.
Recently, ophthalmologists have reported several cases of
people having the new visual symptom, transient smartphone
blindness, after looking at bright screens for a long dura-
tion.38–40 Longitudinal research is necessary to study visual
symptoms related to overuse.
Several study limitations should be noted when inter-
preting our findings. First, the cross-sectional design of our
study limited the possibility of making casual inferences
about the relationship between PMG and its health outcomes,
such as BMI and myopia. Second, all the participants were
adolescents who did not have PMG symptoms specific to
adult populations, such as distracted driving. Third, as an
 668
emerging addictive behavior, the diagnostic criteria of PMG
should be confirmed by international consensus. The issue of
whether the criteria of IGD should be modified for PMG
warrants further research. Finally, the assessment of PMG
was determined solely on the basis of participants’ self-
report questionnaires and responses to interviews. Supple-
mentary information or app-recorded data may assist in
confirmation of these symptoms27,29 and correct underesti-
mation of time spent due to the time distortion effect.30
In conclusion, the PMGQ identifies three constructs of
behavioral addiction and the characteristics of PMG. The
cutoff point determined by psychiatrists’ diagnostic inter-
views will be useful for conducting clinical screening and
investigating the prevalence of PMG in children and ado-
lescents. Future studies should explore cross-cultural char-
acteristics and the links to physical, social, and mental health
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.
outcomes of PMG.
Acknowledgments
The authors thank Taipei Computer Association ICT In-
dustry Policy & Law Center, Ms. Fu-Hua Yu, Ms. Zhi-Ni
Zheng, Ms. Yu-Chun Liu, Mr. I-Feng Huang, and Mr. Bo-Yu
Wong for their excellent technical assistance.
Author Disclosure Statement
The authors declare no conflicts of interest.
Funding Information
This study was supported by grants from National Taiwan
University Hospital (106-N3705) and National Health Re-
search Institutes of Taiwan (06A1-PHPP30-014).
References
1. Griffiths M. Gambling on the internet: a brief note. Journal
of Gambling Studies 1996; 12:471–473.
2. Potenza MN, Leung HC, Blumberg HP, et al. An FMRI
Stroop task study of ventromedial prefrontal cortical
function in pathological gamblers. American Journal of
Psychiatry 2003; 160:1990–1994.
3. Slutske WS, Eisen S, True WR, et al. Common genetic
vulnerability for pathological gambling and alcohol de-
pendence in men. Archives of General Psychiatry 2000; 57:
666–673.
4. Hodgins DC, Currie SR, el-Guebaly N. Motivational en-
hancement and self-help treatments for problem gambling.
Journal of Consulting and Clinical Psychology 2001; 69:50–57.
5. Petry NM, Ammerman Y, Bohl J, et al. Cognitive-
behavioral therapy for pathological gamblers. Journal of
Consulting and Clinical Psychology 2006; 74:555–567.
6. Petry NM, Weinstock J, Ledgerwood DM, et al. A ran-
domized trial of brief interventions for problem and path-
ological gamblers. Journal of Consulting and Clinical
Psychology 2008; 76:318–328.
7. Newzoo. (2017) 2017 Global games market report. https://new
zoo.com/solutions/standard/market-forecasts/global-games-
market-report (accessed July 31, 2017).
8. MIC. (2015) Taiwan mobile application market report. http://
mic.iii.org.tw/aisp/reports.aspx?id=CDOC20160225003 (ac-
cessed July 31, 2017).
9. Klauer SG, Guo F, Simons-Morton BG, et al. Distracted
driving and risk of road crashes among novice and expe-
PAN ET AL.
rienced drivers. New England Journal of Medicine 2014;
370:54–59.
10. Gilman L, Cage DN, Horn A, et al. Tendon rupture asso-
ciated with excessive smartphone gaming. JAMA Internal
Medicine 2015; 175:1048–1049.
11. Das DA, Grimmer KA, Sparnon AL, et al. The efficacy of
playing a virtual reality game in modulating pain for chil-
dren with acute burn injuries: a randomized controlled trial
[ISRCTN87413556]. BMC Pediatrics 2005; 5:1.
12. Haik J, Tessone A, Nota A, et al. The use of video capture
virtual reality in burn rehabilitation: the possibilities.
Journal of Burn Care & Research: Official Publication of
the American Burn Association 2006; 27:195–197.
13. Liu C-H, Lin S-H, Pan Y-C, et al. Smartphone gaming and
frequent use pattern associated with smartphone addiction.
Medicine 2016; 95:e4068.
14. Przybylski A. Exploring adolescent cyber victimization in
mobile games: preliminary evidence from a British cohort.
Cyberpsychology, Behavior, and Social Networking 2019;
22:227–231.
15. Godsell S, White J. Adolescent perceptions of sleep and
influences on sleep behaviour: a qualitative study. Journal
of Adolescence 2019; 73:18–25.
16. Davey S, Davey A. Assessment of smartphone addiction in
Indian adolescents: a mixed method study by systematic-
review and meta-analysis approach. International Journal of
Preventive Medicine 2014; 5:1500–1511.
17. Demirci K, Orhan H, Demirdas A, et al. Validity and reliability
of the Turkish Version of the Smartphone Addiction Scale in a
younger population. Klinik Psikofarmakoloji Bulteni/Bulletin
of Clinical Psychopharmacology 2014; 24:226–234.
