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Prevalence and Risk Factors of Video Game Dependency in Adolescence: Results

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CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 13, Number 0, 2010
ª Mary Ann Liebert, Inc.
DOI: 10.1089=cpb.2009.0227

Prevalence and Risk Factors of Video Game

Dependency in Adolescence: Results
of a German Nationwide Survey

Florian Rehbein, Grad. Psych., Matthias Kleimann, Grad. Mediasci., and Thomas Mößle, Ph.D.

Abstract

In this article, results of a German nationwide survey (KFN schools survey 2007=2008) are presented. The
controlled sample of 44,610 male and female ninth-graders was carried out in 2007 and 2008 by the Crimin-
ological Research Institute of Lower Saxony (KFN). According to a newly developed screening instrument (KFN-
CSAS-II), which was presented to every third juvenile participant (N ¼ 15,168), 3% of the male and 0.3% of the
female students are diagnosed as dependent on video games. The data indicate a clear dividing line between
extensive gaming and video game dependency (VGD) as a clinically relevant phenomenon. VGD is accompa-
nied by increased levels of psychological and social stress in the form of lower school achievement, increased
truancy, reduced sleep time, limited leisure activities, and increased thoughts of committing suicide. In addition,
it becomes evident that personal risk factors are crucial for VGD. The findings indicate the necessity of additional
research as well as the respective measures in the field of health care policies.

Introduction use behaviors and a subsumption under one medical cate-

gory could prove premature.

W hile TV usage time could be observed to be fairly

consistent in almost all age groups in the past decade,1
the relevance of interactive entertainment media as leisure-
time activity has grown considerably both for youths and
adults. In Germany, for example, computer ownership among
adolescents ages 12 to 19 increased from 35% to 71% from
1998 to 2008, and ownership of gaming consoles increased
from 23% to 45%. The availability of Internet access in ado-
lescents’ bedrooms rose from roughly 10% in 1998 to 51% in
2008.2,3
Recently, the issue of extensive video game (the term video
games is used for both video and computer games in this
article) behavior has gained further attention in research and
clinical practice.4–8 Young9 specified a wide range of poten-
tially addictive phenomena, such as cybersexual addiction,
cyberrelational addiction, Net compulsions, information
overload, and computer addiction. Subsequently, frequent
attempts to explore these phenomena on an aggregated level
called computer-related addictive behavior,10 Internet addic-
tion, or compulsive Internet use11,12 are observed. However,
due to the richness of different computer- and Internet-
related activities, these terms could be criticized as not being
precisely operationalized.7 To date there has been little em-
pirical insight into these diverse kinds of problematic media
With video game dependency (VGD), we focused our re-
search efforts on a clinical phenomenon currently reported to
be notably widespread among computer-related problematic
behaviors.8 Video games can satisfying a wide number of in-
dividual psychological needs and, because of their interactive
structures, give rise to an intense experience of gratification in
the user.13,14 In sophisticated games such as massively mul-
tiplayer online role-playing games (MMORPGs), players can
regularly acquire or obtain points, placements on ranking
lists, pieces of virtual equipment, new abilities, and oppor-
tunities to configure their own avatar. The allocation of these
rewards frequently follows a pattern of intermittent rein-
forcement to the effect that the placing and magnitude of
rewards are rarely predictable.5 According to learning psy-
chology, reinforcement schedules of this kind generate the
highest response rates as well as the highest resistance to
extinction15 and therefore particularly promote an excessively
rewarding behavior. Hence, video games in their very con-
ception show a structural similarity to gambling and, as a
consequence, are suspected of bearing a similar psychotropic
dependency risk for some people.16
The distinctive mechanisms, however, involved in binding
certain players to certain virtual worlds are roughly system-
atized and barely understood in detail to date. Different risk

Criminological Research Institute of Lower Saxony (KFN), Hanover, Germany.

