After the inclusion of internet gaming disorder (IGD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013 [1], World Health Organization (WHO) recognized gaming disorder (online and offline) as a disease in the 11th Revision of International Classification of Diseases (ICD-11) in 2019 [2]. The reported range of prevalence of IGD among Chinese adolescents is wide (2.4% to 21.5%), possibly due to methodological differences [3]. Adolescents are vulnerable to IGD, which has many adverse consequences (eg, loneliness and depression [4-6]).

Maladaptive cognition is an important intrapersonal factor of addictive behaviors like pathological gambling [7] and internet addiction [8]; maladaptive cognitions related to internet gaming (MCIG) have also been associated with IGD [8-10]. A systematic review of 36 studies of MCIG proposed a 4-factor cognitive framework (ie, overvaluation of gaming rewards, maladaptive rules, gaming for self-esteem, and gaming for social acceptance) [11]; the 4 types of MCIG were all positively associated with IGD among adolescents [9]. A recent validation study modified this 4-factor model and revealed a new 3-factor model (ie, perceived rewards of internet gaming, perceived urges for playing internet games, and perceived unwillingness to stop playing without completion of gaming tasks) that demonstrated satisfactory psychometric properties [12]. The 3 domains of MCIG were all positively correlated with IGD [12]. The revised scale was used in this study.

Impulsivity and self-control are 2 important intrapersonal factors of addictive behaviors, including substance use [13,14], smoking [15], alcohol drinking [16], internet addiction [17], and IGD [4,18-21]. Impulsivity and self-control fit into the dual-process theories of decision-making for risk behaviors [22-25]. Impulsivity represents reactive, intuitive, and affective processes with high responsiveness to temptations and prompt actions without deliberation [24]. In contrast, self-control reflects the reasoned process and ability in regulating impulses deliberatively [26,27]. The 2 processes jointly affect decisions in the performance of risk behaviors [22-25]. Adolescents with high impulsivity may exhibit heightened spontaneous responses to behavioral cues to internet gaming, while those with low self-control may find it difficult to resist the temptation of playing internet games and stop playing.

Interpersonal influences are important factors of IGD. Empirical studies have reported positive associations between interpersonal influences (eg, parents’ invitations of playing internet games and intensity of peers’ gaming behaviors) and IGD or internet addiction among high schools students [28,29]. Interpersonal influences may affect IGD in different ways. Significant others’ direct invitations to play internet games may trigger prompt engagement in internet gaming. According to the health belief model, such invitations to play internet games represent cues to action, which is an important determinant of health-related behavior [30]. Frequent invitations may increase adolescents’ gaming intensity, which is associated with risk of IGD [28]. In addition, the reciprocal determinism construct of social cognitive theory (SCT) postulates that one’s environment, personal factors, and health-related behaviors interact with each other [31]. Having significant others playing internet games frequently forms a social environment that may increase adolescents’ gaming frequency. More importantly, SCT postulates that observational learning is an important factor of health-related behavior [31]; adolescents may play internet games frequently through observational learning from their significant others’ frequent internet gaming.

Importantly, MCIG are potential mediators of the association between impulsivity or self-control and IGD. Brand’s model [32] proposes that dysfunctional personality traits increase addictiveness to specific internet applications (including internet gaming), through mediation of changes in related cognitions (eg, expectations). Cognition of outcome expectancy regarding addictive behaviors has been shown to partially mediate the associations between impulsivity (a type of dysfunctional personality trait) and addictive behavior (eg, substance use and alcohol drinking) [33,34]. These studies, however, did not look at IGD. Following Brand’s model, this study hence tested whether MCIG would mediate the association between impulsivity and IGD. This contention is indirectly supported by a study that reported a partial mediation of the association between maladaptive personality traits (ie, negative affectivity, detachment, and psychoticism) and IGD via the cognition of expectancies related to using internet gaming to escape from reality [35]. That study, however, did not include other types of MCIG. Furthermore, we did not locate studies that looked at MCIG as a mediator between self-control and IGD. This study thus sought to fill some of deficiencies in the relevant literature.

