Review

Current Status of Internet Gaming Disorder (IGD) in Japan:
New Lifestyle‐Related Disease in Children and Adolescents
George Imataka 1,*, Ryoichi Sakuta 2, Akira Maehashi 3 and Shigemi Yoshihara 1
Department of Pediatrics, Dokkyo Medical University, Tochigi 321‐0293, Japan
Child Development and Psychosomatic Medicine Center, Dokkyo Medical University Saitama Medical Center,
Saitama 343‐8555, Japan
3 Faculty of Human Sciences, Waseda University, Saitama 359‐1192, Japan* Correspondence: geo@dokkyomed.ac.jp; Tel.: +81‐282‐86‐1111
12

Abstract: The World Health Organization recognizes Internet gaming disorder (IGD) as a disorderthat causes problems in daily life as a result of excessive interest in online games. The causes of IGD
have become more apparent in recent years. Because of prolonged exposure to games, the mecha‐
nisms controlling the reward system, such as the prefrontal cortex, limbic system, and amygdala ofthe cerebrum, do not function properly in IGD. This mechanism is similar to that of various behav‐
ioral addictions, such as gambling addiction. IGD is particularly risky in children and adolescents
because it easily causes brain dysfunction, especially in the developing brain. IGD should be re‐garded as a new lifestyle‐related disease in younger individuals, and lifestyle modifications, includ‐ing counseling and family therapy, are critical for its management.
Keywords: Internet gaming disorder; lifestyle‐related disease; prefrontal cortex; limbic system; amygdala
Citation: Imataka, G.; Sakuta, R.;
Maehashi, A.; Yoshihara, S. Current
Status of Internet Gaming Disorder(IGD) in Japan: New Lifestyle‐
Related Disease in Children andAdolescents. J. Clin. Med. 2022, 11,4566. https://doi.org/10.3390/
jcm11154566
Academic Editor: Elena Tomba
Received: 4 July 2022
Accepted: 3 August 2022
Published: 4 August 2022
Publisher’s Note: MDPI stays neu‐
tral with regard to jurisdictional
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Copyright: © 2022 by the authors. Li‐
censee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and con‐ditions of the Creative Commons At‐
tribution (CC BY) license (https://cre‐
ativecommons.org/licenses/by/4.0/).

1. Introduction
Animation, the Internet, and video games are becoming the primary concerns amongchildren and young adults globally [1,2]. The majority of today’s society is made up ofyoung adults who grew up with animated characters and Internet/video games [3,4]. In‐
ternet gaming disorder (IGD) has become a global problem in recent years, as people havebecome overly enthusiastic about Internet games, devoting a large amount of time andenergy from their personal lives to gaming [5]. Young Asian males appear to be the mostprone to IGD [6,7]. Prevalence rates are highest in Eastern Asian countries and in maleadolescents aged 12 years to 20 years. A Taiwanese study showed an Internet gaming
disorder prevalence rate of 3.1% [8], a Korean study reported a prevalence of 5.9% [9], anda Chinese study reported a prevalence of 17% [10]. The prevalence ranged from 3.3% to18.7% among Japanese college students (based on a broader screening for Internet addic‐tion) [11,12]. The differences in prevalence rates can be attributed to differences in study
population, cultural factors, and assessment or diagnostic criteria. However, the preva‐
lence in Asian countries seem very high [2,13] compared to the West. The diagnostic cri‐
teria for IGD are similar to those for other addictive disorders, such as pathological gam‐bling. Neuroimaging studies on individuals with IGD have focused on structural andfunctional brain changes, similar to neuroimaging studies on disorders such as substanceand behavioral addictions [14]. The major concern with IGD is the dependency symptoms
it causes [15]. IGD patients have large‐scale functional network changes that explain theircore symptoms, such as low emotional competence, cue reactivity, and desire, habitual
addictive behaviors, and decreased executive control [16]. According to a recent meta‐
analysis, one in every three IGD patients experienced depression [17]. Japanese students
tend to have a high risk of IGD and physiological stress [18]. Furthermore, more people

