Thank you so much for coming. We are keenly aware that this is the absolute last session in the entirety of the APA annual meeting. So we appreciate you guys making the time. And if you have to catch a flight in the middle of it, no hard feelings, but I will remember your face. That's a joke. All right, technical difficulties thwarted. Once again, thanks for coming, everybody. My name is James Scherer. I'm an addiction psychiatrist at Hackensack, Moody, and Jersey Shore University Medical Center. We are here today to talk about diagnosing and treating internet gaming disorder. Again, thanks for being here. And if you were here at the talk last year, thanks for coming again. No financial disclosures from any of us. So let's talk about our agenda for today. So we're going to talk about the importance of treatment collaborations when it comes to really treating anything, especially something like internet gaming disorder, which really is inherently kind of at the intersection between addiction psychiatry, child psychiatry, community psychiatry. And that's why we have a combination of those psychiatrists on this talk today. So I'm a board-certified addiction psychiatrist. Dr. Ramon Silca here is not only board-certified in addiction psychiatry and addiction medicine, but also in child and adolescent psychiatry. He's an overachiever. And then we also have, Skyping, and we have Lauren Koska-Weiss. She's board-certified in child psychiatry. And Dan Weiner, who is the chief of behavioral IT at Hackensack Meridian and also has a private practice. So really, when we're thinking about how can we most effectively treat internet gaming disorder, especially those difficult cases, I think it really does need to be a collaboration between all of those different specialties and subspecialties, as well as with pediatricians, so on and so forth. We're going to talk a little bit about the unique nature of internet gaming disorder. We're going to talk about how we got here. And by that, I mean, how did video games become this giant juggernaut, this media sensation that everyone plays and can be quite addictive to some people? And then we're going to get into very specific practice recommendations with regards to screening, diagnosis, and treatment. This is really something. Internet gaming disorder is really something that should be of concern to all of us. If you crack open the DSM and you look in the back and you see internet gaming disorder, which is listed under their requires further research section, you'll see that the prevalence is estimated to be around maybe 1.5%, 2%. And there are other studies that, depending on the region, especially in Asia, that may be as high as 10%. So we're talking about a behavioral addiction which is hugely prevalent. And now you might be out there asking yourself, well, I don't see it. How can it possibly have a prevalence of 2%, much less 10%, if I am not seeing this in my clinic all the time? And really, the reason for that, and this is what I always say, is that we don't ask enough. I always make it a point to ask my patients if they play games. And you'd be shocked about the breadth and diversity of patients who will tell you, yes, I play. And a lot of those patients are going to tell you, yeah, I think I might be struggling with it a little bit. It cuts across socioeconomic strata. It cuts across age. While the bulk of the patients that we're going to be treating are likely children, because concerned parents are going to be the ones that bring them to us, it really is something that I've even had a 65-year-old who was addicted to Candy Crush. And it was a big problem and something we had to work on over the course of years of psychotherapy. Having a working understanding of what makes video game addiction an addiction versus what makes a video game addiction, or what's healthy engagement, what's normal use, is hugely important when it comes to differentiating a real case of IGD from what most kids are going to be experiencing. And to that end, in this talk, we're going to talk a little bit about, what are the new games that are popular? What should you be looking out for when you're talking to your patients about these things? And I'm going to try to show you, as best I can, maybe what internet gaming disorder looks like, although it's a very difficult thing to show. I think it's important to know that there's a lot of literature on this. There's a lot of effective treatments that have already been outlined in the literature, and we're going to go over those as well. Like I said, IGD does not fall neatly within any one psychiatric subspecialty or even psychiatry itself. It's not just a concern for child psychiatrists. The average age of a mobile gamer in the US is 35. However, in terms of IGD, the prevalence might be the highest in the 13 to 19 age range. And it's not just a concern for addiction psychiatrists, because there's a huge connection between things like IGD and ADHD. And that's been borne out in multiple imaging studies that show that in both IGD and ADHD, there are fewer connections between more cortical frontal areas of the brain and more deeper structures. And it's not just a concern for community or outpatient psychiatrists, because I have certainly seen on the inpatient unit severe cases of IGD usually comorbid with something like schizoaffective disorder, where I've had patients who spend their entire life I've had patients who spend their entire life savings inside of a single game. And really, when we're dealing with serious mental illness and people who are hospitalized, this is an easy way for them to really lose all of their life savings and, even in the case of this patient I'm referring to, cause homelessness. All right, so I've got two YouTube videos here. They don't have sound, so don't look out for sound. So by day, I'm the director of an addiction consult service. At a busy academic hospital, I treat, oh my goodness, what a Freudian slip, I teach medical students, residents, and fellows. And one of the common questions I get from all three of those trainees, those types of trainees, when they come to my service, where we're treating things like opioid use disorder, cocaine use disorder, alcohol use disorder, is they want to know what addiction looks like. They want to know what a patient with addiction looks like. Now, I was thinking about that question when I made this slide, and I don't know what internet gaming disorder looks like. It could look like this. This video on the left is the video of a troubled young man who had his gaming system taken away from him, and he's about to engage in self-injurious behavior. And certainly, if you are the parent of a child who's maybe struggled with internet gaming disorder, and you had to take the step of taking the gaming system away, you might have seen some sort of behavior like that. So internet gaming disorder might look like that. Internet gaming disorder might look like this. This is a shot from PAX 2023. PAX is the largest video game expo in the US, 60,000 to 80,000 attendees a day. And this is kind of descending into the show floor for that convention. And I want you to think about where you might have seen a scene similar to that, maybe in the last two seconds. And the reason I show that is so that I can explain that video games are this huge industry. Yes, there are people who play them too much, but it's also this huge professional industrial complex with conventions just like we have. And when you're going about treating this, you have to think about that. You have to think about, you're going to have kids, you're going to have patients who tell you, well, I can't be addicted because I want to grow up to be a video game developer. And so you're going to have to think about that type of response. And if you were nice enough to join us last year, you'll remember that I talked about this game, which was Elden Ring. This was like last year's kind of game of the moment. I'm going to have this playing so that you get a sense of the gameplay while I'm talking about it. Elden Ring is this huge open world action adventure game with a very steep difficulty curve. It's extraordinarily challenging but highly, highly rewarding. I speak from experience. I put probably over 100 hours into this game easily. This game, since it was released last year, sold 20.5 million copies. It sold 12 million copies in the first two weeks of its release. And assuming a sales price of $70, that's $1.4 billion, a single game. Now, if we take a look here about the how long to beat stats, which is a website that I'm going to teach you about in a little bit because it can be an excellent treatment aid, it'll tell you that if you're playing Elden Ring, it'll take you about 60 hours to beat if you just rush through. But if you want to do everything, see everything, beat every boss, be able to brag to your friends that you completely destroyed the game, you're going to invest at least 130 hours in this game. Now, let's talk about this year's kind of game of the moment, another one that I personally am enjoying. And I hope that you're getting a theme here. So I think the game of the moment right now is The Legend of Zelda, Tears of the Kingdom. You'll see a lot of similarities in the gameplay, but you'll see one big difference between this and Elden Ring. This is also an open world action adventure game. There's a huge more of an emphasis in this game on puzzle solving. And there's a building mechanic that's very similar to a game that you guys might be familiar with called Fortnite, which is probably one of the most popular games out there these days, that allows the player to address puzzles and address combat scenarios by building whatever you want. And you're seeing a little bit of that here. It encourages creative play. And again, I think it's a wonderful game, and I've already spent too much time in it. So let's talk about sales of this game, which came out on May 12th. Since this game was released in May 12th, well, actually, we don't know. But in the first three days it was out, it sold 10 million copies. It's the fastest selling Zelda game. That's $700 million in three days. And I think it wouldn't be outrageous to assume that if you take into account console sales and everything else, this game probably made Nintendo over a billion dollars in about three days. And just take a look here at the how long to beat stats. Again, if you really want to go for it, you really want to be able to brag to your friends and say that you did everything there is to do, you're talking 174 hours. And as psychiatrists, as child psychiatrists, what is that going to eat into? That's going to eat into sleep. That's going to