Understanding internet gaming addiction among South Korean adolescents through photovoice

Accepted Manuscript Understanding internet gaming addiction among South Korean adolescents through photovoice

Hee Joung Seok, Jeoung Min Lee, Chi-Yong Park, Ji Young Park PII: DOI: Reference:

S0190-7409(18)30236-6 doi:10.1016/j.childyouth.2018.09.009 CYSR 3980

To appear in:

Children and Youth Services Review

Received date: Revised date: Accepted date:

28 March 2018 9 September 2018 9 September 2018

Please cite this article as: Hee Joung Seok, Jeoung Min Lee, Chi-Yong Park, Ji Young Park , Understanding internet gaming addiction among South Korean adolescents through photovoice. Cysr (2018), doi:10.1016/j.childyouth.2018.09.009

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Understanding Internet Gaming Addiction among South Korean Adolescents through

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Photovoice

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Abstract Internet gaming addiction is a serious problem for some adolescents in South Korea, although it has not yet been fully explored. The present study aims to explore adolescents’ motivations for internet games, how their lives are affected, how they perceive internet games, what they gained and lost, and how they made sense of internet gaming addiction. Interviews, focus

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groups, and photovoice with a sample of ten adolescents at risk of internet addiction were

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conducted. The participants reported serious symptoms of internet game addiction, which

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negatively affected their psychological health and self-identity. They also reported that they were aware of how internet games negatively affected their daily lives, academic

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performance, and family relationships worsened once they became addicted to internet games. However, they also perceived internet games as avenues for entertainment, stress relief, and

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peer bonding. Understanding adolescents’ perceptions and meaning of internet gaming addiction can facilitate the development of effective psychosocial intervention programs,

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development and identity.

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which can subsequently contribute to healthy coping strategies and positive adolescent

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South Korea

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Keywords: adolescents; internet gaming addiction; psychosocial problem; photovoice;

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Introduction As a result of national high-speed internet infrastructure investment, South Korea emerged as an ‘internet country’ or ‘mobile game country’ and as a leader in the development of the gaming industry and gaming contents. South Korean teenagers spend a great deal of

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time playing internet games as part of their leisure activities. According to the Statistics Korea (2018), adolescents in South Korea, aged 13-24-years, spend most of their time during

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the weekdays and weekends playing computer games (68.3%), and internet searches (59.7%).

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Due to availability of smartphones, personal computers, and other mobile devises, internet gaming addiction is increasingly becoming a serious social concern (Choi, 2014; Kim &

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Baik, 2011; Kwon & Lee, 2000). A survey of elementary, middle, and high school students

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conducted by the Korean Creative Content Agency (2017) found that 0.7% were addicted to internet games, 1.9% developed internet addiction, 81.5% were average internet game users, and 16.0% held a positive perception of internet games. Although the rate of internet

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addiction is low, the rate of youth becoming addicted to internet games had increased from 1.18% in 2012 to 1.89% in 2017, which suggests that additional research is needed. In South Korea, research on adolescent internet gaming addiction has been actively

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conducted since 2000 when internet games were found to be related to physical and

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psychosocial problems. Adolescent internet gaming addiction has attracted research interest among South Korean scholars of various disciplines, particularly quantitative research (Kim, 2001; Lee, 2003; Lee & Kim, 2017; Min et al., 2018; Yun et al., 2012). Earlier studies in South Korea had focused on the overall situation, factors, and outcomes of internet gaming addiction (Kim, 2001; Lee, 2001; Lee, 2002). However, over the years, researchers also focused on factors associated with internet gaming addiction within multiple contexts (e.g., family relationships, school life; Bae, 2014; Choi & An, 2010; Jang, 2005; Joo & Ja, 2011; Jung & Kwon, 2003; Kim & Lee; Lee, 2003; Lee & Hong, 2005). Although these quantitative

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studies have advanced our understanding of factors and outcomes of internet gaming addiction and internet addiction in general, it is unclear how adolescents make meaning of their experiences with internet games. To address this, the present study utilizes qualitative research methods to explore adolescents’ meanings of internet game addiction and it may affect them. More specifically, this study examines adolescents’ psychosocial problems

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associated with internet gaming addiction and contextual factors related to addiction through

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in-depth group interviews and visual representations.

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Definition and Conceptualization

Internet gaming addiction is recognized as a recent societal problem resulting from

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the advancement of internet technology and the changes in the gaming environment. In South Korea and in several countries, there are debates on the concept and diagnosis of internet

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game addiction. The American Psychological Association (APA, 2013) categorizes ‘Internet Gaming Disorder (IGD)’ in section III under the DSM-V (5th edition). DSM-V identifies

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people with internet gaming addiction as ‘“gamers” as those who play internet games

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compulsively, to the exclusion of other interests, and their persistent and recurrent online activities resulting in psychosocial impairment or distress. People with internet gaming

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addiction have compromised academic or job functioning because of the amount of time they spend playing. They experience symptoms of withdrawal when they are not playing internet

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games.’ The DSM-V postulates that the IGD’s 9 diagnostic standards are limited in their application across various cultures, and the conceptualization of internet gaming addiction has not been fully agreed upon and is under constant discussion and debate (Griffiths et al., 2016; Kardefelt-Winther, 2015; Petry et al., 2014). It is uncertain whether internet gaming addiction is a similar problem as alcohol or drug addiction, whether it is a behavioral problem, or whether it should be classified as an addiction. Kuss (2013) reviewed recent empirical studies on Internet Gaming Disorder and concluded that there must be a

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comprehensive understanding of the various contextual factors associated with this disorder (i.e., unique traits, living conditions, gaming preference, cultural environment). The preliminary International Classification of Diseases (ICD)-11 discusses the subject of ‘gaming disorder’ and there is currently an on-going debate on whether internet gaming addiction should be classified as a disease.

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Although there needs to be a consensus regarding the conceptual validity of ‘internet

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game addiction’, ‘internet gaming disorder’, and ‘problematic internet gaming’ in research,

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extant studies have conceptualized it as obsessive use of internet games, which results in decreased academic performance, withdrawal symptoms, psychosocial maladjustment,

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interpersonal problems, and somatic symptoms. This study refers to the abovementioned conceptualization of ‘internet gaming addiction’.

