Prevalence and Prediction of Video Gaming Addiction Among Saudi Adolescents, Using the Game Addiction Scale for Adolescents (GASA)

Background

Video gaming (VG), also known as digital games or e-games, has various definitions, and several scholars have conceptualized the term from different perspectives. Some conceptualize VG as a technological platform that requires a set of audio-visual materials and specific technical connections, such as a television set, a computer, tablet devices, or mobile phones.^1,2 Others conceptualize VG as a rewarding and enjoyable technique that uses a motive approach for physical and psychological engagements that enhance cognitive and psychomotor skills.^3–5 Depending on the players' interests, adolescents play VG for several reasons, including adventure, action, wrestling, racing, role-playing, and simulation.^3–5 However, Brock and Johnson(2021)⁶ claimed that beyond playing for enjoyment, adolescent gamers view VG as a craft-consuming activity that derives “material consciousness as they rehearse actions to achieve goals”.

The global pooled prevalence of VG addiction ranges between 1% and 9%.⁷ According to Stevens et al, the global gaming disorder is 3.05%.⁸ The prevalence of VG addiction varies from one country to another because of social aspects differences, and it depends on the assessment tools that have been used to measure the addiction. For instance, the prevalence of VG addiction among adolescents in Europe ranged between 1% and 15%^9–12 In the United States (US), it ranged from 3% to 8.5%.^12,13 However, it was highest in the United Kingdom (UK) and Iran, reaching approximately 14% and 17%, respectively.¹¹ In Saudi Arabia, previous studies in different regions reported a prevalence of VG addiction among Saudi adolescents that ranged from 3.5% to 62.1%.^11,14–18 Different methodologies used to assess the prevalence of VG addiction might influence the difference in these figures.

Cultural differences play a significant role in shaping behaviors and attitudes toward gaming, including addiction.^19,20 Cultural attitudes towards gaming, where gaming may be viewed as either a harmless or a cause for concern in Saudi Arabia, where traditional cultural beliefs may impact leisure activities.^21,22 Social Structures, where family game nights and other communal interactions may be more prevalent in Saudi culture, may help to lessen the isolation that is frequently linked to addiction.^23–25 Saudi Arabian restrictions and censorship have a major impact on the accessibility of gaming content. Islamic principles are important in shaping Saudi Arabian society standards and can affect perceptions of gaming.^12,16,26 Cultural differences can be significant in terms of knowledge and availability of resources regarding gaming addiction.^12,16,20,26 People in Saudi Arabia may turn to gaming as a preferred social outlet due to a need for social connection and interaction, especially in a digital age where opportunities for other forms of socializing may be limited.^23–25

Recent studies have highlighted several negative influences of VG on adolescents. These include detrimental impacts on academic performance, physical health, mental health, and social skills. Regarding academic performance, evidence indicates that online game addiction is linked to reduced motivation for academic achievement.^26–28 This is partly due to decreased learning engagement and increased adolescent sensation-seeking behaviors.^26,27,29 Furthermore, excessive gaming can lead to poorer parent-adolescent relationships, negatively affecting students’ motivation and academic success.^27,30 Excessive internet use, including online gaming, has been associated with physical and mental health issues. These issues include problems with self-consciousness, peer relationships, and increased stress and anxiety levels.^31–33

Immersive gaming can lead to a loss of self-awareness and neglect of physical self-care, further exacerbating these problems.^34–36Further, prolonged exposure to VGs can hinder the development of crucial social skills, as children struggle with face-to-face interactions and interpreting nonverbal cues, which are essential for effective communication and social relationships.^33,37,38 The current high-technology environment and the virtual-based world endorsed in VGs have led the younger generations to become more addicted to such games.³⁹ Thus, it often impacts adolescents’ energy and various brain abilities, including lack of sleep, increased stress levels and bullying, low interactions and socialization, and increased aggressive behaviors.^1,40–46