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2 of 14in Asian countries are showing behaviors associated with gaming disorder and online
addiction amid the coronavirus (COVID‐19) pandemic [19,20].
IGD has negative effects on a person’s physical, emotional, and social welfare. Patho‐
logical gaming has negative effects on one’s mental health, academic performance, phys‐
ical violence, and depressive symptoms. It is also associated with poor sleep quality andsleep‐related issues, decreased interest in schoolwork, and extracurricular activities [21].
Considering growing prevalence of IGD in Asia, children and adolescents deserve moreclinical attention. In this expert review, the following topics are discussed: (1) what addic‐
tion is, (2) the relationship between history of games and game addiction, (3) what IGD is,(4) approaches to game addiction, and (5) treatment of IGD based on the latest findings.
2. What Is an Addiction?
2.1. Two Kinds of Addictions: Dependence on Substances and Dependence on Behaviou
Briefly, addiction is defined as a state in which a person is unable to stop using aparticular substance or engaging in a particular behavior despite negative consequences[22,23]. Disorders caused by substance use include those caused by a single instance orrepeated use of substances with psychoactive properties, including certain medications.
In most cases, the first use of these substances produces pleasant or appealing psychoac‐
tive effects that become rewarding and reinforcing with repeated use. Many of the sub‐stances included have the potential to cause dependence if used repeatedly. They also
have the potential to be harmful to both mental and physical health. Disorders caused by
addictive behaviors are identifiable and clinically significant syndromes characterized by
distress or interference with personal functions and caused by repetitive rewarding be‐
haviors other than the use of dependence‐producing substances (Figure 1). Gambling dis‐order and gaming disorder, which can involve both online and offline behavior, are ex‐amples of behavioral addictions [24]. Both substance and non‐substance‐related disorders
refer to compulsive indulgence in a specific behavior or type of behavior that causes harmto the person, as well as the person’s inability to moderate or manage those behaviors
without treatment [25]. Behavioral addictions such as substance‐related disorders exhibit
similar psychological and behavioral patterns, such as craving, impaired control over be‐
havior, tolerance, withdrawal, and a high rate of relapse [26–29]. Addiction and related
behavior was added to the DSM‐5 in 2013 [22]. A behavioral addiction category has been
proposed within this category, which would include pathological gambling and possiblyInternet addiction [30–32]. The DSM‐5 now recognizes two behavioral addictions: gam‐bling addiction and gaming disorder. The DSM‐5 Section 3 includes IGD as a condition,
but Internet addiction is not included, which needs more clinical research and experience
before it can be considered for inclusion in the main book as a formal disorder [33].

Figure 1. Two kinds of addiction: what is gaming disorder?