eat into other social activities. And let's talk a little bit about how much does gaming actually cost. Well, it really depends. If you are the kind of gamer where you just buy a Nintendo Switch and then maybe you buy one or two games a year, it's probably not that expensive. Still, not nothing. The cheapest Switch costs about $200 these days. An average new AAA game from one of the big publishers costs about $70. However, let's say that you're into computer gaming, which a lot of the patients that I treat who do this are into because not only do they want to play the game and enjoy it, but they want to stream, and they want to become a popular streamer, and they want to learn how to code. So a lot of our patients are building these very fancy computers that I am envious of. These computers require various components, not the least of which is a graphical processor unit or GPU, a video card. Now, a standard video card can cost $300, $400, but you can also spend $2,000 on a video card, just one component of a machine that you'll use for gaming. A really premium gaming computer, maybe $4,000 or $5,000 more if you want to do something esoteric like liquid coolant. And all of that doesn't take into account the cost of microtransactions. We'll talk more about those in a second, but microtransactions are a way that publishers can extend your purchasing options into the game so that it's no longer you buy the game and that's the end of it. You've spent your money and you have the game. You've bought the game. You might have access to some of the game. And to unlock the game completely, you'll need to spend more once you've started playing. We'll talk more about that. So really, the price is difficult to quantify. I even tried, with the help of my wife, to quantify how much I spend on gaming in a year, and it was really difficult. And honestly, I have no idea. And she's pretty good with money. She's better than I am, and even she couldn't parse it, so who knows. But what we do know is that time is money, right? If a kid or a young adult who should be advancing in their career is spending too much time on this, it's obviously coming at the expense of their professional life. Let's go over this really briefly. I'm going to talk about the history of games and just give you kind of an idea of how we got here, as I said earlier. Since the 70s, game sales have skyrocketed. I just showed you two wonderful examples of that. Games are everywhere. Games are on the devices that we have in our pocket. Games are on the device that I'm using to present this presentation. You can't get away from them. And video games are more profitable than movies and sports combined, just to give you a sense of what a juggernaut this industry is. Video game sales in 2022, greater than $56 billion in the US alone. So let's talk about the video game industry over time. On the right here, we have kind of where we are now with a popular streamer. If you ever take the plunge and watch one of the popular video game streamer on Twitch or YouTube, you'll see that they often have colored hair and they have a really nice desktop computer. But we didn't start there. We started with the Atari 2600 back in the 70s. Over the lifetime of that console, about 30 million of those were sold. 1982, let's fast forward a little bit to the Nintendo Wii in 2006. That sold, at the time, an unthinkable 100 million units of a console. And now we don't really talk about gaming consoles as much in terms of sales as we talk about concurrent players for a specific game like Fortnite. Fortnite has, at its peak, it had about 350 players. And at any one time, there would be about 15 million people playing this game at once across the globe. I put this slide in just to give you guys a sense of how chimeric gaming is in terms of the industry and how big mobile gaming has become. And you can see that, most recently, mobile gaming at $85 billion really takes up the bulk of sales in terms of video games. And it's not just consoles. It's not just a certain type of game. It's everything. All right, very important to know that playing video games has tangible benefits that have been borne out in research time and time again. They can improve high coordination. They can improve visual tracking. They can improve multitasking skills. And they can even treat mental illness. For example, Endeavor RX is an FDA cleared app that is used to treat ADHD. And Lyft Now is a new app that was talked about at this conference to treat insomnia. It's a video game. Video games also serve, for a lot of our young patients, as the primary way that they are engaging in social networking. And this is for good and bad. It's easy to make and maintain friends if you have something easy that you can do every night, regardless of where they are. You don't need to go to their house. Even if you're on vacation, you can still play the game with them. But of course, some of the negative aspects of social media, which has been talked about a lot at this conference, are starting to creep into games, including a lot of toxic subcultures, because games really do rely on social networking. And along with that, we see a lot of social pressure to be good at games. It's not just the kid wants to play games. They want to beat their friends at the game. They want to surpass their friends in terms of skill. And the pressure for this is so much that there are tutors who will teach kids to play games and be good at games, just so that the kid can kind of have that social cachet and be able to say, I beat my friends last night. And video games aren't going away. They're going to continue rising in popularity. So I think this just goes back to the idea that this is something that we, as psychiatrists, regardless of our subspecialty, we should be confident in treating. We should be confident in identifying. And it's going to become an ever-increasing part of what we do. And of course, games are ubiquitous. And I'm sure at least one of you right now is, I hope not, but could be playing a game. And I would never know. I'll put it away. Thanks, Ramon. Because games are so ubiquitous, I really believe that a harm reduction approach is warranted here. If you just try to cut the cord, well, first off, you can't, because there's no cord to cut anymore. And secondly, you might run into a situation where a child or a young adult or an adult becomes acutely agitated, because there can be strong emotional withdrawal symptoms when games are taken away. And you also have to realize that if you were to do that and you were just to shut a kid off from games entirely, you are closing that social door. And you're making it much more difficult for them to socialize and make and keep friends. So let's get into the numbers a little bit more. There is a wonderful organization called Common Sense Media. I love showing their research in my presentations. And this one is no different. We're also going to talk about their website a little more in depth later, because they can be a huge resource for us. So this is just a chart that shows screen time, total screen time, among teens and tweens. And you can see year over year, the gray bar is 2015 and the green is 2021, which is the last time they collected data like this. You can see that in teens, average total screen time, over 8 and 1 1⁄2 hours a day. Now, for someone like me, that is no longer a surprising fact. Kids do spend a lot of the school day on a laptop. They spend a lot of the school day doing research online. But it still really is a staggering number. It's over half their waking hours, most likely, on a screen. So let's talk a little bit more about gaming specifically. And I think that the biggest thing here is to show that where kids are playing and how they're playing. So the data from 2021 is the best to look at. So mobile gaming is still going strong, but actually console computer gaming is even stronger in 2021 among older kids as well as younger kids. Play on a device, smartphone or tablet, is very popular. But a lot of kids are building those hyper-expensive gaming computers that I talked about. There's a lot of reasons why they may want to do that, as I discussed. But I think the real takeaway is that the average time of that 8 and 1⁄2 hours of screen time, close to two hours of that, especially in older kids, is probably gaming. And that's something that I think is going to be a big part of the future of mobile gaming. And that's split across various things, but mostly going to be on a console like the Nintendo Switch. We know that media use escalated incredibly quickly during the pandemic, and more than it has ever done, which makes sense. We were confined to our houses. Even those of us who maybe don't struggle with IGD, we're relying on games to give us back a little bit of that social structure we lost. Over 8 and 1⁄2 hours of screen time every day. Now, of those who play games, 60% of that time is on gaming. So that's a little confusing, given the previous slide, but I just want to emphasize that. If you have a patient who tells you that they play games and they're in the 13 to 18 range, about 60% of their screen time is going to be gaming. That's at least five or six hours a day spent on gaming. And mobile games are on the rise in tweens, and just generally video games are just on the rise in teens. There's a subset of gamers who play much more than even those numbers that I just described. Sometimes when I'm speaking with my older colleagues and I tell them, if you meet a child who plays games, it's likely that that child may be playing games for four or five, six hours a night. Sometimes they take a step back and say, that's impossible. I can't believe you. And then I tell them this, that 5% of girls, 14% of boys spend as much as 10 hours a day gaming. And in these patients, this is really the place where video games are really displacing healthy behaviors. They're displacing socializing. They're displacing exercise. And they're really becoming the center of our patients' lives. And some sources indicate that there is a, quote unquote, dose-dependent relationship between mood and gaming, i.e. the more you game, the worse you feel in terms of depression, anxiety, so on and so forth. This is certainly something that I see in my patients who struggle with this. If they have a period of time, maybe they go on a vacation and they don't have access to their Nintendo Switch. They might not connect the dots, but they might notice during that time their mood was much improved. And then they come back home, the Switch is there, they're pouring 10 hours a day into the latest Zelda, and they notice that they're a little more irritable, a little more reactive. I