However, evidence proposes that VG has positive behavioral effects among adolescents. It reduces their stress, promotes positive feelings, enriches their lives, and helps them socialize with others in their comfort zone.^2,43,47–49 They also indicate that VG, mainly e-sport games, fosters physical activities, cognitive abilities, mental health, and relationships and strengthens adolescents’ social ties.^49–52 The notion of VG is a helpful tool for encouraging introverted adolescents to interact with their peers in real-life situations.³⁷ Effective use of VG can enhance socialization among adolescents with mental or psychological disabilities. For instance, a qualitative study indicated that VG enhances the socialization of autistic adolescents and empowers positive adolescent-parent interactions and relationships, which improves their quality of life.⁵³ Thus, they require a deeper understanding through a constructed scientific methodology to examine the effect of such factors and the level of VG addiction.

In Saudi Arabia, previous studies with their reported prevalence ranging from too low (3.5%) to too high (62.1%)^11,14–18 have not provided us with the answer to the question of whether VG addiction is a problem among Saudi adolescents due to different methodologies. Therefore, the aims of this study were 1) to estimate the prevalence and types of VG addiction among Saudi Adolescents using the Arabic-validated Game Addiction Scale for Adolescents (GASA),^54,55 and 2) to identify the significant predictors of VG addiction in the Saudi context. GASA is one of the most frequently used questionnaires for game addiction. The scale was theoretically based on the DSM-5 criteria for pathological gambling, namely salience, tolerance, mood modification, withdrawal, relapse, conflict, and problems.^54,55 The DSM-5 requires half (or more) of its criteria to be met when diagnosing pathological gamblers. This tool has solid psychometric properties and can be used for diagnosis and research. It has not been used in any previous studies on Saudi adolescents. This study may be a pilot study for similar studies in Saudi Arabia and the Arab world.

Methods

Study Design

This study was a cross-sectional study using an online questionnaire via Survey Monkey (https://www.surveymonkey.com/r/5KQDH2Y) restricted to one participant per unique internet protocol (IP) address. The survey had two parts, which included a) an online debriefing page, which includes a general overview of the study, its purpose, instructions on how to use the online questionnaire, and the agreement to participate in the survey, and b) the online self-administrative questionnaire, which explored all the participants throughout the study period, between July and August 2022.

Study Participants

A convenient sampling technique was used to select the participants. These included Saudi adolescents who lived in the Riyadh region, spoke and read in Arabic, had internet access, and agreed to participate in the study. Any adolescent with physical, mental, or psychological conditions that prevented them from comprehending the study questionnaire was excluded. The sample size was calculated based on a previous study’s prevalence of 9% VG addiction among adolescents,⁵⁴ With a 95% confidence limit and a 2% margin of error, the estimated sample size was 786; those who responded to a completed questionnaire were 787 participants.

Data Collection

The investigators developed questions covering the following:

Data Analysis

Data entry and statistical analysis were performed with the statistical package for the social science (SPSS) software program for Windows (version 28.0.1.1, © Copyright IBM Corporation, Armonk, NY, USA). Descriptive statistics such as percentages, means, and standard deviations were calculated. The Pearson chi-square test and Chi-square test for linear trend were applied for categorical data, and the Student’s t-test was used for continuous data. Logistic regression analysis was performed to identify the significant predictors of VG addiction, with adolescent gender, school performance, father’s education, and parents’ perception of VG positivity as independent variables. ROC curve was applied to determine the optimum cut-off score of the GASA above which an addicted gamer is predicted. Statistical significance was considered at p < 0.05 for all analyses.

Results

Adolescent Characteristics

Table 1 shows 787 Saudi adolescents; most of them (59.2%) were females under the age of 16 (90.7%) and in intermediate school (59.8%). Nearly one-half of all adolescents reported an average school performance (48.9%) and being sociable (55.6%). Most adolescents reported being interactive (71%) and regularly praying (76.7%), while regular exercising was reported by only (31.9%) of all adolescents.