1
2 REHBEIN ET AL.
factors of VGD have been discussed, such as playing more
complex games such as MMORPGs,4,17 gaming in terms
of dysfunctional coping,6,7,18 low parental support,19 school-
related behavioral problems,19 higher aggressiveness, and the
acceptance of violence as an inherent part of social life and
part of one’s own behavioral repertoire,4,20 as well as in terms
of male gender in general.4,7 Video game–dependent youths
have also been assumed to exhibit a lower education level,7
whereas other studies have not proven the educational
background to be of importance for predicting VGD.19 VGD
is often reported to be accompanied by psychopathological
stress indicators, such as attention deficit hyperactivity dis-
order (ADHD), as well as affective disorders.8,10 Their rele-
vance for predicting VGD, however, is still a matter under
discussion, and large-scale studies considering them alto-
gether are missing.
Like other forms of potentially addictive computer use,
VGD has not been clinically accepted so far. In 2007, the ap-
plication to the Diagnostic and Statistical Manual of Mental
Disorders (DSM) of the American Psychiatric Association was
still assessed negatively with the note that the database for
such a step was not yet sufficiently secured.21 Against this
backdrop, in the past years, increasing efforts have been
made to develop diagnostic instruments to examine VGD and
to determine the percentage of persons affected by it.4,6,7 To
allow for clinically significant statements, analysts frequently
refer to criteria of substance-related dependency or patho-
logical gambling.5 These criteria, however, have been applied
and weighted inconsistently so far. Due to this heterogeneous
definition and varying sampling approaches in different age
groups and populations, prevalence estimates for VGD cur-
rently range from 1.5% to 9.3% between different studies.4,6
The first aim of the present study was to validate the newly
developed, short, and easy-to-administer Video Game De-
pendency Scale (KFN-CSAS-II) in a German nationwide
representative sample of ninth-graders. It was intended to
get a first nationwide prevalence estimate of VGD in a well-
defined age group. A second aim was to identify risk fac-
tors predicting VGD in adolescence. We assumed factors of
gaming behavior such as playing complex and often online
used games like MMORPGs, shooters, and strategy games, as
well as gaming in terms of dysfunctional coping and gaming
as a source of self-efficacy to contribute to the risk of VGD.
We also expected social factors such as a lack of success in
leisure-time activities and school related behavioral problems
to increase the risk of a dependency. Regarding socio-
demographic parameters, we supposed male participants to
be at higher risk, but did not expect parental or juvenile ed-
ucational background to be of any importance for predicting
VGD. With regard to psychological constructs, we hypothe-
sized that personal factors such as lower levels of social
competence, higher levels of impulsiveness, a higher accep-
tance of violence, a history of ADHD, a diagnosis of depres-
sion or anxiety disorders as well as physical abuse in
childhood could contribute to the risk of VGD.
Methods
Procedure
From April 2007 to October 2008, the Criminological Re-
search Institute of Lower Saxony (KFN) conducted a survey
with 44,610 ninth-grade students in 61 randomized regions
of Germany. Using a proportional sampling of regions from
eastern and western Germany as well as independent cities
and administrational districts (counties) of different sizes, a
representative sample of the population of German ninth-
graders at schools offering a general education was
achieved.22 A 31-page standardized inventory was adminis-
tered within the context of the class and completed by the
students on their own after instruction by a trained inter-
viewer. The inventory covered a wide range of research in-
terests, such as juvenile delinquency, drug use, victimization,
xenophobia, school absenteeism, and parental educational
styles. A further inventory of six pages containing more fo-
cused questions on the topic of media use and VGD was
handed out at random to every third participant. Thus, re-
garding VGD, 15,168 cases resulted for further analysis. The
return quota was 88%.
Measurement of VGD
The Video Game Dependency Scale (KFN-CSAS-II) is
based on the Internet Addiction Scale (ISS-20),11 which was
extended and adapted to the issue of VGD.5 The KFN-CSAS-
II consists of 14 items (4-point scale: 1, incorrect, to 4, absolutely
true). It follows the classification of dependency of ICD-10
and covers the dimensions preoccupation=salience (4 items),
conflict (4 items), loss of control (2 items), withdrawal symptoms
(2 items), and tolerance (2 items). Out of the 15,168 adolescents
who took part, 10,060 responded to all of the 14 items. Three
hundred forty-two persons responded to 13 of the 14 items,
whereas the missing item was substituted by the scale mean.
Out of the 4,766 participants who could not be diagnosed
because of two or more missing values, 2,635 persons were
nonplayers or occasional players.
The mean item values reveal high item difficulties for all
items (see Table 1). All of the items show good discriminatory
power (ri(t-i)
0.6). For the diagnostic status, all four-level
variables are added together so that the scale assumes a value
of between 14 and 56 points (a ¼ 0.92). The mean scale value
for our representative sample of 15-year-old adolescents is
19.8 points (SD ¼ 7.42, SE ¼ 0.07). The cutoff values for the
KFN-CSAS-II were defined according to the ISS-20.11 A sum
score of 35 to 41 indicates that a person is at risk of developing
VGD, as the items on an average are not rejected any longer
(142.5 ¼ 35). Persons who reach this value are already about
2 standard deviations above the population mean. With a
sum score of 42 and higher, by which on average all items
meet with approval, a person is classified as dependent on
video games. Those who reach this critical value are about 3
standard deviations above the mean. With these compara-
tively strict cutoff values, the sensitive subject matter is to be
taken into account by accepting a lower diagnostic sensi-
tiveness in favor of a higher diagnostic specificity.
Measurement of validation variables
For a general assessment of VGD, participants were asked
on a 6-point scale (not at all to strongly), ‘‘To what extent, do
you believe, you are dependent on video games?’’ (Note that
all quoted items are translated from German.26) Participants
were also asked to estimate the time they spent on different
media activities on school days and on weekend days, in-
cluding online and offline gaming (15-point scale: 0 minutes to
5 hours and more). Based on this data, a daily usage time was
PREVALENCE AND RISK FACTORS OF VIDEO GAME DEPENDENCY 3

