©Freund Publishing House Ltd. Int J Adolesc Med Health 2010;22(l):3-38
An international perspective on youth gambling prevalence studies
Rachel A Volberg, PhD1, Rina Gupta, PhD2, Mark D Griffiths, PhD3, Daniel T Olason, DPhil4 and Paul Delfabbro, PhD5
lGemini Research, Northampton, Massachusetts, United States of America; 2 International Center for Youth Gambling Problems and High-Risk Behaviors, McGill University, Montreal, Canada; 3 International Gaming Research Unit, Nottingham Trent University, Nottingham, United Kingdom; ^University of Iceland, Reykjavik, Iceland; and ^University of Adelaide, Adelaide, Australia
Abstract: In the wake of rapid expansion of legal gambling internationally, studies of adolescent gambling involvement and problem gambling prevalence have been carried out in numerous jurisdictions. This paper reviews adolescent gambling prevalence studies that have been carried out in North America, Europe, and Oceania. Based on this review, work is clearly needed to assess the impact of survey methods on identified prevalence rates and to improve the measurement of problem gambling among adolescents. From a substantive perspective, several clear demographic and behavioral characteristics arc associated with gambling involvement and problem gambling among youth. However, early assumptions about youth gambling and problem gambling must give way to more nuanced understandings of how these phenomena change in response to changes in the social and cultural environment. We may have traveled some distance down the road toward understanding the determinants as well as the distribution of youth gambling and problem gambling, but we still have a long way to go.
Keywords: Adolescence, gambling, prevalence, behavior
Correspondence: Rachel Volberg, PhD, Gemini Research, Ltd., PO Box 1390, Northampton. MA 01061 USA. E-mail: rvolbcrgffigeminiresearch.com
Submitted: June 01,2009. Revised: August 27,2009. Accepted: September 12,2009.
INTRODUCTION and severity of gambling problems among Few people regard gambling as a serious adolescents and young adults, issue for adolescents, although many There are many other reasons to be researchers have noted that an entire concerned about adolescent gambling, generation has now grown up in an era Research among adults has shown that when lottery and casino gambling is individuals with severe gambling-related widely available and heavily advertised difficulties begin gambling much earlier than (1-4). Concern among researchers and those without gambling problems (5,6). clinicians who treat people with Another reason for concern is that adolescents gambling problems is that the increased tend to begin gambling before they begin availability of legal gambling and experimenting with tobacco, alcohol, drugs, decreased stigma has led to increases in and/or sexual behavior (7-9). A third, related adolescent gambling and the prevalence concern is that gambling often co-occurs with
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM YOUTH GAMBLING PREVALENCF-: STUDIES other risky behaviors and mental health adult psychiatric criteria for pathological problems and if unaddressed, could gambling (DSM-IV-J and DSM-IV-MR-J) affect adolescents' success in overcoming (17,18). In a study comparing these two other difficulties in their lives (10-12). screens and one other measure of problem Finally, although access to most legal gambling (Gamblers Anonymous (GA) 20 forms of gambling is age-restricted, the Questions), Derevensky and Gupta (19) found evidence suggests that large numbers of substantial agreement among all three high school and underage college instruments, although the DSM-IV-J yielded a students are able to gamble in casinos lower prevalence estimate than either the and buy lottery tickets (13,14). SOGS-RA or the GA 20 Questions. The three The impact on adolescents of the measures identified between 3.4% and 5.8% widespread availability, heavy advertising of participants in the study as probable and sanctioning of multiple forms of pathological gamblers. However, only 1.1% of legal gambling are an increasing concern the participants in the study classified in the fields of public health and themselves as such (20). addictions. Nevertheless, a significant Despite uncertainty about precisely what lack of consensus remains around the adolescent problem gambling screens measure, question of what constitutes problem work has been carried out to identify the gambling among adolescents and how to patterns of gambling and problem gambling measure the disorder. Although well- among adolescents in many jurisdictions. accepted methods for identifying patho- Given the amount of research that has been logical gambling in the adult population done, there is value in taking a comparative have emerged (15), there are good look at what these studies can tell us about reasons to hesitate in applying such youth gambling and problem gambling from methods to adolescents. The psychiatric an international perspective. In this paper, we criteria for identifying pathological review the methods and results of adolescent gambling among adults were developed prevalence surveys that have been carried out based on adult life experiences, and in North America (the United States and younger individuals have not yet had Canada), Europe and the Nordic countries, and time to develop the same depth of Oceania (Australia and New Zealand). We experience. Another concern is that the conclude by review ing some of the consistent psychiatric criteria for pathological findings across these studies and drawing gambling have never been clinically some important lessons for the future. A tested among adolescents, and little synopsis of the key features of all of these information has emerged about their surveys is provided in Table 1. validity in this subgroup of the population. UNITED STATES OF AMERICA The few instruments developed to The development of adolescent gambling measure adolescent problem gambling prevalence research in the United States (US) are primarily derived from instruments spans three distinct periods. The early period developed to assess adults. The majority (1984 to 1989) coincided with the growth of of adolescent studies have used either an state-run lotteries. The middle period (1990 to adaptation for adolescents of the widely- 1999) coincided with a rapid expansion of used South Oaks Gambling Screen casino gambling in the wake of the passage of (SOGS-RA) (16) or an adaptation of the the Indian Gaming Regulatory Act of 1988.
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The past decade (2000 to 2009) saw long term trend has been a progressive changes in strategies for collecting data increase in the amount of serious gambling- about adolescent gambling and problem related problems reported by juveniles in the gambling, increased analytic sophisti- US." This view is in contrast to the conclusion cation, and growing interest in the links reached by other researchers (3,28,29) that between adolescent gambling and other rates of youth gambling and problem risky behaviors. gambling tend to be quite stable over time.
Early period (1984-1989) Middle period (1990-1999) In an early review of adolescent In the US, the period between 1990 and 1999 prevalence surveys, Jacobs (21) identi- saw rapid growth in the number and quality of fied six studies that were completed adolescent gambling prevalence surveys. before 1990 (22-27). Carried out in Although some states funded only one such California, Connecticut, New Jersey, and survey during the decade, several states Virginia, all the studies were conducted funded two or more surveys. in high schools using self-completed Single survey's. During the 1990s, single questionnaires. The students participating school-based or telephone surveys were in these studies were probably not completed in several states, including Georgia, representative of their schools or of Louisiana, New York, and Vermont. The adolescents in their states because as reasons for funding these studies varied. In Jacobs noted, "...none of these Georgia, there was concern about the impact independent unsponsored investigators of a new state lottery on adolescent gambling had the resources to employ formal and in New York concern about the impact of stratified sampling procedures" (21:433). a single new lottery game, five-minute keno. Sample sizes were relatively small, In Louisiana, the State Health Department ranging from 147 to 892, and different desired information on which to base a youth instruments were used in each study. In gambling prevention program. California and Virginia, separate surveys t-ln 1995, Vermont was the first state to add were carried out before and after state a gambling module to the Youth Risk lotteries were introduced. In the wake of Behavior Survey conducted annually by the the introduction of lotteries, Jacobs (21) Centers for Disease Control and Prevention reported that past-year gambling partici- (30). The survey was administered to 8th to pation among high school students rose 12th grade students (n=21,297) in public and from 20% to 45% in California and from private schools across the state. Two questions 40% to 58% in Virginia. related to gambling were included in the In a subsequent analysis that included survey, one assessing past-year gambling these six studies along with nine participation and the other assessing problems additional surveys carried out between caused by gambling. Apart from gambling, the 1989 and 1999, Jacobs (1:120) concluded risk behaviors assessed in this survey included that the rise in the median level of drug and alcohol use, seatbelt use, violence, gambling participation from 45% before and sexual activity. Among the 16,948 students 1990 to 66% "...leaves little doubt that who answered both gambling questions, juvenile gambling throughout the US has problem gamblers reported significantly more increased significantly". Jacobs (1:134) risky behaviors than gamblers, and gamblers further concluded that, "...the dominant reported significantly more risky behaviors
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM YOUTH GAMBLING PREVALENCE STUDIES than did non-gamblers. The Vermont age of onset for gambling participation was researchers recommended that gambling significantly younger than smoking tobacco be included as a regular part of health and use of marijuana and alcohol. assessments of adolescents and used to Repeat cross-sectional surveys. In the identify youth at risk of developing other 1990s, several states funded multiple adoles- risk behaviors. cent prevalence surveys (e.g., Oregon, Texas, In 1996, the Georgia Department of and Washington State). In all these states, the Human Resources funded an adolescent surveys used methods very similar to those prevalence survey (31). Telephone inter- employed in the surveys in Georgia and New views with a sample of 1,007 Georgia York. The major difference across these states adolescents aged 13 to 17 years used the was the interval between the baseline and SOGS-RA to assess problem gambling. replication surveys. In Texas, the gap was 3 A modified scoring method was used to years (34,35); in Washington State, the gap classify respondents in this survey as was 6 years (36,37); and in Oregon, the gap non-problem, at-risk and problem was 9 years (38,39). gamblers. Based on this multi-factor In Texas, Wallisch (34,35) found that method (also used in surveys in Texas whereas lifetime gambling participation and Washington State), 2.8% of the among adolescents aged 14 to 17 years Georgia adolescents surveyed were increased in the wake of the introduction of a classified as problem gamblers. A state lottery, past-year gambling participation multiple regression analysis showed that remained stable. The prevalence of problem male adolescents with high weekly gambling, assessed using the SOGS-RA, incomes but low self-esteem were more declined from 5.0% in 1992 to 2.3% in 1995. likely to be classified as problem In Washington State, Volberg, and Moore (37) gamblers than were other adolescents in found that past-year gambling participation the study. A similar adolescent survey declined slightly from 70% to 65%, whereas was carried out in 1997 in New York the prevalence of problem gambling, using the State (32). The sample in New York SOGS-RA, was unchanged at 0.9%. included 1,103 adolescents aged 13 to 17 Finally, Volberg et al (39) found a years and the SOGS-RA was used to significant decline in gambling participation assess problem gambling. Based on the among adolescents in Oregon over a 9-year multi-factor method, 2.4% of the adoles- period, from 66% in 1998 to 46% in 2007, cent respondents were classified as with no change in the prevalence of problem problem gamblers. gambling. Volberg et al (39) hypothesized that In 1998, Westphal and colleagues the substantial drop, particularly in age- (33) conducted a large school-based restricted gambling activities, could be due to prevalence survey in Louisiana. The several factors, including sampling error, study included a random sample of lifelong exposure to gambling, changes in 11,736 students in grades 6 through 12 attitudes toward youth gambling, and attending both public and private schools extensive efforts undertaken by the State of throughout the state. One third (34%) of Oregon to educate youth, parents, and teachers the final sample was African-American. about the risks of adolescent gambling. Based on the SOGS-RA, 5.8% of The presence in Minnesota of a well- students were classified as problem established research center in adolescent risk gamblers. The researchers noted that the behavior and the introduction of a state lottery
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG combined to support an extensive (43,44). One of these two school-based program of research into adolescent surveys was carried out on a Northern Plains gambling. In 1990, Winters, Stinchfield, reservation (n=227 students, ages 12-19) and and Fulkerson (40) conducted a the other was completed on a Great Lakes telephone survey of 702 Minnesota reservation (n=185 students, ages 12-19). The youth aged 15 to 18 years to obtain a two surveys used identical methods, and the baseline measure of youth gambling results focused on comparisons of American before the introduction of the state Indian and non-Indian adolescents living on or lottery. One year later, 532 participants near the reservations. The self-administered from the baseline survey (76%) were re- questionnaire included a combination of interviewed by telephone (41). Although SOGS, 20 Questions, and DSM-III-R items. no statistically significant changes were Both studies found that the majority of found in regular participation in specific Native American youth gambled and that gambling activities, a shift from informal Native American youth started gambling at an private games to legal gambling earlier age than non-Indian youth. Zitzow (44) activities over the one year interval was reported that 5.6% of the non- Native observed. Ðé is report was the first American youth scored as "pathological instance of a prospective study of gamblers" compared with 9.6% of Native gambling behavior. American youth. Peacock et al (43) did not A series of three school-based report on the proportion of youth in their prevalence surveys were subsequently sample that scored as problem or pathological carried out in Minnesota in 1992, 1995, gamblers. However, these researchers and 1998 (29,42). In each year, two concluded that Native American youth were at items (feeling bad about gambling and greater risk for developing gambling problems wanting to stop gambling) were added to because of extremely high rates of loss of the Minnesota Student Survey, a self- important people in their lives and the administered questionnaire that inquires widespread belief that money would solve about multiple behavioral domains and is their problems. administered every 3 years to nearly all Interestingly, in considering the impact of 9th and 12th graders in Minnesota. the introduction of casino gambling in Indian Between 1995 and 1998, the researchers country, Zitzow concluded that "...the recent found that although fewer youth introduction of a large stakes casino within gambled, the proportion of youth who this reservation community may not be the gambled frequently increased. The most significant event in promoting gambling researchers also found that the proportion ... The most significant events appear to have of youth self-reporting gambling already occurred within the last 15 years due problems based on these two items to the onset of bingo, pulltabs, state-supported remained relatively stable between 1992 scratch tabs, and the state lottery" (44: 25). and 1998. Native American youth. In the 1990s, Present period (2000-2009) Class III (casino) gambling on Native Since 2000, the number of surveys designed American reservations expanded rapidly. specifically to measure adolescent gambling In the wake of this development, two prevalence has declined in the US. Instead, small prevalence studies were carried out researchers are finding new ways to obtain among Native American adolescents information about adolescent gambling and
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM YOUTH GAMBLING PREVALENCE STUDIES are focusing more on risk and protective Substance Abuse Services, students were 15% factors associated with problem more likely to have played card games for gambling. money and 43% more likely to have played Adding gambling modules to other lottery games in 2006 compared with 1998 surveys of youth. Ten years ago, the (48). The 2006 survey in New York was the National Gambling Impact Study only one that included a problem gambling Commission (45) recommended adding screen; notably, 28% of the students in New gambling components to existing research York who were deemed to be in need of panels. Although this recommendation chemical dependence treatment services had was never implemented at the national experienced gambling problems in the past level, several states (e.g., Arizona, year. Louisiana, New York) added gambling The national picture. As part of the modules to existing surveys of youth national Gambling Impact and Behavior (46-48). Unfortunately, only the New Study, Gerstein et al (49) completed a survey York survey included any questions of 534 youths aged 16 to 17 via a randomized about gambling-related problems. telephone survey of US households. Youth Because the focus of these surveys is were interviewed with the same questionnaire on risk and protective factors for a range used in an accompanying adult survey and of behaviors, all include large samples of screened for gambling problems using the students. Adding questions that assess NODS, a screen derived from the DSM-IV past-year involvement in a range of criteria for pathological gambling and gambling activities enables an designed specifically for telephone survey examination of gambling involvement in administration. The most striking finding relation to gender and age, as well as in relates to the different pattern of youth relation to other risk behaviors, such as gambling compared with adults. Adolescent alcohol and substance use, anti-social gambling was predominantly composed of behavior, and school performance. One private betting on games of skill, particularly interesting finding from the surveys in card games. Over one-quarter of youths (28%) Arizona and Louisiana is that, in contrast compared with just 11% of adults had bet on to many other adolescent gambling such games in the past year. The other most prevalence studies, older youth in these prominent youth games were betting in sports states were less likely than younger pools and buying lottery tickets. Another youth to say that they gambled. interesting finding was that the prevalence of Another advantage to adding at-risk, problem, and pathological gambling gambling modules to youth risk behavior among the adolescent respondents was surveillance surveys is that changes in substantially lower than among adults, if the gambling participation can be tracked same cutpoints were used. over time. In Arizona, where gambling Between 2005 and 2007, a nationally questions were asked in 2006 and 2008, representative survey of youth gambling and significant increases in gambling problem gambling was carried out with participation were identified among 8lh, funding from the National Institutes of Health 10th· and 12th graders (46). In New York, (4,10). Telephone interviews were completed where gambling questions were included \\ith 2,274 youths and young adults aged 14 to in the 1998 and 2006 annual School 21 years in all 50 states and the District of Survey of the Office of Alcoholism and Columbia. The data were weighted to adjust