Table 1 Personal and General Characteristics of Saudi Adolescents and Their Parents

Parent’s Characteristics

Most adolescents (80.1%) reported living with both of their parents. Nearly half (53.5% and 46.9%) reported that their mothers and fathers had a bachelor’s or higher education.

Videogame-Related Characteristics

Most adolescents reported starting VG at the age of 5–6 (53.2%), playing for more than 2 hours a day (72%), and having one or more kids in the family playing VG (63.9%). Nearly all adolescents reported that their parents permitted them to play VG (95.4%), while those who said their parents favored VG playing represented only 56.6% of all adolescents.

Table 2 and Figure 1 show adolescents’ responses to the game addiction scale, comprising 21 items in 7 domains: salience, tolerance, mood modification, relapse, withdrawal, conflict, and problems. The statement preceded every item: “How often during the last 6 months?” Players rated all game addiction items on a 5-point continuum scale: 1 (never), 2 (rarely), 3 (sometimes), 4 (often), 5 (very often). The prevalence of addiction for each of the seven domains when using often or very often as a cut-off point. It ranged from 40.5% prevalence for the “salience” domain to 50.2% for the “withdraw” domain.

Table 2 Adolescents’ Responses to the Game Addiction Scale for Adolescents (GASA) Domains

Figure 1 Prevalence of addiction for each of the seven GASA domains.

Table 3 shows the prevalence of VG addiction categories according to some adolescents, parent-related, and VG characteristics. Using often or very often as a cut-off point, 8.3% of all adolescents were considered addicted gamers, 33.4% were problem gamers, and 2.2% were highly engaged. The tendency for VG addiction was significantly more with male gender (X2LT =4.13, p = 0.04), above average school performance (X2LT = 13.06, p < 0.001), higher father’s education (X2LT = 8.06, p = 0.005), and favorable parent’s perception to VG (X2LT = 7.00, p = 0.008). The percentage VG addiction mean score was significantly associated with adolescent high school education (t=2.20, p=0.03), adolescent regular interaction (t=2.70, p=0.007), adolescent normal socialization (t=2.60, p=0.009), regular physical activity (t=2.31, p=0.021), regular praying (t=2.34, p=0.02), VG for 2 hours or less during the day (t=2.13, p=0.034), and favorable parent’s perception to VG (t=5.47, p<0.001).

Table 3 Prevalence of Videogame Addiction Categories According to Some Adolescents, Parent-Related, and Videogame Characteristics

After adjusting for all possible confounders, gaming addiction disorders were significantly predicted with male gender (OR=1.36, p=0.038), higher fathers’ education (OR=1.62, p=0.001), and favorable perception of parents to VG (OR=1.51, p=0.007), Table 4.

Table 4 Logistic Regression of the Predictors of Gaming Addiction Disorders Among Adolescents

When the ROC curve was applied (Figure 2), an optimum VG score of 85 was the threshold above which the adolescent was more likely to be an addicted gamer. At this cut-off point, the sensitivity will be 50/65=76.9%, the specificity will be 608/722=84.2%, and the area under the curve will be 88.5%.

Figure 2 Receiver operating characteristic curve of the cut-off score of addicted gamers on GASA.

Discussion

This study investigated the prevalence and predictors of VG addiction among Saudi adolescents, focusing on various demographic and socio-cultural factors. Our findings align with existing literature, confirming that males,^{3,11,14,15,45,56} and those with favorable parental perceptions of gaming are at a higher risk of gaming addiction.^14,45,57,58 Additionally, the association of higher father’s education with increased addiction risk highlights a potential cultural shift in attitudes toward gaming as a leisure activity. To our knowledge, no previous study was conducted addressing the role of the parent’s educational background, mainly fathers’, and its association with VG addiction among adolescents. However, Farchakh et al highlighted a significant association between the father’s education and the level of academic attention and cognitive abilities of Lebanese adolescent video gamers.⁵⁹ Previous research also suggests that parental attitudes and family dynamics play a significant role in adolescent gaming behavior, including special needs adolescents.^60,61 For instance, according to Hughes et al (2024), VG has been shown to enhance socialization in autistic adolescents, fostering better adolescent-parent relationships.⁵³