Table 1. Item Parameters of the Video Game Dependency Scale KFN-CSAS-II (n ¼ 10,402)

M SD ri(t-i)

Preoccupation=salience
During the time that I don’t play video games, in my 1.64 0.87 0.61
thoughts I am very much occupied with games.
My thoughts continually circle around playing video 1.26 0.62 0.69
games, even when I’m not playing.
At certain times or in certain situations, I actually 1.55 0.90 0.63
always play: That has almost become a routine for me.
It happens that I’m virtually doing something 1.36 0.73 0.60
completely different and then, without thinking, start a video game.
Conflict
My school achievement suffers under my game habits. 1.31 0.68 0.64
I am so frequently and intensively occupied with video 1.35 0.70 0.70
games that sometimes I have problems in school.
People important to me complain that I spend too much time playing. 1.55 0.83 0.64
Because I play too much, I undertake less with others. 1.38 0.72 0.63
Loss of control
I often spend more time playing video games than I planned. 1.50 0.83 0.65
I have a feeling that I cannot control my gaming time. 1.42 0.79 0.64
Withdrawal symptoms
If I can’t play, I am irritable and dissatisfied. 1.39 0.71 0.70
If I don’t play for quite a while, I become restless and nervous. 1.23 0.59 0.67
Tolerance
I have a feeling that video games are getting more and more important for me. 1.47 0.78 0.73
I feel forced to play longer and longer to be satisfied. 1.30 0.68 0.65
Scale Cronbach’s a ¼ 0.92

Note: Items as translated from German. The statistical values refer to the German version.26 Means are based on a four-stage response
format (1, incorrect, 2, hardly correct, 3, rather correct, 4, absolutely true). ri(t-i) ¼ selectivity according to item-rest correlation. Unidimensionality is
safeguarded by factor analysis.