The mediation between interpersonal influences and IGD via MCIG was also tested in this study. The hypothesis is supported by the theory of triadic influence, which is a framework that incorporates influential factors of addictive behaviors from a number of psychological and sociological theories [36]. It distinguishes between distal or ultimate factors that influence proximal factors of changes in health-related behaviors [37]. According to the theory of triadic influence, interpersonal factors are distal or ultimate variables while cognitive factors related to a certain behavior are proximal variables [36]; the theory suggests that cognitive factors (eg, outcome expectancy) mediate between interpersonal influences and health-related behaviors [38,39]. Such mediations were found for some addictive behaviors (eg, substance use [40], alcohol drinking [41], and internet addiction [29]). One study also reported full and partial mediation of the cognition of positive outcome expectancy of internet gaming between interpersonal influences (peers’ positive attitude toward gaming, intensity of peers’ internet game use, and the frequency of peers’ invitation to play internet games) and IGD among high school students [28]. To our knowledge, however, no study has looked at the mediation effects of other types of MCIG.

We thus investigated the factors of IGD, including impulsivity, self-control, interpersonal influences exerted by parents and peers, and the 3 types of MCIG (perceived rewards, perceived urges, and perceived unwillingness to stop playing) among junior middle school students (grade 7 to 9 of formal education) in 2 populous cities in China. We then tested the mediation effects of MCIG on the associations between impulsivity or self-control and IGD, and between interpersonal influences and IGD, respectively. We hypothesized that the direct and indirect effects would be statistically significant.

This study revealed an alarmingly high prevalence of IGD (around 14% among all adolescent participants and 18% among adolescent internet gamers). The prevalence was comparable to the 13% among adolescents of 2 other Chinese cities [51], but much higher than the 2% among Chinese Macau adults [52] and the 3.1% among Australian adolescents [9]. These studies all used DSM-5 criteria to assess IGD. The high prevalence of IGD signifies the need to regulate internet gaming behaviors and conduct interventions to reduce IGD among adolescents in China, as adolescent IGD has been positively associated with various behavioral problems (eg, aggression and violence [53,54]) and mental health problems (eg, loneliness and depression [4-6]).

In our study, a number of background factors were associated with a higher risk of IGD, including male sex, higher grades, not living with both parents, and self-reported below-average academic performance. First, corroborating previous studies [18,55,56], males were associated with a higher risk of IGD. This finding may be explained by the sex differences in brain responses [57], motives of internet gaming [58], and a less female-friendly gaming environment [59], among other plausible factors. Second, higher grades were positively associated with IGD in this study. Similar findings have been reported [9], but the direction of the association between age and IGD was mixed [18,60]. Future longitudinal studies are warranted to examine the associations between sex, age, grade, and IGD to develop sex- and age-specific interventions to reduce IGD. Furthermore, disadvantaged adolescents, including those of lower socioeconomic status (eg, self-perceived lower household income) and those not living with both parents were more likely than others to have IGD. Similar results were reported in previous longitudinal and cross-sectional studies [61,62]. Disadvantaged adolescents might have fewer resources for leisure activities and less parental monitoring over internet use, which may lead to more intensive internet gaming and higher risk of developing IGD [61]. A negative association between academic performance and IGD was also reported in our study, which was consistent with previous literature [18,63,64]. It is worth noting that the relationship between academic performance and IGD may be bidirectional. Frustration over poor academic performance may lead to problematic gaming as a means of escape and maladaptive coping [65], which has been associated with IGD [66]. Conversely, IGD may lead to poor academic performance [5,67]. The causal direction needs to be confirmed by longitudinal studies.

To facilitate the design of effective interventions for reducing IGD, it is important to understand the mechanisms (mediation) underlying the associations between risk or protective factors of IGD and IGD. The findings reveal that some intrapersonal (impulsivity) and interpersonal (interpersonal influences) risk factors may elevate the levels of the 3 types of MCIG, which may in turn increase the risk of developing IGD. Furthermore, self-control may reduce MCIG, which may increase IGD (a partial mediation effect). Nonetheless, the presence of significant direct effects between impulsivity, self-control, and interpersonal influences and IGD imply the existence of other unstudied mediators. For instance, coping is a potential mediator, as Brand’s model postulates dysfunctional copying strategies mediate between personality traits and problematic use of the internet (including IGD) [32], while impulsivity can be considered a personality trait. Interpersonal influences may also strengthen the subjective norms of internet gaming (ie, significant others’ support for internet gaming), which is a construct of the theory of planned behaviors [68]; these subjective norms are expected to be associated with MCIG. Future studies should look at other mediators.