Our study also reveals that adolescents with above-average school performance were more likely to be problem gamers. This aligns with the findings by Dou and Shek (2021), who highlighted a complex relationship between internet use and academic values.²⁸ It suggests that for some adolescents, gaming might serve as a coping mechanism to alleviate academic stress. Evidence indicates that online game addiction is linked to reduced motivation for academic achievement.^26–28 This is partly due to decreased learning engagement and increased adolescent sensation-seeking behaviors.^26,27,29 However, our study findings contradict some earlier findings that associated poor academic performance with higher addiction risk.^26–29,62 For instance, Rajab et al indicated that game-addicted Saudi adolescents had lower academic achievements compared to those who were not addicted (38.5% vs 51.2%).¹² Our study contradicts Dou and Shack’s (2021) study, which highlighted that internet addiction was a key predictor of decreasing satisfaction with academic performance among Chinese adolescents (b = −0.07, p < 0.001, and Cohen’s f2 = 0.004).²⁸ One possible explanation is that high-performing students might use gaming as stress relief in our study. However, after adjustment for confounders, the association between gaming addiction and school performance was not significant.

Recent studies have highlighted several negative influences of VG on adolescents, and that include detrimental impacts on physical health, mental health, and social skills. Furthermore, excessive gaming can lead to poorer parent-adolescent relationships, negatively affecting students’ motivation and academic success.^27,30 Excessive internet use, including online gaming, has been associated with physical and mental health issues. These issues include problems with self-consciousness, peer relationships, and increased stress and anxiety levels.^31–33 In our study, the tendency for VG addiction was significantly higher with above-average school performance, adolescent high-school education, regular interaction, normal socialization, regular physical activity, praying, and VG for 2 hours or less during the day.

However, after adjustment, all these associations disappeared. Farchakh et al (2020) highlighted a significant association between the father’s education and the level of academic attention and cognitive abilities of Lebanese adolescent video gamers.⁵⁹ In Saudi Arabia, several factors could influence gaming addiction and the applicability of Western-based tools like the Gaming Addiction Scale Assessment (GASA). In Western cultures, gaming is often viewed as a mainstream form of entertainment, fostering significant community engagement. Conversely, in Saudi Arabia, where conservative cultural beliefs may influence leisure activities, gaming might be considered a legitimate pastime or a potential source of concern. These differing attitudes can impact how individuals engage with games and perceive gaming addiction.

Our study showed that 8.3% of all adolescents were considered addicted gamers, 33.4% were problem gamers, and 2.2% were highly engaged. This prevalence of 8.3% gaming addiction mirrors global trends that emphasize the escalating engagement of youth with VG.61. This figure agrees with the 9% figure in a previous study on Dutch adolescents.²⁶ It supports the assertion by the WHO that disordered gaming behavior is a significant concern, warranting its inclusion in the ICD-11. However, our study indicated that VG prevalence is lower than other national studies. For instance, Alrahili et al reported a prevalence of VG addiction among 393 Saudi adolescents reached up to 62.1%.11 Based on Alfaifi et al, the prevalence of 62.1%. VG addiction among Saudi adolescents.¹⁴ Saquib et al reported a prevalence of 16% among 276 students in Buraidah, Al-Qassim.¹⁵ Alhamoud et al reported a prevalence of 21.85% in Dammam.¹⁶ Bumozah et al reported a prevalence of 19%17 among secondary-grade schools in Al-Ahsa. However, Alghadmi and Alghamdi (2023) reported a prevalence rate of VG addiction of 3.5% only among the Saudi adolescents in Al bahah region.¹⁸ Further, Rajab et al found that the prevalence of VG addiction was 5%; however, they correlated to the level of stress among Saudi adolescents who live in Al-Qassim region.¹² These different figures for the prevalence of gaming addiction in various regions of Saudi Arabia could be attributed to different methodologies used in the operational definition of addicted gamers. Thus, the need for a consensus on a single operational definition with a single detection methodology is recommended.

