B was a 15-year-old boy referred to an inpatient unit for severe disruptive behaviors after being expelled from his school. He lived with his 10-year-old younger brother and two half-brothers (aged 20 and 30 years). The parents were separated although living together. B had commonly been exposed to severe arguing and fighting between them. Both parents were unemployed. The father had an untreated alcohol addiction and the mother had no specific past psychiatric history. The family had been followed by social services since B was 3.
The patient's pregnancy was complicated by gestational diabetes and occasional maternal alcohol intake. B was born prematurely at 35 weeks of gestation. He had a delayed onset of speech (first words at 2 years) and fine motor difficulties. At entrance in first grade, he had difficulties understanding verbal instructions and performing graphomotor activities. Distractibility and emotional dysregulation were also noted. At age 6, a Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III) test found a heterogeneous functioning in normal range (Verbal IQ = 100, Performance IQ = 75). At age 7, the patient was addressed to a foster care family with a full-time inclusion in an educational facility for youths with behavioral problems. Improvement in emotional control was noted.
At age 13, B faced multiple adverse life events (incarceration of his half-brother, left foster care to return to family home, and change in the pedagogic team). He became physically aggressive against peers and adults with several rage outbreaks per day. Different medications were tried with no or partial improvement: tiapridum (a first generation antipsychotic) up to 15 mg/day, carbamazepine up to 200 mg/day, risperidone gradually increased to 4 mg/day. B was excluded from his educational facility following the aggression of a member of the educational staff. Since then, the patient has stayed at home all day. He was described as severely irritable with multi-daily outbursts of uncontrollable anger. He was verbally and physically aggressive against his parents in a context of frustration and tried to strangle a neighbor after a banal remark. During this period, B maintained his interests in his usual activities, for example, caring for animals or cooking.
He drastically increased time on his computer following school expulsion. He mostly played Role-Playing Games and First Person Shooter Games, with violent scenarios. Daily playing sessions lasted 2-6 h, occasionally during the night. He could compulsively watch online videos during several hours, either childish cartoons or violent videos of aggression. B had daily alcohol consumption usually alone of one glass of wine or a can of beer with binge-drinking sessions almost every month (i.e., 10 g of alcohol each day or 8.75 units per week on average). He explained that alcohol was a means to "calm down." Of note, the patient was very critical of his father's addiction problem, criticizing his father's inability when drunk to care for him. He also had very occasional cannabis use (smoked one joint every 2 months).
During individual interviews, B was calm. He described a feeling of hostility, persisting anger and ambivalent feelings toward adults ("worry, shame and anger at the same time"). He reported being exposed to violent conflicts at home and frequently having to take care of his drunk father. Globally, he described a situation of physical and emotional neglect at home. B expressed concern about the consequences of his behavior and his future (he wished to become a cook). He was afraid of "being always angry" after leaving the hospital or that similar problems would repeat with his young brother. Sleep and appetite were preserved.
In the unit, he had few contacts with other youths. He was too clumsy to be involved in sport activities and was often rejected by the group when playing board games. He felt more comfortable with younger patients with whom he shared common interest in animals. When he felt worried, the patient sought attention from adults with provocative behaviors or threats. He could suddenly give a blow to a wall, against a window, or against a piece of furniture without any explanation.
Psychomotor assessment showed evidence of a developmental coordination disorder (F82): general motor and coordination test score was at 0.1 percentile, visuomotor integration test score was very low, and he had -7 standard deviations for writing abilities ( Table 1 ). Language evaluation showed evidence of severe dyslexia (Reading disorder, F315.0) with normal to weak abilities in oral language but very deficient reading competency ( Table 2 ). The diagnosis of disruptive mood dysregulation disorder (F34.8) in an adolescent with multiple learning disabilities (developmental coordination disorder, dyslexia, dysgraphia) was set up and explained to the patient and his parents.
The treatment with carbamazepine was discontinued and risperidone was decreased to 2 mg/day, a dose more typically used in youths with disruptive behaviors. A benzodiazepine, diazepam, was added for its anxiolytic effect. The patient also started a psychomotor rehabilitation in the service (weekly group relaxation and individual sessions). The need for an intensive speech therapy was explained to the parents. Collaboration with social services was of main importance in this hospitalization. He was accompanied to a juvenile court session where a placement decision was set up. During the last week of the hospitalization, he visited a new residential care facility.
A major clinical improvement was observed during the hospitalization with a decrease in the behavior problems. At discharge, B no longer presented diagnostic criteria for IGD, and no specific intervention was required. Six months later, B no longer presented clinical or functional impairment.
We found in this vignette a relation between disruptive behaviors and gaming misuse in line with preexisting literature in adolescents. A Spanish study showed that disruptive behavioral disorder was the most frequent diagnosis associated with IGD in a clinical sample of youths. It seems that IGD is associated with both proactive and reactive (impulsive) types of aggressive behaviors in adolescents. Wartberg et al. found that in a large community-based sample of adolescents, those who self-reported symptoms for IGD were more prone to anger control problems, antisocial behavior, and SDQ hyperactivity/inattention subscale, in multivariate analysis.
The description of patient B's usual way of dealing with emotional stressors since his early childhood was strongly evocative of an anxious-resistant subtype of attachment disorder (also called ambivalent attachment). Children with an anxious-resistant subtype of attachment disorder exhibit a high level of distress on separation and tend to be ambivalent when his/her caregiver returns. In middle childhood, these children are more likely to adopt "controlling" behavior (i.e., role-reversed) on caregivers. The displays of anger or helplessness towards the caregiver on reunion have been regarded as a strategy for maintaining the availability of the caregiver by preemptively taking control of the interaction.
A persistent lack of predictability of the caregiver's responses, such as found in B's family, did not allow children to develop reliable expectations about adults' behaviors. As a consequence, these children did not develop a proper sense of trust in their own ability to interpret their social world: they have, in general, more difficulties to accurately anticipate and interpret emotional cues (e.g., facial expression) and to understand their own mental state.
The fact that these children are immersed in a social world unintelligible to them and have more difficulties to stay "attuned" to others' emotional state explained the difficulties to develop optimal emotional regulation strategies and the myriad of associated behavioral problems (e.g., oppositional behavior, poor tolerance to frustration, temper tantrums, impulsive aggressive behaviors, peer rejection).
A low level of emotional regulation skills in childhood is a significant risk factor for behavioral addictive disorders in adolescents, including GD and Internet-related disorders. Youths with difficulties to regulate their emotions could engage in such repeated behaviors to avoid or regulate negative feelings and emotions or to prolong positive emotional states. In the Discussion, we explain how poor emotional regulation strategies could represent both shared vulnerability factors and mediators of the relation between psychopathology and gaming misuse in the patient.