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG for household size and to match the month. Respondents who have engaged in one gender, age, and race distributions of the or more activities in an average month are US Census. The primary measure of asked four questions about difficulties related problem gambling was the SOGS-RA to their gambling that assess the DSM-IV although the researchers also included a criteria of preoccupation, tolerance, loss of 13-item module from the Diagnostic control, and withdrawal. In 2008, the Institute Interview Schedule that was used to reported that monthly rates of card playing, assess pathological gambling in an particularly on the Internet, had spiked in 2005 earlier adult survey (50). The study and 2006 in the wake of a "card playing found that 68% of the youth and young (poker) fad" and had since declined and adult respondents had gambled in the stabilized. The researchers reported that sports past year. Males were much more likely betting increased among male youth in 2008 than females to gamble regularly, as were but that the long-term trend in overall weekly older adolescents. African Americans gambling since 2002 had been downward for were less likely than youth of other races both male and female youth (52). to have gambled in the past year but, if they gambled, they were more likely to CANADA do so regularly. As with the earlier Whereas numerous studies of adolescent national survey, this study found that gambling have been conducted in Canada, rates of problem and pathological relatively few prevalence surveys have been gambling were lower than those in the completed. Most studies consist of adult sample assessed by the same convenience samples, assessing adolescents research team and with the same within the school system and usually include questionnaire. A separate analysis of the only youth living close to major city centers. data found a close relationship between Nonetheless, such studies have proved useful the mean number of gambling activities in understanding gambling patterns, engaged in by youth and problem preferences, and trends, as well as a sense of gambling (51). After controlling for the proportion of youth who experience involvement in other games, the gambling-related problems. researchers found that card games, games of skill and gambling at casinos Early investigations (1988-1995) were the activities most closely associated Early surveys, completed in Nova Scotia in with an increased risk of gambling-related 1993, in Ontario in 1994, and in Alberta in problems among adolescents and young 1996, included the adult SOGS rather than a adults. problem gambling screen specifically Since 2002, the Adolescent Risk designed for adolescents (53-55). Wynne Communication Institute (created by the Resources reports that the Alberta youth Annenberg Foundation) has funded an survey was carried out by telephone, but the annual telephone survey of youth aged modality used in the Nova Scotia and Ontario 14 to 22 years. The sample size was 900 adolescent surveys is unclear. Two early in each year except for 2004 and 2008. surveys in Quebec City, Quebec, and Windsor, Respondents are asked questions about a Ontario were classroom-based but included range of risky activities, including different problem gambling screens. The frequency of engaging in specific Quebec City survey was based on the gambling activities in an "average" "pathological gambling signs index" used in
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 10 YOUTH GAMBLING PREVALENCE STUDIES another early youth survey in New Jersey The rates of problem gambling identified (26,56). The Windsor survey used the among adolescents in the national prevalence SOGS-RA to assess the extent of survey in Canada were substantially lower problem gambling (57). Both past-year than rates identified in provincial prevalence gambling and the rate of patho-logical surveys conducted in roughly the same period. gambling were lower in Quebec City This finding is particularly true for British than in New Jersey; the Windsor survey Columbia and the Prairie provinces of Alberta, found higher rates of both past-year Saskatchewan, and Manitoba. Also gambling and problem gambling than noteworthy is that the national survey included reported in other provinces. individuals to age 24 years who were Across the board, these early interviewed in person, whereas provincial investigations found that Canadian youth surveys have focused primarily on those under participated in a multitude of gambling the age of 18 or 19 years and have been activities, usually self-organized forms completed in classrooms or by telephone. of wagering (e.g., card games for money, Accordingly, differences between the betting on games of skill including video provincial surveys and the national survey games) although lottery products were must be interpreted with caution. also popular among adolescents (7). British Columbia. Aside from the national prevalence study, little research on adolescent Recent period (1999-2009) gambling has been carried out in British The national sun-ey. The Canada-wide Columbia. One small study, conducted in mental health survey (Canadian Langley in 2001-2002 among 454 students Community Health Survey: Mental aged 15 to 19 years, included completion of I lealth and Well-Being 1.2) is the largest the SOGS-RA. Ninety percent of the nationally representative data set participants in this study reported gambling in assessing gambling participation and the previous year and five percent met the problem gambling prevalence among narrow criteria for serious gambling-related individuals aged 15 years and older. The problems (59). youth data consist of a subset of 5,666 The Prairie provinces. Based on recent Canadian residents aged 15 to 24 years. studies in all three provinces (Alberta, Respondents were interviewed face-to- Saskatchewan, and Manitoba), the rates of face, and the Canadian Problem adolescent gambling participation appear Gambling Index (CPGI) was used to lower in Alberta than in the other two measure gambling and problem provinces. In 2002 and 2005, the Alberta gambling. Although minor regional Youth Experience Survey included questions differences were seen, overall 61% of about gambling participation and problem youth reported gambling in the previous gambling in classroom surveys completed year, 56% ranked as non-problem with students in grades 7 through 12 (60,61). gamblers, 3.5% scored as being at slight In 2002, 41% of the students reported risk for gambling problems, and 2.2% gambling in the past year. The most popular ranked as being moderately at risk for gambling activities included scratch tabs and/or meeting the criteria for problem (31%), playing cards for money (23%), and gambling. Those at greatest risk were betting on sports events (21%). Alberta young, male, and living in the Prairie adolescents held favorable attitudes toward region (58). gambling and perceived it as a socially
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERO II acceptable activity. Based on the SOGS- the 32% of the sample still under 18 years of RA, 3.8% of Alberta students were age, the study found that the overall rate of considered problem gamblers, of which gambling participation had not changed. the majority were male, in high school. However, respondents were more likely to Aboriginal, and from larger cities. Three participate in legal forms of gambling, such as years later, a repeat survey found that casinos and VLTs, and less likely to gamble in past-year gambling participation had home or school settings. The at-risk and increased to 63% with scratch tabs problem gambling rates decreased slightly replaced by card playing as the most from 1999, but the authors concluded that frequent activity (41%). The prevalence these changes were not statistically significant. of problem gambling based on the In 2004, a study conducted in Manitoba SOGS-RA remained almost unchanged included 6,673 students aged 12-18 years from at 3.6%; but the prevalence of at-risk across the province. The sample included gambling increased from 5.7% to 8.8% more rural schools than in previous surveys in (61). Manitoba and was more representative of the A study commissioned by Saskatche- youth population of Manitoba. Using the wan Health in 2003 included a sample of DSM-IV-MR-J the results differed significantly 1,884 students aged 15 to 18 years (62). from previous adolescent surveys in Manitoba, The majority of youth (81%) reported with only 35% of the students reporting gambling with scratch tickets, games of having gambled in the previous 12 months. skill, and self-organized poker games However, the rate of problem gambling being among the most popular activities. (2.3%) is very similar to rates previously Although problem gambling was not reported in Manitoba (65). These results assessed, the authors concluded that suggest that youth in rural areas are less likely Saskatchewan youth were actively than urban youth to gamble. involved in gambling, and that gambling Ontario. The Centre for Addiction and represented a significant proportion of Mental Health's Ontario Student Drug Use their monthly expenditures. Survey (OSDUS) is the longest ongoing The Addictions Foundation of school survey of adolescents in Canada, Manitoba conducted a prevalence study having been conducted every two years since of youth in 1999. One thousand youth, 1977. Beginning in 1999, the OSDUS aged 12 to 17 years, were interviewed by included questions about gambling and telephone and administered the SOGS- gambling problems in these surveys, which RA. The majority of the adolescents encompass students in grades 7 to 12 (ages 12- (78%) reported gambling in the previous 18 years). Although the SOGS-RA was used year, with the most popular activities until 2003, the 12-item screen was reduced to being the purchase of raffle tickets, 6 items in the 2005 survey. In 2005, 33% of playing cards for money, and betting on the students acknowledged playing cards for dice or games of skill. Based on the money in the past year; 18% purchased lottery SOGS-RA, 8% of these adolescents were tickets, and 17% bet money in sports pools. at-risk gamblers and 3% were problem The least prevalent activity was casino gamblers (63). Three years later, a gambling (1%), followed by Internet gambling follow-up study was completed with 410 (2%). Among all the students, 6% were individuals from the 1999 cohort, now identified as heavy gamblers and 4.5% were aged 15 to 20 years (64). Looking only at classified as problem gamblers.
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Developmentally, heavy gambling school students were at-risk gamblers and 2% rates were found to vary significantly by were problem gamblers. The prevalence of grade, peaking in grade 12 at 8.5%. problem gambling was twice as high among Although the researchers identified a students who spoke a language other than sharp decrease in the rate of problem French at home (Anglophones/Allophones) gambling between 1999 and 2003 (from compared with Francophones (4% vs. 2%) 6.2% to -3.5%), between 2003 and 2005 (68). they found a slight increase in problem The Atlantic provinces. In 1998, a survey gambling prevalence (from 3.5% to was conducted across all four Atlantic 4.5%), a change that was not statistically Provinces: Nova Scotia, New Brunswick, significant (66,67). Newfoundland and Labrador, and Prince Quebec. Quebec is a unique province Edward Island. A total of 13,549 students with meaningful cultural differences from grades 7 through 12 in the public school between Francophones (French-speaking), systems completed a questionnaire that Anglophones (English-speaking), and included the SOGS-RA. Overall, 70% of the Allophones (neither English- nor French- students reported gambling in the previous speaking). Whereas Quebec's population year; the most popular gambling activities is predominantly Francophone, significant were scratch tabs (60%), playing cards for numbers of Anglophones and Allophones money (35%) and betting on sports (30%). live around the major city centers, The prevalence of at-risk gambling among primarily Montreal. Problem gambling these adolescents was 3.8% and the prevalence rates in Quebec have been shown to vary of problem gambling was 2.2%. The according to these cultural differences. In prevalence of problem gambling did not vary 2006, a province-wide, representative on the basis of age (69). sample of 4,571 students in grades 7 to 11 was surveyed using the DSM-IV-J to EUROPE assess problem gambling (68). The Recent reviews of gambling participation results showed that 36% of high-school across many European countries suggest that students had gambled in the past 12 research into adolescent gambling is compara- months with participation rates being tively rare in this part of the world. In this higher among Allophone students (42% section, research conducted in the Baltic and vs. 35%). Thirty percent of students were Balkan countries, Germany and Belgium, the classified as occasional gamblers and 6% Latin European countries of Italy and Spain, were classified as habitual gamblers (i.e., and Great Britain is reviewed. This is followed gambling at least once per week). The by a review of research conducted in the Nordic rate of habitual gambling was higher countries of Denmark, Finland, Iceland, among Anglophone and Allophone Norway and Sweden. students compared to Francophone youth (9% vs. 5%). The most popular forms of Baltic and Balkan States gambling among Quebec high-school Central and Eastern European countries in students included card games (21%), which some adolescent gambling research has instant lotteries (17%), games of skill been completed include Estonia, Lithuania, (14%), and private sports gambling Romania, and Slovakia. In Estonia, two (13%). Approximately 4% of these high prevalence surveys have been carried out
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 13 among residents aged 15 to 74 years gambling (27% vs. 9%). Male adoles-cents (70,71). The 2004 survey included 1,000 were three times more likely to be respondents and the 2006 survey 2,005 pathological gamblers (6% vs. 2%). Being respondents. The SOGS was translated male, having cognitive distortions regarding into Estonian and used to assess problem gambling, having parents who gambled, and pathological gambling (72). The having parents who gambled to excess, using results were not presented separately by alcohol regularly, and smoking regularly all age groups. In 2004, 61% of the contributed independently to pathological participants had gambled and 2.4% were gambling status. classified as probable pathological As in Lithuania, some research on adoles- gamblers, whereas in 2006, 75% of the cent gambling has been conducted in Romania participants had gambled and 3.4% were (77). Lupu, Onaca and Lupu (78) examined the classified as probable pathological prevalence of problem gambling using the GA gamblers. In comparing the results of the 20 Questions in three Romanian counties. two surveys, Laansoo and Nut (73) Based on a sample of 500 high-school students observed that younger respondents in (57% female and 43% male) between the ages these surveys were more likely to gamble of 14 and 19, the games most frequently played and more likely to be classified as by Romanian teenagers were: football pools probable pathological gamblers. (56%), poker (35%) and bingo (32%). Two- A youth gambling study was recently thirds of the sample (64%) gambled frequently completed in Kaunas, Lithuania's second and 82% indicated that they gambled in groups. largest city (74). The sample comprised The mean age at which these Romanian youth 835 randomly selected adolescents began gambling was 14 years. Among the 7% between the ages of 9 and 16 years from of participants identified as problem gamblers, all of the Kaunas secondary schools 82% were male. Analysis showed that 18% of (47% male, 53% female). Two problem the problem gamblers had fathers who were gambling screens, the SOGS-RA and the alcoholics and 12% had fathers who were DSM-1V-MR-J, were translated into problem gamblers. No significant differences Lithuanian (75,76). Males were signifi- were found between problem and non-problem cantly more likely than females to be gamblers in relation to family income or social both occasional and regular gamblers. status. Based on the DSM-IV-MR-J, 4% of the In a separate study, Lupu and colleagues study participants were identified as (79) examined the risk factors for problem pathological gamblers; based on the gambling among 231 Romanian adolescents SOGS-RA, 5% of participants were aged 14 to 18 years. Using the GA 20 defined as pathological gamblers. The Questions, the researchers categorized the DSM-IV-MR-J was used as the main participants into three groups based on their screen because of its conservative nature level of gambling and problem gambling and because of its similarity to the DSM- severity. Among these youth, 54% endorsed IV criteria. Compared with other between two and six of the GA-20 questions gamblers, the pathological gamblers in and another 12% endorsed seven or more this study were significantly more likely items. Risk factors for the most severe to gamble on slot machines (51% vs. problem group included: parental divorce, 8%), cards (17% vs. 7%), and SMS serious physical illness in a family member,
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 14 YOUTH GAMBLING PREVALENCE STUDIES death of a family member, family break- (36%) and private card games for money up, psychological illness in a family (29%) were the most popular activities. Other member, sexual abuse, and being in a popular activities included state-run sports severe accident. Based on the data, Lupu betting (18%), amusement-with-prizes et al (79) identified two distinct types of machines (17%), private games of skill (17%) problem gambler: and private dice games (15%). The prevalence • adolescents from unfavorable family rate of problem gambling using the DSM-IV- and social environments who were MR-J was 3% among all participants. dealing with stress and trauma (e.g., However, boys were five times more likely neglect, physical, and/or sexual than girls to be problem gamblers. Problem abuse), and gamblers reported significantly more stressful • adolescents from favorable family life events than non-problem gamblers, and social environments, where consumed psychoactive substances more parents neglected the child because of frequently, and were dissatisfied with their life work involvement. situation. The researchers concluded that these adolescent problem gamblers lacked coping Among the first group, gambling was skills for handling day-to-day demands. a coping mechanism to deal with chronic The only study of adolescent gambling in stress; among the second group, Belgium was part of a larger study of youth gambling was a way to spend time risk habits (83). This survey of 38,357 youth and/or attract a parent's attention. aged 12 to 18 examined participation in four Finally, a recent overview by Zivny gambling activities (slot machines, lotteries, and Okruhlica (80) made reference to a card games, and betting). Results showed that study that examined the comorbidity of 40% of these adolescents had gambled on one gambling and psychoactive substance or more of the four activities in their lifetime, use in primary and secondary schools in reflecting a decrease from 53% in 2001 and Slovakia (81). In this survey of 1,142 42% in 2005. primary and secondary students, 12% of primary school children reported they Latin Europe had gambled occasionally and 1.5% Very little research has been done on admitted gambling regularly. Among adolescent gambling in any of the Latin secondary school children, 15.5% European countries. In Italy, Capitanucci, gambled occasionally whereas 1.6% Biganzoli and Smaniotto (84) examined youth played regularly. gambling in a student sample from of a technical college in Northern Italy (520 males Germany and Belgium and 59 females; aged between 13 and 20 The sole study examining the prevalence years). Using a translated version of the of adolescent problem gambling in SOGS-RA to assess problem gambling, the Germany was carried out by most popular form of gambling among these Hurrelmann, Schmidt and Kähnert (82). Italian youth was sports betting (14% of the Comprising 5,000 youth aged 13 to 19 respondents bet on sports once a week or more years from the Federal State of North often), and 6% of the respondents were Rhine-Westphalia, the results showed classified as problem gamblers. Pathological that 62% of the respondents had gambled gambling strongly correlated with being male, for money in the past year. Scratch cards gambling out of habit or for relaxation, and