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Factors and Outcomes Linked to Internet Gaming Addiction The internet game addiction among adolescents can be seen as being influenced by a

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combination of internal motivation, family relations, school life factors, and media. First, it

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seems that the internal motivation of an individual adolescent to be addicted to internet games is affected by mental health symptoms such as impulsivity, aggression, depression, low self –

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esteem, low self-control, and anxiety. Moreover, internet gaming addiction can be influenced by unstable relationships between adolescents and their parents, caregivers’ parenting

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behaviors (over-protection or high expectation, controlling behavior, lack of parental attachment, lack of family cohesion), school maladjustment (e.g., bullying, school violence, sexual stress, and negative relations with teachers). Furthermore, the high level of internet use and the proliferation of the internet game market in South Korea can also make internet games more accessible, which can contribute to internet gaming addiction. Internet gaming addiction can contribute to adverse health conditions, such as insomnia, headache, gastrointestinal symptoms, cardiovascular system, vision problems,

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wrist pain, and symptoms of attention deficit/hyperactivity disorder (Choi, 2014; Kwon et al., 2005; Lam, 2014; South Korea Information Technology Promotion Agency, 2014b). Adolescents who are addicted to internet games are also likely to display depressive symptoms, anxiety, aggressive behavior, impulsivity, feeling of guilt, lethargy, and emotional problems (Cheung & Chan, 2018; Lee, 2001; Lee, 2003; Kwon & Lee, 2005; Shaira et al.,

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2000). According to Lee (2001), adolescents with internet gaming addiction sometimes have

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difficulty distinguishing reality from virtual world (Lee, 2001). If they discontinue the game,

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they are likely to experience withdrawal symptoms, along with anxiety, irritability, and delusion (Lee, 2001).

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As studies have shown, adolescents who are addicted to internet games may develop negative relationship with their parents at home, and more specifically, lack of

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communication with their parents, as well as lack of secure attachment (Choi & Ahn, 2010; Jang, 2014; Kim, 2012; Park & Mun, 2012; Yun, 2011). In addition, relations with peers and

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teachers are also negative impacted by internet gaming addiction (Jung, Park & Suh, 2014;

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Kim & Baek, 2011; Lee & Kwon, 2000). Although many adolescents form friendships through internet games, spending excessive amount of time on the internet can also be

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problematic (Jeong & Park, 2014). Moreover, internet gaming addiction has been found to be linked to poor school performance and difficulty in concentration (Lemmens et al., 2011;

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Shapira et al., 2003), as well as conflicts with teachers and negative attitude towards school. Other studies also found that internet gaming addiction is positively related to school violence, alcohol consumption, running away from home, and suicidal thoughts and behaviors. For instance, Yun and Chae (2014) reported that adolescents who are addicted to internet games have difficulty distinguishing reality from fantasy and are likely to re-enact violent behaviors they had seen on the internet. Anderson and Dill (2000) also found that frequent exposure to internet games can increase aggressive behaviors, and Lee’s (2001)

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study findings revealed that internet addiction is correlated with fighting and positive attitude towards violence. Given the negative impact of internet gaming addiction, an in-depth exploration of this phenomenon is important, which is a necessary first step towards development of positive adolescent identity (Suler, 2005).

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Method Study Design

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This study utilized photovoice, a participatory research method, which was

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developed by Wang and Burris (1997). Photovoice participants describe various aspects of their lives through photography (Novak, 2010), allowing them to author their own personal

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experiences (Duffy, 2011). The use of photovoice opens possibilities to look at the world

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from the perspectives of the study participants (Wang & Barris, 1994). This approach values experiential knowledge formed by the study participants, as it allows them to record their own life experiences and the opportunity to tell their story (Fleury, 2002). This study

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examines (a) psychosocial problems of South Korean adolescents who are addicted to internet games and (b) the purpose of internet games through the perspectives of these adolescents. Photovoice is a useful tool that can help clinicians who work with adolescents

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addicted to internet games. Clinicians can utilize the findings from photovoice research to

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help adolescents in expressing their feelings and thoughts, and in reflecting on their personal experiences. Photovoice can also be used as a tool for the study participants to comfortably express their emotions concerning their past experiences. Study Participants A research team contacted a youth center in South Korea and introduced their proposed study to the director of the center who assisted in recruiting adolescents who were undergoing treatment for internet gaming addiction. The researchers explained in detail the purpose of the research to the adolescents. Those who agreed to participate were asked to

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provide a consent from their caregivers. Ten adolescents who were addicted to internet games participated in the photovoice research project after obtaining a signed consent form from their caregivers. All participants were male, aged between 12 to 17 years old. Two were high school students (15-17-years-old) and eight were middle school students (12-14-year-old). They played games for three to ten years since the age of 12 (fifth grade) and spent an

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average of at least 5-20 hours per day on internet games.

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Two of the participants lived with a single parent (mother), and eight lived with both

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parents. The most popular sites for playing internet games were home, followed by PC room (internet cafe) and friend’s house. Adolescents who cannot play internet games at home

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because of restricted use played games using their cell phone in their room. Those who were unable to use their cell phone either went to the PC room or their friends’ houses. Most of the

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participants reported that they would ignore their parents’ admonition because they were unable to stop playing games.

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Procedure

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The researchers purposefully sampled the participants to obtain rich information. Ten adolescents who participated in the center for youth with internet gaming addiction problems

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at a local youth counseling center were selected for the study. The center provides a boarding house-type treatment program for 12 days and 11 nights. The patients in the center receive

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assistance with managing their internet and smartphone use through a variety of services such as diagnosis, individualized counseling, peer group counseling, parent education, family counseling, and alternative activities to curb their internet and smart phone addiction. The research team has established a rapport with some of the adolescents who received treatment. Prior to the research, a mutual understanding between the study participants and researchers was established to help create a comfortable environment for discussions. The present study focused on adolescents, and the research team seriously considered

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research ethics in conducting interviews and in complying with the research ethic codes. Prior to the interview, the research purpose and methodology were clearly explained to the participants and their parents, and consent letters were also obtained. Those who were unable to provide parental consent were excluded from the study. Confidentiality in the recordings and meeting notes was ensured. Also, participants were informed that the risks were minimal,

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and they had the right to discontinue with the study participation at any time. Adolescents

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who participated in the individual therapy and group therapy were included in the study, and

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if there were questions that participants felt uncomfortable answering, the interviewers moved onto a different topic.