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3 of 142.2. IGD in DSM‐5 and ICD‐11Internet gaming disorder is a psychiatric disorder characterized by a persistent andrecurring interest in video games that significantly impairs daily, professional, or educa‐
tional activities [33,34]. IGD was placed in the section of substance‐related and addictive
disorders, together with gambling disorder, “reflecting evidence that gambling behaviors
activate reward systems similar to those activated by drugs of abuse and produce somebehavioral symptoms that appear comparable to those produced by the substance use
disorders”. It is the only online behavioral addiction that is well recognized in both DSM‐
5 and ICD‐11, in addition to gambling [33].
The symptoms of IGD resemble other Internet addictions and include repetition:seeking stronger stimulation, trying to stop but not being able to, and being unable to get itout of one’s head at all times. Initially, there is no difficulty; however, over time, these symp‐
toms become exceedingly challenging for a person’s social life [34]. The DSM‐5 states that fiveout of the nine diagnostic criteria (preoccupation or obsession, withdrawal, tolerance, loss ofcontrol, loss of interest, continued overuse, deceiving, escaping negative feelings, and func‐
tional impairment) must be met within a year in order to be diagnosed with IGD [33].
In 2022, the World Health Organization (WHO) included the category of gaming dis‐order in ICD‐11. To be officially diagnosed with gaming disorder (“digital gaming” or“video gaming”), a patient must exhibit three symptoms: impaired control over gaming,
increasing priority given to gaming over other activities to the extent that gaming takes
precedence over other interests and daily activities, and continuation or escalation of gam‐ing despite the occurrence of negative consequences [24]. The WHO’s distinction between
online and offline gaming modes is significant because online gamers have the highest
disordered gaming scores, followed by mixed gamers (those who say they prefer both online
and offline gaming), and offline gamers [35]. In comparison to the DSM‐5 IGD diagnosis cri‐
teria, the ICD‐11 diagnosis criteria emphasize functional impairment [36]. A recent survey in‐volving five Mexican universities showed that the demographics, comorbid mental disorders,service use, and impairment variables of DSM‐5 cases detected and undetected by ICD‐11 cri‐
teria were similar; however, cases detected by ICD‐11 had severe symptoms and had a prob‐
able drug dependence compared to undetected DSM‐5 cases [37].
3. Children and Adolescents Are Particularly at Risk for Onset of IGD
Internet game addiction is a major concern for Asia’s three largest economies, South
Korea, China, and Japan. The reasons for its ubiquity in the region are complex. There areseveral factors attributed to the rising rate of gaming addiction. These countries have easeof access to a wide range of games, as well as computers and the Internet. The presence of 24
h video game cafés with fast Internet speeds exacerbates the gaming addiction problem.
The enormous social loss caused by game addiction has become a problem over the past
decade necessitating that all stakeholders take countermeasures. In South Korea, the govern‐
ment has seriously considered the fact that many young people are wasting substantial time
gaming. The Cinderella Act is a youth protection law, prohibiting youth under the age of 16
years from playing online games from midnight to 6:00 a.m. The system forcibly disconnects
the online connection at 12:00 a.m. [38]. In South Korea, the law was enacted to counter sui‐cides and Internet crimes, with an estimated one million “netgeeks” due to IGD.
There is currently little significant research evidence that playing games for a set pe‐
riod of time is associated with disorganized behavior. However, a number of negative
consequences of excessive gaming enthusiasm in childhood have been identified. China
issued a notice on the Prevention of Underage Online Game Addiction in 2019. Logging
into online games from 10:00 p.m. to 8:00 a.m. the next morning is not allowed, and online
games are shut down after 3 h on weekends and holidays and 1.5 h on weekdays [39]. In
addition, billing is not allowed for those under 8 years old, with a monthly limit of about
30 USD for those between 8 and 15 years old, and about 60 USD for those between 16 and17 years old. In China, the government is taking the lead in creating an environment that