calculated: (school day5 þ weekend day2)=7. Indicators of
academic performance were assessed as well: participants
stated their grades in the last school report (1, very good, to 6,
insufficient) and marked whether they skipped single lessons
or whole school days in the past half-year. Based on this in-
formation, a total number of skipped lessons was calculated
(school day5 þ single lessons). Multiple truancy was de-
fined as missing more than 5 school days in the last half-year.
Additionally, participants stated whether video gaming was
the reason for their truancy (2-point scale: yes or no). Sleeping
time was calculated as the time span between the self-
reported time of going to bed the day before and the time of
getting up on the day of the interview (33-point time scale: 15-
minute breakdown). Participants were further asked whether
they had difficulties in falling asleep in the past week (5-point
scale: never to always). Sleeping disturbance was coded when
participants quoted always for the week before. Using a wide
range of items regarding organized youth activities (e.g.,
sports club, music school, youth association), participants
who in the past year had not participated in at least one
activity were identified. Finally, for assessing psychological
stress indicators, we asked students about suicidal thoughts:
‘‘Have you ever thought of committing suicide?’’ (4-point
scale: no, never to yes, often).
Measurement of risk factors
To assess risk factors regarding gaming behavior, students
were asked for their usage times of nine different video game
genres in the preceding year, including MMORPGs, first-
person shooters, and strategy games (7-point scale: never to
daily). Participants were identified as using particular genres
if they played the respective genre at least monthly. The
adolescents were also asked to name their three currently
favorite video games. The resulting string variables were
recoded to numeric variables by a trained coder, whereas
different versions of one game (e.g., Counterstrike, Counter-
strike Source, Counterstrike Condition Zero) were merged
into one group. The impact of gaming in terms of dysfunc-
tional coping was assessed by the item ‘‘I usually play video
games when my life is not going well’’ (4-point scale: incorrect
to absolutely true); the role of gaming as a source of experi-
encing self-efficacy was assessed with the question ‘‘How
relevant is it for you to feel powerful and in control when
playing action games?’’ (4-point scale: irrelevant to very rele-
vant). We refrained from including gaming time and variables
that are clearly confounded with gaming time as predictors
for VGD, since they can be expected to be indicators rather
than risk factors of VGD.
Regarding social predictors, participants were asked—
referring to a wide range of different areas of youth leisure
activities and aspects of common life such as sports, music,
friends, family, school, and video games—whether they
succeeded in these areas within the previous year (2-point
scale: yes or no). Subsequently, participants who could name
only video games as a domain of success were identified.
School-related anxieties were assessed by a five-item scale (4-
point scale: incorrect to absolutely correct) mainly regarding
embarrassing situations and failures in test situations
(a ¼ 0.78). Previous failures in academic achievement were
4 REHBEIN ET AL.
accounted for by the question whether the participants ever
had to repeat a school year (2-point scale: yes or no).
For assessing demographic predictors, we used the gender
of students as well as juvenile and parental educational
background measured by the question ‘‘What is the highest
qualification of your parents?’’ A low parental educational
background was classified if neither of the parents had at
least completed the middle secondary school Realschule (Re-
alschule is usually completed at the end of tenth grade which
qualifies a student to go on to upper secondary school), and a
low juvenile educational background was classified if the
participants themselves attended the lower secondary school
Hauptschule (Hauptschule is usually completed at the end of
ninth grade which qualifies a student for entering into vo-
cational training or apprenticeship or to switch to Realschule).
With regard to psychological predictors, a five-item scale
(2-point scale: no or yes; a ¼ 0.71) mainly indicating social
competence and the ability of putting oneself in the place of
another interacting person (e.g., ‘‘Before I criticize people I try
to imagine how I would feel in their place’’) was used. Im-
pulsiveness was measured by using two items of the impul-
siveness inventory IVE23 (‘‘I often get in uncomfortable
situations because I didn’t think it over’’ and ‘‘I often get in
trouble because I can’t control myself’’ (2-point scale: no or
yes). Additionally, four items were used to assess the accep-
tance of violence as an inherent part of social life and part of
one’s own behavioral repertoire (4-point scale: incorrect to
absolutely true), in which participants had to appraise their
beliefs about the role of violence in everyday life (a ¼ 0.87).
Psychological disorders (depressive, anxiety, and attention)
in the students’ personal history were assessed by the ques-
tion whether a physician or psychologist had ever diagnosed
these disorders (2-point scale: yes or no). Finally, participants
were asked if they had been severely physically abused by
their mothers or fathers before the age of 12 (6-point scale:
never to repeatedly per week) regarding the following incidents:
hit with an object, punched or kicked, beaten or bashed.
Students were classified as frequently abused if they had
experienced such events at least monthly during childhood.
Participants
The average age of the participants was 15.3 years
(SD ¼ 0.69), about half of them being male (51.3%), and 27.4%
with a migration background. On average, the students use
video games 141 minutes a day. Online games made up al-
most 60% of the time spent with video games (83 min). Boys
play 130 minutes on school days (77 min online) and 167
minutes on weekend days (97 min online). Girls play about 53
minutes on school days (33 min online) and 64 minutes on
weekend days (38 min online). Altogether, girls with an av-
erage daily gaming time of 56 minutes use video games 90
minutes less than boys; 12.6% of the girls and 39% of the boys
could be characterized as extensive gamers spending more
than 2.5 hours a day with video games.
Results
Prevalence
Of the adolescents surveyed, 2.8% are classified as being at
risk and 1.7% as being dependent on video games. Mainly
boys are affected: 4.7% of them are at risk and 3% are de-
pendent. In comparison to boys, a small number of girls are
affected: 0.5% are at risk and 0.3% are dependent. Hence,
roughly 90% of the youths at risk and 91% of the ones de-
pendent are males.
Validation
For a validation of the Video Game Dependency Scale
(KFN-CSAS-II), only data of male participants were used
because most of the variables under consideration are con-
founded with gender. As expected, boys classified as video
game dependent show increased usage times ( p < 0.01).
While this group in particular shows a high daily online
gaming time of 188 minutes, offline game usage is compar-
atively modest (see Table 2). The self-evaluation of the par-
ticipants corresponds with the classification to a considerable
extent (r ¼ 0.59, p < 0.01).
Similar patterns are found with regard to school achieve-
ment and school absenteeism. While boys who game exten-
sively show slightly worse grades in German, history, and
sports (larger numbers indicating lower performance), the
school performance clearly deteriorates in the group of video
game–dependent boys ( p < 0.01). Additionally, extensive
gamers play truant similarly to inconspicuous male youths;
video game–dependent boys, however, have skipped more
lessons and are more often classified as multiple truants with
more than 5 days of absence from school ( p < 0.01). More-
over, members of this group more often give video gaming as
the reason for their truancy ( p < 0.01).
Regarding health-related factors, results show successively
reduced sleep time through the groups, culminating in video
game–dependent boys with the shortest average time of sleep
( p < 0.01). Consistent with this observation, especially video
game–dependent boys, but not at-risk boys, report intensive
problems falling asleep in the past week ( p < 0.01). In addi-
tion, an increased part of the video game–dependent male
adolescents report not participating in any regular, organized
leisure-time activities ( p < 0.01). The more frequent thoughts
of committing suicide among boys at risk ( p < 0.01) and es-
pecially dependent boys ( p < 0.01) indicate an increased
mental stress within these two groups.
Predictors of video game dependency
The top 10 games among boys, in order of their circulation,
are Counterstrike (27%), FIFA Soccer (16.1%), Need for Speed
(11.4%), Grand Theft Auto (10.1%), World of Warcraft (9.8%),
Call of Duty (7.8%), Battlefield (5.1%), Warcraft (4.9%), Pro
Evolution Soccer (4.8%), and Guild Wars (2.7%). A compar-
ative analysis of these 10 games among male adolescents
found that every fifth player of the online role-playing game
World of Warcraft shows a risk for or an already existing
VGD. Users of Counterstrike, Warcraft, Battlefield, Call of
Duty, and Guild Wars, games that are often or preferably
played online, show an increased share of dependent persons,
too. The data also suggest a higher share of VGD in males
using games played exclusively on personal computers. With
the three sports games Pro Evolution Soccer, Need for Speed,
and FIFA Soccer, a reduced share of persons at risk becomes
obvious. The daily video game times follow a similar pattern,
with the highest daily gaming times observed for boys using
World of Warcraft (see Table 3). An increased risk of devel-
oping VGD seems to be inherent in certain video games. One
PREVALENCE AND RISK FACTORS OF VIDEO GAME DEPENDENCY 5