think it's very important to remember that we can't just take the hours spent gaming, however, and just take that and tie it directly to an addiction. This is a bit of a sticking point, and this is something that I think addiction psychiatrists generally accept, but is not generally accepted, I think, in our profession as a whole, and that is this. The majority of people who use anything don't qualify as having an addiction, even opioids. And I certainly think that's the case with gaming. The vast majority of people who play games are not gonna come close to qualifying as having internet gaming disorder. And you can't just take the sheer amount of hours and then just say, okay, this kid has a problem. You really have to be looking at the whole patient. You have to take the hours played in conjunction with are they performing in school, do they have friends, are they engaging in some extracurricular activities. If a kid is playing four hours or five hours a day of The Legend of Zelda, but they're also on the varsity soccer team, they also get straight A's, and they also got into their number one college, maybe that kid doesn't have a problem, even though five hours sounds like a lot. All right, do parents try to limit a kid's screen time? According to parents, they do. And they also say that it's a constant battle. But kids say even if their parents do try, it's not successful. And that isn't to say that we shouldn't be trying and you shouldn't be counseling your patient's parents to try to set limits. Dr. Solcott told me last night that limits are good all the time, and certainly we know that if the parent does not set limits, that kid's gonna play twice as much. All right, so let's switch gears a little bit and let's talk about adults. I already talked about how during the pandemic, gaming was a very needed and healthy social outlet. What I wanna say here that's very important is that when it comes to young adults, more than half of them who play games say they feel like they're addicted, which is pretty scary. And now, if you're a young adult, or any age, the average gamer spends at least eight hours a week playing. Men can spend up to three hours daily on weekends and holidays, and for women, it's a little bit less. It kind of reminds me of our recommendations with regards to alcohol use disorder. Now, when it comes to studies looking at kids and gender breakdowns in gaming, there is still a huge gender gap. When it comes to adults and older adults, that gender gap is starting to dissolve, and in fact, in older adults who play mobile games, it may be women who play more than men. Let's talk a little bit about why games are addictive. This is an easy question to answer, and the reason why games are addictive is because they're designed to be addictive, and this is coming from someone who's a passionate gamer myself. These big corporations that make video games, Microsoft, Sony, Nintendo, they employ behaviorists who, the second that they're on the payroll, have to sign a nondisclosure agreement that they will never discuss with press or with the APA the details of what they're doing and how they're programming these games, and that's why we don't, we're kind of behind the eight ball. We don't know what they know, because the developers and behaviorists who are making games are not the ones who are making games. The developers and behaviorists who are making games are keenly aware of what color is more likely to make you spend money in the moment, what sound is more likely to make you spend money in the moment. These are the people who are studying exactly how we're scrolling through Facebook and Twitter and learning about how to keep us scrolling ad infinitum, and these are really, this is knowledge that I don't think that we may never know, because these companies are very savvy about keeping it under wraps. One thing that's quite obvious if you play games is that really variable ratio reward schedules are heavily used. We know in the world of addiction psychiatry, I was attending a talk a few days ago about contingency management, and contingency management works best not when you're paid for clean urines, but when you earn a chance to get paid because of a clean urine, and that's what games do in spades. Games allow you the opportunity, the chance to get a certain item, but oftentimes you'll need to pay again and again and again or keep playing for longer and longer and longer to get that item, because you're never quite sure you're gonna get it. These companies have big research labs that look at every click we make and every movement we make, and they're logging all this data away. They have extensive Q&A testing. That's a huge part of the development process where they look at how human users interact with the game and how they could optimize it so that we play more. And games aren't, as I said earlier, games aren't just a one-and-done purchasing kind of thing. Now with microtransactions, games can change, they can evolve. A game like Fortnite, when it was originally designed, did not have the building mechanic in it. The company released the game, the game flopped, and then they changed it and they added in a new mechanic, which led it to become one of the biggest games of all time. There's a lot of cross-media integration with special outfits and guns and so on and so forth. I would be remiss if I didn't mention microtransactions and loot boxes. These are the ways that the game companies get you to spend more even after you've made that initial purchase. These are generally small purchases that can be made within the game that are usually for items that are purely cosmetic. For example, a different hat or a different outfit that your in-game avatar can wear. However, in some games, you can just buy the ability to win by having a better weapon, so on and so forth. As someone who has kind of been also one foot in the video game industry for over a decade as well, and I attend a lot of these video game industry talks and conferences and meet a lot of developers and interview them, I know that especially in the mobile gaming space, there is this concept of a whale. And that is to say that Candy Crush isn't developed for most of us. Candy Crush is developed for the one to 10% of players who will not be able to resist the urge to spend tens of thousands of dollars in Candy Crush. And really, when a game is being developed, those are the players that the game company is aiming to hook. And we'll play too. We might pick it up for an hour and then put it down. But really, the entire game is being designed for those quote-unquote whales. And as I said before, video games can use both fixed and variable ratio reward schedules, although variable is certainly the most powerful and more used in gaming, generally speaking. Another reason why games are addictive is because they have a huge opportunity to let our patients escape, escape from reality. This is where games kind of started in 87. This is one of my favorite game series, Final Fantasy. This is where they were in 1997 when I was kind of in the peak of my game playing. And this is where they are today. You can imagine how easy it is to escape into this world if you're unhappy with your life or you're unhappy with your social situation or home situation, how easy would it be to jump into that wonderful-looking fantasy city. Another reason why games can hook us is that they excel at keeping us in the flow state. Flow is a psychological concept based on the premise that our brains really like being challenged just a little bit, but not overwhelmed, and we really don't like being bored. So games develop challenges that keep us right in the middle. They teach us more and more and they challenge us more and more, but they don't overwhelm. They don't usually try to get us to the point where we're throwing the controller down in anger, but they're also not boring us. We're also not losing interest. And when you are kind of riding that line between boredom and anxiety and you're in the flow state, it's easy for those hours to just melt away. All right, so let's talk a little bit about the warning signs in kids. So these are the things that you all can look out for and might tip you off that maybe there's an issue. These guidelines and the recommendations that we're going to make were made largely with the ACAP SUD treatment guidelines in mind, but with our own expertise and experience kind of peppered in. So one thing that you really want to watch out for is rapid use of multiple substances with escalating severity. And again, this is language from the ACAP general guidelines. So if you have a patient who is playing games, trying more games, playing them for longer, they started with a Nintendo Switch, but very quickly they bought a PlayStation. And then very quickly after that, they bought a $3,000 computer. That is kind of rapidly escalating use. And that might be a bit of a warning sign. We have to keep in mind that the gateway theory of substance use really doesn't hold water these days. It really isn't true that, for example, cannabis use leads directly to alcohol, cocaine, opioid use. Now, is it true that all substance use disorders are highly comorbid with all other substance use disorders? Yes, but that isn't to say that one leads to the other. We have to watch out for significant acute mood changes. We also have to watch out for changes in cognition and behavior, right? Because games, as I mentioned, they do kind of excel when someone gets into them really deeply for the first time. Something that parents often most frequently notice is my kid's just irritable. You know, he goes from zero to 100 with like no warning. And that never used to happen. And then if you ask about video games, maybe there's more of that in the picture. Some behavioral changes, other ones that either parents or loved ones will notice, or even a patient will tell you about, more disinhibition, more lethargy. And this can be simply because the patient is, you know, staying up until 4 a.m. and then needs to still get up in the morning and go to work or go to school. Hyperactivity, this could be, as we saw earlier, when maybe the games are taken away, right? If you don't have something for the kid to pour their focus into, and we all know that ADHD is an inability to regulate attention, right? Not an inability to pay attention. If the kid doesn't have something to pour their attention into, all of a sudden those symptoms of ADHD and hyperactivity are unmasked and the kid's bouncing off the walls. Agitation, as we've described. Insomnolence, again. Hypervigilance is one that I have seen in very severe cases of internet gaming disorder, usually in comorbid