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4 of 14prevents gaming dependency among people. Although there is a tendency in Japan toconsider gambling addiction as a series of spectrum‐like conditions as IGD, Japan is lag‐ging behind in government‐led measures regarding Internet gaming addiction.
3.1. Age‐Related Development of Neurocognition: Scammon’s Developmental Curve
In the environmental adjustment of IGD, keeping smartphones and computers awayfrom the surroundings is important. The Japan Pediatric Association and the Society of
Obstetricians and Gynecologists are working to educate people not to let smartphones geta grip on their children. The American Academy of Pediatrics has recommended that par‐ents limit screen time for children aged 2 years or younger, when the brain is particularly
malleable, due to concerns that a young, developing brain may be particularly sensitive
to chronic exposure to computers, smartphones, tablets, or televisions [40]. According to
Scammon’s developmental curve, where the age of 20 is 100% of the human organ‐specificdevelopmental level, the nervous system is 50% formed at age 2, 80% formed at age 4–5,
and 90% formed at age 8–9 [41]. Excessive gaming and digital stimulation of the develop‐
ing brain has a negative impact on subsequent brain development owing to specific neu‐rodevelopmental plasticity in adolescents. It has been reported that the volume of the graymatter of the brain, including the prefrontal cortex, in the brains of younger individuals
with IGD is smaller than the average for the same sex and age [42]. The prefrontal cortex,
along with the limbic system of the brain, regulates the emotions of desire and anger, anda small portion of the prefrontal cortex reduces the ability to reason and suppress emo‐
tions. Gaming exposure at younger ages causes changes in brain morphology [6,43–45].
3.2. Online Games Are Easy to Depend on and Are Cleverly Designed
IGD disrupts the rhythm of life due to the huge amount of time spent, resulting insleep deprivation and reward system deficiency. This reduces satisfaction and leads to a
constant state of dissatisfaction. A recent study demonstrated that adolescent students
and their siblings had mutual impacts of IGD on psychological health and sleep [46]. In
addition, many games and Internet sites are designed as candy and whips to keep young
people returning to the same sites. Common symptoms of IGD include day and night
reversals (changing the sleep–wake cycle), domestic violence, destruction of property,
staying indoors, not eating, not being able to get up in the morning, persistent absentee‐
ism, and poor grades [6,43]. IGD has a greater connection with achievement motivationcompared to social or immersion motivation. The desire to explore the virtual world may
not be genuine motivation, but rather a means of escaping from various real‐life problems[47]. In several games, people play in teams where each individual plays the role of play‐ing in a battle game to survive against the enemies. Teams gather in a virtual space atnight after school or work, and, each time they win a game, their ranking increases. Ac‐
knowledging the relevance of socializing and the relationship motivation subcomponents
to IGD and its management is essential [47]. Online games not only allow players to honetheir skills but also exposes them to the use of violent weapons online and increases therisk of children’s dangerous behavior around weapons such as firearms [48]. Game com‐panies have smartly created a system that makes it easy for people to be dependent on
their games, increasing their profits in the process. In other words, the longer young peo‐ple spend time gaming, the greater the profit for the companies. Excessive game playing
can lead to a lack of exercise and even sleep, making it easier for children and adolescents
whose central nervous system is still immature in development to be more detrimental totheir health than adults.

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4. Relationship between the History of Games and Game Dependence
4.1. History of Games: Ancient to Modern
The history of games dates back to BC times (Figure 2). Humans have been fascinatedwith games since ancient times, and games have changed and developed worldwide
along with human history. However, the history of games is connected to the history ofgambling, betting, exposition, and addiction. From Roman emperors to Marie Antoinette,
there are many historical anecdotes of people who lavishly gambled in games [49,50].

Figure 2. History of gaming: From “person vs. person” to “person vs. machine”.

4.2. The Spread of Arcade Games and the Problem of Slot Machines, Pinball, and Pachinko
In 1927, David Gottlieb created an arcade game in Chicago that became the prototype
for “pinball”. During the post‐prohibition era in the United States, many pinball machines
were installed in arcades and bars. In the 1930s, the pinball was labeled as a gamblingmachine, and the movement of citizens to ban pinball grew stronger. Finally, in 1936–1937,
the Chicago Pinball Prohibition Act was enacted. Historically, this was the first law toprohibit gambling game machines. At the same time, pachinko parlors appeared in Japan.
Pachinko is a Japanese mechanical game that is played as a recreational arcade game andmuch more frequently as a gambling device, occupying a niche in Japanese gambling sim‐
ilar to that of the slot machine in Western gambling as a low‐stakes, low‐strategy kind ofgambling (Figure 3). As soon as slot machines, pinball, and pachinko were introduced to
the Japanese market, gambling was seen as a problem.

Figure 3. Pachinko parlor.

