Problematic gaming is often recognized in clinical practice, but can be challenging to treat. Here’s what you can do.
“It didn’t work,” announced Eric’s exasperated mother. “He’s still up all night and won’t go to school in the morning.”
Upon learning that the 16-year-old boy regularly played Fortnite in his bedroom until 4 AM, Eric’s psychiatrist had recommended removing the gaming console from his bedroom. “I’m sorry to hear that. Do you know what’s keeping him awake now?”
Eric’s mother was quick to reply, “Sure. Now he stays downstairs with the gaming console all night and never sets foot in his bedroom.”
A substantial body of literature demonstrates how excessive habitual video game play can develop into an impairing disorder.1 Problematic gaming is often recognized in clinical practice, but can be challenging to treat. Clinicians can start by educating families on how video games interact with the brain’s reward system, making it difficult for some to disengage. Gaming grants players immediate gratification, mediated by an abnormal surge of dopamine in their neural reward pathway.
The ultimate goal of treatment is to find a balance between “high-dopamine activities” (HDAs) and “low-dopamine activities” (LDAs). HDAs include behaviors that are instantly and continuously rewarding such as video gaming, streaming videos, and scrolling through social media. LDAs, on the other hand, are characterized by delays and require patience; some examples include bike riding, painting, and practicing a musical instrument.
Although some activities fall somewhere in the middle, encouraging families to dichotomize hobbies as HDAs or LDAs allows the creation of a schedule that prioritizes dividing time between both.
Problem gamers, desensitized by continuous exposure to HDA surges in a state of reward deficiency syndrome, lack the capacity to experience pleasure from LDAs and typically reject plans for moderation.2 It is quite difficult for those accustomed to HDAs to disengage, leading to contentious confrontations with parents attempting to enforce limits. For such patients, turning off their console after an hour of gaming is akin to individuals with alcohol use disorder trying to stop after 1 drink. Going directly from excessive use of HDAs to a balance of HDAs and HLAs is therefore challenging.
Although complete abstinence can interrupt and prevent the cycle of addiction, abstaining from all screen media is increasingly infeasible, given our growing dependence on the many useful functions of screens, many of which qualify as LDAs (eg, writing and completing homework on computers, writing and sending emails).
A period of temporary abstinence from screen use is often both feasible and necessary to subsequently achieve balanced use. Similar to cases of drug addiction, a period of abstinence may be accompanied by the restoration of postsynaptic dopamine receptors, providing temporary relief from both reward deficiency syndrome and cravings for HDAs such as gaming.
Inpatient programs and residential treatments that disallow screen use provide ideal settings for abstinence, but typically fail to include a necessary follow-up period during which screen media is reintroduced in a controlled manner. Therefore, problematic gamers who detox in inpatient settings and are discharged without sufficient follow-up care typically relapse, similar to those who detox from substances of abuse.3
Eric struggled with excessive gaming and attention-deficit/hyperactivity disorder for years. He gamed after school until late at night, neglecting homework and acting out aggressively toward his parents when they attempted to get him to stop. At times, he even threatened to harm them or kill himself. During 1 such confrontation in the spring, he punched a hole in the wall and was subsequently referred to psychiatry.
His parents agreed to take a weeklong, screen-free camping trip. The change of scenery supported structured LDAs with no access to screens. The results surprised everyone:
Years of experience by the authors prescribing dopamine detoxes have yielded a remarkably consistent marked reduction of game-seeking behaviors and gaming withdrawal symptoms. Most cases have taken only 3 days to produce this result. Therefore, 3 days is the minimum length of detox—a sufficiently ambitious goal for many families. Screen-free summer camps, family vacations, and other structured activities have proven to be excellent tools for families planning a dopamine detox.
Dopamine detoxes not only help patients, but also improve the alliance between prescriber and parents, as well as parental compliance. Parents are often amazed by the results. The detox seems to reset the reward system of the brain and to set a perfect groundwork for introducing a more balanced lifestyle.
However, a return to the same environmental cues (with similar unfettered screen access) typically leads to relapse. A period characterized by careful regulation of screen media use provided by caregivers is necessary before the desired self-directed balance can be achieved. Digital detox is, therefore, the first in a 3-phase recovery plan, with the second phase being balanced use with external support and the third phase being self-regulation.
As the demand for gaming disorder treatment for teenagers continues to soar in the wake of the pandemic, clinicians have many opportunities to practice its use. See the Table for tips on executing a dopamine detox in your practice.
Six years following Eric’s digital detox, his mother gratefully reports that Eric has continued to find passions outside of gaming, achieved academic success, and earned admission into law school. We project that scheduling LDAs will not be a challenge for Eric going forward!
Dr Sussmanis a child and adolescent psychiatrist who has been in private practice in Washington DC since 2008. He is an expert on internet and video game use disorders whose work has been featured in The New York Times, Parents Magazine, and TIME Magazine for Kids. He was recently a guest on the NPR show 1A. He is dedicated to helping individuals achieve a more balanced relationship with digital technology through his clinical work and frequent presentations and trainings for parents, teachers, students, and mental health clinicians. He also serves on the volunteer clinical faculty at George Washington University School of Medicine.
Dr Weigle is associate medical director at Natchaug Hospital of Hartford Healthcare and assistant professor of psychiatry at UConn School of Medicine. He serves as cochair of the American Academy of Child & Adolescent Psychiatry’s media committee, and on the National Scientific Advisory Board of the Institute of Digital Media and Child Development. He lives in Mystic, Connecticut, with his wife and 2 teenaged social media enthusiasts.
1. Sussman CJ, Harper JM, Stahl JL, Weigle P. Internet and video game addictions: diagnosis, epidemiology, and neurobiology. Child Adolesc Psychiatr Clin N Am. 2018;27(2):307-326.
2. Gondré-Lewis MC, Bassey R, Blum K. Pre-clinical models of reward deficiency syndrome: a behavioral octopus. Neurosci Biobehav Rev. 2020;115:164-188.
3. Tao YJ, Hu L, He Y, et al. A real-world study on clinical predictors of relapse after hospitalized detoxification in a Chinese cohort with alcohol dependence. PeerJ. 2019;7:e7547.