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The photovoice study was conducted for a total of six sessions, from June to August of 2015, and each session was held during the weekend and lasted for three hours. Before the

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orientation, the researchers divided the roles of each research team member. The first and last noted authors carried out the interviews, took research notes, and analyzed the contents of the

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interviews. Graduate students were given the task of transferring the photos to a computer,

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arranging research sites and preparing refreshments, and announcing the research meetings. The first session consisted of an orientation and a digital camera was provided to all

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the study participants. The researchers explained that the goal of study was to expand knowledge on internet gaming addiction. The topic of the subsequent session was decided

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through the consensus of the group at the end of each session. The study procedure followed Wang and Burris’ (1997) guidelines: “who used the camera, what the user photographed, what the user chose not to photograph, who selected which photograph to discuss, and who recorded whose and what thoughts about whose and which photographs” (p. 374). Questions and the topics were all decided by the research participants. The researchers did not participate in the process of selecting a topic but facilitated the decision of the study participants to choose what they wanted to share. The participants were asked to take five or

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more photos on their topics for each session. The participants photographed images that best reflected their experience related to internet games and the meaning of the internet game addiction. In sessions 2 to 5, the participants were given some time to share the insights gained from their photograph (ten minutes per participant) with the group members, which was followed by a group discussion (1 hour 30 minutes) on the topics. All participants were

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asked to submit their photos and select two main pictures to be used for group discussions.

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They were asked to come up with a title for each photograph and think about the following

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questions: “What is happening in the picture?” and “why this is happening?” (Wang, 1999). The participants provided in-depth information regarding the photos during group discussion.

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They showed their photos and expressed their thoughts and feelings as the research assistants facilitated the group discussions. In the last session, the participants reviewed their photos

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and discussed what they learned from their photovoice experiences. Analysis

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Data for photovoice included photos that the participants brought to the discussions,

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researchers’ notes, and the interview notes. Analyses were repeatedly conducted to categorize topics from the photos and the interviews. Data were analyzed by through a continuous

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comparison method. Through group interviews, meanings and experiences within the photos were revealed, and important topics were derived from each session. Participants shared their

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experiences by using the photos, and the researchers repeatedly analyzed the participants' stories in the meetings. The research team conducted the study to categorize each of the cases (Internet Gaming Addiction) and the reactions (the impact on the study participants’ lives). Analyses were conducted by the researchers reading, thinking, and sharing their opinions through multiple repeated cycles to piece together the stories. In the final analysis, the participants provided feedback. Several strategies were employed in the data analysis. First, a parentheses method was

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used to minimize researchers’ beliefs regarding the participants’ psychosocial status (e.g., disconnection in peer relationships), assumptions, and prejudices. Researchers used a note for this method, and the recordings of each of the participants’ individual interviews and group discussions were maintained. These tasks allowed the researchers to be more involved in the data, which helped them to better understand the study participants’ experiences (Tufford &

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Newman, 2010).

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In order to establish credibility of the research, the research team conducted

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prolonged engagement and persistent observation, triangulation, audit trail, and debriefing. The first noted author conducted multiple photovoice and other qualitative research over the

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past fifteen years. The last noted author is a researcher who has experiences working with adolescents with internet gaming addiction and behavioral disorder. Triangulation was

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established through the multiple perspectives of the research team and a variety of sources of data for the research. At each meeting, the research team shared their opinions on the research

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and recorded their thoughts. Discussions were mainly focused on the internet gaming

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addiction that the study participants had experienced. Data sources included interview recordings, pictures, and research notes in an attempt to diversify different data to synthesize

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the analysis. For an audit trail, all the data generated during each meeting were recorded and traced for tracking observations. Session notes, pre- and post-researcher meeting minutes, and

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recordings were also obtained for this purpose. Findings

As shown in the Table 1, six major themes and 19 subthemes emerged: (1) motivated to play games, (2) life mostly playing games, (3) my image after being addicted to games, (4) things gained from games, (5) things lost because of games, and (6) meaning of game. <> Motivated to Play Games

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Mimicking friends. All the study participants said that curiosity expressed by their family and friends reinforced their interest in internet games. From childhood, they grew up in a family environment where parents and brothers were enjoying the internet games and they later developed interest in the game to become closer to their friends. One participant stated, "I remember when I was four years old… my father played the computer game called

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‘Maple Story’… it looked interesting since then ..."

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Most of the participants also stated that their parents told them about the game site

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and allowed them to gain access the game for free on their smart phones. Some of the participants learned about the game when they visited their friend’s home or learned how to

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play the game when they watched their friends enjoying games with many of their classmates. Playing games with close friends motivated them to be immersed in internet

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games, as reflected in one statement: “I think many of my friends played FIFA game. So, I did it too. After I watched my friends played it, and I wanted to try once....”

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Home alone. The study participants spent a great deal of time alone at home during childhood. Some participants also said they were alone at home and did not have anything to do while their parents were away at work and their siblings were away at school. Most of the

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participants found many game sites that they had not seen before and become immersed into

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it. They played games without parents’ interference. One participant stated that the reason why he became immersed in the game is “no one was at home…nothing to do at home…so I discovered through Naver [a South Korean web search engine] all these computer games and I began playing them since third grade. Being at home alone was the best place to play all these games.” <> Family members’ reactions to games. All the study participants expressed that

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family members were lenient about their gaming activities. One stated, “I pressured my mom into letting me to get membership to the games and my parents did not say much. They thought it was not a big deal”. Another study participant reported that his parents allowed him to play games because they felt bad that he was being left alone at home. Another recalled a time when he was six years old, he was allowed to play the game if he finished his

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homework. Many of the study participants also mentioned that sanctions and punishments by

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parents were rare and parents believed that the games were for entertainment use.