Table 2. Psychosocial Stress Indicators by Usage Group (Boys Only, n ¼ 7,761)

Main group Extensive players Players at risk Dependent

Psychosocial (<2.5 h=day) (>2.5 h=day) (RS
35) players (RS
42)
stress indicators n ¼ 4,621 n ¼ 2,619 n ¼ 324 n ¼ 197

Primary validation
Online gaming time 26 min 159 min** 172 min** 188 min**
Offline gaming time 33 min 100 min** 74 min** 78 min**
Self-assessment VGD (1–6) M ¼ 1.8 M ¼ 2.4** M ¼ 4.1** M ¼ 4.8**
Grades at school
German 3.14 3.28** 3.32** 3.46**
Mathematics 3.05 3.07ns 3.30** 3.29**
History 2.83 2.92** 3.03** 3.17**
Sports 2.05 2.17** 2.19ns 2.42**
School absenteeism
Skipped lessons 10.1 h 10.0 hns 16.4 h** 18.6 h**
Multiple truancy 12.5% 12.2%ns 21.6%** 22.4%**
Motive: video gaming 8.2% 23.2%** 44.9%** 63.8%**
Health-related factors
Time of sleep 7.5 h 7.3 h** 7.1 h** 6.9 h**
Sleep disturbance 4.1% 6.1%** 7.6%ns 15.1%**
No regular leisure-time activities 30.4% 36.9%** 39.0%* 44.6%**
Frequent thoughts of suicide 2.4% 3.0%ns 6.3%** 12.3%**

Note: To the main group and to the group of extensive players, there were assigned only boys who in accordance with KFN-CSAS-II were
not classified as conspicuous either because they did not reach the critical value (RS < 35, n ¼ 6,367) or could not be diagnosed because of two
or more missing values (n ¼ 873). Grades at school do correspond to the German grading system: 1, very good, to 6, insufficient. Test of
significance by means of analysis of variance (ANOVA). Post hoc testing with Scheffé test. RS ¼ raw score in KFN-CSAS-II. The deviation
from the main group is given.
*p < 0.05; **p < 0.01; ns, not significant.

would expect, however, that certain person-immanent factors
as well as factors of the person’s social environment add to the
risk of VGD, too. These factors could similarly increase the
likelihood of using certain types of video games.
To determine which of the risk factors contributes to the
development of VGD in a significant way, we performed a
logistic regression analysis, predicting the classification as
being dependent (KFN-CSAS-II RS
42). Only boys and girls
who were gaming regularly were included in the analysis,
since we intended to predict VGD and not video gaming in
general. Table 4 shows the descriptive measures of the pre-
dictors used in this model.
Sixty-one percent of the regularly playing adolescents are
male. Most of the other predictors are moderately distributed,
such as the use of the three game genres (24–30%), lower
educational background (19–29%), and previous repetition of
a school year (22%). As expected, with regard to the predic-
tors no success in leisure-time activities besides gaming (2%),
frequent abuse in childhood (3%), and psychological disorders in
personal history (4–8%), only a small number of adolescents

Table 3. Imperiled and Dependent Persons among Players of the 10 Most Popular Games
of Male Adolescents (Boys Only, n ¼ 6,230, Weighted)