The use of the GASA provides a robust framework for assessing addiction across multiple domains, such as salience, tolerance, and withdrawal. According to Lemmens et al^54,55 Videogame addiction was classified into monothetic and polythetic formats. In the polythetic addiction format, the adolescent should endorse at least half of the criteria to conclude a positive diagnosis of video game addiction. In the monothetic format, which may be easier than the polythetic format as a screening method for game addiction, the total GASA scores are obtained by summing the adolescents’ response scores. Total scores range from 21 to 105; a cut-off score is defined above which the adolescent is considered an addicted gamer. A previous study on Dutch adolescents⁵⁴ recommends that a score above 90 indicates a possible addiction to VG. It has been noticed that when using the cut-off point of 85 in our study with the Arabic version of GASA, the sensitivity will be 79.6%, the specificity will be 84.2%, and the area under the curve is 88.5%. However, this is not a diagnostic tool but only an indicator that an adolescent might be addicted to VG. Only an in-depth clinical assessment could provide such a diagnosis. Although our findings pertain only to Saudi adolescents, we hope that our scale will contribute to the general measurement of game addiction and provide a better and easier estimate of the prevalence of addicted gamers in other communities.

Strengths and Limitations

Our study could be a pilot study of similar studies in different countries of the region. The study’s strength lies in its large sample size of Saudi adolescents. However, this study has some limitations: First, it was conducted on a sample of Saudi adolescents from a particular region (Riyadh), and it’s unclear if the results can be extrapolated to the entire Saudi adolescent population or other cultural contexts. This could affect the generalizability of the study’s conclusion. Second, it is self-reported; thus, it might be subjected to recall bias. Third, the reliance on convenience sampling via online platforms like SurveyMonkey could introduce biases. Adolescents with frequent internet access may have been overrepresented, leading to skewed results. Fourth, the study is a cross-section design, which does not guarantee the cause-and-effect relationship between the level of VG addiction as an outcome and the predictors, such as adolescents’ educational background, school performance, interactions, socialization, physical activities, praying, and duration of playing VG. Future research could explore longitudinal designs to understand better the causal relationships between the identified factors and video game addiction. Some potential confounding factors, such as socioeconomic status, types, and mode of video games, might have influenced the results but were not accounted for in the analysis. Further, lacking consistent tools to measure VG addiction was one of the challenges that led to a lack of comprehensive comparison with the prevalence figures from national or international sources.

Conclusion

This study could be a pilot study for similar studies in other countries of the region. Male adolescents of educated fathers and those with favorable parental perceptions of gaming are at a higher risk of gaming addiction. These findings may redirect the scientific approach toward the positive parental role in VG that fits the global view of e-sporting and VG sports. However, these findings indicate the need for more extensive research and serve to highlight vital next steps needed in future papers, such as identifying predicting factors that could aid in the early detection of video gaming addiction in adolescents. Additional studies are necessary on how cultural differences might influence gaming addiction.

The use of the polythetic addiction format for gaming addiction screening with GASA is recommended, with a cut-off score of 85 to predict addicted gamers. However, further studies are necessary to apply Western-based tools like GASA to Saudi contexts. Modifying Western-based instruments like GASA to better represent regional cultural norms, values, and social dynamics to evaluate and treat gaming addiction in Saudi Arabia could be required. This could entail considering regional viewpoints, implementing community involvement techniques, and gaining a deeper comprehension of the social ramifications of gaming in a particular cultural setting. Further, community-based potential educational programs, parental involvement strategies, or activities to promote alternative hobbies are recommended. Cultural differences play a significant role in shaping behaviors and attitudes toward gaming, including addiction.