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6 of 144.3. Space Invaders and Regulations against Underage Game Dependence
In June 1978, Taito Corporation released the table‐integrated arcade game “Space In‐
vaders”, which was the first fixed shooter, and it laid the groundwork for the shoot ‘em
up genre (Figure 4a,b). The goal is to earn as many points as possible and defeat wave
after wave of descending aliens with a horizontally moving laser. Considered one of themost influential video games of all time, Space Invaders contributed to the growth of thevideo game industry from a novelty to a global industry, ushering in the golden age ofarcade video games [51]. The game became the biggest hit for an arcade‐type game. How‐ever, it caused the problem of underage gaming dependency in Japan. Within a year anda half of its release, approximately 500,000 units had been shipped in Japan. Invader cafés,
which were coffee shops that turned into game centers, appeared in towns. The long wait‐
ing lists for games at Invader cafés received news coverage. Eventually, illegal Invader
machines that could be played at low prices were installed in candy stores where children
congregated, and adolescents flocked to these places with cash. Thus, long waiting lists
for Invader games and the occupation of game machines became a problem. In due course,
Invader cafés and game centers attracted adolescent delinquents. Police and schoolgroups investigated the situation, and just 1 year after the announcement of Invader, the
All‐Japan Amusement Park Association declared a voluntary restraint on Invader games.
In 1985, the government enforced the Entertainment Business Law prohibiting anyone
under the age of 18 from entering game arcades after 10 p.m. (At present, anyone under
the age of 16 is not allowed to enter game arcades in Japan after 10 p.m.). Because of theInvaders boom’s unique cultural context in Japan, the Space Invaders boom and IGD havebeen explored collectively. As interest in the issues of Internet and game addiction grewin Japan, the Japanese government attempted to address both issues as a series of IGDs,
with specialists such as pediatric neurologists and psychiatrists.

Figure 4. Space invaders game: (a) computer old retro version; (b) table‐top version game.

5. What Is Game Addiction?
5.1. Background of the Invader Game Craze: Reward System and Prefrontal Cortex
Why did the industry forgo Invader games after only 1 year, despite their strong
sales? Why did the Japanese government propose to ban it? The reason for the popularityof the game was that people vs. machines, slot machines, and pachinko machines wereregulated by law, whereas Invaders was accessible without age restrictions. However, thisled to a sharp increase in gaming disorders among children. Although there is still insufficientevidence that children’s developing brains are vulnerable to games, it was observed that chil‐dren’s developing brains are vulnerable to gaming [52]. An increasing number of Japanesechildren are dropping out of school as a result of their excessive reliance on video games, theInternet, and social networking services. In other words, the fact that children are more highly
prone to game addiction than adults has been proven by social phenomena.