SMI. It almost comes across as almost like PTSD symptoms, that when the patient is playing, they kind of get a break from those symptoms, but when the game is removed, that hypervigilance comes back. There can also be cognitive changes like impaired concentration, decreases in attention span. There can be perceptual disturbances. I have seen that in some severe cases. There can be delusions. I have also seen that. I've had young people who are having their first break, and while they were developing that break or while they were prodromal, they were playing more and more of maybe a violent game, and that violent game becomes part of a delusional complex. And also, we can see that when the patient's move starts to vacillate quickly, because when they're playing, they feel great, and when they're not, they feel horrible. Obviously, these are gonna change, and much like any drug, it's all about set and setting, right? It's about how the patient is using the game. So if the kid hears his parents argue and then runs to play the game as a coping mechanism, in five months, he may not be, he or she may not be able to play that game because they're going to associate that game with the parental disputes. However, if someone is kind of willingly choosing to spend their time and escape into a game and not using it as a crutch, they might have a very different experience. Let's see. So I really do think that you have to watch for when hobbies fall by the wayside. If it's a kid who's very talented in gymnastics, traveling the country to compete, and all of a sudden, they're not doing that anymore, they have no interest, they're not training anymore, and they also, you know, they've also been playing games, that's really when it's time to dig in and see, okay, when did the gaming behavior go up, and when did they decide that they didn't want to do the gymnastics anymore? These types of changes can include just general conflict or dysfunction within a family. It can include interpersonal conflict between the patient and friends. It can include academic failure, of course. And along with this, you may see increased risk-taking behavior, you may see new mood and anxiety disorders, you may really be appreciating the full extent of ADHD in the patient for the first time, and you may also notice certain learning disorders. It's not uncommon when it, with regards to any substance use disorder in kids, for them to develop these symptoms rapidly, more rapidly than an adult might. Like, we all know about type one and type two alcoholics, and there's a certain subset of alcoholics who just drink progressively, and over the course of their adult lives, over the course of 10 or 20 years, all of a sudden, it becomes a problem, but it happens very slowly. In kids, it can be like that. It's not uncommon to see a lot of spurts of heavy gaming behavior in a child, especially if their friends are playing that game, and it's also not uncommon for that behavior to trail off as they get into their late teens and as they go to college. It's also not uncommon for that gaming behavior to return towards the end of college and early adulthood. And as I say here, if that's the case, and if that problematic use does return, then their chance of actually developing IGD does go up big time. There have been increases in SUDs in kids recently, opioids, even LSD, and inhalants and steroids, and certainly, I think we have to consider gaming in there. All right. There are risk factors that are associated with developing internet gaming disorder. These are both genetic and environmental, as is the case with all substance use disorders. In general, the heritability of a substance use disorder, regardless of the type and including behavioral addictions, is about 40 to 60%. Now, that's a big ballpark, and that's a big generalization, but in some addictions, it may be much higher. In cocaine use disorder, for example, heritability in some studies is maybe 80%, but I certainly think that there is a heritable aspect to this, and it may have more to do with temperament than anything else. If you have an impulsive parent who has struggled with gaming in the past and has spent too much on it, it's likely that their kid may be the same, especially if they see the parent engaging in that behavior. And I think that generally, as I said, we have to take the entire picture of the patient into account when we're thinking about risk factors and seeing how we can help them best. The earlier they start, the earlier the problematic behavior starts, the more likely the child is to develop internet gaming disorder. As I said, temperament can play a huge role. Puberty itself, in many studies, is seen as a time when gaming spikes and may or may not return to baseline. In terms of developmental risk factors that have been associated with use disorders and internet gaming disorder, feelings of being invulnerable, issues with autonomy, peer pressure can be a huge one. And as we know, childhood sexual abuse and other adverse childhood events hugely predispose to all use disorders and behavioral addictions. Children are also very susceptible to media presentations of substance use and behavioral addictions, so the more that heavy gaming becomes socially acceptable, the more that kids are gonna think, well, there's no problem with this, everyone games. Early intervention can really go a long way. We know that programs like D.A.R.E. did not have the type of impact that we hope they might have when it comes to use disorders, but when it comes to internet gaming disorder, I think intervening early, identifying any comorbidities, adequately treating those, and getting the kid into treatment can be hugely beneficial. As with any use disorder in a kid, you can't really counsel them on the long-term effects because kids generally think they're invulnerable and they won't become addicted and they don't have that predilection. So instead, it's better to focus on the short-term things. Oh, if you're gaming too much and you don't exercise, you might gain a little weight, and how would you feel about that? And with that, I'm gonna hand it over with Dr. Soka, and he will go into our specific practice recommendations. Right, I think I can do it, yeah, I'll give you the clicker so that when we transition, so, that's good, yeah. So I'm gonna take the lead here in getting us into some of the impact of where we should be focusing our practice, and just summarizing some of the thoughts that we've covered already, right, we know that internet gaming disorder, IGD, is pervasive, anywhere between one to 10% of the general population, as Dr. Scherer said, certainly in that 2%, you know, I think in my practice, it's probably on the order of just about 5% that I end up coming across that as some aspect of a clinical issue. You know, I think that, given those numbers, right, it's not gonna be subspecialists who are able to take on the brunt of treatment, it's gonna be all of us together who are gonna need to be familiar with this and be able to manage that treatment demand. You know, focusing on these practice recommendations allow us to make sure that everyone in whatever type of practice are able to address this and, you know, certainly bring some of the basic skills, at least, into your practice. As Dr. Scherer said earlier, we've taken these practice recommendations and they've been developed starting with the ACAP practice parameters on adolescent substance abuse and then modifying them for the behavioral addictions. So, certainly, recommendation one here is observing confidentiality. Patients will be more truthful if they believe their information, at least detailed information, will not be shared. Whenever I'm doing an evaluation with a teen, right, I start that in the waiting room, in that discussion. You know, mom and dad, when I go back with little Johnny, we're gonna be talking about things that you would probably wanna know as a parent, but I'm not gonna come back and tell you them, necessarily, unless there are issues where I'm particularly concerned about their safety or other people's safety. Now, that being said, IGD, the family's usually aware of it in some way, right? They got that credit card bill that all of a sudden had that massive charge from the microtransactions, right? Or that Amazon package showed up with the new gaming computer, or whatever it is, right? So there's usually some trigger that the family's become aware of it. They may not be aware of the details, but they're certainly aware of, at least, that that's part of what's gonna be going on. Before the encounter, certainly review exactly which information needs to be shared and with whom, right? And there is certainly part of this that's been written about in the literature, that part of the attraction for gaming is not just the fact that there's the dopamine stuff that's going on from all the flashing lights and the action and all of those sorts of things, right? But it's a place where we have a little bit of control, right? We get to choose our name in the game. We get to choose our avatar skin. We get to choose the clothing that we're gonna wear. We get to choose the gender. So all of those things may be something that the child, the teen, may not want shared with the parent, and you have to be mindful of that, right? And the one standard that we follow is, of course, if there is any threat, then that's always gonna have to be something we need to be aware of. And then certainly if there is something that we're concerned about but is not rising to the level of where we're gonna break confidentiality, but that we wanna disclose that with the family, that's gonna be a discussion with them. We're gonna get their permission and we're gonna do that. And often what I'll do in my treatment is really role-playing some of that. Listen, we really gotta talk to mom about what's happening here, so let's role-play that. I'll be mom, you be you, or vice versa. I'll be you, you be mom. What are they gonna be? Some of those reactions that we're gonna expect, and let's work it through so we can try and get a sense of where that conversation is gonna go. So these are just general screening instruments for substance use problems in adolescents. All of them are great. I personally use the CRAFT. I find that the six items there are very easy to use, easy to remember. It doesn't take a lot of time out of the interaction. You can just Google CRAFT and go to the website and you'll be able to download them. They're nice and easily used in our Pediatric Psychiatry Collaborative in New Jersey. We use the CRAFT as our routine screening for addiction among teens and kids. Certainly you do wanna make sure that you're asking about