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Life Mostly Playing Games

Uncontrollable gaming behavior. Most of the participants played games during the

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weekend or vacation rather than on weekdays or on school days because they were busy with their schoolwork. During vacation, they immediately started playing games all day right after

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they get up in the morning. Although their parents set time limits, they would play games beyond the time limit. To maintain their game skills and keep up with the trends, they would

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play the game excessively. As one study participant stated, “my character in the game is

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outdated. Selecting a new character is of course cheating. It is definitely difficult to win, and then say, ‘Shall I give up?’ but…I just can’t.”

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Play games in solitude. Most of the participants who were addicted to the internet game showed more interest in the world of games rather than everyday life. They would

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spend a large amount of their time thinking about nothing but the game world. Some of the participants also reported being angry if their parents restricted their game playing. They were unable to forget about the game even while going to bed. Other participants said they were deeply immersed into the games during break in school and talked only about the game. Although one of the participants voluntarily joined a treatment program to overcome game addiction, he stated that he played games soon after. Moreover, most of the participants expressed feeling frustrated when they were told they could not play games.

One stated, “A

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little bit stuffy, right? I cannot do what I have been doing. So, I don't like to do anything...If someone tells me not to play games, I just do nothing.” Adverse effects of irregular daily life.

All the study participants who were

playing internet games excessively had irregular life patterns and had experienced various physical, psychological and social problems. Most of the participants did not eat meals at any

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given time or skipped meals altogether because they were too busy playing games, especially

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during weekends. They were complaining about chronic fatigue and lack of sleep because of

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game addiction. They played games after coming home from school and could not concentrate on their studies. One participant felt a serious pain on his wrist and was

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diagnosed with arthritis. Most could not stop playing games although they were suffering from sudden vision loss due to prolonged exposure to computer screens and mobile phones.

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My Image after Being Addicted to Games

Emotional ups and downs. All participants showed emotional instability and

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changed personality because of internet games. For instance, one study participant was

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cheerful and social before becoming immersed into internet game. Once he started playing internet games, he had been changed and got into lots of trouble with the people. He said, "I

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was laidback before…but...I think I got worse after playing games. If anyone talked to me, I would respond in an irritated tone.” Many of the participants also reported feeling annoyed

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and angry for no apparent reason, and they experienced emotional problems while arguing with people around them. My hidden personalities. Some of the study participants were immersed in internet games, which affected the way they act and think in their daily life. Although one study participant mentioned that he was quiet and timid, he began to change. He said, “whenever I play games, I change completely. I feel like I am not myself.” One participant who was frequently picked on by his peers would act out aggressively in the game world, which he

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said made him feel good. Other participants became withdrawn once they became addicted to internet games, although they had been extroverted and frequently communicated with their friends in everyday situations. Thirst for victory. Although most of the participants started playing internet games to make friends, they became more obsessed with mastering the rules and strategies of the

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game in order to win. Also, they felt like they needed to be stronger to win. In addition, they

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said that they only focused on learning a variety of strategies to win and concentrated on

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raising their level . The study participants also noted that they had to win the game rather than just enjoying it with their friends. To maintain high scores, they selected a game which they

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had a good chance to win. One stated, “You know. It's fun when you win the game. We receive many good items when we first enter the game. I won once even though I had been

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abused by my game partner. But, it was fun when you win many times. Yeah, I realized I was

Things Gained from Games

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addicted since I played the game continuously.”

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Many participants reported that the game was a positive influence in their life although they also lost a lot.

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New and improved relationships and the formation of friendship. Most of the participants said that they had interactions with new friends through the same game either by

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chance or by sharing ideas of the game. They almost did not have the opportunity to become friends with classmates at the school because they preferred playing internet games over spending time with their classmates. Some of the participants stated that they made several friends after starting the internet game when they entered middle school. They first heard from their classmates, "What kinds of game do you play?" If they played the same games, they would say, “Let’s be friends” right away. If not, they would say, “If you haven’t started the game, let’s play it together.” They recommended a game to other game players and

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became friends as a result. Other participants expressed having better relationships with some of their classmates whom they didn’t get along with initially. The games on the internet were not only perceived as games, but also a leisure activity to be spent with peers. According to one participant, “we have more chances to talk with friends (while playing games) and I think that's a good thing. And they would also inform me about things I did not know, which is

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good too”.

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Reputation and rewards of the game. The participants also stated that as they were

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playing internet games, they would receive monetary rewards and fame. Although they had complained about psychosocial symptoms and difficulties playing internet games, they

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established a reputation based on their nickname (ID), which would be known in the virtual world. They would also make money by selling their own nicknames to other gamers.

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Furthermore, the participants stressed that they needed to earn their reputation which would improve their game skills.

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Concentration and a sense of accomplishment. The participants reported having a

games.

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high degree of concentration and a sense of accomplishment whenever they played internet They had not experienced something they were particularly interested in and

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focused only on winning and had a clear goal when they played the game, which surprised them. The participants also mentioned that the internet games gave them a feeling of

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accomplishment and made them feel valued, more so than their school work or everyday life. Although most of the participants agreed that there are negative effects of internet games, they also emphasized that there were opportunities for discovering one’s potential. One participant stated: “But, there are many kids had become addicted to the internet recently. Well... I don't know if I could say this...In my case, from the beginning, I’ve made many friends and became popular. So, I think I could focus more on games than on studying.” Things Lost Because of Games

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Neglecting schoolwork and poor academic performance. Although most of the study participants enjoyed playing game, they would also put aside their schoolwork and homework to play the games. According to one study participant, “I think it has become a little bit strange since I started playing games. I felt awkward because I would play more and

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more and cannot do things I was supposed to do.” They also lamented that their daily life was a mess. Other research participants expressed that it was difficult to concentrate on studying

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in class and they would skip going to academic institute (after-school classes) and head for

academic performances had suffered tremendously.