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG IS believing chance games to be skilful scored as probable pathological gamblers and (e.g., erroneous cognitions). A separate 6.6% scored as problem gamblers based on the study by Baiocco, Couyoumdjian, SOGS. Langellotti and Del Miglio (85) examined aspects of pathological Great Britain gambling among adolescents living in More research into adolescent gambling has Rome. The sample comprised 300 been completed in Britain than in any other adolescents (118 boys, 182 girls; aged European country. This achievement is likely between 14 and 20 years). The results due to the widespread availability and showed that Roman adolescents accessibility of fruit (slot) machines. Early preferred games of skill to games of large-scale studies carried out by local councils chance or card games, with just over 2% and voluntary organizations in the United of the sample being classified as problem Kingdom (UK) did not investigate problem gamblers. These adolescent problem gambling. However, these studies did show that gamblers had greater difficulties in terms the majority of British children gambled of school performance and discipline. occasionally and nearly 20% gambled weekly Problem gamblers also had higher scores (92). In the wake of the introduction of a on impulsiveness, aggressiveness, and National Lottery, a study of 4,516 adolescents resentment toward their parents. Finally, aged between 11 and 16 years found that 24% problem gambling was associated with of respondents reported gambling on the lottery parental gambling in this sample. or buying scratch cards once a week or more In contrast to other Latin European (93). In the same period, a school-based study countries, substantial research has been of approximately 1,000 adolescents aged 11 to done on problem gambling in Spain. A 15 years found that 6% of respondents met the number of studies have been carried out DSM-IV-J criteria for problem gambling (94), on adolescent gamblers, although most whereas another small-scale study of 204 boys have been on small local samples (e.g., aged 11 to 16 years found 5% who met these 86-90). Two extensive studies have been criteria (95). carried out among primary and National youth prevalence surveys in secondary school children in Galicia Britain were conducted in 1996, 1997, 1999, (89). In the first study, the DSM-IV-J 2000, 2006, and 2009 under the aegis of the and the SOGS-RA were used to assess Office of the National Lottery (later the problem gambling among children aged National Lottery Commission) (96-101). The 11 to 16 years. The researchers found 1996 survey included 7,200 pupils aged 12 to that 0.8% of their respondents scored as 15 drawn from 48 schools around the country. severe problem gamblers on the DSM- The survey found that 15% of a representative IV-J, whereas 4.6% of their respondents subsample of 3,724 pupils had spent their own scored as problem gamblers on the money on the National Lottery in the SOGS-RA. In a separate study of youth preceding week, with the majority of these aged 14 to 21 years, Becofia et al (89) purchases (60%) made legally by a parent. found that 4.6% scored as problem Past-week lottery purchases were significantly gamblers based on the SOGS-RA. associated with being male and having a Finally, in a study with a large sample of higher level of spending money (96). The university students from Madrid (aged most recent wave of this ongoing youth- 17 to 35 years), Viloria (91) found 4.5% tracking study found that slot machines were
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 16 YOUTH GAMBLING PREVALENCE STUDIES the most popular form of commercial studies of adult gambling and problem gambling among adolescents, with 9% of gambling in the past five years. Research on the sample of 8,598 adolescent partici- adolescent gambling is less extensive and pants having played these machines in differs widely between countries (107,108). the past week (down from 17% in 2006 (101). A review of over 30 British Denmark studies of youth gambling (102) A prevalence survey of adolescent gambling indicated that: in Denmark was recently completed, using a • At least two-thirds of adolescents sample of 5,096 adolescents aged 12 to 17 have ever played slot machines; years randomly selected from the national • One third of adolescents have played register (109,110). A total of 3,814 youth slot machines in the last month; participated in the study (representing 75% of • Up to 20% of adolescents are regular the drawn sample), with results showing that slot machine players (playing at least 51% of youth had gambled at least once and once a week) (9% in the latest 2009 7.2% had gambled in the past month. Boys national prevalence survey); were more likely to gamble than girls and • Up to 6% of adolescents are probable older adolescents (16 to 17) were more likely pathological gamblers and/ or have to gamble than younger adolescents. The most severe gambling-related difficulties popular gambling activities among Danish (2% in 2009, down from 3.5% in youth were scratch tickets, slot machines, and 2006,4.9% in 2000 and 5.4% in 1999 Lotto. (98-101). Problem gambling was assessed using a modified version of the NODS. A total of In some areas of Britain (e.g., Scotland), 7.5% of the adolescents endorsed one or more adolescent problem gambling prevalence of the 5-item abbreviated NODS, with 0.8% rates that are two to four times higher endorsing three or more items. Boys were than those identified in the adult British more likely to have gambling problems than population have been reported (103). girls and prevalence was higher in the oldest Research in the UK has found that age group (16 to 17 years) than in the younger very few female adolescents have age groups. Further analysis suggested that gambling problems on slot machines. A problematic gamblers played mostly scratch strong correlation between adolescent tickets, slot machines and poker (110). gambling and parental gambling (94, 104) suggests that adults may to some Finland extent foster adolescent gambling in Only one study of adolescent gambling has Britain. Other factors that have been been carried out in Finland (111). This study, linked with adolescent problem gambling using a random sample of adolescents aged 12 in Britain include working class youth to 17 years from the personal register, culture, delinquency, alcohol and substance included 5,000 adolescents interviewed by abuse, poor school performance, theft, telephone (112). The results showed that 52% and truancy (e.g., 93,105,106). of the adolescents had gambled in the past year and 18% in the past week. Gambling was Nordic Countries more common among boys than girls and All of the Nordic countries have among adolescents aged 15 to 17 years conducted one or more epidemiologic compared with younger age groups. The most
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 17 popular gambling activity was slot Two more recent studies on adolescent machines, followed by scratch cards and gambling and problem gambling in the greater the Lotto (111,112). A Finnish version of Reykjavik area found similar results. In 2007, the SOGS-RA was administered to a sample consisting of 1,513 students aged 16 adolescents who gambled at least twice a to 18 was surveyed (115). In this study, 62% month. Overall, 2.3% of Finnish acknowledged gambling in the past year, with adolescents were classified as problem 11% gambling on a weekly basis. Using the gamblers. Boys were three times more DSM-IV-MR-J, the study found that 3.0% likely than girls to score as problem scored as problem gamblers and 3.8% as at- gamblers. Further analysis showed that risk gamblers. Also in 2007, a study was adolescent problem gamblers were most conducted in Hafnarfjöröur, a neighboring likely to gamble on slot machines, town to Reykjavik. From the total population scratch cards, Internet poker, and sports aged 13 to 18 years in Hafnarfjöröur, 1,537 betting (111). participated in the study (a response rate of 81%). The results showed that 57% of the Iceland adolescents had gambled in the preceding year In Iceland, four school surveys have and 8% gambled weekly. Based on the DSM- been carried out in the capital of IV-MR-J, 2.2% were classified as problem Reykjavik or in surrounding towns. The gamblers with another 2.7% classified as at- first survey, completed in 2003, included risk gamblers (116). In all four Icelandic 750 students aged 16 to 18 years from 12 studies, boys were more likely to gamble than upper secondary and comprehensive girls and were more likely to be classified as schools in the greater Reykjavik area and having gambling problems. Akureyri. Some differences were found In all these studies, potential risk factors of in problem gambling rates between the problem gambling were systematically two instruments used; the DSM-IV-MR- evaluated. In general, problem gambling among J identified 2.0% of the sample as adolescents in Iceland is strongly related to problem gamblers (score 4+) with illicit drug taking and alcohol abuse, cognitive another 3.2% at risk for gambling distortions, emotional and conduct problems, problems. Based on the SOGS-RA, 2.7% attention deficit hyperactivity disorder, poor were classified as problem gamblers and attendance at school, and poorer grades. 4.4% were classified as at risk (113). Gambling on slot machines, poker, and on the In 2004, a larger study was Internet are the favorite gambling activities completed with 3,511 students aged 13 among problem gamblers (107,113-116). to 15 in Reykjavik (114). The results showed that about 70% of the partici- Norway pants had gambled in the past 12 months Three adolescent prevalence studies have been and 8% gambled weekly. Using the completed in Norway since 1999. The first DSM-IV-MR-J, 1.9% of the students Norwegian study of youth aged 12 to 18 years were classified as problem gamblers and included both telephone interviews and a another 3.7% were deemed at risk for postal survey. The telephone survey was based gambling problems. Based on the SOGS- on a representative sample of 10,000 RA, 2.8% were classified as problem telephone numbers drawn from households gamblers and 4.1% were classified as at- likely to include adolescents. The sample for risk. the postal survey was based on 3,000
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 18 YOUTH GAMBLING PREVALENCE STUDIES participants aged 12 to 18 years drawn cards and slot machines were the most popular from the Norwegian central register activities. (117,118). The overall response rate for In 2002, problem gambling was estimated the study was 45%. Gambling partici- using the two-item Lie/Bet screen (121) and pation rates were high, with about 82% an additional item assessing chasing behavior. of the participants having gambled in the Respondents were classified as problem past 12 months and 25% having gambled gamblers if they endorsed all three items. The weekly. Boys were more likely to rate of problem gambling was 3.2% using this gamble than girls. Problem gambling cutoff. If problem gambling was defined as was assessed using a ΙΟ-item version of endorsing the two Lie/Bet questions, the the DSM-IV that was administered only prevalence rate increased to 6%. Regardless of to those who gambled weekly or more the scoring method, boys were much more often. The study found that 1.8% of the likely than girls to be classified as problem total sample scored as potential gamblers (119). In 2004, problem gambling pathological gamblers (answering yes to was estimated using both the Lie/Bet screen at least 5 criteria), and an additional and the SOGS-RA (120). Problem gambling 3.5% were denoted as "at risk" gamblers prevalence based on the Lie/Bet (lifetime) was (3 or 4 DSM-IV criteria). Boys were four 3.5%, whereas problem gambling prevalence times more likely than girls to be based on the SOGS-RA (past year and 4+) classified as potential pathological was 2.5%. Based on the SOGS-RA, an gamblers. One interesting finding was additional 6% of the respondents were that the prevalence of potential patho- classified as at-risk gamblers. Boys were more logical gambling was two times higher likely than girls to be classified with gambling among the adolescents interviewed by problems, regardless of the screen used. telephone compared with those who Further analysis, comparing the classifi- answered the postal survey (117). cation rates between instruments, suggested The second and third Norwegian only moderate congruence between the two studies share a number of similarities problem-gambling screens, but this result may (119,120). Both studies were school- be due to the different time frames of the based surveys of students aged 13 to 19 instruments, with Lie/Bet estimating lifetime years. The second study was conducted prevalence and SOGS-RA 12-month preva- in 2002 and included about 13,000 lence (120). It is interesting that problem adolescents from 72 schools, with a gambling prevalence, based on the Lie/Bet response rate of 92% (119). The third screen was considerably lower in 2004 (3.5%) study was carried out in 2004 and than in 2002 (6.0%). included all primary and secondary schools in Norway. A total of 20,703 Sweden Norwegian adolescents participated in Studies on gambling and problem gambling the study, resulting in a response rate of among Swedish adolescents are scarce, and no 80% (120). Past-year gambling partici- recent studies of adolescent gambling appear pation declined slightly from 78% in to have been done. In 1997, however, a large- 2002 to 74% in 2004, and weekly scale epidcmiologic study on gambling and gambling declined from 14% in 2002 to problem gambling was conducted that 11% in 2004. In both studies, boys included a sample of 9,917 individuals aged gambled more than girls, and scratch 15 to 74 randomly selected from the Swedish
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 19 personal register (122,123). The survey adulthood reflect patterns of involvement that included an over-sample of 1,000 extend back several years. adolescents aged 15 to 17 years. Specific analysis of youth showed that 76% had Survey studies in Australia and New gambled in the past year and 16% Zealand gambled weekly or more often. Youth Although most adolescent gambling studies in were most likely to have gambled on fast Australia and New Zealand have been lottery games, slot machines, and local undertaken with very similar purposes, there lottery games. Using a Swedish have been some differences in the translation of the SOGS-R (124), this methodologies employed. Some studies have study found 0.9% of the Swedish youth been entirely confined to individuals under the sample to be probable pathological age of 18 years, whereas others have included gamblers (> 5) with another 4.2% young adults. The data have been collected scoring as problem gamblers (scores 3-4) from both school-based surveys and through (122). Two years after the original telephone interviews. The studies have also survey, follow-up interviews were differed in terms of the measures used to completed with 93 adolescents from the capture the frequency of gambling, as well as study. Based on the SOGS-R, two-thirds the prevalence of problem and pathological of the adolescents classified as problem gambling. gamblers in 1997 scored as non-problem The first major study of youth gambling in gamblers in the follow-up. Among those Australia was undertaken by Moore and youth classified as probable pathological Ohtsuka (136,137) in the State of Victoria. gamblers in 1997, about half were Over 1,000 school and university students classified as problem gamblers two years aged 14 to 25 completed a questionnaire about later. However, several youth classified their gambling habits, gambling attitudes, the as problem gamblers in 1997 were role of family and social influences, and a classified as probable pathological modified ΙΟ-item version of the original gamblers in 1999 (125). As in other SOGS (138). The researchers found that 3.1% longitudinal studies, these findings scored in the pathological range, and regular support the notion that problem gambling was found to be associated with gambling is a highly transitional state having more positive attitudes towards among adolescents and young adults gambling and having friends and family (126,127). members who approved of gambling. A similar study involving 769 individuals from AUSTRALIA AND NEW ZEALAND Melbourne under the age of 18 found that In both Australia and New Zealand, 3.8% of students scored in the pathological empirical evidence derived from large- range (139). Other relevant Victorian research scale population surveys has consistently conducted during this period was undertaken shown that the highest rates of problem in 1997, although the full results were not gambling tend to be observed in the 18 to published until quite recently (140). In this 24 age-range and particularly amongst study, 2,788 secondary school students aged males (e.g., 128-135). The results from 13 were asked if they had participated in the these studies suggest that gambling may last year in five gambling activities. Problem often have its origins in adolescence so gambling was not assessed, although a that problems observed during early distinction was made between students who
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 20 YOUTH GAMBLING PREVALENCE STUDIES had gambled at all in the past year and adolescents is significantly lower than in the those who had gambled on three or more other studies. activities. Overall, 41% of the students had gambled in the past year and 8% had Variations in activity preferences and gambled on three or more activities. individual differences Multivariate analyses indicated that Across these five surveys, the most popular significant independent predictors of activities amongst young people have tended greater involvement in gambling for to be scratch tickets, lotteries, card games, and males were drinking, marijuana use, and betting on sports. In the two South Australian antisocial behavior. For females, greater classroom surveys, approxi-mately 40% of involvement in gambling was predicted students gambled on scratch tickets, by dissatisfaction with peer relationships approximately 25% gambled on card games, and low perceived rewards at school. and 15% to 20% gambled on sports; relatively Since the late 1990s, five studies to few gambled on gaming machines (only 5% in examine the prevalence of gambling and the most recent South Australian survey). In pathological gambling among youth all these studies, boys were found to gamble using instruments validated for use in on a wider range of activities than girls, with this population have been carried out in the largest differences observed for card Australia and New Zealand (135,141- games, racing, and sports. Boys were also 145). Although not all of these studies significantly more likely than girls to be were entirely confined to under-aged classified as pathological gamblers (e.g., 7.8% populations (some of Rossen's New vs. 2.7% in South Australia; 3.5% vs. 1.2% in Zealand sample were aged 18 to 21), the the ACT) (141,143). Pathological gambling results are unlikely to have been rates have also been found to be higher in significantly influenced by these specific ethnic groups. For example, the two sampling differences. Almost all of these largest classroom studies in Australia found studies used the DSM-IV-J or DSM-IV- that indigenous students were much more MR-J as developed and validated by likely than non-indigenous students to be Fisher (17,18). All but one study was classified as pathological gamblers (28% vs. based on the complete school population 4.1% in the ACT, 141; 9% vs. 2.2% in South or a random sampling of students from Australia, 143). In New Zealand, Pacific classrooms in secondary level schools Island students were 11.5 times more likely (high schools and colleges). than other students to be pathological Some consistency was found in the gamblers (144). overall participation rates across these Another consistent finding has been the studies, all of which are based on strong link between gambling and other risk- classroom samples (mean past-year taking behavior, as well as various measures gambling - 64%). With the exception of of psychosocial adjustment. For example, in the South Australian Department for the ACT study (146), three-quarters of Families and Communities (135) pathological gamblers reported drinking telephone survey in South Australia, the alcohol on a weekly basis as compared with prevalence rates for pathological only 50% of the rest of the sample. Cigarette- gambling clustered around 3.5%. smoking rates among pathological gamblers Notably, the prevalence rate obtained in were four times higher than among non- the only randomized telephone survey of problem gamblers, marijuana rates were six
