The concept of IGD mediate ADHD pathways leading to DMDD are not entirely clear before. The purpose of the study was to prove how gaming disorder mediated the effect of ADHD to DMDD. Under the hypothesis, this SEM analysis (analysis of symptom developmental pathways) found gaming disorder enhancing the symptom of ADHD to DMDD. IGD is the risk and associated to the emotional dysregulation among ADHD youth.
If we explain this finding by the Research Domain Criteria (RDoC) dimensions model perspective, children with ADHD have deficit in domain of Cognition (specifically in Working Memory) and Positive Valence (in rewarding anticipation/ delay /receipt)(26). The children with IGD may exhibit problem on domain of Negative Valence Systems, Positive Valence Systems, Cognitive Systems, Systems for Social Processes, and Arousal and Regulatory Systems (27). Therefore, IGD and ADHD may have mixed or overlapped disturbance on domain of Executive function, Incentive Salience, and Negative Emotionality (28). Our result indicated that gaming disorder might aggravate negative emotional symptom of ADHD symptoms of ADHD become emotional dysregulation is congruent from RDoC model perspective. This SEM pathway analysis indicated IGD may indeed lead children with ADHD become severe in their symptom of inattention, hyperactivity/impulsivity, and ODD symptom.
Following explanation can be used to explain why IGD having mediating role to lead ADHD become severe in their symptom even developing negative mood. A vicious cycle started from gaming addicted ADHD youth characterized as following by our descriptive analysis: 1, more likely have poor interpersonal relationship. 2, more comorbid with DMDD clinically. 3, have an older parent. 4, have parent with more marital discord, and a poorer parenting strategy for managing stress than ADHD youth without gaming disorder. It means they live under a vulnerable state with their severe symptom presentation of ADHD with emotional irritability, also they had poor interpersonal relationship and poor family interaction. Through the long process of becoming IGD, these vulnerable youths became youth with DMDD. Vicious cycle is IGD might lead ADHD youth spend more time on gaming to avoid more family or social interaction, gradually gaming addiction lead them become lonelier and more irritable in mood especially when they were stopped to using gaming overly.
Our finding detailed the etiology from genetic and environmental aspect regarding the development of gaming disorder. For youth with IGD, the untreated ADHD were genetic loading to lead youth with IGD burst out severe symptom of ADHD, impulsivity, and irritability. Gradually, IGD might enhance the genetic risk of untreated ADHD youth further present more severe symptom just like DMDD. Also, the environment or family risk like untreated ADHD living with a lower family cohesion, more family conflicts, and a poorer family relationship and family functioning (29), sooner or later these ADHD youth become more irritable mood even to disruptive mood through the process of long term addicted on gaming. Thus, for treatment toward family with internet addicted ADHD youth with irritable mood, there is a strong need to development bio-psycho-social modal. It means specific combining pharmacotherapy for ADHD or/and antipsychotic drug for disruptive mood with parental program including parent’s marital therapy, improving communication with gaming addicted youth, and parental stress management in addition to healthy digital using principle.
In last two decades, more researcher focused on other comorbid psychiatric disorders among gaming addicted adolescents, such as IGD co-occurring more with depression (30, 31), social anxiety, other substance use disorders (32), nicotine use disorder, alcohol use disorder, somatoform disorders, pathological gambling, adult type ADHD symptoms, sleep disturbances, suicidal ideation, suicidal plans (33), social phobia (34), phobias, psychosis with the exception of paranoia (35), loneliness, and problematic behavioral disinhibiting (36), reported withdrawal psychosis (37, 38). But this SEM study results only first further make an important association from children with ADHD will present increasing irritability, anger, bad temper, and to a degree their symptoms look like DMDD. It is important to know that this severe irritable mood is closely intensified by the long-term the process of overly playing gaming.
This study has the following limitations. First, the DMDD diagnosis in this study is made by a psychiatrist according to the new criteria in DSM-5; however, the stability of the DMDD diagnosis after gaming disorder has not been followed up on after this study. Therefore, the differentiation between the real DMDD and withdrawal symptoms after gaming disorder like DMDD symptoms need to be taken into consideration. Second, for convenience of study, only child and adolescent with ADHD diagnostic antecedents were selected as risks. Other risks like socially accepted internet overusing behavior leading parent self also being IGD victim may also lead children with ADHD with IGD develop DMDD related symptoms. Despite these limitations, the use of SEM to explore the multiple correlated risks leading to juvenile mood dysregulation and the fits all seem good or appropriate to indicate SEM being a useful way to elucidate the simultaneous risks leading more severe mental disorders.
ADHD should be treated earlier to prevent the serious consequences such as antisocial personality disorder, substance related and addictive disorder (39) . Before these bad consequences developing, this study further implied overly gaming behavior among child and adolescent is not only a game playing problem, but also a serious risk to lead child with ADHD to have disruptive mood dysregulation disorder like symptoms.
Our present and future society will have more youth with IGD problem(40). The recent child psychiatrist should get insight to watch out the silent hazard brought by gaming disorder, especially for youth with untreated ADHD. Here we suggest for those severely internet addicted ADHD youth with warning sign of DMDD like irritable mood and aggressive behavior, the intensive treatment program should include the standard combining pharmacotherapy for ADHD or/and antipsychotics pharmacotherapy for children with disruptive mood with cognitive behavior therapy for IGD youth and their parents.
In summary, Internet Gaming Disorder among youth with ADHD is neglected and remains under-treated, new mental disorder in our society. This study finding indicated gaming disorder indirectly mediate children with ADHD present irritable symptom like DMDD. Therefore, no more as usually phenomenon that children with ADHD commonly being neglected or undertreated in some developing countries. Since now, child and adolescent psychiatrists and related pediatric ADHD experts should consider Internet Gaming Disorder as a warning sign of possible escalating child and adolescent’s neurodevelopmental disorder of ADHD to disruptive mood dysregulation symptoms.