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internet game room because they were so obsessed with the games. As a result, their

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<>

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Beyond one’s control. Some of the research participants stated that once they start the game, they became so immersed in it and feel out of control. They also expressed forgetting about all the daily tasks such as studies, appointment, and plans. They enjoyed the

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initial stage of the game during their leisure time such as weekends or holidays and they could control themselves. However, they also said the game completely changed their lifecycle and they were unable to control themselves when they were playing excessively.

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According to one study participant, he stated, "I feel like opening the idiot box," meaning he

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felt like he became an idiot when he began playing internet games. He further stated, “It is a problem because you cannot control the game as you can control television, which is also called an idiot box.” Another study participant also mentioned that he agreed that the game had a major impact on him and it dominated most of his daily activities such as sleeping, meals, and time with family. “Now I am totally out of control,” he stated. <> Excessive game expenses. The participants also mentioned incurring tremendous amount of expense playing games over the years. Although all participants spent their

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allowance, they started to run out of money when they needed to purchase new items in the computer games. There were many ways to defray the cost of playing games. Some had used their rewards points from the games. Others made money by selling their game usernames or game points to purchase items. Some admitted borrowing money from friends to play games.

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One described the internet game as “often (money) spend through (picture)”.

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Family conflicts and miscommunication. All the participants reported experiencing

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severe family conflicts, which worsened when they became addicted to internet games. Ever since they started the game, they were having problems communicating with their parents and

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admitted that they spent much less family time than ever before. Their parents would become angry and demanded that they spend less time with internet games. The participants often felt

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guilty about disappointing their parents. Meanings behind the Games

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Having fun and killing time. All the participants emphasized that internet games

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were fun and playing them was a great way to spend time. When they come home from school, they were alone for the most part, with no one to speak to, so they would turn to their

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games. Even when they were with their family on the weekend, they rarely spent time with them. In addition, the participants expressed feeling disappointed because there was nothing

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to do at home but play internet games, especially when they entered middle school. When they were in elementary school, they had enjoyed playing in the playground with their neighborhood friends. One stated, “I initially played soccer and we rode our bikes together…and my friends would ask if we wanted to play games. One of my friends first introduced me to internet game. So, I said we should play games. Many of my classmates spent a great deal of time.” Internet games became perceived as valuable. Means to relieve stress. All participants experienced an enormous amount of stress

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because of their new school environment and new classmates once they entered middle school. They also felt stressed out because learning subjects in middle school was very difficult and they felt pressured to study many different subjects. Moreover, they were having difficulty getting along with classmates and one participant reasoned that “most of the time, we would talk about internet games or phone games. At that time, we would just say hello at

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our school. Moreover, it is a little difficult to go to an academic institution immediately after

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school.” The participants gave a new meaning of the internet games. They perceived them as

A Functional Alternative to the Real World

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“friends who help release stress,” “another friend,” and “a source of stress relief”.

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Most of participants perceive playing the internet games as more than simply playing with their friends. While they become immersed into the virtual world to play computer

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games, ironically, it becomes an extremely important platform to for establishing relationships with their friends and sharing their interests and information with their friends

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in the real world. Whenever they made new friends at school or at a hakwon (a private

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academic institution where students receive lessons in subjects after school), they would first talk about the game and most of the conversation topics revolved around games. In addition,

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the participants often formed solidarity with their friends by achieving a common goal. One participant stated: “I wondered what would happen if there were no internet games?” He also

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expressed that he no longer felt lonely because he could share a hobby and exchange conversations with his friends through video calls. Another participant also said, “Can’t just say go play outside? That statement no long held true once I entered middle school. I would just play games these days and most of my friends would do that same thing, I guess.” It appears that the participants are moving away from the real world to a virtual world. Discussion The present study is the first study that aimed to explore the attitude, perceptions,

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purpose, and problems that South Korean adolescents have about internet games through the photovoice method. Previous studies mostly focused on the causal relations by examining factors or the negative impact of internet gaming addiction. This study is unique in that it does not just identify what the problem is; rather, the study participants are given a platform for expressing themselves visually and how they would make meaning of their addiction to

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internet games.

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Through photovoice, we found that internet gaming addiction was related to

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adolescents’ desire for relationships with others. Adolescence is a crucial stage in the development of identity formation as youth interact with and have relationships with others,

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including their peers, parents, and teachers. Therefore, for the study participants, ‘relationship making’ is one of the most important life developmental tasks. They learn to socialize with

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others in an environment that is closest and most familiar to them. For example, an adolescent might have seen his parents or friends play internet games and socialize with them

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through internet games. In some cases, if there is a lack of relationships or interactions in an

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offline setting, such as home (e.g. if parents both work and they are left alone at home), the adolescent might form relationships in an online setting, which is supported by previous

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study findings which suggest that parental/peer relationships and school life can be a push factor for internet gaming addictions (Douglas et al., 2008; Jung, Park, & Suh, 2014).

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However, contrary to previous studies which found that negative parental relationships or negative school experience can lead to stress which can induce internet gaming addiction, this study found that internet gaming addiction can occur through relationships even in the absence of negative experiences. Adolescents are first introduced to internet games through those they interact most often with in their daily lives, such as family members and friends. Findings from the present study suggest that intervention involving family and friends is crucial and meaningful for South Korean adolescents experiencing internet gaming addiction.

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Additionally, adolescents addicted to internet games should be provided with assistance to form healthy interpersonal relationships not only in online settings, but also offline settings. Adolescents must also be taught that while the virtual world is accessible, the relationships formed online are instantaneous and provide only temporary satisfaction. South Korea has educational, counseling, and treatment programs for internet gaming addiction but these

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programs are problematic in that they mostly focus on treatment rather than on prevention.

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Furthermore, the present study found that adolescents with internet addiction become

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entrapped in internet games (Lee, 2001; Sung, 2003) and easily lose self-control (Douglas et al., 2008). Adolescents stated that internet games were meant to be used as a tool for

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satisfying curiosity or forming relationships with others but over time, they develop into an obsession.