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IGD is a typical example of machine dependency, and the mechanism of IGD involves
the release of dopamine, a pleasure substance in the brain, which activates the “reward sys‐tem”, a sensor that provides a sense of accomplishment and euphoria. It was also discoveredthat the cause of IGD is an abnormality in the functioning of the brain that reduces the func‐
tioning of the prefrontal cortex, which controls human reasoning [43,53–56].
5.2. Game Addiction Is Similar to Other Addictions
Screen‐based media use (including Internet‐related addictive behaviors) is associatedwith a less efficient cognitive control system in adolescence. Adolescents with IGD more
frequently exhibit decreased short‐ and medium‐range connectivity among the subcorti‐
cal, frontal, and parietal regions involved in attentional and control networks, in line withother behavioral addictions [57–59]. IGD is linked to functional and structural neuralchanges in the fronto‐striatal and fronto‐cingulate regions [43]. Fronto‐striatal dysfunctionis also thought to promote a compulsive use of the Internet and screen devices in general.
It has been reported that adolescents who play action video games more frequently strug‐
gle to maintain their attention over time [58]. Adolescents typically exhibit more reward
anticipation brain activity than adults do. They are more susceptible to the intense re‐wards that are provided by gaming activities (Figure 5). Excessive gaming on a regularbasis can reinforce adolescents’ propensity to seek out instant gratification, which theyvalue higher [58]. Several studies have tried to establish the dynamics involved in IGD
etiology. Paulus et al. [6] described that IGD is a highly complex phenomenon, with inter‐play of psychological, sociological, and neurobiological factors. The authors proposed an
integrated IGD model depicting complex interaction between serval internal and external
factors. Structural brain deficits in prefrontal cortex, amygdala, connectivity, dopaminer‐
gic/serotonergic system, and neurobiological deficits (self‐regulation and decision mak‐ing, dysregulation of mood, and reward systems) are implicated in IGD. Among external
factors, poor parental care, inadequate social skills, and game‐related factors such as re‐wards can increase the risk of IGD. Adolescents with IGD have similar traits to those with
substance dependence, including higher impulsivity, greater propensity to make risky
decisions, less capacity to defer gratification, and impaired ability to assess risk. Schettler
et al. [60] reported that adolescents with problematic gaming have altered brains thatshow deficits in executive functioning (including working memory and attention), emo‐tion management, and reward processing, as well as cognition, which includes decision
making. Adolescents with IGD seem to exhibit a stronger imbalance between cognitive
control (including fronto‐parietal areas) and the affective system (including subcorticaland limbic structures) than non‐IGDs [42]. Lower gray‐matter density in the dorsolateralprefrontal cortex was linked to more severe IGD symptoms, more depression, more life‐
long gaming, more impulsivity, and more time spent gaming. Previous neuroimaging
studies revealed that IGD and addiction may have comparable neurobiological pathways,
such as aberrant fronto‐striatal networks that are important in reward processing and cog‐
nitive regulation [14]. Given that the DLPFC is essential to the top‐down control systemthat manages cognition and behavior, its involvement in IGD is not unexpected. It can beassumed that the prefrontal dopaminergic system partially controls impulsivity, cravingsfor online gaming, and poor mood [42,43,52]. Furthermore, in response to punishment,
IGDs were found to use an avoidance system, indicating a distinct pattern of reward pro‐cessing among people with IGD [61]. Recent studies suggest that IGD individuals may
have greater appetites for video games than for more fundamental rewards such as food,and they subjectively attach greater importance to gaming as the primary reward. When
compared to food‐related cues, gaming‐related cues induced stronger functional connec‐
tivity in precuneus–caudate relationships in IGD individuals [62]. Patients with IGD
demonstrated considerable bilateral hyperactivation in the precuneus and cingulate, as
well as significant bilateral hypoactivation in the insula, during cue reactivity tasks, butthere were no alterations in the striatum. Patients with IGD showed significant hypoacti‐
vation in the left inferior frontal gyrus and hyperactivation in the right superior temporal

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8 of 14gyrus, bilateral precuneus, bilateral cingulate, and insula during executive control tasks.
IGD patients showed significant hypoactivation in the left superior frontal gyrus, left in‐
ferior frontal gyrus, and right precentral gyrus during risky decision‐making paradigms,
as well as significant hyperactivation in the left striatum, right inferior frontal gyrus, andinsula [63]. Some of these changes are linked to aspects of addiction or to changes in thebrain’s motor, sensory, and cognitive functions [55].

Figure 5. The reward system and the prefrontal cortex (level of satisfaction/activity of the reward system).