18. Kwon M, Lee JY, Won WY, et al. Development and val-
idation of a smartphone addiction scale (SAS). PLoS One
2013; 8:e56936.
19. Lin YH, Chang LR, Lee YH, et al. Development and val-
idation of the Smartphone Addiction Inventory (SPAI).
PLoS One 2014; 9:e98312.
20. Király O, Sleczka P, Pontes HM, et al. Validation of the
Ten-Item Internet Gaming Disorder Test (IGDT-10) and
evaluation of the nine DSM-5 Internet Gaming Disorder
criteria. Addictive Behaviors 2017; 64:253–260.
21. Sigerson L, Li AY, Cheung MW, et al. Psychometric
properties of the Chinese Internet Gaming Disorder Scale.
Addictive Behaviors 2017; 74:20–26.
22. Pearcy BT, Roberts LD, McEvoy PM. Psychometric testing
of the personal internet gaming disorder evaluation-9: a
new measure designed to assess internet gaming disorder.
Cyberpsychology, Behavior, and Social Networking 2016;
19:335–341.
23. Lopez-Fernandez O, Männikkö N, Kääriäinen M, et al.
Mobile gaming and problematic smartphone use: a com-
parative study between Belgium and Finland. Journal of
Behavioral Addictions 2018; 7:88–99.
24. Lin YH, Pan YC, Lin SH, et al. Development of short-form
and screening cutoff point of the Smartphone Addiction
Inventory (SPAI-SF). International Journal of Methods in
Psychiatric Research 2017; 26:e1525.
25. Lin YH, Chiang CL, Lin PH, et al. Proposed diagnostic
criteria for smartphone addiction. PLoS One 2016; 11:
e0163010.
26. Billieux J, Van der Linden M, d’Acremont M, et al. Does
impulsivity relate to perceived dependence on and actual
use of the mobile phone? Applied Cognitive Psychology
2007; 21:527–537.
 ASSESSMENT OF PROBLEMATIC MOBILE GAMING
27. Lin YH, Lin SH, Yang CCH, et al. (2017) Psychopathology
of everyday life in the 21st century: smartphone addiction. In
Montag C, Reuter M, eds. Internet addiction: neuroscientific
approaches and therapeutical implications including smart-
phone addiction. Cham: Springer International Publishing,
pp. 339–358.
28. Kwon M, Kim DJ, Cho H, et al. The Smartphone Addiction
Scale: development and validation of a short version for
adolescents. PLoS One 2013; 8:e83558.
29. Lin YH, Lin YC, Lin SH, et al. To use or not to use?
Compulsive behavior and its role in smartphone addiction.
Translational Psychiatry 2017; 7:e1030.
30. Lin YH, Lin YC, Lee YH, et al. Time distortion associated
with smartphone addiction: identifying smartphone addic-
tion via a mobile application (App). Journal of Psychiatric
Research 2015; 65:139–145.
Downloaded by NATIONAL TAIWAN UNIV. HOSPITAL from www.liebertpub.com at 10/17/19. For personal use only.
31. Kaptsis D, King DL, Delfabbro PH, et al. Withdrawal
symptoms in internet gaming disorder: a systematic review.
Clinical Psychological Review 2016; 43:58–66.
32. Yen CF, Hsiao RC, Ko CH, et al. The relationships be-
tween body mass index and television viewing, internet use
and cellular phone use: the moderating effects of socio-
demographic characteristics and exercise. The International
Journal of Eating Disorders 2010;43:565–571.
33. Howe KB, Suharlim C, Ueda P, et al. Gotta catch’em all!
Pokemon GO and physical activity among young adults:
difference in differences study. BMJ (Clinical Research Ed)
2016; 355:i6270.
34. Xian Y, Xu H, Xu H, et al. An initial evaluation of the
impact of Pokemon GO on physical activity. Journal of the
American Heart Association 2017; 6:e005341.
669
35. Wong FY. Influence of Pokémon Go on physical activity
levels of university players: a cross-sectional study. Inter-
national Journal of Health Geographics 2017; 16:8.
36. Althoff T, White RW, Horvitz E. Influence of Pokemon Go
on physical activity: study and implications. Journal of
Medical Internet Research 2016; 18:e315.
37. Annie A. (2016) App Annie—the app analytics and app
data industry standard. www.appannie.com/cn (accessed
July 31, 2017).
38. Alim-Marvasti A, Bi W, Mahroo OA, et al. Transient
smartphone ‘‘blindness.’’ New England Journal of Medi-
cine 2016; 374:2502–2504.
39. Irshad F, Adhiyaman V. Transient smartphone blindness.
Canadian Journal of Ophthalmology Journal Canadien
D’Ophtalmologie 2017; 52:e107–e108.
40. Sathiamoorthi S, Wingerchuk DM. Transient smartphone
blindness: relevance to misdiagnosis in neurologic practice.
Neurology 2017; 88:809–810.
Address correspondence to:
Dr. Yu-Hsuan Lin
Institute of Population Health Sciences
National Health Research Institutes
35 Keyan Road, Zhunan
Miaoli County 35053
Taiwan
E-mail: yuhsuanlin@nhri.edu.tw