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Moreover, the present study showed that as adolescents became addicted to the internet games, they became aware of the changes they were going through, both physically

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and mentally. These adolescents found themselves displaying extreme mood swings or anger,

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although previously they were quiet and timid. Through internet games, their behavior began to change dramatically, such as using profanity and exhibiting aggressive and obsessive

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behavior. They also found that their daily lives changed after becoming addicted to gaming. They reported experiencing irregular sleeping and eating patterns, as well as feelings of

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school disengagement, decline in parental relationships, physical pain. However, through internet games, they reported becoming closer to their online friends, as well as feeling a sense of pride and confidence through victory. Although they had become obsessed with internet games, they also have an understanding of how internet games may or may not be useful, which may be important in assessment for practitioners working with adolescents. All of the study participants reported that internet games “cured” boredom or stress in their everyday lives. This is incongruent with past findings which suggest that adolescents’

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internet addiction would negatively impact their daily lives. Although they were experiencing internet gaming addiction, in actuality, they did not place much meaning to the games which shows that they understand better than anyone else the problems of being addicted to internet games and as a result, they would try to distance themselves from the problems. Additional studies need to explore adolescents’ recognition of internet gaming addiction, their attempt to

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distance themselves from internet games, and how these attitudes could influence their

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process of recovery.

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Limitations of the Study

There are some limitations to the present study. First, given the small number of the

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study participants, it is difficult to generalize the findings to adolescents in South Korea. The study participants were selected from a particular province in South Korea (i.e.,

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Gyeongsangnam-do). In addition, the study did not consider the level of severity in internet gaming addiction, which might vary by individuals. Future research might consider the level

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of internet game addiction. Furthermore, social desirability biases might have resulted from

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photovoice study. The study participants may find it is difficult to share some of their thoughts and feelings accurately. To minimize social desirability bias, a strong rapport

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between the researchers and the study participants is necessary. The researchers made every attempt at establishing rapport by actively participating in the treatment center and spending

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time with the participants by watching baseball game and having a meal together. Practice Implications These limitations aside, the study has implications for practice, which can provide some key points of interest for policy makers and practitioners. First, interventionists must understand the root cause of internet gaming addiction by conducting a thorough assessment. Practitioners might assess whether internet games are played frequently by parents in the home, whether they are used by adolescents to interact with their peers, or whether they are

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used to kill time. Internet gaming addiction appears to be a problem, but as this study has shown, its impact may vary. Practitioners might screen why some adolescents form an attachment to internet games and whether such attachment is negatively impacting their daily lives. For some adolescents, playing internet games gave them opportunities to bond with their peers as well as feelings of confidence and accomplishments. Moreover, it is important

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to assess the multiple contexts of internet gaming addiction. A bulk of the research on internet

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gaming addictions have considered individual level factors, such as impulsivity, anxiety,

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aggression, or depression (Kim & Boo, 2006; Jang, 2005; Shapira et al., 2003; Young, 1996), while few studies have considered contextual factors such as negative family relations (Choi

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& An, 2010; Park & Moon, 2012; Yoon, 2011), and troubled school life (Ah & Jeoung, 2011; Kim, Song, & Lee, 2008). Practitioners might also consider macrosystems level factors, for

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example, lack of school rules and how that may contribute to internet gaming addiction. For South Korean adolescents, it is fair to propose that ‘internet games’ are a tool for

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entertainment and relationship-building that is a major part of their daily lives. Merely

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restricting youths’ access to internet games, or reinforcing the notion that “internet games are harmful” may not be the most effective treatment strategy, considering that South Koreans

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have access to the internet in many public areas. For many adolescents, internet games are used for the sole purpose of entertainment and making friends. For some, however, they may

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be a source of psychosocial distress and physical health and mental health problems. Policies and practices in South Korea need to consider both the positive and negative aspects of internet games. To do so, adolescents’ attitudes and perceptions of internet games need to be seriously considered. Although the study participants displayed psychosocial problems of internet games, they were also able to recognize on the negative impact of playing internet games excessively and were motivated to seek help. Self-awareness and meaning-making of adolescents are critical in the treatment plans.

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References Ah, Y. A., & Jeong, W. C. (2011). The mediating effect of internet addiction between academic stress and school maladjustment in adolescence. Korean Journal of Youth Studies, 18(2), 27-50. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

PT

Disorders: DSM-5. Washington DC: American Psychiatric Association.

RI

Anderson, C. A., & Dill, K. E. (2000). Video games and aggressive thoughts, feelings, and

SC

behavior in the laboratory and in life. Journal of Personality and Social Psychology, 78(4), 772-790. doi:10.1037//0022-3514.78.4.772

NU

Bae, S. M. (2014). Exploration of predictive factors of internet game addiction in children and adolescents by using data mining. Korean Journal of Youth Studies, 21(9), 259-

MA

278.

Ballabio, M., Griffiths, M. D., Urban, R., Quartiroli, A., Demetrovics, Z., & Kiraly, O.

D

(2017). Do gaming motives mediate between psychiatric symptoms and problematic

PT E

gaming? An empirical survey study. Addiction Research & Theory, 25(5), 397-408 Chang, K. S. (2014). The influence of the types of parent communication on children's game

CE

addiction: Mainly focused on the mediated effect of family function. The Journal of Welfare Administration, 27(1), 181-188.

AC

Chen, L. S. (2007). Subjective well-being: Evidence from the different personality traits of online game teenager players. Cyber Psychology & Behavior, 11(5), 579-581. doi:10.1989.cpb.2007.0192 Cheung, J. C. S., Chan, K. H. W., Lui, Y. W., Tsui, M. S., & Chan, C. (2018). Psychological well-being and adolescents’ Internet addiction: A school-based cross-sectional study in Hong Kong. Child and Adolescent Social Work Journal.

ACCEPTED MANUSCRIPT

25

Choi, J. O. (2014). Influence of youth internet game addiction on ADHD and academic achievement - focusing on elementary school students in Seoul, Incheon, and Gyeonggi region. Korea Institute of Youth Facility & Environment, 12(2), 19-28. Choi, T. S., & An, J. Y. (2010). The effect of psychological environment of home and

the Korean Society for Computer Game, 23, 131-140.