5.3. The Need for Treatment of IGD
Individuals with IGD frequently overestimate the benefits of playing online games,
where they invest a substantial amount of time. As a result, they neglect social and aca‐
demic obligations, which can lead to social dysfunctions [64]. Therefore, IGD must be con‐sidered a disease. According to a survey by Japan’s Ministry of Health, Labor, and Welfare
in 2017, about 97% of teenagers in Japan use the Internet on a daily basis. The results ofthe survey (n = 38,630) reported that 59.7% of users access the Internet through asmartphone, while 52.5% of them use the Internet via desktop and/or laptop computers[65]. Approximately 1.82 million males 20 years of age and older were living with Internet
addiction in 2018 in Japan, almost three times the number reported in 2013 [66]. Anecdotal
evidence indicates that the majority of patients with Internet addiction are primarily ad‐dicted to gaming, and male Internet users favored online gaming through smartphones[67]. Sleep disturbance, day or night reversal, inability to get up in the morning, inability
to attend school, poor concentration, irritability, lack of communication, nervous anxiety,lack of exercise, obesity, and poor academic performance [6,68,69] are all symptoms of
IGD in adolescents, indicating a serious concern about the dangers of excessive gaming.
Moreover, over the last decade, there has been an increase in research on the mental healthissues associated with IGD. Adolescents are vulnerable to a variety of mental health issues
linked to excessive online gaming, including depression, social anxiety, loneliness, andattention deficit hyperactivity disorder (ADHD) [69]. The degree of depressive symptoms
and physiological resilience were found to be positively correlated in a study of large Chi‐nese secondary school students, suggesting that psychological resilience training may be
helpful as an intervention for IGD [70].

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6. Approach to Game Addiction and Treatment
6.1. The Pathology of Game Addiction Is Psychological Dependence
Physical dependence requires treatment for withdrawal symptoms when the drug isdiscontinued. Process dependence, on the other hand, is mental dependence. Therefore,
IGD is expected to have a number of clinical effects through environmental adjustment,
counseling, and cognitive behavioral therapy [6,44,45].
6.2. Diagnosis of Game Dependence
IGD is difficult to recognize until it becomes serious, and it tends to be delayed until
later. Therefore, the first step in dealing with IGD is for the patient and family to self‐
recognize IGD. Outpatient diagnosis of IGD and counseling of the patient and family areimportant [6]. For this purpose, first, a therapeutic target should be approached from fam‐
ily therapy. Data on management are available for younger patients, but not for children.
Few cases have been reported emphasizing early treatment in children in order to avoid
a longer and more intensive approach when the child progresses to higher education. In
children, the clinical approach should include assessment, rapport building, parent edu‐
cation, child/teenager education, child/teenager motivational interviewing, and individ‐
ual therapy based on psychological symptoms.
6.3. Toward Less Games, Not More, and Zero‐Game Day
The next thing to consider is the process via which gaming can be dealt with. It might
be a beneficial idea to dispose of the games; however, this should be evaluated on a case‐to‐case basis. First and foremost, people with IGD have trouble managing their reasoning;as such, if games are forced away from them, they are at risk of impulsive behaviors, suchas violence and running away from home [6,43]. Since IGD is basically a psychologicaldependence [71,72], the next step is to counsel the person on how to deal with games once
they are aware of the dependence. If it is difficult to stop playing games, the aim is to
reduce the number of games played. Working not only with the individual but also withthe family as much as possible is important. In several cases, the inability to escape IGD
may be caused by members of the family [73].
6.4. IGD Initiatives in Japan
According to a survey of Youth Internet Environment 2018, Cabinet Office Japan,
95.9% of senior‐high‐school students, 58.1% of junior‐high‐school students, and 30% of
elementary‐school students have their own smartphones [74]. Junior‐ and senior‐high‐school students use their smartphones for greater than 4 h a day on average, and 10–20%
of Japanese junior‐ and senior‐high‐school students are already suffering from IGD.
Therefore, it is important for families and schools to discuss gaming as a collective. Addi‐
tionally, social regulations and measures are necessary. For example, the Japan Pediatric
Association has issued a call for “Smartphone Time, What Am I Ushering in?” Kanagawa
Prefecture has uploaded an animated YouTube video on its website and has over 30,000
registered users. Kagawa Prefecture enacted Japan’s first gaming regulation ordinance on
1 April 2020. The ordinance states that games must be used for 60 min and 90 min on
weekends and holidays, and that smartphones must be used until 9:00 p.m. for junior‐high‐school students and younger, and until 10:00 p.m. for all others, except for those used
for study purposes [75]. Although the ordinance has no penalties, it has been criticized bylibertarians. However, given the fact that the WHO has recognized IGD as a disease andthe government has not set any laws, several people in Japan are of the opinion that theordinance of Kagawa Prefecture should be enforced.