legal and illegal use of drugs. A lot of kids, I'll start talking to them about melatonin and finding out when they're using that in inappropriate ways. Also now with the legalization states for cannabis and cannabis products, is that part of what you also have to talk about. I'm always amazed at kids who think that things are natural and that makes them okay. I remind them that so are sharks. So not everything that's natural is an okay thing to put in your body, right? And then certainly quantity, frequency, and one thing that's left off the slide here is history. So every once in a while I'll get myself into a trap. I'll ask someone, do you drink alcohol? They'll say no and I'll forget to go back and ask about historical use, right? And then 10, 15 minutes into the interview, find out that the reason that they're not using is because they had a problem three years ago and that they went into sobriety then. So making sure to ask historically is always helpful as well. So there are certainly lots of reviews here for us around IGD specifically. And there's this great review that goes into some of that. And I'd like you all to read this right now. I'm gonna read it in detail here for you. So just a reminder that there are lots of tools, as is true for most disorders that we have, right? Lots of screening tools that you could use. I'd recommend you look at a couple and sort of get your sense of what's comfortable for you to use, what's easy to use, certainly what's in the public domain so that you're not having to pay for that. Any of these are pretty reasonable to utilize as a screening tool. And I saw people taking pictures before, by the way. If you look in the app, the slides are in there so you don't need to, you'll have all of this as reference material for you when you leave here today. This is just a breakdown from that article just showing that the different scales and which components they're asking, right? So depending on what you're looking for in terms of escapism or other things, right? You're gonna find them there. Some of them are designed to meet particular criteria for either the DSM-5 research criteria or the ICD-10 code, so you can, excuse me, ICD-11 code, so you can also correlate it with that, right? So recommendation three, obviously, if the screen is positive, that's gonna lead you to go on to a full evaluation. As Dr. Scherer said, lots of kids are gonna come to you, teens, adults as well, and mention that they play video games. You're not gonna have to necessarily talk with any of them about this unless it's really that there's some screening that goes on that you feel is gonna lead you to further evaluate that, right? For me, the threshold is always if there's impairment in their functioning, right? So if they're getting into disagreements with their family, that's where you start having your radar get twitchy, right? Your antenna get twitchy to think about, I better be looking at this a little bit more deeply. Or if the school problems are developing, so a kid who was a straight-A student is now all of a sudden having academic difficulty. As James said, one of the most sensitive items for me is when they give up those after-school activities or those sports activities that they normally were heavily into and all of a sudden now, that's changed, or their circle of friends maybe has changed. So you can then use that to really go on and decide if you need to do a further evaluation. Most people, like James and myself, do not have a substance use disorder or a gaming internet disorder. I should say we just play the games for research purposes. Right, and these same behavioral things that we think of with other substance use disorders, other addictions, are likely true here for internet gaming disorder, right? So the desire to cut back, the thought that there's too much time being spent on that activity, failure to fulfill their role obligations, social problems, you know, we don't typically see the tolerance and withdrawal, right? We're not gonna see physiologic symptoms as much. Although certainly we'll see some of the psychological withdrawal, right? We saw that video where when the parents took away the video gaming, then there was certainly that withdrawal pattern that could be for just about any other substance, right? And then if some of those are present, right, mild, more of them are present, moderate, and then when you've got a serious amount of them, right, more severe. So these are just a reminder that there are two disorders that we typically think are pretty close to interchangeable but not quite, right? So if you do the ICD-11 codes, it's gaming disorder. DSM-5 codes, it's internet gaming disorder. If you look in the back of the DSM-5, as Dr. Scherer said, that's where you'll find the research criteria. So that tends to be the one that I use personally the most. And as is true with most substance use disorders, you need five of nine criteria in order to really make that diagnosis, and particularly within one year that those symptoms have been present. Because as Dr. Scherer had mentioned during the initial part, kids can go through some ups and downs. So when that Zelda game comes out and Dr. Scherer calls out from work so that he can play it in those first 48 hours or whatever else, right, that's where we're gonna think, but then maybe the week goes by and it settles down, but then after a couple weeks, he figures out there's some cheat or some other things, or his paycheck comes in, and then he's able to go and get the whatever, right? So you'll see that sort of cycle of ups and downs. The names have been changed to protect the innocent. So you'll see that ups and downs, and that's why we really wanna look at the time period over the course of those 12 months, right? And this is just, again, a breakdown of those differences between the two disorders. And again, if you're familiar with substance use disorders, the internet gaming disorder, it's just following that along. So some general keys here, right? Be non-judgmental, be flexible. You know, the last thing that you wanna do when you're trying to build trust and rapport with a patient who's dealing with a gaming issue is to wag the finger, right? And say, you shouldn't be doing that. That's what their parent has been telling them, or that's what their significant other has been telling them, right? If that was sufficient, they would have stopped already. So instead, it's about trying to understand it and using motivational interviewing as the framework, certainly a harm reduction approach. You do wanna get the family involved, because that's gonna give you the history and the sense of the scope of the problem, right? The kid's gonna come in and say, I don't have a problem. I'm only playing, you know, 20 hours a day. That's not a big deal. And my friends are, you know, having to drink Red Bull all the time to stay up all night and play those games, and I'm not doing that, so clearly it's not that bad. So you don't want just their perspective. You want the family's perspective, right? Again, patterns are really critical, particularly as was discussed earlier, right? The whole model has sort of changed over the past several years. So it's not just I've got my Xbox and I'm playing my Xbox, but it's the new game comes out. I get very involved with it. Maybe that tapers over a little bit of time. Then the next one comes out and I go through that cycle again. So there's definitely a pattern. There's definitely cyclical timeframes that you wanna watch and all of that, right? So using once, anything once, right? Even an opiate doesn't mean that it's an underlying use. As a adolescent addictionologist, certainly that's one of the things I'll get kids referred to me because the, you know, random urine test was positive that one time or the parents found marijuana that one time. That in and of itself doesn't mean that the kid meets criteria. And so it's the same thing with gaming, just because they have a problem that one weekend or for a week or whatever, right? It's the consistent pattern we're looking for. And then you do have to take into account what's the milieu? What are the kids involved with? And so certainly I've seen that a lot of families do Fortnite parties for birthdays, right? And so they're doing some of that. I've seen parents give, you know, the kids who attend, all of them, they get a gift card so they can all log in, right, and sort of play together. So you'll see lots of that. And that's some of the pro-social stuff that you do have to keep in the back of it, right? If this kid otherwise is not able to engage with his peers, his or her peers, but then they're able to do that in this event, you have to take that into consideration and figure out where does it cross the line between moderate use and then problematic use. And I think with a recommendation for her treat, I'll turn it over to my colleague, Dr. Kashka Weiss. All right. Lauren, if I may. Hi, everyone, can you hear me? Yes, we can hear you great. And what I'll do, Lauren, for you is I'll just make the whole slide visible and you just let me know when you'd like me to advance, okay? That's perfect, thank you so much. So I'm gonna move into treatment recommendations. So generally speaking, we look at substance use disorder treatment to be similar in kids as an adult and to be just as effective. So the longer the treatment relationship, the better the outcome. And I could certainly speak to that as a child psychiatrist who now has patients who are in their transitional age youth period. I've definitely seen many kids be successful, go on to college and unfortunately leave me because they go out of state. It can lead to a decrease in criminality and improvement in comorbid psychiatric disorders as we'll talk about with some of the psychopharmacology in a little bit, as well as the psychotherapeutic modalities. So the modalities with the most evidence are family therapy, cognitive behavioral therapy alone, abstinence-based therapy with motivational interviewing and community reinforcement with adding in contingency management. Likely in the future, we'll see more of that literature come out. Next slide. So the treatment goals according to ACAP, I will say, our practice parameters, unfortunately from 2005, I know they are updating all of the practice parameters to clinical practice guidelines. So they are working on this. Obviously the landscape of the internet and video gaming and internet gaming disorders is rapidly changing as you... The graphics are much more realistic than they have been when I was a child. And our treatment goal in children with regards to IUD is a harm reduction model. And we're looking at this as an