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 21 times higher, and hard drug involvement adult gambling patterns than those obtained at was 10 to 20 times higher, depending a younger age. The findings highlighted the upon the type of drug. The ACT study importance of using longitudinal analyses to also showed that young pathological study the stability of gambling patterns over gamblers scored poorly on measures of time. self-esteem, negative mood, and general health, and had poorer family CONCLUSIONS adjustment. Similar findings were Several conclusions can be drawn from this reported by Rossen (144) in New extended review of adolescent prevalence Zealand. Young pathological gamblers in studies. First, from a methodological that country were more likely to have perspective, this review has shown that been suspended from school and to feel school-based surveys and telephone surveys alienated, and were more likely to report are the primary modalities used in adolescent having poorer attachments to their prevalence surveys. In Australia, the one parents. survey conducted by telephone obtained a significantly lower prevalence rate than in the Links between adolescent and adult classroom studies. Similarly in the US, gambling surveys conducted by telephone obtained Australian research has also provided somewhat lower prevalence rates than those insight into the association between conducted in classrooms. In Canada, the adolescent gambling and gambling prevalence rates obtained in classroom and during early adulthood. A South telephone surveys were generally higher than Australian study conducted by Delfabbro, the prevalence rate obtained (using a different Winefield, and Anderson (147) investi- problem gambling screen) using face-to-face gated the gambling habits of 578 young interviews. In Norway, problem gambling people who were tracked for four years prevalence was two times higher among from mid-adolescence (age 15 years) adolescents interviewed by telephone into adulthood (18-19 years). Each year, compared with those who answered a postal the same participants were administered survey. Clearly, work is needed to assess the standardized measures of gambling impact of survey modality on identified participation. The results showed that, prevalence rates among adolescents, as has although mid-adolescent gambling was recently been done among adults (148). positively associated with later gambling Another important methodological trend is as adults, considerable individual that the sample sizes for adolescent surveys variability in gambling patterns from one have increased over time. Early stand-alone year to the next was observed. Only one adolescent gambling surveys tended to include in four young people who gambled at the samples of only a few hundred participants, as age of 15 years continued gambling in the period 1984 to 1989 in the US, in the yearly, and it was rare to find young mid-1990s in Canada, and in recent studies in people whose participation in specific the Balkan and Baltic countries. In cases in activities was consistent from one year to which gambling modules are added to larger the next. Using logistic regression health surveys of adolescents, the sample sizes models, participation data obtained from can be extremely large, as in Louisiana and young people closer to the time they left Minnesota in the US and the national survey in school were found more predictive of Canada. These studies, along with surveys in
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Britain, the Nordic countries, and youth are less likely than other youth to Australia and New Zealand, have been gamble, the former are more likely to gamble valuable in docu-menting the links regularly when they do gamble and to between gambling and other risk experience problems (e.g. Native American and behaviors (e.g., drug and alcohol use, African American youth in North America, seatbelt use, poor school performance, non-Francophone youth in Quebec, indigenous conduct problems, truancy, delinquency, youth in Australia and Pacific Island youth in violence and sexual activity). Except in New Zealand). There are other clear cases like Britain, where the focus of the demographic patterns. For example, the most study is primarily on gambling, an popular youth gambling activities tend to be important limitation in large school-based private, peer-related activities, such as card studies is the trade-off between the size games and betting on sports. Older youth are and focus of the overall study and the more likely to engage in accessible forms of number of gambling items that can be age-restricted gambling, such as lotteries. added. An important direction for future However, studies that have compared gambling research will be assessing the relation patterns of youth with those of adults in the between reduced sets of gambling items same jurisdiction found that older youth tend to (particularly problem gambling screens) migrate towards age-restricted gambling and their full-length versions. activities, such as casino gambling, only as they A particular measurement concern is near the age when they would be legally able to that the most widely used problem participate. Other common demographic gambling instruments used with adoles- characteristics are that youth problem gamblers cents are derived from adult problem are more likely to start gambling at a younger gambling screens and may not be suited age and to have parents who gamble. to assessing gambling-related problems Also from a substantive perspective, the in younger people. Questions have been information from this review suggests that early raised regarding the validity of both assumptions about youth gambling and problem SOGS-RA and DSM-IV-MR-J (e.g., gambling must give way to a more nuanced 19,149-155). However, pending a better- understanding of how these phenomena change validated problem gambling instrument in response to changes in the social and cultural for adolescents, these two instruments environment. For example, it has been widely are likely to continue to be viewed as the assumed that gambling participation among best approximations for the measurement youth in jurisdictions where legal gambling is of problem gambling among adolescents. widespread will be higher than in jurisdictions Their use is certainly preferable to the where legal gambling is restricted. It has also use of either full-length or shortened been widely assumed that large numbers of versions of adult instruments. underage youth will be able to participate in From a substantive perspective, some age-restricted gambling activities when these generalizations can be made with regard become available. Finally, it has been widely to the demographic characteristics of assumed that problem gambling prevalence adolescent gamblers and problem rates will be much higher among youth in gamblers. Across the board, boys are jurisdictions where legal gambling is broadly more likely to gamble than girls and more available compared with youth in jurisdictions likely to experience problems. It also where legal gambling is both less visible and appears that while ethnic and indigenous less available. Instead, as a recent study of
Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 23 youth in Nevada as well as several of the adolescent gambling participation has remained surveys reviewed here have shown, the stable or has decreased substantially in those rates of gambling participation can be jurisdictions. Similarly, repeat studies in North substantially lower among youth in America and in Europe have shown that since mature gambling jurisdictions; access by the early 1990s, adolescent problem gambling underage youth to some (but not all) age- prevalence rates have remained stable or restricted forms of gambling can be very decreased. More frequent surveys have the low; and problem gambling prevalence added value of helping to monitor trends in rates can be significantly lower among adolescent participation in specific activities. adolescents in such jurisdictions For example, in the wake of extensive media compared with others where gambling is coverage of professional poker tournaments in less available (156). the first half of the decade, in 2005 and 2006 An emerging concern is the recent the ARCI surveys documented a spike in card explosion of Internet and mobile playing among youth and young adults. After gambling, although, as yet, little research 2006, the ARCI surveys showed that the has been done (157,158). Since its monthly rate of card playing declined and then inception in 1996, online gambling has stabilized. Subsequently, the surveys showed become one of the most popular Internet that following the "poker" spike, sports betting activities and while base rates are still increased and card playing declined (52). low, gambling on the Internet has As with adults, prospective longitudinal increased (159). Strong links between studies of adolescent gambling yield vital online gambling and non-gambling information about how gambling and problem fantasy games, role-playing games, board gambling status can change at the individual games, and card games are an additional level over time. The few studies that have cause for concern as youth migrate from been carried out, beginning with the first early free gaming sites to online gambling sites. study in Minnesota (41) and continuing The most recent survey of adolescents in through more recent studies in Sweden (125) Oregon found that gambling for free on and Australia (147), all point to the highly the Internet was now the most popular transitional nature of gambling and problem gambling activity, although only a few of gambling among youth. Although we have these youth had gambled on the Internet learned a great deal over the last 25 years, using money (39). research on adolescent gambling and problem Perhaps most significantly, this review gambling to date has been largely descriptive. underscores the value of conducting We may have traveled some distance down the repeated studies of adolescent gambling road toward understanding the determinants as within jurisdictions to improve our well as the distribution of youth gambling and understanding of how youth gambling problem gambling (28), but we still have a patterns change over time and in relation long way to go. to lifelong exposure, changes in attitudes toward youth gambling, and efforts at prevention. Repeat studies in Minnesota, REFERENCES Oregon, Washington State, and Manitoba 1. Jacobs DF. Juvenile gambling in North in North America as well as in Belgium, America: An analysis of long-term trends Britain, and Norway in Europe, clearly and future prospects. J Gambl Stud demonstrate that since the early 1990s, 2000; 16(2/3): 119-52.
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VO O «Í r I-J» 2 Oi > £εοoο Io cIo co CO CO OO Chasin g SOGS- R 1 1 Measur e — Q Lie/Be t + i co SOGS-R A á á Q Q Q c1o 1 No t assesse d Q 1 0-ite m SOG S Q •o õ Is g 1o 8-8 •gõ. lassroo m lassroo m lassroo m lassroo m lassroo m lassroo m lassroo m lassroo m lassroo m !! 1 lassroo m õ H õ H u U H õ 0 u ° õ õ õ S (Ë S O Os Ã*ΐ Os r~ °° O -" «ο Os oo õ ° 0 | «i 1 CN 1 Ï — tN ο ο 7 ST r-^2 ~ m f*l f*^ Ï ÃΙ I; OS ¼ i rf ri ^wn* acd u O t> Os ÃΜ S 8 § § ο OS es (N <Í m 00 O 8 s 0 Os Ss 0 8 >M· vJ o ο o ο Os Os Os o o CM <Í r·! CN «N IN õ vi cd •á õ B .*: 3. á -^ s O "cd e oc i Delfabbro , La h Rosso w & Hanse n Rosso w & M o R nnber g e t a l & Grabosk y Delfabbr o & S . A Dep t fo r Communitie s Lambo s e t al . Kristjansdotti r Johansso n & G testa m Familie s & Moor e & Ohts i Jackso n 1 Thrup p 00 • W ZEALAN D 1 0 Z S cd «0 o. cd a cd oc 'S) a I cd 1 •σ !? f Μ" .2 .S Locatio n itor y tralia n C a § 1 à 'S t h Austra l t h Austra l o o / Zealan d § g CJ õ CJ 1 Q u o 2? o D D g S u CJ 3 F, 0 > Z z Æ oo Z* 00 CO CO > > Z Z Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 30 YOUTH GAMBLING PREVALENCE STUDIES 2. Shaffer HJ, Hall MN. Estimating Dintcheff BA. Shared predictors of preva-lence of adolescent gambling youthful gambling, substance use and disorders: A quantitative synthesis and delinquency. Psychol Addict Behav guide toward standard gambling 2005;19:165-74. nomenclature. J Gambl Stud 1996; 12: 11. Vitara F, Brendgen M, Ladouceur R, 193-214. Tremblay RE. Gambling, delinquency, 3. Stinchfield R, Winters KG. Gambling and drug use during adolescence: and problem gambling among youths. Mutual influences and common risk Ann Am Acad Political Soc Sei 1998; factors. J Gambl Stud 2001 ;17(3): 171- 556:172-85. 90. 4. Weite JW, Barnes GM, Tidvvell MC, 12. Winters KC, Anderson N. Gambling Hoffman JH. The prevalence of involvement and drug use among problem gambling among U.S. adolescents. J Gambl Stud 2000; 16(2- adolescents and young adults: Results 3): 175-98. from a national survey. J Gambl Stud 13.Arcuri AF, Lester D, Smith FO. 2008;24(2): 119-33. Shaping adolescent gambling behavior. 5. Bürge AN, Pietrzak RH, Petry NM. Adolescence 1985;20:935-8. Pre/early adolescent onset of gambling 14. Fels her JR, Derevensky JL, Gupta R. and psychosocial problems in treatment- Lottery playing amongst youth: seeking pathological gamblers. J Implications for prevention and social Gambl Stud 2006;22(3):263-74. policy. J Gambl Stud 2004;20(2):127- 6. Kessler RC, Hwang I, LaBrie RA, et 54. al. DSM-IV pathological gambling in 15. Abbott MW, Volberg RA. The the National Comorbidity Survey Rep- measurement of adult problem and lication. Psychol Med 2008;38:1351-60. pathological gambling. Int Gambl Stud 7. Gupta R, Derevensky JL. Adolescent 2006;6(2): 175-200. gambling behavior: A prevalence study 16. Winters KC, Stinchfield R, Fulkerson and examination of the correlates J. Toward the development of an associated with problem gambling. J adolescent gambling problem severity Gambl Stud 1998; 14(4):319-45. scale. J Gambl Stud 1993;9:63-84. 8. Jacobs DF. Illegal and undocumented: 17. Fis her SE. Measuring pathological A review of teenage gambling and the gambling in children: The case of fruit plight of children of problem gamblers machines in the UK. J Gambl Stud in America. In: Shaffer HJ, Stein SA, 1992;8:263-85. Gambino B, Cummings TN, eds. 18. Fis her SE. Developing the DSM-IV- Compulsive Gambling: Theory, MR-J criteria to identify adolescent Research, and Practice. Lexington, problem gambling in non-clinical MA: Lexington Books, 1989:249-92. populations. J Gambl Stud 2000; 16 9. Westphal JR, Rush B, Stevens L, (2/3):253-73. Johnson LJ. Pathological gambling 19. Dereven sky JL, Gupta R. Prevalence among Louisiana students: Grades six estimates of adolescent gambling: A through twelve. Paper presented at the comparison of the SOGS-RA, DSM- Am Psychiatr Assoc Ann Meet, IV-J, and the G A 20 Questions. J Toronto, 1998. Gambl Stud 2000;16(2/3):227-51. 10. Barnes GM, Weite JW, Hoffman JH, 20. Hardoon KK, Derevensky JL, Gupta Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 31 R. Empirical measures vs. perceived 29. Stinchfield R. A comparison of gambling severity among youth. gambling among Minnesota public Addict Behav 2003;28(5):933-46. school students in 1992, 1995 and 2I.Jacobs DF. A review of teenage 1998. J Gambl Stud 2001;17(4):273-96. gambling in the US. In: Eadington 30. Proimos J, DuRant RH, Dwyer Pierce WR, Cornelius JA (eds). Gambling J, Goodman E. Gambling and other Behavior and Problem Gambling. risk behaviors among 8* to 12th grade Reno, NV: Institute for the Study of students. Pediatrics 1998;102(2):e23. Gambling and Commercial Gaming, 31. Volberg RA. Gambling and problem 1993:431-41. gambling among adolescents in 22. Jacobs DF, Marston AR, Singer RD. Georgia. Atlanta, GA: Georgia Study of gambling and other health- Department of Human Resources, threatening behaviors among high 1996. school students. Loma Linda, CA: 32. Volberg RA. Gambling and problem Jerry L. Pettis Memorial Veterans gambling among adolescents in New Hospital, 1985. York. Albany, NY: New York State 23. Jacobs DF, Marston AR, Singer RD. Council on Problem Gambling, 1998. A post-lottery study of gambling 33. Westphal JR, Rush JA, Stevens L, behaviors among high school students. Johnson LJ. Gambling behavior of Loma Linda, CA: Jeffrey L. Pettis Louisiana students in grades 6 through Memorial Veterans Hospital, 1987. 12. Psychiatr Serv 2000;51(l):96-9. 24. Kuley N, Jacobs DF. A pre-lottery 34. Wallisch L. Gambling in Texas: The benchmark study of teenage gambling 1992 Texas survey of adolescent in Virginia. Loma Linda, CA: Loma gambling behavior. Austin, TX: Texas Linda University, Department of Commission on Alcohol and Drug Psychiatry, 1987. Abuse, 1993. 25. Kuley N, Jacobs DF. A post-lottery 35. Wallisch L. Gambling in Texas: The impact study of effects on teenage 1995 Texas survey of adolescent gambling behaviors. Loma Linda, CA: gambling behavior. Austin, TX: Texas Loma Linda University, Department Commission on Alcohol and Drug of Psychiatry, 1989. Abuse, 1995. 26. Lesieur HR, Klein R. Pathological 36. Volberg RA. Gambling and problem gambling among high school students. gambling among adolescents in Addict Behav 1987;12:129-35. Washington State. Olympia, WA: 27. Steinberg M. Gambling behavior Washington State Lottery, 1993. among high school students in 37. Volberg RA, Moore WL. Gambling and Connecticut. Paper presented at the problem gambling among Washington Third National Conference on State adolescents: A replication study, Gambling, New London, CT, 1988. 1993 to 1999. Olympia, WA: Washing- 28. Sha ffer HJ, LaBrie R, LaPlante DA, ton State Lottery, 1999. Nelson S, Stanton M. The road less 38. Carlson MJ, Moore TL. Adolescent travelled: Moving from distribution to gambling in Oregon. Salem, OR: determinants in the study of gambling Oregon Gambling Addiction Treatment epidemiology. Can J Psychiatry 2004; Foundation, 1998. 49:504-16. 39. Volberg RA, Hedberg EC, Moore TL. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 32 YOUTH GAMBLING PREVALENCE STUDIES Oregon youth and their parents: behaviors and problem gambling Gambling and problem gambling among adolescents in New York State: prevalence and attitudes. Salem, OR: Initial findings from the 2006 OASAS Oregon Department of Human school survey. New York, NY: NYS Services, 2008. Office of Alcoholism and Substance 40. W inters KC, Stinchfield R, Fulkerson J. Abuse Services, 2007. Patterns and characteristics of adoles- 49. Gerstein DR, Volberg RA, Harwood cent gambling. J Gambl Stud 1993; II, Christiansen EM, et al. Gambling 9(4):371-86. impact and behavior study: Report to 41. Winters KC, Stinchfield R, Kim LG. the National Gambling Impact Study Monitoring adolescent gambling in Commission. Chicago, IL: National Minnesota. J Gambl Stud 1995; 11 (2): Opinion Research Center at the 165-83. University of Chicago, 1999. 42. Sti nchfield R, Cassuto N, Winters KC, 50. Weite JW, Barnes G, Wieczorek WF, Lassiter W. Prevalence of gambling Tidwell M-C, Parker J. Alcohol and among Minnesota public school gambling among U.S. adults: students in 1992 and 1995. J Gambl Prevalence, demographic patterns and Stud 1997;13(l):25-48. comorbidity. J Stud Alcohol 43. Peacock P, Day A, Peacock TD. 2001;62(5):706-12. Adolescent gambling on a Great Lakes 51. Weite JW, Barnes GM, Tidwell M, Indian reservation. J Hum Behav Soc Hoffman J. The association of form of Environ 1999;2:5-17. gambling with problem gambling 44. Zitzo w D. Comparative study of among American youth. Psychol problematic gambling behaviors Addict Behav 2009;23(1):105-12. between American Indian and non- 52. Adolesce nt Risk Communication Indian adolescents within and near a Institute. Internet gambling stays low Northern Plains reservation. Am among youth ages 14 to 22 but access Indian Alsk Native Ment Health Res to gambling sites continues; sports 1996;7(2): 14-26. gambling makes resurgence. Phila- 45. National Gambling Impact Study delphia, PA: Annenberg Public Policy Commission. Final report. Washington, Center, 2008. DC: National Gambling Impact Study 53. Insi ght Canada Research. An Commission, 1999. exploration of the prevalence and 46. Arizona Criminal Justice Commission. pathological gambling behaviour 2008 Arizona Youth Survey: Shining among adolescents in Ontario. Report light on Arizona youth. Phoenix, AZ: to the Canadian Foundation on Arizona Criminal Justice Commission, Compulsive Gambling, 1994. 2008. 54. O mnifacts Research. An examination 47. Esters I, Biggar R, Lacour J, Reyes M. of the prevalence of gambling in Nova 2008 Louisiana study on problem Scotia. Halifax: Nova Scotia gambling. Lafayette, LA: Cecil. J. Department of Health, 1993. Picard Center for Child Development, 55. Wy nne Resources. Adolescent University of Louisiana at Lafayette, gambling and problem gambling in 2008. Alberta. Report to the Alberta Alcohol 48. Rainone G, Gallati RJ. Gambling and Drug Abuse Commission, 1996. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 33 56. Ladouce ur R, Mireault C. Gambling of problem gambling in adolescents: behaviors among high school students Findings from the 1999 Ontario in the Quebec area. J Gambl Beh Student Drug Survey. Can J 1988;4(1):3-12. Psychiatry 2000;45(8):752-5. 57. Govoni R, Rupcich N, Frisch GR. 67. Adla f EM, Paglia-Boak A, Beichman Gambling behaviour of adolescent JH, Wolfe D. The mental health and gamblers. J Gambl Stud 1996; 12(3): well-being of Ontario students 1991- 305-17. 2005: Detailed OSDUS findings. 