Deviation from Deviation from

Usage scale mean mean gaming
Player of… Genre (hardware) (KFN-CSAS-II) At risk Dependent time (min=day)

World of Warcraft MMORPG Online (a) þ5.1** 11.6% 8.5% þ88**

Guild Wars MMORPG Online (a) þ2.8** 5.8% 3.8% þ56**
Warcraft Strategy Online (a) þ2.5** 8.7% 3.8% þ53**
Counterstrike Shooter Online (a) þ2.3** 8.2% 4.9% þ49**
Call of Duty Shooter Both (a, b, c) þ1.0** 6.2% 4.0% þ33**
Battlefield Shooter Online (a, b) þ0.8ns 6.5% 4.1% þ33**
Grand Theft Auto Genre mix Offline (a, b, c) 0.8* 4.5% 2.7% 28**
Pro Evol. Soccer Sports Offline (a, b, c) 2.0** 3.5% 1.9% 36**
FIFA (Soccer) Sports Offline (a, b, c) 2.4** 2.9% 1.2% 50**
Need for Speed Racing Offline (a, b, c) 2.7** 2.8% 1.8% 35**

Online, primarily used with active Internet connection; offline, primarily used without active Internet connection; both, similarly used
online and offline; a, used on PC systems; b, used on TV video game consoles; c, used on handheld video game consoles.
Test of significance with t test (two-tailed). Difference between mean of participants playing a certain game and participants playing only
other games. Included in analysis are only male participants using video games at least occasionally. General mean values for this group:
(KFN-CSAS-II scale) mean, 21.8; at risk, 4.9%; dependent, 3.1%; gaming time, 145 min=day.
*p < 0.05; **p < 0.01; ns, not significant.
6 REHBEIN ET AL.

Table 4. Predictors in the Logistic Regression Analysis Predicting Video Game Dependency
in Boys and Girls Gaming Regularly

Predictors Min Max M SD

Gaming behavior
Gaming in terms of dysfunctional coping 1 (incorrect) 4 (correct) 1.56 0.89
Gaming as source of self-efficacy 1 (irrelevant) 4 (relevant) 2.36 1.06
Usage of MMORPG 0 (no) 1 (yes) 0.24 0.43
Usage of strategy games 0 (no) 1 (yes) 0.30 0.46
Usage of shooter games 0 (no) 1 (yes) 0.24 0.43
Social predictors
No success in leisure-time activities besides gaming 0 (no) 1 (yes) 0.02 0.14
School-related anxieties 1 (no) 4 (many) 1.95 0.66
Previous repetition of a school year 0 (no) 1 (yes) 0.22 0.42
Demographic predictors
Male gender 0 (no) 1 (yes) 0.61 0.49
Low parental education 0 (no) 1 (yes) 0.19 0.39
Low juvenile education 0 (no) 1 (yes) 0.29 0.46
Psychological predictors
Lower social competence 0 (higher) 1 (lower) 0.39 0.32
Impulsiveness 0 (lower) 2 (higher) 0.54 0.74
Acceptance of violence 1 (lower) 4 (higher) 1.57 0.73
ADHD in personal history 0 (no) 1 (yes) 0.08 0.27
Depression disorder in personal history 0 (no) 1 (yes) 0.05 0.21
Anxiety disorder in personal history 0 (no) 1 (yes) 0.04 0.20
Frequent physical abuse in childhood 0 (no) 1 (yes) 0.03 0.17