acceptable interim goal because games really are such a crucial part of the social landscape as Dr. Sulco was just mentioning. I literally just had a birthday party for my six-year-old where we took them to the arcade on the boardwalk. Everybody got $25 gaming cards and the kids got to play video games with each other. That's what I've had kids do. Video game trucks, they are literally in this big bus and it's dark inside and there's multiple different video game consoles. And that's the parties that they all play on this bus together, right? So it is such a crucial part of a child's social landscape, it's not gonna go away. And so looking at how we can reduce the harm. And a lot of that is education and educating parents on the risks and educating caregivers on what are appropriate media boundaries, what are appropriate use boundaries, encouraging healthy behavior. If you get your homework done, you play outside most of the day, you eat dinner, you shower, okay, you can have 15 minutes on your Switch, right? But making sure, obviously, and I know my colleague will talk about MI, but kind of meeting patients where they're at and not coming off as being paternalistic with kind of rolling with their resistance and wherever they are, we can advance. Again, you wanna keep assessing what's going on and assessing functionality in an ongoing fashion, right? So just because use hours and things may decrease, it is possible that their overall functioning may not have improved, right? So you wanna make sure that you're not just assessing hours, types of games, and things like that, but also what their overall functioning looks like. Are they maintaining improvement and outcomes, whether that's playing sports, whether it's improved family relationships, whether it's improved... This is a model, we're looking at this from an addiction model with treatment and also relapsing and remitting symptoms. There's going to be setbacks, there's gonna be slip-ups, there's gonna be relapses, that's okay. And coming across as being accepting of that and in a non-judgmental fashion. So one of the things that you can have them do is track the number of days that they're using per month, just kind of as a basic metric. Again, similar to kind of how you would quantify use, but also making sure that you're following the overall outcomes and functioning. If they are involved in groups, which I actually haven't seen too much in the literature in terms of IBD, but what their engagement is in groups if they're participating in that type of treatment. And so you do really wanna come from a motivational interviewing perspective. Family involvement is key. I know I've had the tantrums where I went at my limits, I control the limits of my children, I control the switches. When that software gets shut down, I've seen them get thrown. I've seen the kids punch the pillows and punch the bed. And so you really have to involve the caregivers and provide psychoeducation and give them the skills to be able to handle these kinds of tantrums and outbursts when these things happen. If there are any psychiatric comorbidities or even medical comorbidities, these are things that you wanna look at and treat. You wanna encourage a pro-social behavior with gaming, so gaming together. One of the things, I have a personal switch and I have games that I can play with my children. Not that they're kind of locked in a room by themselves playing, but that they're playing together with the family, but also making sure too that they have great follow-up care. Next slide. Again, continuing to assess, I think is our take-home message here, right? And continuing. My son's eight, so this is kind of my first step into games with microtransactions and things like that. So this is kind of a new thing for us, right? And so make sure that you're constantly kind of educating yourself on what's out there and asking specifics. What games are they playing? Are they playing alone? Are they playing together? Are they playing on a new console? Did they get a new computer for Christmas? What did they want to use the computer for? Obviously peer support is important as well as 12-step facilitation for IGD, as well as any type of substance use disorder. And like we said, relapses and slip-ups are going to be par for the course. And it's not a reason to get mad or frustrated. Sometimes we do have patients that get down on themselves when they do kind of have a relapse or a slip-up and just kind of maintaining that supportive therapeutic environment is really beneficial. Next slide. So this slide looks at stages of a relapse. So what you may see first is kind of omno-emotional relapse, so isolation, less sharing of emotions, and then hedonia. Mental relapse for the second stage, right? So starting expressing that they want to play more and more. They might be going to these conferences. They might be hitting up the arcades more. There might be things that you may notice. Credit card bills may start to go up and things like that. And then the actual relapse where they begin to use again. And so it is difficult to watch, obviously, this occur. And so creating that supportive environment, not only for the person struggling with IGD, but the person who is helping navigate the situation. Next slide. Oh, and that's obviously very important at the end of the day. This is where the child psychiatrist piece really comes in, right? Is figuring out what the child's motivation is compared. And you have to remember, you know, the caregiver is the one typically bringing the child and occasionally you will have a child who says, yes, I want to go speak to a psychiatrist. I think I'm, you know, struggling with internet gaming disorder, but it's usually the flip side where you have the caregiver who has concerns. And so making sure that you are addressing both motivations in the room. So there are a few ideas to looking at relapse prevention and the five rules of recovery. I'm not gonna read them here just in the interest of time, but they are in your slide deck. So there has been a good bit of research actually into medications for IGD over the past few years. There's not a ton of rigorous, large-scale, randomized controlled trials. And there's a lot of these studies just looking at short-term effects of medication use. One of the biggest, or the medication that has the most literature is bupropion. So there's quite a good bit of studies out there, but there's also some good studies looking at acetalopram as well as stimulant medications and etamoxetine. So everything that I've looked at in terms of psychopharmacology for treating IGD has shown to be beneficial. But again, we don't have long-term, you know, longitudinal studies that can say, okay, these effects are maintained over a certain period of time. So we definitely need to continue our further research. Next slide. So there is one randomized controlled trial where they looked at, or there's actually, excuse me, there's a couple of randomized controlled trials. There's one for bupropion and there's one for acetalopram. Both of those RCTs showed that the medications were superior to no treatment. And another one found that bupropion was better compared to placebo for IGD symptoms. A study with a pre-test and post-test design for children with ADHD, but also then we're looking at internet gaming disorder symptoms, and we're able to find not only a decrease in symptoms of inattention and impulsivity, but also decreased amount of screen time online and hours spent online and video game usage. In head-to-head comparisons, they did not find any medication to be superior when looking at adamoxetine versus methylphenidate and another bupropion versus acetalopram. So they were all found to be superior and efficacious. Next slide. They've also done a ton of research looking at psychotherapy, and a lot of this is linked to the substance use disorder literature, but kind of now moved over to looking at the behavioral addictive disorders like IGD. And a lot of it is framed on reducing use rather than abstinence. So we know CBT is highly effective for reducing internet gaming disorder symptoms in the short term. It didn't reduce time spent gaming and the effects did not last beyond the initial treatment window. Standard CBT as well as CBT for internet addiction are both effective, and motivational interviewing has proven to be effective, although could be a slower process compared to CBT. So there, I know one of the studies I looked at, they're looking now at doing more further research with SSRIs as well as atypicals and stimulant and non-stimulant medications to kind of round out this section. So more to come hopefully in the near future. Next slide. Is this still me? I can't remember. Yeah. I'm up. Okay, I couldn't remember. No. I'm going to pass it on to Dr. Weiner. Thank you. Hi, everyone. Can you hear me okay? We can hear you fine, Dan. Thanks. Excellent. So, you know, as we move into talking about psychotherapy, you know, family therapy is critical to the success of treatment for adolescents with substance use disorders and likely the same for internet gaming disorder, and we're going to talk kind of about some of those similarities and things. Network therapy is one evidence-based treatment we have to address IGD and SUD in adults, and we're going to talk about that briefly. I'm going to put Dr. Sher on the spot for that one. You know, parental family network issues can impact treatment outcomes, and we know this, right? If a family member is also dealing with the same issue, if they also have an issue with an internet gaming disorder, or if there's a substance use issue, right, that increases the likelihood that our patients are going to be struggling with that as well, and it's going to be harder for them to get better if the behavior that's being modeled in their family system is also addictive in nature, right? And then, of course, there's the concern about, you know, poor parenting skills. If the child has, you know, low support from their family members, if there's poor communication or poor supervision, these are all things that we want to think about, not just the individual that we're treating, but the entire system around them. And, of course, we all think that way, but that's really important to point out when we're trying to treat these things, because it isn't just the burden of the individual, it's the entire system that we want to be keeping in mind, and we want to always be thinking systemically, right? And to that end, right, what's good about thinking this way is that when we hear about things like insufficient parental monitoring, and we know how advanced adolescents are in terms of technology use compared to