The observed mediation effects suggest that modifications of the 3 types of MCIG can potentially reduce the harmful impacts of impulsivity or interpersonal influences on IGD and increase the protective effect of self-control against IGD. Targeted interventions to improve MCIG may include training to increase awareness of the 3 types of MCIG and skills to perform related cognitive reconstructions [69], provision of alternative sources of rewards (eg, outdoors activities) to reduce perceived rewards of internet gaming, removal of sources of temptations and stimuli (eg, gaming devices), and introduction of distraction skills to reduce perceived urges or unwillingness to stop playing internet games [70,71].

There are also plausible explanations for why impulsivity was positively associated with the 3 types of MCIG. First, impulsivity may increase reward sensitivity that enhances adolescents’ drives to seeking more rewards from addictive behaviors [72,73]; impulsive adolescents may thus possess a higher reward drive and perceive more rewards from internet gaming. Second, impulsive adolescents may be more responsive to cues of internet gaming and thus hold stronger urges for playing. Third, impulsivity in general may reduce impulse inhibitions against addictive behaviors, even in the presence of negative consequences [74-76]; adolescents with weakened inhibitions of gaming impulses may thus be less able to resist stimuli inductive to playing internet games and may perceive stronger unwillingness to stop playing. Self-control was negatively associated with the 3 types of MCIG, possibly because of the negative association between impulsivity and self-control [22-25], but other reasons may also apply. Interventions for modifying impulsivity and self-control may remove temptations and strengthen self-efficacy in regulating impulses [77]). In particular, the if-then planning intervention that specifies when, where, and how to regulate impulses is potentially useful [78]; a review reported that this type of intervention showed efficacy in reducing addictive behaviors (eg, in binge drinking and cigarette smoking) [79].

This study also found positive associations between interpersonal influences and MCIG. Having significant others who are frequent internet gamers was positively associated with MCIG. The SCT suggests that, through reciprocal determinism and observational learning, social interactions may influence both adolescents’ attitudes and behavior [31]. It is likely that adolescents’ parents or peers who play internet games frequently may also perceive higher levels of MCIG (eg, the 3 types of MCIG). Adolescents’ maladaptive cognitions may be influenced by those of their parents via multiple means, such as social learning, subjective norms, and reinforcement. Furthermore, peers influence each other to form common perceptions regarding particular behaviors [80]. Future confirmation is needed. Family-based interventions for reducing IGD are potentially useful. A psychoeducation on maladaptive and adaptive use related to internet games showed preliminary effectiveness [81]. Another intervention that involved parental monitoring on adolescents’ self-regulation practice and gaming behaviors showed short-term (3 month) efficacy in improving attitude, knowledge, self-regulation, and IGD among adolescents [82]. Although a meta-analysis showed that peer-led interventions were efficacious in reducing tobacco, alcohol, and substance use among adolescents [83], our literature search did not locate similar interventions for IGD. Future evidence-based interventions are warranted.

This study has several limitations. First, reporting bias, such as recall bias and social desirability bias, might have been introduced. Second, as the participating schools were selected based on convenience, there might have been selection bias, and generalization of the study results should be done cautiously. Third, the prevalence of IGD assessed by using the DSM-5 checklist might have been overestimated compared with that based on the ICD-11 criteria [84]. Fourth, we were unable to make causal inferences due to the cross-sectional nature of this study. Fifth, the revised assessment tool of interpersonal influences has not been validated although we conducted confirmatory factor analysis to test its 2-factor structure, which showed an acceptable goodness of fit. Finally, this study only investigated internet gaming but not offline video games, while both online and offline video games are included in the ICD-11 under the category of gaming disorder, as the 2 types of gaming disorder differ in etiology, epidemiology, and treatment.

In conclusion, MCIG partially mediated the associations between impulsivity, self-control, or interpersonal influences and IGD. Modifications of the 3 types of MCIG may effectively reduce the harmful impacts of impulsivity or interpersonal influences on IGD and increase the protective effect of self-control against IGD. Future longitudinal studies are warranted to verify these findings and explore other potential mediators.