58. Hua ng JH, Boyer R. Epidemiology of Toronto: Centre for Addiction and youth gambling problems in Canada: Mental Health, 2006. A national prevalence study. Can J 68. Martin I, Gupta R, Derevensky JL. Psychiatry 2007;52(10):657-65. Participation aux jeux de hasard et 59. Gregg JD. Youth gambling in British d'argent. In: Dube" G (ed). Enquete Columbia. Master's thesis. Langley: quebdcoise sur le tabac, 1'alcool, la Trinity Western Univ, 2003. drogue et le jeu chez les e"leves du 60. Alberta Alcohol and Drug Abuse secondaire, 2006. Montreal: Institut de Commission. The Alberta youth la statistique du Quebec, 2007:125-44. experience survey 2002. Edmonton: 69. Poulin C. Problem gambling among Alberta Alcohol and Drug Abuse adolescent students in the Atlantic Commission, 2003. provinces of Canada. J Gambl Stud 61. Alberta Alcohol and Drug Abuse 2000;16(l):53-78. Commission. Gambling among Alberta 70. Faktum Uuringukeskus. Elanike youth: The Alberta youth experience kokkupuuted hasart-ja önnemängudega survey 2005. Edmonton: Alberta [Gambling prevalence in Estonia]. Alcohol and Drug Abuse Commission, Tallinn, 2004. 2007. 71.Laansoo S. Patoloogiline hasart- 62. Dicki nson H, Schissel B. University of mängimine: ulatus Eestis ning seosed Saskatchewan survey—youth gambling käitumuslike ja isiksuslike riski- in Saskatchewan: Perceptions, behav- faktoritega (Pathological gambling in iours, and youth culture. Regina: Estonia and the relationships with Saskatchewan Ministry of Health, behavioral and personal risk factors). 2003. Master's thesis. Talinn: Tallinna 63. Wiebe J. Manitoba youth gambling Ülikool Eesti, 2006. prevalence study: Summary of 72. Laa nsoo S, Nut T. South Oaks findings 1999. Winnipeg: Addictions Mängurisöel (South Oaks Gambling Foundation of Manitoba, 1999. Screen). Talinn: Tallinna Ülikool 64. Le maire J. Manitoba youth gambling Eesti, 2004. behaviour: Follow-up to the 1999 73. Laa nsoo S, Nut T. Estonia. In: Meyer AFM report. Winnipeg: Addictions G, Hayer T, Griffiths MD (eds). Foundation of Manitoba, 2004. Problem Gaming in Europe: 65. Mackay TL, Patton D, Broszeit B. Challenges, Prevention, and Inter- Student gambling report 2005. ventions. New York, NY: Springer, Winnipeg: Addictions Foundation of 2009. Manitoba, 2005. 74. Skokauskas N. Lithuania. In: Meyer G, 66. Adla f EM, lalomiteanu A. Prevalence Hayer T, Griffiths MD. eds. Problem Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 34 YOUTH GAMBLING PREVALENCE STUDIES Gaming in Europe: Challenges, pre- lence and prevention]. Düsseldorf: vention, and interventions. New York, Ministerium für Gesundheit, Soziales, NY: Springer, 2009. Frauen und Familie des Landes 75. Skoka uskas N, Satkeviciute R. Nordrhein-Westfalen, 2003. Adolescent pathological gambling in 83. Kinable II. Bevraging van Vlaamse Kaunas, Lithuania. Nord Psykiatr leerlingen in het kader van een Tidsskr2007;61(2):86-91. Drugbeleid Op School. Synthese- 76. Skoka uskas N, Satkeviciute R, Burba rapport schooljaar 2005-2006. [Inquiry B, Rutkauskiene I. Gambling among of Flemish students within the adolescents in Kaunas. Lithuanian Gen framework of a School Drug Policy. Pract2005;5(9):ll-5. Summary report school year 2005- 77. L upu V. Romania. In: Meyer G, Hayer 2006]. Brussels: VAD, 2006. T, Griffiths MD (eds). Problem 84. Capitan ucci D, Biganzoli A, Gaming in Europe: Challenges, Pre- Smaniotto R (eds). Reti d'azzardo vention, and Interventions. New York, [Gambling networks]. Varese: NY: Springer, 2009. Edizioni And-In-Carta; 2006. 78. L upu V, Onaca E, Lupu D. The 85. Baiocco R, Couyoumdjian A, Langel- prevalence of pathological gambling lotti M, Del Miglio C. Gioco in Romanian teenagers. Minerva Med d'azzardo problematico, tratti di 2002;93:4I3-8. personal itä e attaccamento in 79. L upu V, Boros S, Miu A, Iftene F, adolescenza. [Problematic gambling, Geru A. Factor! de rise pentru jocul personality traits and adolescence patologic de noroc la adolescent» attachment]. Etä Evolutiva 2005; 1:56- rornani [Risk factors in pathological 65. gambling in Romanian adolescents]. 86. Arbina ga F. Conductas de juego con Revista SNPCAR 2001 ;4(4):33-8. apuestas y uso de drogas en una 80. Zivny H, Okruhlica L. Slovakia. In: muestra de adolescentes de la ciudad Meyer G, Hayer T, Griffiths MD de I luelva [Game of chance behavior (eds). Problem Gaming in Europe: and drug consumption in a sample of Challenges, Prevention, and Inter- adolescent of the city of Huelva]. ventions. New York, NY: Springer, Anälisis y Modification de Conducta 2009. 1996;22:577-601. Sl.Kotrc D. Uzivanie psychoaktivnych 87. Becofia E. Pathological gambling in latok a patolokicko hräcstvo na Spanish children and adolescents: An zakladnych a strednych skoläch v emerging problem. Psychol Rep 1997; obvode Kysucke Mesto [Using 81:275-87. drugs and gambling in elementary and 88. Becofia E, Gestal C. El juego pato- high school in the Kysucko logico en ninos del 2° ciclo de E.G.B Mesto region]. Alkoholizmus a [Pathological gambling in children of drogovo zavislosti 2005;40:223-39. primary school]. Psicothema 1996; 82. Hurrel mann K, Schmidt L, Kähnert H. 8:13-23. Konsum von Glücksspielen bei Kindern 89. Becona E, Miguez MC, Vazquez FL. und Jugendlichen—Verbreitung und El juego problema en los niflos de Prävention [Participation in gambling Galicia [Problem gambling in the of children and adolescents—Preva- children of Galicia]. Madrid: Sociedad Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 35 Espafiola .de Psicopatologia Clinica, BMRB Social Research, 2000. Legal y Forense, 2001. 100. MORI. Under 16s and the National 90. Villa A, Becofia E, Vazquez FL. Juego Lottery: Final report. London: National patologico con mäquinas tragaperras Lottery Commission, 2006. en una muestra de escolares de Gijon 101. Ipsos MORI. British survey of [Pathological gambling with slot children, the National Lottery and machines in a sample of Gijon' gambling 2008-09: Report of a scholars]. Adicciones 1997;9:195-208. quantitative survey. London: National 91. Viloria C. El juego patologico en los Lottery Commission, 2009. estudiantes universitarios de la 102. Griffiths MD. Great Britain. In: Meyer Comunidad de Madrid [Pathological G, Hayer T, Griffiths MD (eds). gambling in university students of the Problem Gaming in Europe: Chal- region of Madrid]. Clinica y Salud lenges, Prevention, and Interventions. 2003; 14:43-65. New York, NY: Springer, 2009. 92. Abbott MW, Volberg RA, Bellringer 103. Moodie C, Finnigan F. Prevalence and M, Reith G. A review of research on correlates of youth gambling in aspects of problem gambling. London: Scotland. Addict Res Theory 2006; Responsibility in Gambling Trust, 14:365-85. 2004. 104. Wood RTA, Griffiths MD. 93. G riffiths MD, Sutherland I. Adolescent Adolescent lottery and scratchcard gambling and drug use. J Community players: Do their attitudes influence Appl Soc Psychol 1998;8:423-7. their gambling behaviour? J Adolesc 94. Wood RTA, Griffiths MD. The 2004;27:467-75. acquisition, development and mainten- 105. Griffiths MD. Adolescent gambling. ance of lottery and scratchcard London: Routledge; 1995. gambling in adolescence. J Adolesc 106. Yeoman T, Griffiths MD. Adolescent 199821:265-73. machine gambling and crime. J 95. Griffiths MD. Scratchcard gambling Adolesc 1996; 19:183-8. among adolescent males. J Gambl 107. Olason DT. Youth gambling in the Stud2000;16(l):79-91. Nordic countries. Sixth Nordic 96. Fis her SE, Balding J. Under sixteen's Conference on Gambling Studies and find the Lottery a good gamble. Educ Policy Issues. Copenhagen, 2007. Health 1996;13(5):5-7. 108. Olason DT. Gambling and problem 97. Fis her SE. Gambling and problem gambling studies among Nordic gambling among young people in adults: Are they comparable? Seventh England and Wales. Plymouth: Centre Nordic Conference on Problem for Research Into the Social Impact of Gambling, Treatment and Prevention. Gambling, University of Plymouth, Helsinki, 2009. 1998. 109. Nielsen C, Heideman J. Pengespil 98. A shworth J, Doyle N. Under 16s and blandt unge: En rapport om 12-17 the National Lottery 1999. London: ariges spillevaner [Gambling among BMRB Social Research, 2000. youth: A report on gambling habits 99. A shworth J, Doyle N, Howat N. among 12 -17 years old]. Under 16s and the National Lottery: Copenhagen: SFI - Det Nationale Tracking survey July 2000. London: Forskningscenter For Velfaerd, 2008. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 36 YOUTH GAMBLING PREVALENCE STUDIES 110. Sorensen NU, Nielsen JC, Witten- year old adolescent in comprehensive dorff N. Unge og Gambling: 12-17 schools: Evaluation on risk factors]. äriges pengespiladfaerd i et risiko- og Salfraeoiritio [Icelandic J Psychol] trivselperspektiv [Young and gambling: 2008;13:27-46. 12 to 17 years old gambling habits 116. Kristjansdottir E. Mtttaka penin- within a risk perspective]. Copen- gaspilum, spilavandi og tengsl viö hagen: Aarhus University, Center for ahantubastti hjä 13-18 ära nemendum Ungdomsforskning, 2008. i Hafnarfiröi [Gambling participation, 111. Jaakkola T. Finland. In: Meyer G, problem gambling and association Hayer T, Griffiths MD (eds). Problem with risk factors among 13-18 year Gambling in Europe: Challenges, old students in Hafnarfjöröur]. Prevention, and Intervention. New Dissertation. Reykjavik: University of York, NY: Springer, 2009. Iceland, 2008. 112. Ilkas H, Aho P. Nuorten Rahapel- 117. Götestam KG, Johansson A. Norway. aaminen. 12-17 vuotiaiden nuorten In: Meyer G, Hayer T, Griffiths MD rahapelaaminen ja peliongelmat— (eds). Problem Gambling in Europe: puhelinhaastattelu [Youth gambling. Challenges, Prevention, and Inter- Youth of 12-17 years gambling and vention. New York, NY: Springer, gambling problems—telephone 2009. survey]. Helsinki: Taloustutkimus 118. Johansson A, Götestam KG. Ltd., 2006. Gambling and problematic gambling 113. Olason DT, Sigurdardottir KJ, Smari with money among Norwegian youth J. Prevalence estimates of gambling (12-18 years). Nord Psykiatr Tidsskr participation and problem gambling 2003;57:317-21. among 16-18-year old students in 119. Rossow I, Hansen M. Underholdning Iceland: A comparison of the SOGS- med bismak: Ungdom og pengespill RA and DSM-1V-MR-J. J Gambl [Entertainment with a smack: Youth Stud2006;22(l):23-39. and gambling]. Oslo: NOVA— 114. Olason DT, Skarphedinsson GA, Norwegian Social Research, 2003. Jonsdottir JE, Mikaelsson M, 120. Rossow I, Molde H. Chasing the Gretarsson SJ. Prevalence estimates criteria: Comparing SOGS-RA and of gambling and problem gambling the Lie/Bet screen to assess among 13- to 15-year-old adolescents prevalence of problem gambling and in Reykjavik: An examination of 'at-risk' gambling among adolescents. correlates of problem gambling and J Gambl Issues 2006; 18:57-71. different accessibility to electronic 121. Johnson EE, Hamer R, Nora RM, Tan gambling machines in Iceland. J B, Eisenstein N, Engelhart C. The Gambl Issues. 2006; 18:39-56. lie/bet questionnaire for screening 115. Baldursdottir K, Olason DT, Gret- pathological gamblers. Psychol Rep arsson SJ, Davidsdottir ÄR, 1997;80:83-8. Sigurjonsdottir AM. Peningaspil og 122. Rönnberg S, Volberg RA, Abbott MW, algcngi spilavanda medal 16 til 18 ära et al. Gambling and problem gambling framhaldsskolanemenda: Mat & in Sweden. Stockholm: National ähaettubättum [Gambling and problem Institute of Public Health, 1999. gambling prevalence among 16 to 18 123. Volberg RA, Abbott MW, Rönnberg Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RA VOLBERG 37 S, Munck IM. Prevalence and risks of 133. Queensland Treasury. Queensland pathological gambling in Sweden. household gambling survey 2003-04. Acta Psychiatr Scand 2001; 104(4): Brisbane: Queensland Government, 250-6. 2005. 124. Abbott MW, Volberg RA. The New 134. Roy Morgan Research. The third Zealand National Survey of problem study into the extent and impact of and pathological gambling. J Gambl gambling in Tasmania with particular Stud 1996; 12(2): 143-60. reference to problem gambling. 125. Jonsson J, Rönnberg S. Sweden. In: Hobart: Department of Health and Meyer G, Hayer T, Griffiths MD Human Services, 2001. (eds). Problem Gambling in Europe: 135. South Australia Department for Challenges, Prevention, and Inter- Families and Communities. Gambling vention. New York, NY: Springer, prevalence in South Australia. 2009. Adelaide: Government of South 126. Slutske WS, Jackson KM, Sher KJ. Australia, 2007. The natural history of problem 136. Moore S, Ohtsuka K. Gambling gambling from age 18 to 29. J activities of young Australians: Abnorm Psychol 2003;! 12(2):263-74. Developing a model of behavior. J 127. Winters KC, Stinchfield RD, Botzet Gambl Stud 1997; 13:201-36. A, Slutske WS. Pathways of youth 137. Moore S, Ohtsuka K. Beliefs about gambling problem severity. Psychol control over gambling among young Addict Behav 2005; 19(1): 104-7. people, and their relation to problem 128. Abbott MW, Volberg RA. Frequent gambling. Psychol Addict Behav and problem gambling in New 1999; 13:339-47. Zealand. Wellington: Department of 138. Lesieur HR, Blume SB. The South Internal Affairs, 1992. Oaks Gambling Screen (SOGS): A 129. Dickerson M, Maddern R. 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Delfabbro PH, Lahn J, Grabosky P. household gambling survey 2001. Further evidence concerning the Brisbane: Queensland Government, prevalence of adolescent gambling 2001. and problem gambling in Australia: A Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 38 YOUTH GAMBLING PREVALENCE STUDIES study of the ACT. Int Gambl Stud rates inflated? J Gambl Stud 2003; 2005;5:209-28. 19:405-25. 142. Delfabbro PH, Thrupp L. Youth 151. Jacques C, Ladouceur R. DSM-IV-J gambling in South Australia: The role Criteria: A scoring error that may be of attitudes and economic sociali- modifying the estimates of patho- zation. J Adolesc 2003;26:313-30. logical gambling among youths. J 143. Lambos C, Delfabbro PH, Pulgies S, Gambl Stud 2003; 19:427-31. DECS. Adolescent gambling in South 152. Ladouceur R, Bouchard C, Rheaume Australia. Adelaide: Independent N, et al. 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Int J Adolesc Med Health 2010;22(l):39-58 Risk and protective factors associated with youth problem gambling N Will Shead, PhD, Jeffrey L Derevensky, PhD and Rina Gupta, PhD International Centre for Youth Gambling Problems, McGill University, Montreal, Quebec, Canada Abstract: Risk factors for youth gambling problems are best understood within an ecological model recognizing the interwoven relationship that exists between the individual and their environment. Empirical studies covering individual, relationship, community, and societal factors associated with adolescent gambling problems are reviewed. The cumulative body of research suggests that males who are exposed to gambling at an earlier age are at greater risk of developing gambling problems. Individuals who report poor family cohesion, have family members or friends who also gamble, and those exposed to and engaged in a wider variety of gambling options are at greater risk. Adolescents with impulsive, high sensation-seeking personalities and exhibit emotion-focused coping styles are more likely to experience gambling problems. Anxiety, depression, ADHD, poor academic performance, substance use, and delinquency are also strong predictors. Many of these risk factors appear to predict a general behavior syndrome encompassed by overall mental health problems, substance abuse, delinquency, and problem gambling. Increased exposure to gambling opportunities and marketing of gambling is recognized as a potential risk factor at a community level while gambling-permissive cultures may instill positive attitudes and beliefs toward gambling. A call is made for more research that can identify the causal risk factors that lead to gambling problems among youth which will ultimately improve our prevention efforts. Keywords: Youth, adolescents, gambling problems, risk factors Correspondence: N Will Shcad, PhD, Post-doctoral Fellow, International Centre for Youth Gambling Problems, 3724 McTavish Street, Montreal, Quebec. Canada H3A 1Y2. Tcl:514-398-4374; Fax: 514-398-3401 ; E-mail: [email protected] Submitted: July 15,2009. Revised: September 05,2009. Accepted: September 18,2009. INTRODUCTION that severe gambling problems often The field of gambling research has grown originate in childhood and adolescence (2). enormously over the past two decades but A better understanding of the factors there remains a paucity of research on risk contributing to the acquisition and the factors associated with problem gamblers development of disordered gambling (1). While there is a growing body of behavior among youth will ultimately help literature, there remains a lack of consensus clarify the etiology of gambling problems regarding the risk factors and their relative in the general population, weight in contributing to problem gambling Some strides have been made to foster a among youth. Studying the risk factors better understanding of the onset and among youth is particularly important given developmental course of gambling problems Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 40 RISK AND PROTECTIVE FACTORS that form the basis of this review. This instance, if lack of family cohesion is growing body of research focuses upon associated with gambling problems, greater identification of the biopsychosocial family connectedness should lower the risk mechanisms underlying excessive gambling of developing a gambling problem. Thus, behavior among youth. As risk factors that risk factors can help to extrapolate contribute to gambling problems are better significant protective factors that offset elucidated, the information can be used to their impact and increase resiliency. improve assessment, treatment, and In addition, raising public awareness of prevention programs. With more knowledge the factors that contribute to the about which youth are at the highest risk of development and maintenance of problem becoming problem gamblers, these programs gambling among youth will ultimately will be able to better target specific types of bolster the advancement of services for youth with the goals of stopping or young problem gamblers (4). The more minimizing gambling problems before they society at large understands about disordered occur and improving the effectiveness of gambling, the more likely it will be viewed treatment for those who suffer from as an important public health concern. gambling problems. Parents, teachers, health professionals, Examination of the factors associated policy makers, and the public in general with youth gambling problems provides a need to stay informed about risk factors in more complete description of the nature of order to help youth avoid and overcome these problems, their onset, and how they gambling problems. are maintained. Knowledge about these risk This review outlines existing research factors is also critical for identifying the on risk factors associated with child and potential warning signs of gambling adolescent problem gambling. Empirical problems. This information can be used to studies covering several categories of risk develop prevention initiatives geared factors are examined. These categories of toward youth with gambling problems. For risk factors are presented using an example, public service announcements ecological model to recognize the multiple aimed at youth gambling prevention can interacting contexts in which gambling incorporate aspects that appeal to youth problems occur. The ecological model who are at greatest risk of becoming addresses individual risk factors as well as heavily involved in gambling activities. overlapping inter-personal, community, and Such an approach has been taken by societal systems that create the conditions developers of anti-drug media campaigns in for youth to develop gambling problems (5). designing public service announcements At an individual level, personal attributes with high sensation value to appeal to high that increase the likelihood of gambling sensation-seeking youth who are at greater problems are examined. Interpersonal level risk for substance use problems (3). influences address the potential of close As risk factors become better under- others to shape an individual's gambling stood, a complementary understanding of behavior including risk factors related to resiliency can be achieved. Risk factors relationships \\ith family and friends. tend to represent extremes on certain Community level factors encompass the biopsychosocial dimensions such that influences of the greater environment in opposing ends of the same dimensions may which the individual lives and interacts represent important protective factors. For with others. When considering youth Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NWSHEADETAL 41 gambling behavior, the availability and an important protective factor, especially marketing of gambling within a community given the fact that, among adolescents, the are the most relevant community level transition between social gambler and factors. Finally, at the societal level, the problem gamblers is more rapid compared influence of broad, macro-level factors are with adults (10). examined. These risk factors address the cultural beliefs, societal norms, and world- wide trends that can potentially lead to GENDER gambling problems among children and The cumulative body of gambling research adolescents. The ecological model provides clearly shows that gambling is more popular an appropriate framework for under- amongst males than females and males are standing the multitude of risk factors that more likely to experience problem or contribute to youth gambling problems and pathological gambling behaviors (11,12). the complex interactions that exist between This gender difference has been found in factors nested within different ecological adolescents as well (8,13-15). More frequent systems. gambling among boys compared with girls has also been shown in a sample of primary DEMOGRAPHIC FACTORS school children (16). In a recent study of Adolescent problem gamblers are more middle and high school students, males were likely to have reported gambling for the found to be almost six times more likely than first time at a younger age (approximately females to be identified as having a 10 years of age) compared with their peers gambling problem and twice as likely to be who report gambling but experience few classified as at-risk gamblers, endorsing a gambling-related problems (6-8). Similarly, number of criteria for gambling problems adults with gambling problems report but not meeting the clinical cut-off for having been introduced to gambling earlier pathological gamblers (17). in their childhood compared with adults A study by Gupta and Derevensky (7), who do not experience problems (9). testing Jacobs' General Theory of Addictions Together, these findings suggest that youth (18), which proposed that disordered who are exposed to their first gambling gambling is a habitual coping response to experience at an earlier age are at increased abnormal physiological resting states, risk of developing problems which makes revealed that male and female adolescents intuitive sense given that children who may be differentially predisposed to initiate gambling when they are 10 years of gambling problems. Among males, high age will likely have more opportunity to excitability and total dissociation while become involved in further gambling gambling predicted categorization as activities compared with children who do problem or pathological gamblers, whereas not initiate gambling until they are in later among females, depressed mood, dissociation, adolescence. In addition, older children and stimulant drug use were strong without gambling experience have more predictors. These findings suggest that opportunity to develop more mature, among adolescents who gamble to relieve realistic perspectives about gambling before chronic stress conditions, males and initiating gambling compared with younger females generally differ in terms of how children. Delaying the onset of gambling they experience and manifest abnormal exposure as long as possible appears to be resting states. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 42 RISK AND PROTECTIVE FACTORS RACIAL AND ETHNIC GROUPS stable over the lifespan, likely contribute to There is mounting evidence that adult problem gambling. Examining pe'rsonality members of racial/ethnic minority groups traits associated with problem gambling and lower socioeconomic classes are at a among youth is particularly useful in terms significantly greater risk of developing of determining the direction of the gambling problems (19), a finding that has relationship between gambling problems been replicated in adolescent studies and personality traits. As gambling (20,21). In a sample of United States (U.S.) behavior is relatively new among youth, it adults, gambling problems were significantly is unlikely to have significantly impacted more common among minority groups, their personalities. Thus, if certain with Blacks, Hispanics, Asians, and Native personality traits are found to be over- Americans being 3 to 5 times more likely to represented in youth with gambling experience at least some gambling problems problems, they are likely to be underlying compared with Whites when holding gender, traits that lead to gambling problems rather age, and socioeconomic status (SES) than having been caused by a pattern of constant (19). However, a study of adoles- excessive gambling. cents showed contradictory results (13). Whereas most studies on personality After controlling for socioeconomic status, risk factors have focused on specific Black youth actually reported gambling less personality variables, a recent study frequently than White youth. A study of examined a multitude of personality factors youth in Montreal, Canada (22) revealed to identify those most highly associated that a group comprised of Allophone with gambling problems in youth (26). adolescents (neither French nor English High school students in the Montreal region being the primary language) had the highest with moderate to severe gambling-related proportion of youth who reported weekly problems obtained scores that deviated gambling and experienced self-reported significantly from the normative means on gambling problems, followed by Anglo- four personality traits—excitability, confor- phones and Francophones. Overall, the mity, self-discipline, and cheerfulness. paucity of research and the lack of These findings suggest that adolescents consensus regarding the potential influence with gambling problems exhibit less self- of minority status on youth gambling, regulatory behavior (i.e., impulsivity, racial/ethnic group cannot necessarily be distractibility, over-activity, self-indulgence, considered a strong, overriding risk factor difficulty conforming to group norms) for youth gambling problems. Further while exuding the impression of being research is necessary to determine the carefree, sociable, and happy. The impact on youth of racial/ethnic group, adolescents with the most severe gambling socioeconomic status, and their interaction. problems reported the highest levels of frustration, impulsivity, anxiety, impatience, PERSONALITY and irritability. In addition, adolescents Research has pointed toward the presence with gambling problems obtained higher of dispositional attributes of problem scores on the Disinhibition and Boredom gamblers (23-25). The suggestion is that Susceptibility subscales of the Sensation certain personality characteristics, most of Seeking Scale, indicating that they have which emerge at a young age and are fairly higher risk-taking tendencies. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NWSHEADETAL 43 IMPULSIVITY age compared with those with only It has been proposed that gambling among gambling problems (30). Together, the youth is the product of an impulsive findings of these prospective studies personality type (27-30). Impulsivity can be emphasize the significance of impulsivity described as behavior carried out in a as a personality trait among youth that is spontaneous or unintentional manner highly predictive of gambling problems at a without thought or self-control. This later age. It also raises the possibility that definition describes many of the features of impulsivity may be an important focal point disordered gambling; accordingly, patho- of treatment for youth with gambling logical gambling is currently classified as a problems. For example, treatment for disorder of impulse control in the adolescents might aim to help them develop Diagnostic and Statistical Manual of Mental skills for delaying immediate gratification Disorders, Fourth Edition-Text Revision and placing more weight on the long-term (DSM-IV-TR) (31). Indeed, research has consequences of their behavior. consistently shown that adults with gambling problems exhibit higher scores on RISK BEHAVIOR both self-report and behavioral measures of Risk-taking is an intrinsic element of impulsivity (23,25). gambling. Problem gamblers tend to take Studies have shown that the relationship more risks in general and on gambling tasks between impulsivity and problem gambling in particular (23). Both gambling and has direct implications for youth as well problem gambling have been shown to be (29,30,32,33). A study of 754 adolescent associated with high sensation-seeking boys from low socioeconomic environments behavior (23) as indicated by a high degree investigated the relationship between of seeking out novel, exciting experiences impulsivity and problem gambling severity with an element of risk. Ë study of middle- (27). Self-report and teacher ratings of and high school students found that risk impulsivity when the boys were 13 years propensity was a particularly strong old were compared with problem gambling predictor of being at-risk or having a status in later adolescence at the age of 17 gambling problem, even after controlling years. Non-gamblers had the lowest for other predictors (17). Youth who impulsivity scores followed by recreational perceive their involvement in risky gamblers, low problem gamblers, and high activities as highly positive while not problem gamblers. appreciating the costs and negative conse- Vitaro and his colleagues reported quences of such activities are at greater risk findings in two papers based on a sample of of developing gambling problems. young low SES boys who were assessed on Accordingly, adolescents who exhibit various personality variables when they "devil-may-care" attitudes should be were 12 to 14 years old and again at age 17. viewed as a high-risk group and youth Disinhibition and response modulation gambling prevention efforts will likely deficits in early adolescence predicted benefit from targeting this audience. gambling problems at a later age (28). In addition, problem gamblers with substance COPING STYLES use problems were more likely to have high The way in which people deal with life self-reports of impulsivity and exhibit circumstances is a function of both person- impulsivity-related behaviors at a younger ality and experience. Some individuals use Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 44 RISK AND PROTECTIVE FACTORS gambling as a form of maladaptive coping events with a tendency to use ineffective in response to problems in their lives (34). coping strategies, particularly emotion- Problem gamblers commonly report focused strategies among males, are at 'gambling to escape', achieved through greater risk of turning to gambling as a mood modification as a means of coping maladaptive outlet to deal with their with stressful life events and negative mood problems. states. Accordingly, problem gamblers are The existing body of research on hypothesized to face more life challenges personality variables and youth gambling and use less-effective coping styles that problems suggests that there are qualitative employ avoidance or mood modification differences in personality traits across tactics rather than dealing with the cause of adolescents with varying severity of the problem. Indeed, adolescents with gambling behavior. Adolescents who gambling problems report more stress, daily generally exhibit less self-regulatory hassles, and major traumatic life events (35) behavior, higher risk-taking tendencies, and and have poor general coping skills ineffective coping styles are more (10,17,32). susceptible than others to developing A pattern of more stressful life events gambling problems. and ineffective coping among adolescent problem gamblers was also demonstrated in MENTAL HEALTH FACTORS a study that examined stress, coping, and As described, some individuals engage in gambling severity in a sample of 11- to 20- gambling in order to modify undesirable year-olds (36). Adolescents with gambling mood states (32,34). For these individuals, problems reported more negative life events gambling becomes a form of negative and major life events compared with social reinforcement by alleviating unwanted and non-gamblers. In addition, adolescents emotions such as anxiety and depression. with gambling problems used less task- Consistent with the Pathways Model of focused coping and more avoidance- problem gambling (37) and Jacobs' General focused coping. Males with gambling Theory of Addictions (18) that some problems reported using more emotion- problem gamblers engage in the activity to focused coping strategies but there were no cope with abnormal physiological resting differences among females in terms of states, adolescents with severe gambling emotion-focused coping. A study of problems experience higher levels of state gambling and childhood maltreatment and trait anxiety (7.8,35,38). For these showed that, among adolescents and young adolescents, the experience of anxiety may adults, reports of maltreatment increased as be diminished as gambling provides an gambling severity increased (35). At-risk "escape" allowing individuals to disengage and pathological gamblers reported child- from stressful life events or problems. This hood maltreatment of all types (physical, hypothesis is supported by findings that and verbal abuse and neglect) and that the adolescent problem gamblers score higher effects of their maltreatment had negatively on measures of dissociation and are more impacted their daily behavior suggesting likely to report gambling in order to achieve that they may be gambling as a means to feelings of dissociation (10). cope with psychological problems and In addition to increased anxiety levels, "escape" from past experiences. In sum, adolescent problem gamblers report lower youth who experience more stressful life self esteem and greater depressive sympto- Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NW SHEAD ET AL 45 matology compared with non-gambling and Excitability factor of the High School social gambling adolescents (7,8,10, Personality Questionnaire, comprised of 26,35,39). Likewise, older adolescents with items that query the extent to which serious gambling problems are at a respondents are easily distracted, frustrated, heightened risk for suicide ideation and annoyed, overactive, and impulsive. These suicide attempts (7). For these youth, characteristics match up to the criteria for gambling may provide emotional relief ADHD, as outlined in the DSM-IV-TR (31). from symptoms of depression by inducing A prospective study examined a sample positive feelings of well-being. Indeed, of children diagnosed with ADHD at two youth with gambling problems report that points in time—initially between the ages they gamble for excitement, to escape of 7 and 11 and later between the ages of 18 problems, and alleviate depression (7,35,38). and 24 (33). At the follow-up assessment, Another adolescent study showed that participants were identified as either still probable pathological gamblers and at-risk meeting the criteria for a diagnosis of gamblers more heavily anticipated pleasure ADHD or no longer meeting the criteria. and excitement from gambling and No differences were found between the expected to feel good about themselves as a participants with persistent ADHD, non- result of gambling compared with social persistent ADHD, and a group of controls and non-gamblers (40). in terms of gambling participation or frequency. However, those with persistent ADHD ADHD were significantly more likely to be There has been a great deal of research classified as pathological gamblers when interest in the possible association between compared with those with non-persistent Attention Deficit Hyperactivity Disorder ADHD or no ADHD. The findings suggest (ADHD) and pathological gambling. Given that symptoms of ADHD that persist into that ADHD is normally diagnosed during young adulthood are particularly significant childhood, the potential link between these risk factors for gambling problems among two psychiatric conditions is particularly youth. important for understanding risk factors for problem gambling among youth. Notably, ACADEMIC ACHIEVEMENT existing knowledge about the progression of Among adults, a negative consequence ADHD can provide a developmental commonly associated with gambling framework for understanding risk factors problems is poor performance at work. for gambling problems among youth. Apart from absences and lateness due to Studies have reported a relationship gambling, the quality of work can suffer as between gambling problems and ADHD individuals become preoccupied with (41,42), and more recently, a study by gambling, thinking about their next Hardoon, Gupta, and Dervensky (43) has gambling activities and experiencing shown that there are similar traits that negative emotional consequences in underlie ADHD and gambling problems. response to losses. Similarly, children and Adolescent problem gamblers in high adolescents are subject to poor school school were found to be similar to those performance as a result of excessive adolescents with ADHD on several gambling. Dickson et al (17) found in a dimensions (26). Youth with gambling sample of adolescents that the report of problems tended to score high on the school problems predicted at-risk and Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 46 RISK AND PROTECTIVE FACTORS probable pathological gambling with a large with substance use disorders. For example, proportion of probable pathological in the DSM-1V-TR (31), substance gamblers (43.5%) experiencing significant dependence and pathological gambling are school problems. Likewise, the proportion both characterized by preoccupation, a need of students with below average self- to increase the behavior to achieve the perceived grades increased linearly as desired effect, symptoms of withdrawal, gambling severity increased with almost loss of important social, occupational, or one quarter of probable pathological recreational activities, and continuation gamblers perceiving that they performed despite knowledge of its negative worse than other students at school consequences. Among adults, there is a compared with only 6.5% of non-gamblers. high co-occurrence between substance use Meanwhile, feeling welcome and integrated disorders and gambling disorders (44), into the school environment was a which is not surprising given the striking protective factor such that lower school- similarities in their defining features, connectedness was associated with suggesting that common variables contribute adolescent problem gambling. A link to the development of both disorders. between gambling problems and poor Research on adolescents mirrors the school performance has been demonstrated finding of a significant association between in several studies (8,15,43). substance abuse and gambling problems in Given that the above findings are adults. A number of studies have shown correlational in nature, it is not possible to that adolescent problem gamblers are at determine whether school problems arise as increased risk for the development of a result of gambling problems or if multiple addictions (7,10,15,19). In a problems in school tend to lead to gambling sample of Minnesota youth, those with problems. It has been shown that a high greater gambling involvement were more proportion of youth with gambling likely to be regular drug users (15). problems report having a learning disability Similarly, among New York State (43) suggesting that innate academic adolescents, heavy drinking males were difficulties may precede gambling problems. significantly more likely than non-drinkers However, the relationship is most likely or moderate drinkers to gamble at least reciprocal with excessive gambling activity weekly (13). As well, studies assessing leading to poorer performance in school alcohol, tobacco, illicit drug, and marijuana which, in turn, contributes to increased use among Minnesota youth showed them gambling involvement. The extent to which to be reliable predictors of gambling one causes the other cannot be determined frequency (14,45) as did a study of without prospective data that examines the Washington State youth demonstrating a sequential nature of these problems. positive association between tobacco, alcohol, and drug use and both gambling frequency and gambling problems (46). SUBSTANCE ABUSE Clearly, data on adolescent substance use Problem gambling is often conceptualized as and gambling indicate that these behaviors a non-pharmacological "addiction" because, tend to co-occur in youth suggesting that although one does not ingest a substance substance use should be viewed as a with chemically addictive properties when warning sign for comorbid gambling gambling, it shares several defining features problems and vice versa. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NWSHEADETAL 47 DELINQUENCY relationship between youth gambling and Despite prohibitions against youth gambling, antisocial behavior was found in an analysis prevalence data indicate that the majority of of Minnesota public school students which youth have gambled (8,10,14, 15), revealed that antisocial behavior—including suggesting that many youth view gambling vandalism, physical fights, stealing, and as a normative activity. Notwithstanding getting thrills from dangerous activities— the high rates of gambling participation was the strongest predictor of gambling among youth, government restrictions tend frequency (14). Stinchfield and his colleagues to categorize underage gambling along with posited that frequent gambling may be a underage drinking, deeming them both part of a collection of deviant behaviors adult activities that pose a significant risk to including violence, vandalism, shoplifting, youth. Disordered gambling among youth is and substance use. This type of young delinquent behavior, not only in the sense gambler fits with Blaszczynski and Nower's that it normally involves repeated violation (37) "anti-social impulsivist" pathway of of the law, but also because many of the problem gambling. Youth who are prone to associated problems relate to other "acting-out" behaviors, violence, deceitful- delinquent activity to fulfill gambling ness, and consistent violation of rules may intentions. In fact, when one overlaps the be at risk for gambling problems. typical personality features of problem gambling over norms for delinquent RELATIONSHIPS behaviors on the High School Personality Children and adolescents spend a large Questionnaire, the profiles look remarkably portion of their lives with their immediate similar (26). family with behaviors being modeled by One of the DSM-IV-TR criteria for family members having a strong impact on pathological gambling is the commission of the future behavior of young people. illegal acts to finance gambling including Consequently, gambling by family members forgery, fraud, theft, or embezzlement (31). contributes to the gambling behavior of Adolescent research has likewise youth. For example, most youths become demonstrated a strong association between exposed to gambling by their parents (43). delinquency and gambling problems (8,10, Gupta and Derevensky (6) administered 15). For some youth, gambling may be an questionnaires to children between the ages outgrowth of a more general behavior of 9 and 14 to assess their gambling problem syndrome. Youth who have activities, including where and with whom difficulty following rules and behaving in the gambling occurs. A large majority socially acceptable ways are more likely to (86%) of those who gambled regularly engage in delinquent activities that include reported gambling with family members. gambling (13). Antisocial tendencies among Other studies have also reported that youth youth are characteristic of conduct disorder with greater gambling involve-ment are representing a persistent pattern of behaviors more likely to have parents or family that violate age-appropriate social norms members that gamble (8,15,21). (31). A recent study showed a strong co- In another study, a sample of adoles- morbidity between conduct disorder and cents from middle and high school were gambling problems, particularly among examined to test the extent to which various younger respondents in a sample of 14- to protective factors increased resilience to 21-year-olds (47). Further evidence of a adolescent problem gambling (17). Problem Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 48 RISK AND PROTECTIVE FACTORS gamblers were less likely to report feeling Poor caregiving can also contribute to connected to their families compared to at- future gambling of youth. In a study of risk gamblers, social gamblers, and non- childhood maltreatment and youth gambling, gamblers. Self-reported ratings of family pathological gamblers reported significantly cohesion decreased from non-gamblers higher emotional and physical neglect as across each level of gambling severity children compared with at-risk, social, and group. Family cohesion remained a non-gamblers (35). Living in a non- significant predictor when tested along with nurturing family environment appears to be other protective factors in their ability to an additional risk factor for gambling predict participant classification as either problems among youth. non-problem gamblers (i.e., non-gamblers and social gamblers) or problem gamblers PEERS (i.e., at-risk and probable pathological Friends play an important role in shaping gamblers). These results support previous the risky activities of young people. Before findings in which youth with gambling adolescents are allowed to participate in problems were more likely to report having regulated forms of gambling (e.g., casinos, poor family connectedness, family lotteries, machine gambling), they often dysfunction, low perceived social support, begin gambling amongst friends. When and low parental supervision (8,43,29). gambling becomes a regular activity among In the same study (17), several family- friends, it may become viewed as a related risk factors were also examined. normative activity that is both desirable and Probable pathological adolescent gamblers safe. Indeed, one study found that only 10% were more likely to report having family of students aged 13 to 14 years feared being members with gambling problems compared caught for gambling by parents suggesting with other adolescents, and the proportions that gambling is generally regarded as a generally decreased as severity of problems socially acceptable activity among adoles- diminished. When tested with other risk cents (6). As such, having friends who factors to predict problem gambling status, gamble makes gambling less likely to be only having a sibling with a gambling perceived as a high-risk activity and problem remained a significant predictor. adolescents may exhibit less caution when Other family factors related to stressful life considering their involvement in future events were examined for their ability to gambling behavior. In the same study (6), differentiate between gambling severity 75% of 9- to 14-year olds who regularly groups but were not tested in the overall gambled reported that they gambled with prediction models. The death of a friend or their friends and the tendency to gamble close family member and the arrest of a more at a friend's home and at school family member differed across groups with increased with age. Not only does having probable pathological gamblers having friends who gamble increase the likelihood generally higher rates. Parental divorce of gambling involvement, clinical testimony and/or remarriage of parents, moving to a suggests that adolescents who develop new town/city, loss of a parent's job, and a gambling problems tend to lose their non- close family member having a serious gambling friends as they spend more time illness did not differentiate between with gambling associates (48). This pattern gambling severity groups. has the potential to be particularly harmful Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NWSHEADETAL 49 given the protective factor of high-quality COMMUNITY friendships is replaced with a friendship At a community level, the most obvious milieu in which gambling is both socially risk factor for problem gambling is the acceptable and the predominant extra- presence of gambling opportunities that are curricular activity. accessible to community members. Research Having a friend with a gambling problem is currently inconclusive regarding the has also been found to differentiate youth impact of gambling availability on the based upon their gambling severity groups prevalence of gambling problems. While in that over 40% of probable pathological conventional wisdom predicts that more gamblers and over one third of at-risk gambling opportunities within communities gamblers had a friend with a gambling lead to higher incidences of gambling problem compared with only 10% of social problems, findings are mixed in this regard gamblers and 6% of non-gamblers (17). In and it has been suggested that the addition, it was a significant predictor of relationship between exposure to gambling problem gambler status over and above all and the prevalence of gambling-related other risk and protective factors. Also of problems is non-linear, varying across note was the finding that having friends people, place, and time (49). Accordingly, with substance use problems increased with it is difficult to determine whether youth increasing problem gambling severity, who are exposed to more gambling suggesting that having friends who engage opportunities in their communities are at in any addictive behavior, and not just greater risk of developing problems. gambling, poses a significant risk factor. However, among young people who Similarly, having friends who engage in gamble, there is evidence suggesting that delinquent behaviors is predictive of specific types of gambling activities pose a gambling problems among youth (13,29). greater risk than others (50). The general quality of peer relationships A national sample of U.S. youth between also appears to predict problem gambling the ages of 14 and 21 were interviewed to severity among youth. A study of Australian assess their gambling activities and severity adolescents revealed that problem gamblers of gambling problems. Youth who have had have poorer relationships with non-friend experience with more types of gambling peers in their class, despite reporting having over the previous year were more likely to as many close friends as non-problem have gambling problems (50). When gamblers (39). Problem gamblers indicated involvement in other games was controlled, that they dislike twice as many classmates card playing, games of skill, and casino as non-problem gamblers and also reported gambling were highly associated with that significantly more classmates dislike increased risk of gambling problems. These them. Among various measures of psycho- data merely examine the association between logical well being, social alienation was the specific forms of gambling and gambling- strongest predictor of gambling severity related problems among youth, making it with adolescent problem gamblers being difficult to determine whether exposure itself significantly more disillusioned with leads to more problems or if youth with society. Regardless of the quality of close gambling problems are more likely to friendships, it appears that poor relation- participate in multiple forms of gambling, ships with peers, in general, is a risk factor which is likely the case. Nonetheless, the for youth problem gambling. results suggest that certain gambling Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 50 RISK AND PROTECTIVE FACTORS activities and overall level of gambling activity within their respective communities. engagement can be useful predictors of In addition, the central message of these gambling problems among youth. High advertisements, that gambling is a thrilling gambling versatility appears to be a and worry-free activity, is more likely to be particularly salient risk factor for youth accepted and pursued by children and problem gambling (39). When youth are adolescents. Derevensky et al (52) found presented with and have access to more that 47% of adolescent males and 38% of gambling options they may be more likely to adolescent females reported that gambling find a preferred form of gambling which can advertisements made them want to try increase the risk of developing a problem. gambling. In addition, problem gamblers were much more likely to report MARKETING "sometimes" or "often" gambling after Related to the availability of gambling seeing an advertisement (32%) compared within communities is the way gambling is with social (3%) or non-gamblers (0%). marketed toward community members. Such findings have led researchers to Although most jurisdictions have laws that suggest that the presence of gambling prohibit minors from participating in advertisements is a strong risk factor for regulated forms of gambling, youth are youth gambling involvement (51). exposed to the same messages advertising Accordingly, community-level regulation gambling opportunities as adults. A broad of these advertisements that reduces range of marketing strategies are typically exposure to youth and prohibits overly used to promote gambling opportunities to positive portrayals of gambling should the public. Television and radio reduce the normalization of gambling and commercials, billboards and other signage, lead to subsequent reductions in gambling point-of-sale advertisements, sponsorship problems among youth. deals, and promotional products are examples of marketing efforts that use SOCIETY various forms of media to endorse Beyond individual-, interpersonal-, and gambling opportunities (51). These community-level factors that have an advertisements tend to focus on the fun, impact on youth gambling behavior, there entertainment, and possibility of "winning are macro-level risk factors that reflect the big" with no mention of the potential wider culture and society. Throughout consequences of gambling. Adolescents history, cultural norms have dictated the report that these advertisements portray legality and availability of gambling gambling as a rewarding and enriching opportunities. At several points in time, activity that leads to a happier lifestyle (52). widespread belief that gambling is sinful Not only do these advertisements led to its prohibition in many parts of the increase the availability of gambling within world. To this day, gambling remains communities by providing information outlawed in most Muslim countries and about local gambling opportunities, they public opposition, often from religious normalize gambling by portraying it as an organizations, has lead to the removal of acceptable and harmless form of entertain- gambling machines in certain jurisdictions. ment. As youth are exposed to more and However, as gambling revenues have been more gambling advertisements, they are shown to be lucrative sources of funds for more likely to perceive it as a normative governments, charities, and businesses, Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NW SHEAD ET AL 51 gambling opportunities have expanded. adolescents reported more gambling Coinciding with this expansion, conservative involvement and gambling-related problems attitudes toward gambling have loosened, compared with non-American Indian and gambling continues to gain acceptance adolescents, which was partially attributed in society as a socially acceptable, even to cultural acceptance of magical thinking charitable, form of entertainment. among American Indians. Thus, cultural Consequently, this prevailing attitude poses beliefs that emphasize an external locus of a serious risk for youth. Children and control and a reliance on 'fate' or 'luck' may adolescents who identify strongly with the encourage more gambling among youth. ideological, social, economic, and political Traditional family configurations may values of a gambling-permissive society also influence gambling behavior. For will be more likely to see it as a normative example, Raylu and Oei (53) suggested that activity themselves, and thus something children in Chinese families with a they may choose to pursue. traditional patriarchal family system have As outlined in the previous section, the increased exposure to and parental approval availability and marketing of gambling are of gambling. Certain cultures also pass on important determinants of youth gambling general attitudes toward gambling to its within communities. However, differences members. Whereas gambling is perceived in gambling rates across communities can as part of the lifestyle, history, and tradition also be attributed to cultural differences of of Chinese people, it has been met with geographic regions (53). In addition, steadfast disapproval in Muslim cultures. differences between cultural groups within Clearly, children growing up in a Chinese the same geographic region can at least culture will be more likely to develop partially explain variations in gambling positive attitudes and have increased attitudes and behaviors. Thus far, the exposure to gambling compared with majority of the review has consisted of Muslim children. Western studies. Although few non- Whereas cultural issues represent Western studies have specifically examined important macro-level factors that influence risk factors for youth gambling problems, it youth gambling, global trends in gambling is instructive to examine some of the are another significant consideration. Most cultural factors known to impact the notably, the Internet gambling industry has initiation and maintenance of gambling. experienced large-scale expansion which Existing research suggests relatively some researchers posit will lead to higher high rates of gambling among certain rates of gambling and related problems cultural groups including Jewish, Chinese, among youth (55). While the presence of and Indigenous peoples (53). And as more gambling venues represents a outlined previously, there is some evidence potential risk factor at a community level, that racial/ethnic minority groups are at the emergence of Internet-based gambling greater risk of developing gambling circumvents the accessibility issue and problems. While these higher gambling allows access to gambling to virtually rates may be caused to some extent by non- anyone, virtually anywhere in the world. cultural factors such as low socioeconomic The high accessibility of Internet gambling status, there is evidence that cultural issues presents new societal concerns, particularly also play a unique role. For example, for youth who may engage in Internet Zitzow (54) found that American Indian gambling despite being prohibited from Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 52 RISK AND PROTECTIVE FACTORS land-based gambling opportunities. of youth gambling problems. However, Although no empirical studies have variables at each of these levels cannot be tested the causal relationship between the considered in isolation. Rather, all risk availability of Internet gambling and factors should be examined in the context gambling problems among youth, the of other risk factors that could potentially results of at least two correlational studies lead to over-involvement with gambling. At suggest that youth who gamble on the the individual level, demographic, personality, Internet are much more likely to experience and psychological factors influence youth's significant gambling problems (56,57). susceptibility to developing gambling These findings are alarming given that problems. Relationship-level factors youth continue to have increased exposure encompass family and friends, whereas to the Internet and its evolving set of community-level factors include availability applications. The academic and extra- and marketing within the community where curricular activities of youth have become the child lives. Finally, at a societal level, well integrated into advancing technologies. cultural factors and worldwide trends in As the popularity and accessibility of gambling (i.e.. Internet gambling) are Internet gambling has increased, so has considered important large-scale forces that Internet usage and computer access among can impact the level of risk. Although these youth. These combined elements make risk factors cover a wide range of variables, Internet gambling a potentially high-risk it is far from being a comprehensive review form of gambling with its own set of unique of factors that are relevant to youth risk factors worthy of increased scrutiny gambling prevention. among researchers. In addition, much of the The current review highlights research appeal of Internet gambling appears to be studies on risk factors that, for the most related to the game of poker which has part, focus on examining the negative garnered an incredible amount of factors associated with gambling problems international attention as a "sport" that among youth. However, efforts to prevent anyone can pursue. As global interest in tobacco, alcohol, and drug use among youth poker continues to grow in the form of have focused on not only decreasing risk increased television exposure, multi-million factors but also increasing protective factors dollar tournaments, and the creation of (58). The success of these initiatives in pseudo-celebrity poker professionals, preventing high-risk behaviors highlight the children and adolescents are more likely to importance of designing youth gambling seek out Internet gambling sites as an prevention efforts to enhance resiliency. opportunity to test their own poker skills. Although the results of one study suggested Societal acceptance of poker as a legitimate that the absence of risk factors contributes and harmless past time poses a risk for more significantly to the prediction of youth gambling. gambling problems among youth than the presence of protective factors (17), another DISCUSSION study demonstrated that risk and protective A myriad of factors are implicated in the factors each contribute uniquely to the development of gambling problems among prediction of youth gambling problems children