could be observed, whereas the prevalence for the psycho-
logical disorders are fairly consistent with other studies.24,25
Nine of the 18 factors considered contribute significantly to
the prediction of VGD, accounting for 41% of the variance of
VGD in adolescents (see Table 5).
As one would expect, behavioral variables gaming in terms
of dysfunctional coping and gaming as a source of self-efficacy
both increase the risk of VGD. Our assumption that the
use of complex and often online-used games contributes to
the risk of VGD is only partially supported, though: while
MMORPGs contribute to the risk of developing VGD, strat-
egy or shooter games do not. Our hypothesis that different
social factors are of importance for VGD could fully be sup-
ported. Adolescents with no success in their leisure-time
activities besides gaming, those with higher levels of school-
related anxieties, and those who have repeated a school year
in the past are significantly at higher risk of developing VGD.
The two sociodemographic variables parental and juvenile
educational background, on the other hand, provide no sub-
stantial contribution to predicting VGD. Hence, our hypoth-
esis of VGD being independent of educational background
and therefore not being restricted to specific social environ-
ments could be confirmed. Regarding male gender, our as-
sumption could not be sustained. Although male participants
are to a far greater extent affected by VGD, when simulta-
neously considering other predictors, male gender loses its
importance in predicting VGD. Finally, our hypothesis of
different psychological factors accounting for VGD could
partially be supported. In this context, only subclinical pre-
dictors, such as low social competence, higher levels of im-
pulsiveness, and the acceptance of violence as an inherent
part of social life and part of one’s own behavioral repertoire,
contribute to VGD. The three considered psychological dis-
orders ADHD, depression, and anxiety disorders do not
significantly contribute to the risk of VGD. A trend was ob-
served regarding frequent physical abuse in childhood,
which remained statistically significant in a recently pub-
lished model predicting VGD.26 In the present model, how-
ever, considering a larger number of variables, abuse in
childhood loses its relevance as a predictor.
Discussion
By means of the KFN schools survey 2007=2008, a first
nationwide prevalence value of VGD for 15-year-olds was
obtained. The resulting prevalence of 1.7% (boys: 3%; girls:
0.3%) is to be found at the lower end of other estimations,
generally showing higher prevalence values in younger6 and
similar age groups.7,10 These studies, however, used different
diagnostic instruments and operated with a comparatively
small number of participants. In either case, the relatively
lower prevalence values of this study should not be under-
estimated, since the observed number of affected adolescents
points out an urgent call for public action: in Germany alone,
in the age group of 15-year-olds (843,000 in 2007), one must
assume about 13,000 video game–dependent boys and 1,300
video game–dependent girls.
With regard to the KFN-CSAS-II, its applicability for
drawing a clear dividing line between VGD and a passionate,
however comparatively less problematic, gaming behavior
could be shown. Video game–dependent adolescents show
characteristics of increased psychological and social stress,
confirming the clinical relevance of the phenomenon as re-
ported similarly in other studies.8,10,19 Our study adds to the
existing research in showing that school- and health-related
stress indicators could be observed both in boys exhibiting
conspicuous mean values in the KFN-CSAS-II and, to a minor
degree, in boys showing just increased gaming times. This
points out the importance of differentiating between exten-
sive gaming without pathological background and VGD.
PREVALENCE AND RISK FACTORS OF VIDEO GAME DEPENDENCY 7

Table 5. Logistic Regression Analyses Predicting Video Game Dependency in Boys

and Girls Gaming Regularly (n ¼ 4,727)

95% confidence interval for Exp(B)

Predictors B SE Exp(B) Lower bound Upper bound

Gaming behavior
Gaming in terms of dysfunctional coping 1.22** 0.10 3.39 2.78 4.13
Gaming as source of self-efficacy 0.45** 0.11 1.57 1.28 1.93
Usage of MMORPG 0.58** 0.20 1.78 1.20 2.65
Usage of strategy games 0.17ns 0.21 1.19 0.79 1.80
Usage of shooter games 0.06ns 0.23 1.06 0.67 1.67
Social predictors
No success in leisure-time activities besides gaming 1.60** 0.32 4.94 2.65 9.18
School-related anxieties 0.54** 0.14 1.72 1.31 2.25
Previous repetition of a school year 0.50* 0.21 1.65 1.09 2.51
Demographic predictors
Male gender 0.39ns 0.36 1.48 0.74 2.97
Low parental education 0.28ns 0.27 0.76 0.45 1.28
Low juvenile education 0.22ns 0.22 1.24 0.81 1.92
Psychological predictors
Lower social competence 0.85** 0.31 2.34 1.29 4.25
Impulsiveness 0.31** 0.12 1.36 1.08 1.73
Acceptance of violence 0.27* 0.12 1.31 1.04 1.64
ADHD in personal history 0.02ns 0.28 0.98 0.57 1.70
Depression disorder in personal history 0.04ns 0.41 0.96 0.43 2.13
Anxiety disorder in personal history 0.43ns 0.46 1.54 0.63 3.77
Frequent physical abuse in childhood 0.59ns 0.39 1.81 0.85 3.85

Nagelkerkes R2 ¼ 0.41.
*p < 0.05; **p < 0.01; ns ¼ not significant. All variables entered simultaneously.