PT

interpersonal relationship skills on adolescents` internet game addiction. Journal of

RI

Creswell, J. W., & Clark, P. V. L. (2007). Designing and conducting mixed methods research.

SC

Thousand Oaks, CA: Sage Publications

Douglas, A. C., Mills, J. E., Niang, M., Stepchenkova, S., Byun, S., Ruffini, C.,...Blanton, M.

NU

(2008). Internet addiction: Meta-synthesis of qualitative research for the decade

doi:10.1016/j.chb.2008.05.009

MA

1996–2006. Computers in Human Behavior, 24(6), 3027-3044.

Duffy, L. (2011). “Step-by-step we are stronger”: Women's empowerment through

D

photovoice. Journal of Community Health Nursing, 28(2), 105-116.

PT E

doi:10.1080/07370016.2011.564070 Fleury, J. (2002). Photo-voice as a method for capturing contextual variables. Community

CE

Nursing Research, 35, 113.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for

AC

qualitative research. Piscataway, NJ: Transaction. Griffiths, M., van Rooij, A. J., Kardefelt-Winther, D., Starcevic, V., Kiraly, O., Pallesen, S., Muller, K., ...Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addiction, 111(1), 167-175.

ACCEPTED MANUSCRIPT

26

Jang, J. H. (2005). The impact of needs for internet use and psycho-social variables on game addiction of adolescents: Comparison by sex. Journal of Future Oriented Youth Society, 2(2), 29-55. Jang, K. S. (2014), The Influence of the types of parents communication on children’s game addiction. Korean Society for Computer Game, 27(1), 181-188

PT

Ju, S. J., & Jwa, D. H. (2011). A prediction model for internet game addicted adolescents:

RI

Focusing on socioeconomic and family related traits. Korean Journal of Youth Studies,

SC

18(5), 165-190.

Jung, J. S., & Kwon, J. H. (2003). The effects of the escape from self and interpersonal

NU

relationship to pathological using of game. Paper presented at the Conferences Korean Psychology Association. Seoul, Republic of Korea.

MA

Jung, Y. T., Park, S. Y., & Suh, Y. S. (2014). A study on internet addiction experiences of adolescents. Korean Journal of Youth Studies, 21(4), 227-255.

D

Kardefelt-Winther, D. (2015). A critical account of DSM-5 criteria for internet gaming

PT E

disorder. Addiction Research & Theory, 23(2), 93-98. Kim, H. W., & Baik, J. S. (2011). A study on school life adjustment according to the level of

CE

internet game addiction among middle school students. Korea Institute of Youth Facility & Environment, 9(1), 27-35.

AC

Kim, J. Y., Song, A. Y., & Lee, J. H. (2008). A study of victimization from school violence, adolescent internet game addiction and mental health. Mental Health & Social Work, 29, 150-176. Kim, K. W., & Boo, J. M. (2006). The relationship between flow state, addiction orientation in online games and personal psychological factors with focuses on self-esteem, selfcontrol, depression, aggressiveness and tendency in sensation seeking. The Korea Journal of Counseling, 7(4), 1169-1187.

ACCEPTED MANUSCRIPT

27

Kim, K. H. (2001). The computer using pattern and computer addiction of adolescents. Journal of Student Guidance, 28, 41-62. Kim, M. K. (2012). Influence of adolescents' psychological variables and attachment with parents upon internet game addicts and cellular phone addicts. The Korean Journal of the Human Development, 19(4), 1-22.

PT

Kim, N. R., Hwang, S. S. -H., Choi, J. -S., Kim, D. -J., Demetrovics, Z., Kiraly, O.,

RI

Nagygyorgy, K., ...Choi, S. -W. (2016). Characteristics and psychiatric symptoms of

SC

internet gaming disorder among adults using self-reported DSM-5 criteria. Psychiatry Investigation 13(1), 58-66. doi: 10.4306/pi.2016.13.1.58

NU

Kim, S. K. (2010). (A) study on the juveniles' online game flow and addiction: In the focus on influence of self-control (Unpublished doctoral dissertation). Hanyang University,

MA

Seoul, Republic of Korea.

Kim, U. C., Park, Y. S., Tak, S. Y., Kim, J. H., & Oh, M. S. (2013). Analysis of the self-

D

concept in the cyberspace, self-efficacy, relationship with friends, subjective well-

PT E

being and academic grade: Comparison of adolescents who are addicted to internet to

318.

CE

non-addicted adolescents. Korean Journal of Culture and Social Issues, 19(2), 285-

Kim, Y. H., & Chong, Y. S. (2005). Parent-child communication, peer relationship and

AC

internet addiction in children. Journal of the Korean Home Economics Association, 43(10), 103-114. Király, O., Urbán, R., Griffiths, M. D., Ágoston, C., Nagygyörgy, K., Kökönyei, G., & Demetrovics, Z. (2015). The mediating effect of gaming motivation between psychiatric symptoms and problematic online gaming: An online survey. Journal of Medical Internet Research, 17(4), e88. doi: 10.2196/jmir.3515

ACCEPTED MANUSCRIPT

28

Korea, National Information Society Agency. (2014). Feature analysis of internet addicts and standardization of counseling record using the counseling record of the Korean internet addiction prevention center (IAPC). (No. NIA V-RER-14028). Seoul, Republic of Korea Kuss, D. J. (2013). Internet gaming addiction: Current perspectives. Psychology Research

PT

and Behavior Management, 6, 125-137

RI

Kwon, J. H., & Lee, E. H. (2005). Predicting game addiction in adolescents: An application

SC

of discriminant function analysis. The Korean Journal of Health Psychology, 10(1), 95-112.

NU

Kwon, J. H., & Lee, S. Y. (2000). Social problem - solving abilities, and communication style of adolescent internet game addicts. Conferences Korean Psychology Association, 1

MA

268-269.

Kwon, S. J., Kim, K. H., & Lee, H. S. (2005). Computer game addiction and physical health

D

of Korean children: Mediating effects of anxiety. Survey Research, 6(2), 33-50.