us, and they're able to run, you know, circles around us in terms of what they're doing with it, and get around any controls we try to put on them, right? So when that happens, it's an opportunity for intervention. We can have a place where we can move into things, and if we see that the discipline isn't working, because it's probably not working, that also provides us an opportunity to take a step back and say, let's try something else that we think will be more effective, all right? Next slide, please. So the modalities that are available, they all have common goals, and we're going to go through some of the modalities briefly in a bit, but, you know, the common framework is we're going to assist families to initiate and maintain treatment to help provide that support to the system around the individual. We're going to help reinforce the importance of reducing that problematic use. You know, if mom and dad or mom and mom or dad and dad don't see this as a problem, but they're seeing the other symptoms of it, they're seeing the irritability, they're seeing the withdrawal, they're seeing the pulling out of school activities and things, if they're okay, oh, well, you know, it's fine that they're playing these video games, that's going to be an issue. So reinforcing that and helping them bring that to the table is important. We know how important structure is for all of our patients and for all of us, and helping the family system provide that structure with things like limits editing and monitoring and working on those communication skills is important. And, of course, if we identify other family members that need treatment for whatever issue, probably less likely to be internet gaming disorder as well, although certainly possible, but if we know that the family members need treatment themselves, that's an impact on the family system that needs to be addressed. So next slide, please. So I want to go through a couple of these. I'm going to go through them fairly briefly because they do have many things in common, but, you know, per ACAP, functional family therapy is a therapy that was really created for individuals ages 11 to 18. It's a short-term therapy for those who are at risk for behavioral problems, and the idea was to help family members support the needs of the individuals and support those relationships that are healthy. So that's one option. Brief strategic family therapy, this actually comes out of the University of Miami. It was about 1978. They were looking at Cuban families, and they were trying to look at changing patterns of interactions within the family system with families that had very close ties to each other in order to try to improve outcomes. Multisystemic therapy was really built originally for juveniles in the criminal justice system with criminal offenses to help kind of foster success and recovery and teach families how to create those. Family systems therapy, it's amazing how similar a lot of these sound, was a framework centered around dealing with youth, the parents, the family, and then the community and looking at all four levels and how support can be provided. And then multidimensional family therapy was another system to try to go and try to help provide that kind of network level effective things. And then of course CBT and motivational interviewing, which I'm not going to provide details on CBT here. I think hopefully we're all comfortable with that idea. But again, a lot of these systems are kind of flowing through cognitive behavioral therapy being part of what informs these, but then bringing it not just to the individual, but to the entire system that we're seeing as well in a variety of different ways, manualized or not manualized. Another option for adults is network therapy. This is work that Mark Galanter is doing up at NYU, where there's this clear delineation of therapeutic roles. Family members and other support individuals are brought into session in order to provide support for the family. And it's very clear what they're able to provide in terms of support and what they're not supposed to do because it won't be helpful for them. This idea of non-judgmental roles that we don't want family members providing judgment, that we want them to be supporting the individuals as much as they can, and having this involvement of them in the actual therapy at the therapist's discretion based on who they think is appropriate, bringing those people in to be part of this discussion and part of this system. And then Dr. Sherrison, my understanding is you work with Mark Galanter. I just want to let you add in anything you want to add. I'll just add one thing really quickly. So I think the power of network therapy is its ability to remove judgment from the family or network internally. So network therapy is a very easy way. Let's say that you have a patient who really shouldn't be playing any video game or maybe shouldn't be playing a specific video game like World of Warcraft. A classic network therapy intervention would be for you as the therapist to see the patient and maybe the mother and father, and you tell the mother and father, all right, if he plays World of Warcraft, I want you to tell me, and I want that to be the only thing that you do. I don't want you to stop him from playing, I don't want you to judge him for playing, I don't want you to condemn him for playing, but I do want you to let me know, and then in our next session we'll address that. So that's really the power of network therapy. It allows you to be in the know, and it prevents the family from maybe unintentionally kind of reinforcing this bad behavior. Thank you very much. And then of course, yeah, so next slide. Thank you. No, you're good. Sorry. Too much. There we go. Thank you. So, you know, whether we're dealing with children or adults, whether or not we're talking about substance use treatment and gaming disorder treatment, the best predictor of outcomes is whether the patient remains in treatment, of course. And the longer, the better, and I think that's obvious. You know, part of it is when there is this backsliding, when people do have relapses, it's important to keep them engaged in treatment and try to set an expectation. Look, with younger individuals, it's okay that you tell me this. That means that we are going to work together to move forward. One of the things I like to do with my patients is say, look, we're going to try an experiment. We're going to see what happens. There's no judgment here. If the experiment works and you get an outcome that you like, that's great. If it doesn't work, we can try something else. But a lot of times there's so much shame involved. There's so much self-blame that that can interfere where people will just stop showing up rather than come in and say, look, I screwed up. So, and even that terminology, screwing up, is part of it, right? So, if we can think of it in this non-judgmental way to say, look, we're going to go and we're going to keep moving forward. Things happen, but we're going to move forward. By the same token, we have to remember there's always that dialectic with, you know, if you screw up, we're going to move forward, but you can't use that as an excuse to say, well, my therapist said it was okay if I go and I relapse again. That's not what we're saying, right? And I always make sure that I make that clear to patients. I try to do it in a humorous way so that maybe when they are getting to that point, they do remember it, right? And again, working that into the treatment plan can help expecting that we're going to be two steps forward, one step back, one step forward, two steps back. But the goal ultimately is over time and with engagement, getting people to move forward, right? And motivational interviewing, of course, can help in this regard, as can the families and the social systems. And as Dr. Sher's example provided, right, that's the whole point of involving these. And I think that's why with all of these different systems that sound very similar, a lot of it is about engaging the families and the individuals, not just the person who's dealing with the thing. Next slide, please. So, let's take a quick sidebar. We're going to talk about motivational interviewing for Internet Gaming Disorder. So, psychotherapies specifically designed for technological additions like CBT-IA can be powerful tools. CBT for Internet Addiction was that work that was done originally by Kimberly Yang. It was originally published in January of 2011. The idea is you had these kind of three phases of CBT-IA. The first phase is kind of working on behavior modification in order to reduce the amount of time that's being spent on video gaming. The second thing is to be doing cognitive therapy to kind of address kind of the thoughts and cognitions that are going on in order to try to deal with that. And then the third thing is looking at it from then a harm reduction standpoint, acknowledging the fact that in the modern day and age, we can't tell patients to abstain from the Internet. It's not going to happen, you know. What we can do is say we can use this more appropriately. I think the analogy to me is more thinking about food addiction compared to cocaine addiction, right. One of them you can say never use it again. We can't tell our patients with a food addiction problem you can't ever eat again. And I think it's important to acknowledge that our lives in these days, with the exception of, you know, certain people living in certain places, is not going to happen. They're going to have to be online. So, we need to figure out how they can make that work despite what's going on, right. And that's to that point, right. They're so pervasive that harm reduction and early engagement treatment are important, right. Motivational interviewing, it's all about ambivalence. I would argue all psychotherapy is about ambivalence, but motivational interviewing really is designed to work despite that ambivalence that the individual is feeling. And so, this is something that might really be useful for helping reduce the game playing. Maybe we can get them to reduce it, but maybe not stop it. But certainly, we can try to get them to not engage in some of these behaviors, especially in kids where they're doing it at the expense of everything else they should be doing as they're growing up. Next slide, please. So, motivational interviewing is this collaborative, oops, sorry, too fast, goal-oriented style of communication where we're looking at the language of change, right. And this is work that Miller and Rolnick did. It's this guiding style that's between listening and directing. But a lot of it is listening, not just listening for the sake of listening