However, further studies are required to validate the KFN-
CSAS-II in clinical samples in order to estimate its diagnostic
sensitivity and specificity and to give further advice for
possible improvements.
Another aim of this study was to identify certain risk factors
predicting VGD. Although our cross-sectional study design
does not allow causal conclusions between many of the risk
factors under consideration and VGD, we found the 10
most common video games among boys in 2007=2008 to differ
largely in the percentage of players being at risk and depen-
dent as well as the time spent with these games. Players of
MMORPGs, strategy games, and shooters show increased
means regarding these aspects. Our regression model, how-
ever, illustrates that when considering other important pre-
dictors, only the use of MMORPGs remains to add the risk of
VGD. The risk of adolescents using these games increases by
78%, whereas the explanatory value of shooter and strategy
games turns out to be insignificant in general. These findings
are in line with other studies reporting especially MMORPG
users being at higher risk of developing VGD.4,17 In this
regard, above all the MMORPG World of Warcraft must be
assessed as critical, since in most countries it is classified as
suitable for adolescents (European States covered by PEGI and
USK rating: 12þ; United States ESRB rating: teen), and 8.5% of
its German 15-year-old male users are being diagnosed as
dependent. More research to identify prominent features em-
bedded in these games with a higher risk potential is needed in
order to explain the existing differences and to sensitize the
local authorities responsible for the protection of minors.
Additionally, our regression model points out that a mul-
tiplicity of risk factors is of importance for the development of
VGD. To our knowledge, this is the first study modeling the
risk of VGD simultaneously accounting for factors of gaming
behavior, social stress, sociodemographic variables, and
psychological predictors. Some of the identified predictors
support other studies: importance of dysfunctional cop-
ing,6,7,18 higher levels of acceptance of violence as an inher-
ent part of social life and part of one’s own behavioral
repertoire,4,20 and school-related behavioral problems.19
Furthermore, our results indicating a higher level of sleep
disturbance and suicidal thoughts in video game–dependent
boys are in line with other studies reporting elevated levels of
psychological stress in persons with conspicuous video game
usage.8,10 ADHD, depression, and anxiety disorders in per-
sonal history, however, do not contribute to the risk of VGD
in adolescence. Longitudinal studies are necessary to clarify
the relationship between VGD and comorbid disorders,
carefully considering cause and effect among developmental
changes.
Finally, some findings of this study are contradictory to
other studies. Our results prove VGD to be independent of
educational background, which is consistent with previous
results of a large-scale assessment of 14,301 ninth-graders
conducted in Germany in 200519 but inconsistent with
another German study reporting lower educational back-
ground of video game–dependent boys.7 One explanation for
this discrepancy could be the smaller sample size of 221
children, 14 of whom were identified as dependent,7 wherein
the importance of educational factors in the population is
hardly predictable. Another explanation could be that the
authors included video gaming time as a selection criteria of
VGD.7 Video gaming time is known to be usually higher in
8 REHBEIN ET AL.
adolescents (especially in children) with lower educational
background,4 which could be expected to lead to a higher
chance for this group to be classified as dependent if gaming
time is part of the diagnoses. In contrast, in our study, gaming
time was not included in the diagnostic assessment of VGD.
Moreover, in our regression analysis, we included only stu-
dents playing at least occasionally in order to predict VGD
and not video gaming in general. Therefore, we assume our
risk assessment of VGD to be less confounded with usage
time and therefore to deliver a better estimate for VGD
among different social groups. Further research is needed to
clarify these assumptions. In this regard, it seems noteworthy
that in our regression model, failures at school, school-related
anxieties, and the absence of success in other leisure-time
activities besides gaming seem to play a crucial part in de-
veloping VGD. Thus, there is growing evidence that not
differences in social status per se but the perception of one’s
own status within the peer group could contribute to an es-
cape into virtual worlds and thereby to the risk of VGD.
We found that male adolescents are affected by VGD to
a far greater extent, which again corresponds with other
studies.4,7 Accounting for other risk factors, however, the
male gender is no longer of relevance in predicting VGD.
Other variables included in the model, such as the more
common use of MMORPGs and the greater extent of gam-
ing in terms of dysfunctional coping and as a source of self-
efficacy among boys explained gender influences on VGD.
Some other factors, however, could account for a gender-
specific risk of VGD as well. These have to be dealt with in
future studies, especially with regard to other possible forms
of media dependency in which girls seem to be far more
prominent (e.g., excessive chatting behavior).
Despite a progressive level of knowledge, up until now,
VGD has not been clinically acknowledged, so treatment of
affected persons is not officially provided by most of the
present health care systems. Further research is needed to
advance our understanding of VGD and other possible types
of media dependencies, especially regarding genesis, long-
term consequences, risk and resilience factors, and adequate
therapeutic strategies. However, a clarification of these ques-
tions can be achieved not only by intensified research efforts
but also by a well-documented clinical practice and a grow-
ing cross-linking of all protagonists involved.
Acknowledgments
We thank the KFN schools survey team: Susann Rabold,
Julia Simonson, Cathleen Kappes, Dirk Baier, and Christian
Pfeiffer. We also thank Bert te Wildt (Medizinische Hoch-
schule Hannover) for his support in the development of the
KFN-CSAS-II.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Florian Rehbein
Criminological Research Institute of Lower Saxony (KFN)
Lützerodestraße 9
D-30161 Hanover
Germany
E-mail: frehbein@kfn.uni-hannover.de
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