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7. Treatment of IGD
7.1. Actual Treatment of IGD
There is a scarcity of literature on various IGD treatment methods. No standard clin‐
ical treatment protocol is currently available, and treatment techniques are typically de‐
rived from those used to treat substance use or gambling disorders. In the literature, indi‐vidual, group, and family psychotherapeutic interventions, pharmacotherapy, and addic‐
tion clinics with multimodal treatment programs have all been mentioned in adolescents[76–78]. Importance is placed on making the person self‐aware regarding the problems intheir life and what they may face in the future due to gaming. In addition, the medical
staff should support the individual and the family in successfully dealing with gaming
and smartphones. The multidimensional family therapy (MDFT) approach seems to be a
viable option for IGD. MDFT exemplifies a practical, adaptable, and widely transportableapproach. The MDFT approach is being applied to IGD cases in two ongoing studies inFrance and Switzerland [78,79].
Psychological counseling and discussions with other children are also important.
Cognitive behavioral therapy, in which the patient and the family live in an environment
without smartphones, such as camping or hospitalization, is also important [80]. It is also
necessary to visualize and self‐manage the time spent gaming and on smartphones to re‐turn to the same environment after discharge [81]. To improve IGD, a multifaceted ap‐
proach involving not only patients, families, and doctors, but also companies, govern‐ments, and administrators is required, and preventive measures are currently being con‐sidered in Asia from a variety of perspectives.
Medications such as bupropion, escitalopram, or methylphenidate have been used totreat IGD and/or comorbid psychopathology (e.g., depression, anxiety, and ADHD) [76].
A recent meta‐analysis involving 5601 children and young adults with Internet addic‐
tion/IGD indicated that pharmacotherapy combined with CBT or multilevel counselingmight be an effective therapeutic strategy for youth with gaming disorder [82].
7.2. Proposition: IGD Is a New Lifestyle‐Related Disease in Children
IGD has emerged as a new behavioral addiction that appeals to the younger genera‐tion despite risks to their physical, mental, social, or financial wellbeing. With the rapid
proliferation of online games, there is a risk that IGD will promote sedentary behavior,irregular eating patterns, and other unhealthy lifestyle choices in children [21]. Further‐more, several studies have found that young adolescents are at risk of substance abuse[83]. New devices are being released worldwide, and the next boom is occurring repeat‐
edly. However, the negative effects of these devices are not observed until a little later.
Today, the population of people who enjoy the Internet and games has grown too large
to conclude that they are uniformly inadequate.
The concern is that IGD is now a lifestyle disease for children. The basis of measuresagainst lifestyle‐related diseases is to raise awareness in society to prevent the onset of thecondition.
8. Conclusions
Despite being identified as a separate entity by DSM‐5, the true scope of the IGD is
yet to be determined and recognized as a valid public health concern. Foremost, there isa diagnostic ambiguity involving Internet addiction and IGD that must be resolved. Most
importantly, research into the management of IGD is in its infancy and needs to accelerate.
There is an urgent need to raise awareness and formulate effective clinical guidelines forthe management of IGD. On the other hand, there has been extensive research on gametheory and gamification, facilitated by advances in information technology in society. It is
hoped that this discussion will not hinder the progress of technology so that the technol‐ogy of game development can benefit humanity.

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Author Contributions: Conceptualization, G.I. and R.S.; methodology, G.I.; writing—original draft
preparation, G.I.; writing—review and editing, R.S.; visualization, G.I.; supervision, A.M. and S.Y.
All authors read and agreed to the published version of the manuscript. All authors have read andagreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: The authors would also like to thank SreeHarsha Bantu for medical writing
assistance and Raghuraj Puthige for editorial assistance from Enago LifeSciences, India in accord‐
ance with good publication practices (GPP3) guidelines.
Conflicts of Interest: The authors declare no conflicts of interest.

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