and not saying anything, but then gently guiding people to where you think it would be appropriate to go, right. It's designed to empower the patients. We're not telling them what to do. We're guiding them. It's that leading to water kind of an idea. And there's respect and curiosity on the part of the provider, right. When you're doing motivational interviewing, your job is to to be interested in what's going on. We think about for how many years physicians have told patients, you got to lose weight. And we see how well that has not worked, right. So, being curious, listening, having that conversation. As psychotherapists, we have the time and the luxury of being able to do this with our patients. So, let's do it, right. And having this conversation about change. Next slide, please. So, here's a question, right. Can this work for IGD? If you just want to stop there, Dr. Sherwood, thanks. So, NIA is evidence-based for lots of use disorders and behavioral addictions. It's widely applicable. I did a quick PubMed search of motivational interviewing for just that phrase. And I found smoking, cessation, substance abuse, medication adherence, cannabis use disorders, treatment success in TB patients, maternal immunizations. Keep going, please. Weight management among women. Keep going. Recovery after stroke, prevention of alcohol misuse, HIV-related behaviors, improving periodontal health, et cetera, et cetera, et cetera, right. So, the point is, this was just me spending a couple minutes on PubMed and finding things that motivational interviewing has been used for. There's a lot here. So, can it work for IGD? Why wouldn't it work for IGD? People are studying it for everything. If you want to go to the next slide, please. So, again, this underlying spirit is providing the presence and attention of the provider. It's this partnership where I, as the therapist, I'm an expert in helping people change, but the patient's the expert on their own life and what they're going through. And as someone who I don't think has an intranet gaming disorder, I'm not really much of a video gamer. I'm not really much of a video gamer. This is something where I don't understand where they're coming from. But part of the curiosity there is learning what life is like for that individual and trying to understand that, right? This idea of evocation, that people already have the tools within them to change, and MI draws out the priorities, values, and wisdoms based in experience. To me, that's very much like Yalom's idea of a patient being a tree, that its natural process is to grow, and that our job as the therapist is to move the rock out of the way that's stopping the tree from growing. So I love this idea that patients have tools within them to change. And, you know, in motivational interviewing, in the big book, they talk about this idea that people spontaneously get better sometimes without any intervention. Our job is to provide an intervention for the people who don't spontaneously get better because they're not in treatment, right? Acceptance is that idea of being non-judgmental and don't approaching the encounter with an agenda. As I mentioned, we have a lot of failures from, you shouldn't do that. We know how well that doesn't work. And then there's this idea of compassion. And, of course, in any psychotherapy, I hope we're being compassionate towards patients. Next slide. So OARS is, this is MI101. MI likes acronyms a lot, by the way. But we're going to ask open-ended questions. We're going to use affirmations to help support the patient. We're going to reflect back on what we're hearing. And then we're going to summarize. And these are the tools that all psychotherapies should be using, right? But we're also going to, within that context of doing a psychotherapy, attend to the language of change. We're going to hear change talk. And we're going to try to reinforce that. And we're going to hear patients saying things that are about not wanting to change or keeping things the way they are. And we're going to want to maybe draw attention to that as well to figure out how we can move from one to the other. And exchanging this information, right? I'm an expert on behavior change. The patient's the expert on what they're dealing with. Next slide. So again, we'll just start moving quickly because I know we're getting short on time here. We want to make sure that MI is engaging. Just want to note, please avoid the self-disclosure trap that, you know, you don't want to disclose if you aren't trained as a peer recovery specialist. And especially if you don't know anything about video games, don't start talking about them like, oh, I play games. Don't go there. Keeping things focused in terms of having an agenda that's negotiated. I always like to start off by asking what the agenda is for the day. I find that helpful. Evoking that why of what's going on and normalizing that ambivalence. Because for a lot of people, it's uncomfortable, of course. But it's important for them to know that this is a normal experience that we all experience. And then kind of that planning part of it, and we're going to show a tool in a minute, of how to get to that change, right? So if you go to the next slide. So here's the decision balance sheet. It's basically a cost-benefit analysis where we're going to go and we can say to a patient, look, you know, if you want to cut down on your internet gaming use, you know, what are the disadvantages of not changing? What are the advantages of it? If you were to cut down by 20%, 10%, 5%, what are the disadvantages of that? What are the advantages? And start to evoke that, and listen, and be curious, and see, and really let them come to their own conclusions about it. And drive things in such a way that that makes sense. And then that readiness rule, right? Asking patients to quantify their readiness to change and defend their position from zero to 10. You know, how much are you thinking about wanting to change? Where are you right now? Have the conversation. Go through the decision balance sheet, benefits, cons, and then say, you know, where are you now? Are you motivated? You know, and if you're not, all right, then we can keep talking. Next slide. So just a couple of other things, right? Remember the setting that you're in, please. You don't want to be sitting in front of a computer typing into it if you're trying to do motivational interviewing, or I would argue any type of psychotherapy, please. We want an environment that you can have this conversation in. It's hard to do this in an emergency room when you're standing and hovering over a patient in a bed in a hallway, right? So sometimes we may try to do things even in those moments, but let's be honest about how effective it's going to be versus being in an office with a patient where you have the time to actually talk to them, or in a room with a patient where you can talk to them, right? We talked about MI not being just for substance use, right? Within psychiatry, we use it for SI, we use it for compliance, other things. We went through those slides. MI is really about reinforcing what you probably already know as a psychotherapist, so it's something that a lot of us are doing in different ways, but this packages it in a way that it can be really useful, and since I'm speaking to an audience of psychiatrists, I think that this is something that adds to what we're doing. I don't think it's learning a whole new style of psychotherapy, and then the final thing is just remember this is, you know, leave what you want for the patient at the door, because if you tell the patient this is what I want to do for you, it's not going to help that change. It's not going to encourage it. All right, next slide. So just our final recommendation, number seven, is to be comprehensive, encouraging those new peer relationships. Remember people, places, and things, so if all your friends are dealing with internet gaming disorder and they're on their computers all the time, maybe we need to think about, you know, are there other peers we can have that aren't doing this, who are doing other things. 12-step programs, I wanted to point a shout out to Online Gamers Anonymous. They have a website and have virtual meetings that can be attended. We want to make sure we're treating the overall patient, making sure that we're not just dealing with this one focus, that we're looking to their medical needs, their legal needs, vocational needs, all of that, because they're a whole person, and if all of those are not where they need to be, this is going to be even harder to treat. And then of course comorbidities, don't forget that, and then of course, you know, aftercare options. What happens after they stop working with us or they leave the environment that we're treating them in? How do we still continue to provide them with support after they're no longer under our care? All right, thank you guys so much. Real quick, I know we're out of time. This is going to be the most useful thing that I'm going to do. I had this workshop, we're not going to walk through it, but this is like the classic question that a patient's parents will give you. My kid wants these three games. Which of these games is the least addictive? I get this question a lot. When I get this question, I have the luxury of kind of being in this world and I kind of know these games. If you are not that person, here's what you do. You go to two sites. You go to howlongtobeat.com and you go to commonsensemedia.org. I'm just going to show you in two seconds what it looks like. Let's take a game like Legends of Zelda Breath of the Wild. Let's go to the Common Sense Media website for that, and I'll just show you. Here's the game. You can search for the game up on the top here. You scroll down. It has scores on educational value, positive messaging, positive role models, ease of play, violence and scariness. Parents need to know, so keep that in mind. The other thing is howlongtobeat.com. I talked about this earlier, but this is just a way where you can literally see, okay, if I buy this game for my kid and let's say they really go hog wild with it, I can expect them to lose 190 hours of their life to this game. So maybe this isn't the best one to choose. That's it. I'm so sorry we went a little over. They probably want us to get out of here, but if you do have any questions, I'll be here, so feel free to come up and ask. Thank you all for staying. I really appreciate it. Thanks, Dan and Lauren.

Internet Gaming Disorder

DSM-5

addiction psychiatry

behavioral IT

ADHD

cognitive behavioral therapy

motivational interviewing

Candy Crush

Elden Ring

The Legend of Zelda

Common Sense Media

HowLongToBeat