PT E

Lam, L. T. (2014). Internet gaming addiction, problematic use of the internet, and sleep problems: A systematic review. Current Psychiatry Reports, 16(4), 444.

CE

doi:10.1007/s11920-014-0444-1 Lee, G. W. (2001). The study on internet addiction of adolescent. (Unpublished doctoral

AC

dissertation). Ewha Woman’s University, Seoul, Republic of Korea. Lee, H. C. (2001). A study on developing the internet game addiction diagnostic scale and the effectiveness of cognitive-behavioral therapy for internet game addiction. (Unpublished doctoral dissertation). Korea University, Seoul, Republic of Korea. Lee, H. G. (2002). Social and psychological variables predicting violence game addiction of adolescents in the internet. The Korean Journal of Developmental Psychology, 14(4), 55-79.

ACCEPTED MANUSCRIPT

29

Lee, H. G. (2003). Effects of individual- and social-related factors and motives for game playing on game concentration and game addiction. Korean Journal of Youth Studies, 10(4), 355-380. Lee, H. C. (2001). A study on developing the internet game addiction diagnostic scale and the effectiveness of cognitive-behavioral therapy for internet game addiction.

PT

(Unpublished doctoral dissertation). Korea University, Seoul, Republic of Korea.

RI

Lee, S. J., Hong, S. H., & Park, J. K. (2005). The study on the personal and social influence

SC

on internet addiction among adolescents. The Korean Journal of Educational Psychology, 19(4), 1179-1197.

NU

Lee, Y. K., & Chae, K. M. (2006). Relations of computer game addiction and social relationship, adjustment of adolescent. The Korean Journal of Clinical Psychology,

MA

25(3), 711-726

Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2009). Development and validation of a

D

game addiction scale for adolescents. Media Psychology, 12(1), 77-95.

PT E

doi:10.1080/15213260802669458

Ministry of Cultural, Sports and Tourism, & Korea Creative Content Agency. (2014). White

CE

Paper on Korean Games. (No. ISBN 9788965143741). Seoul, Republic of Korea. Ministry of Science ICT and Future Planning, & National Information Society Agency.

AC

(2015). A Survey on Internet Addiction. (No. NIA V-PER-14112). Seoul, Republic of Korea.

Novak, J. D. (2010). Learning, creating, and using knowledge: Concept maps as facilitative tools in schools and corporations. New York: Routledge. Park, S. Y., & Moon, H. J. (2012). Trends in child internet game addiction as induced by family strengths and daily stress levels. The Korean Journal of Human Development, 19(1), 143-162.

ACCEPTED MANUSCRIPT

30

Petry, N. M., Rehbein, F., Gentile, D. A., Lemmens, J. S., Rumpf, H. J., Moble, T., Bischof, G.,...O’Brien, C. P. (2014). An international consensus for assessing internet gaming disorder using the new DSM‐ 5 approach. Addiction, 109(9), 1399-1406. https://doi.org/10.1111/add.12457 Schneider, L. A., King, D. L., & Delfabbro, P. H. (2017). Family factors in adolescent

PT

problematic Internet gaming: a systematic review. Journal of Behavioral Addictions,

RI

6(3), 321-333.

SC

Shapira, N. A., Lessig, M. C., Goldsmith, T. D., Szabo, S. T., Lazoritz, M., Gold, M. S., & Stein, D. J. (2003). Problematic internet use: Proposed classification and diagnostic

NU

criteria. Depression & Anxiety, 17(4), 207-216. doi:10.1002/da.10094 Straus, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures

MA

and techniques. Newbury Park, CA: Sage

Suler, J. (2005). Adolescents in cyberspace: The good, the bad, and the ugly. Retrieved from

D

http://users.rider.edu/~suler/psycyber/adoles.html

PT E

Sung, Y. S. (2003). An ethnographic study on the process of online game indulgence among adolescent. The Korea Journal of Youth Counseling, 11(1), 96-115.

CE

Tufford, L., & Newman, P. (2012). Bracketing in qualitative research. Qualitative Social Work, 11(1), 80-96. doi: 10.1177/1473325010368316

AC

Wang, C. C. (1999). Photovoice: A participatory action research strategy applied to women's health. Journal of Women's Health, 8(2), 185-192. Wang, C., & Burris, M. A. (1994). Empowerment through photo novella: Portraits of participation. Health Education & Behavior, 21(2), 171-186. doi:10.1177/109019819402100204

ACCEPTED MANUSCRIPT

31

Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24(3), 369-387. doi:10.1177/109019819702400309 Wang, C. C. (1999). Photovoice: A participatory action research strategy applied to women's health. Journal of Women's Health, 8(2), 185-192. doi:10.1089/jwh.1999.8.185

PT

Yoon, B. S. (2011). Research on youth internet game addiction involving. The Journal of

RI

Welfare Administration, 27, 39-53.

SC

Yoon, H. S., Kyung, S. Y., Lee, E. Y., & Lee, H. K. (2012). A study on recovering process from internet game addiction in adolescents: 'Escaping from confusions and struggle.

NU

Korean Journal of Youth Studies, 19(10), 73-99.

Yoon, J. Y., & Chae, K. M. (2014). The relationship between adolescent internet game

MA

addiction disposition and recognition of school violence - focusing on the mediating effect of reality perception level. Cognitive Behavior Therapy in Korea, 14(3), 455-

D

476.

PT E

Young, K. S. (1996). Psychology of computer use: XL. Addiction use of the internet: A case that breaks the stereotype. Psychological Reports, 79, 899-902.

AC

CE

https://doi.org/10.2466/pr0.1996.79.3.899

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Compliance with Ethical Standards 

This study received no external funding.

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The authors declare that there is no conflict of interest and ensured that all ethical standards were met. This article does not contain any experiments with human

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participants or animals performed by any of the authors. All procedures performed in studies involving human participants were in accordance

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with the ethical standards of the institutional and/or national research committee and with

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Informed consent was obtained from all individual participants included in the study.

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

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the 1964 Helsinki declaration and its later amendments or comparable ethical standards.