and adolescents. Individual, (59). Accordingly, youth gambling research relationship, community, and societal factors should go beyond a basic risk prevention all play a role in the cause and maintenance framework to one that fosters protective Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NWSHEADETAL 53 factors when helping develop youth gambling. While these correlational findings gambling prevention initiatives. One category are useful for secondary prevention of potentially instructive protective factors is measures, they are less helpful for primary positive development constructs. Current prevention efforts aimed at preventing the evidence is limited on the extent to which onset of gambling problems. More such constructs, including cognitive and prospective research is needed to establish emotional competencies, serve as protective the antecedents of problem gambling factors for youth gambling. Parker et al (60) among youth. Such studies should take a found that higher emotional intelligence longitudinal approach to determine which among youth was associated with lower factors are present before gambling scores on a problem gambling measure. problems emerge. Although more costly Among the different components of and difficult to undertake, such research emotional intelligence, interpersonal abilities would provide valuable knowledge about had the highest negative correlation with how gambling problems develop in youth problem gambling severity, suggesting that and the resiliency factors that can help youth with better interpersonal skills are make children more resistant to gambling less likely to spend considerable amounts of problems before they are initiated to time gambling. gambling activities. However, the direction of this Most existing research on risk factors relationship was undetermined. Cognitive has focused on demographic and behavioral competencies and their relation to youth correlates of youth gambling. Much less problem gambling have been left unexplored work has been devoted to examining the for the most part as well. One study showed unique thoughts and attitudes that are that a higher score on knowledge of prevalent among youth with gambling randomness, self-monitoring, and coping problems. These factors represent a crucial skills among older adolescents was area of study given that thoughts and associated with lower scores on a problem attitudes encompass the motivation to gambling measure (61). In addition, an gamble. Current evidence suggests that intervention designed to improve these children and adolescents with positive competencies was shown to result in attitudes toward gambling are more likely significant increases in scores on to develop gambling problems (21). In randomness, self-monitoring, and coping addition, adolescent problem gamblers hold skills knowledge compared with a control more irrational beliefs about gambling, group. In sum, preliminary evidence often failing to understand the true risks suggests that positive development associated with gambling and believing that constructs warrant further investigation as they have more control over gambling out- potential protective factors for youth comes than chance dictates (62,63). Future gambling problems. research on risk factors should closely Much of the research reviewed tended examine the thoughts and attitudes that to examine the factors that co-occur with contribute to gambling problems among gambling problems among youth. That is, youth. By revealing how gambling-related most existing research on risk factors thoughts and attitudes develop, such studies provides an account of the characteristics will ultimately improve prevention efforts and situational factors observed in youth that aim to counter these beliefs before they who already exhibit signs of disordered become more firmly entrenched with age. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 54 RISK AND PROTECTIVE FACTORS Another area of inquiry that warrants identifying risk factors that contribute to further exploration is Internet gambling and this general problem behavior syndrome, its unique set of risk factors. The daily lives which will ultimately have a positive impact of children and adolescents are becoming on the overall development of youth (17). increasingly immersed in technology, Improving youth gambling prevention particularly the Internet, bringing into efforts will require the involvement of question the extent to which Internet usage parents to consider their own children's poses a risk factor for youth gambling. level of risk and to develop open and honest With the rapid expansion of Internet communication with their children about gambling over the past 10 years, these gambling. But before parents can engage in concerns have become a reality. Qualitative frank discussions about gambling with their data suggests that young people are the children they need to become aware of the fastest growing segment of Internet seriousness of gambling as an issue among gamblers (64). Yet, the risk factors teens. Unfortunately, research suggests that associated with Internet gambling among parents are in much need of further youth remain largely unexplored. Video education about youth gambling. Parents game playing —an activity that has become tend to underestimate the probability that more technologically advanced and inter- their own children have gambled or have a active—may also be related to problem gambling problem (66), and gambling gambling among youth. One study found remains very low (in fact, the lowest that adolescents in grades 7 to 11 who concern among 13 potential adolescent risk experienced gambling problems were more behaviors) on their priority list of teen likely to spend excessive amounts of time concerns (67). It is hoped that prevention playing video games compared with non- can begin with a better understanding of the problem and social gamblers (65). Future risk factors for gambling problems among studies should investigate the risk factors youth. New directions in research and the that have emerged with advancing application of corresponding findings to technology, such as video games and prevention efforts will help achieve the Internet gambling. overall goal of minimizing or reducing It is noteworthy that many of the risk problems associated with gambling among and protective factors associated with youth. problem gambling are predictive of multiple Gambling behavior among youth other problem behaviors, including reflects an ongoing trend in society which substance abuse and delinquency, suggesting could be best understood within an that gambling may be part of a larger ecological model recognizing the inter- constellation of high-risk behaviors that is woven relationship that exists between the caused by common underlying factors. individual and their environment. While it Studies on risk factors for gambling is true that individuals are responsible for problems, delinquency, and substance use instituting and maintaining a healthy among youth suggest that all three high-risk lifestyle necessary to reduce risk and behaviors are well predicted by a common improve health (thus the need for set of risk factors, supporting the notion of prevention and education), individual a general problem behavior syndrome behavior is also largely determined by (13,29,39). Prevention efforts will benefit one's social environment in regard to inter- most from research that focuses on personal relationships in addition to Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM NWSHEADETAL 55 community and cultural norms, values, 8. Wynne H, Smith G, Jacobs D. Adoles- regulations, and policies. The mosaic and ent gambling and problem gambling in opportunities for gambling in general, and Alberta. Alberta Alcohol and Drug youth gambling in particular, are rapidly Abuse Commission, 1996. changing. Governments throughout the 9. Productivity Commission, Australia. world are entering a phase of expansion to Australia's gambling industries. Aus- offset the economic downturn. Youth tralian Government. Report number: gambling will no doubt represent an 10, 1999. important social policy issue. 10. Gupta R., Derevensky, JL. Adolescent gambling behavior: a prevalence study and examination of the correlates REFERENCES associated with problem gambling. J 1. Johansson A, Grant JE, Kim SW, Gambl Stud 1998;14(4):319-45. Odlaug BL, Gotestam, KG. Risk 11. Volberg RA. The prevalence and factors for problematic gambling: a demographics of pathological gamblers: critical literature review. J Gambl Stud implications for public health. Am J 2009;25(l):67-92. Health Promot 1994:84 (2):237-41. 2. 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Int J Ment Health the prevention of problem gambling. J Addiction 2007;5(2):93-101. Gambl Stud 2008;24(3):367-80. 56. Byr ne . An exploratory study of 62. D clfabbro P, Lahn J, Grabosky P. It's Internet gambling among youth. not what you know, but how you use Montreal, QC: McGill University, 2004, it: statistical knowledge and adoles- [MA thesis ] cent problem gambling. J Gambl Stud 57. McBride J, Derevensky J. Internet 2006; 22(2): 179-93. gambling behavior in a sample of 63. Moore SM, Ohtsuka K. Beliefs about online gamblers. Int J Ment Health control over gambling among young Addiction 2009:7(1): 149-67. people, and their relation to problem 58. Brounstei n PJ, Zweig JM, Gardner SE. gambling. Psychol Addict Bchav Understanding substance abuse 1999; 13(4):339-47. prevention: Toward the 21 st century - 64. Brow n SJ. The surge in online A primer on effective programs. gambling on college campuses. New Substance Abuse and Mental Health Directions for Student Services 2006; Services Administration, Center for 113:53-61. Substance Abuse Prevention, Division 65. Wood RT, Gupta R, Derevensky JL, of Knowledge Develop-ment and Griffiths M . Video game playing and Evaluation, 1999. gambling in adolescents: common risk 59. L ussier I, Derevensky JL, Gupta R, factors. J Child Adolesc Subst Abuse Bergevin T, Ellenbogen S. Youth 2004;14(1):77-100. gambling behaviors: An examination 66. Ladouce ur R, Vitaro F, Cöte M. of the role of resilience. Psychol Parents' attitudes, knowledge, and Addict Behav 2007;21(2):l65-73. behavior toward youth gambling: a 60. Parker JD, Taylor RN, Eastabrook JM, five-year follow-up. J Gambl Stud Schell SL, Wood LM. Problem 2001;17(2):101-16. gambling in adolescence: relation- 67. Ca mpbell CA. Parents' perceptions of ships with internet misuse, gaming adolescent gambling behavior: a abuse and emotional intelligence. Pers Canadian national study. MA thesis. Individ Dif2008;45(2): 174-80. Montreal, QC: McGill Univ, 2009. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM ©Freund Publishing House Ltd. Int J Adolesc Med Health 2010;22(l):59-75 Adolescent gambling on the internet: A review Mark D Griffiths, PhD1 and Jonathan Parke, PhD2 'international Gaming Research Unit, Nottingham Trent University and 2Centre for the Study of Gambling, University ofSalford, United Kingdom Abstract: Internet gambling is a relatively under-researched area. While our current knowledge remains in its infancy and the prevalence rates are relatively low. researchers and clinicians are predicting greater involvement among youth. A comprehensive search of the relevant literature was undertaken. The resulting relevant literature was classified into four areas. These were (a) the empirical studies on adolescent internet gambling, (b) online gambling-like experiences in adolescence, (c) adolescent gambling via social networking sites, and (d) adolescent gambling via online penny auction sites. Age verification in relation to prevention and regulation is also examined. It is concluded that young people appear to be very proficient in using and accessing new media and are likely to be increasingly exposed to remote gambling opportunities. These young people will therefore require education and guidance to enable them to cope with the challenges of convenience gambling in all its guises. Keywords: Adolescence, gambling, problem gambling, internet Correspondence: Mark Griffiths, PhD, Professor of Gambling Studies. International Gaming Research Unit, Psychology Division, Department of Social Sciences. Nottingham Trent University, Burton Street, Nottingham, NG1 4BU, United Kingdom. E-mail: mark.griffith.s-'iTintu.ac.uk Submitted: May 15, 2009. Revised: August 10,2009. Accepted: August 11,2009. INTRODUCTION 6). For example, many gaming sites offer Gambling is not immune to technological rewards in the form of 'tokens' or 'credits' advance and many new forms of gambling where gamblers can swap the tokens or are continually evolving (1). Furthermore, it credits for a monetary prize, has been argued that many of these new A national internet gambling prevalence forms of gambling are likely to appeal to survey of 2098 people in the UK by techno-sawy youth given the relative ease Griffiths (7) included data from 119 adoles- with which online gambling sites can be cents (aged 15 to 19 years). Although at accessed (2). Early studies indicated that that time no teenagers reported gambling on many online gambling sites failed to provide the internet, 4% of teenage respondents said stringent age checks and/or age verification they would like to try online gambling, procedures (3), although the current situation Another study in Canada suggested at least has improved considerably. Nevertheless, a quarter of young people with serious gambling opportunities for adolescents are gambling problems may be gambling on the ever growing. It has been noted that the internet using'free play'sites (for'practice' distinction between gambling and video and 'demonstration' purposes) (8). It could gaming is becoming ever more blurred and be the case that the internet presents a that gaming convergence is widespread (4- particular danger for those who already Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 60 ADOLESCENT GAMBLING ON THE INTERNET have gambling problems as such findings Specialist libraries: A search of the have been found in nationally repre- following online libraries was conducted sentative adult surveys (9), and children are during July 2009, using the same search commonly thought to be more susceptible terms as outlined above. These libraries are and vulnerable in terms of developing a specialist collections put together by gambling problem (10). While our current governments from jurisdictions worldwide, knowledge remains in its infancy and the and by gambling-related organizations. Any prevalence rates are relatively low, material that appeared relevant to this researchers and clinicians are predicting review was accessed and downloaded. greater involvement among youth as well as • Electronic Journal of Gambling Issues: other high-risk groups including seniors and www.camh.net/egambling/ pathological gamblers. • Gambling Research Australia Secretariat: www.gamblingresearch.org.au METHODS • New Zealand Ministry of Health: In order to fulfill the specifications of this www.moh.govt.nz review, a comprehensive search of the • Ontario Problem Gambling Research relevant literature was undertaken. The Centre: ww w.gamblingresearch.org collection of this literature was carried out • Responsible Gambling Council: www. in two concurrent phases, comprising a responsiblegambling.org search of online electronic databases and a search of specialist web-based libraries. The resulting relevant literature was Online databases: A search of the classified into four areas: (a) the empirical following online databases was conducted to studies on adolescent internet gambling, (b) find any potentially relevant literature: online gambling-like experiences in Academic Search Elite; Business Source adolescence, (c) adolescent gambling via Premier; Ingenlaconnecl; IS! Web of social networking sites, and (d) adolescent Knowledge; PsycArticles; Psyclnfo, Science gambling via online penny auction sites. Direct. The searches were performed during Age verification in relation to prevention July 2009 using the following key words: and regulation is also examined. • (Adolescent) and (gambling or gaming) and (internet) • (Adolescent) and (gambling or gaming) EMPIRICAL STUDIES and (online) Gendron and her colleagues (11-14) carried • (Youth) and (gambling or gaming) and out a study comparing the profiles of young (internet) non-gamblers, gamblers, and internet • (Youth) and (gambling or gaming) and gamblers in relation to severity of substances (online) use in Quebec (using the DEP-ADO (15) and impulsiveness/risk taking. The authors Each search on each database produced surveyed 1,876 high-school students (46% varying numbers of titles and abstracts, male; 54% female) aged 14 to 18 years with varying degrees of overlap between (mean =15.4 years), and reported that 93.5% each database. Full lists of titles and of participants (95% male;92% female) had abstracts were viewed, and for those articles gambled in the previous 12 months, and that appeared relevant to this review, full that 8% (13% males; 3% females) had texts were accessed and downloaded. gambled on the internet in the previous 12 Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 61 Table 1. Substance use by gamblers, internet gamblers and non-gamblers (n=l,876) adapted from Brunelle et al (12) Non-gambler Gambler Lifetime Internet Type of substance use (%) (%) gambler (%) Alcohol** 76.9 91.3 96.3 Tobacco** 26.3 42.6 51.5 Cannabis** 26.8 40.6 55.1 Hallucinogens** 5.4 10.0 12.5 Speed 6.3 13.1 19.9 Cocaine** 1.0 3.8 5.9 Solvents 0.2 1.0 1.5 Heroin* 0.6 1.0 3.7 (Comparison between gamblers and non-gamblers: * p < .05; ** p < .001) months. Gendron also reported that 35% of Using the same data set, Brunelle and youth (49% males; 21% females) had colleagues (14) examined some of the played on the 'free play'/'demo' mode on contextual elements surrounding internet internet gambling sites. Males were gambling among adolescents. The authors significantly more likely than females to examined the types of games played on the gamble in general, gamble on the internet, internet, internet gambling initiation and play the 'free play' modes on internet contexts, and internet gambling contexts in gambling sites. Using the DSM-IV-J, the general (e.g., when, where, with whom, investigators reported that 3% of their how long, etc.). Of the 137 internet participants were problem gamblers and gamblers identified in the sample of 1,876 also found that significantly more internet high school students, only 0.8% had gamblers (11%) were likely to be problem regularly played for money at an online gamblers than those who did not gamble on casino and only 1.9% had regularly played the internet (1.5%). However, there were no for money in online poker (see table 2). The gender differences for any type of problem 'play for free' modes were played more gambling. Further findings revealed that regularly in both online casinos (8.9%) and nearly 7% of the participants had a substance online poker (13.8%) (see table 2). The use problem and that those with results also showed that 37% of online problematic substance use were also more gambling was done mainly with friends, likely to be internet gamblers (4% non- 34% with the immediate family, 23% with gamblers; 8% gamblers; 18% internet other family members, 2% alone, and 4% gamblers) (see table 1). In relation to with others. impulsivity, internet gamblers and non- Brunelle and colleagues (11) also inter- internet gamblers had significantly higher viewed 37 adolescent online gamblers, and impulsivity and risk-taking scores than non- reported that the main types of online gamblers. Problem gamblers also had gambling carried out were poker, blackjack significantly higher scores on impulsivity electronic gambling (slot) machines, bingo and risk taking than non-problem gamblers. and sports betting. Most of this activity was Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 62 AD LHSCENT GAMBLING ON THE ΙΝΤΠΚΜÐ Table 2. Types of internet games played in the last 12 months (n=137) adapted from Brunelle et al(\\) Never Once Oceasionall\ Regularly Type of game (%) (%) (%) (%) Internet Casino 95.4 2.3 1.5 0.8 (for money) Internet casino 75.2 8.5 7.4 8.9 ('free play' mode) Internet poker 94.7 1.7 1.7 1.9 (for money) Internet poker 71.9 8.0 8.0 13.8 ('free play mode') carried out either at home or in school, comprised 1,513 adolescents aged 16 to 18 although most played in the evening so it is years (730 males; 783 females). The second unlikely that playing at school was highly study carried also carried out in school prevalent. Those who played for more than classes comprised 1,537 adolescents aged two hours at a time were most likely to do 13 to 18 years (768 males; 747 females). this on their own whereas playing socially The surveys included questions relating to with others was more likely to be done for gambling on Icelandic internet websites much less time per session. Most online (lotto, sports pools, sports betting) and on gamblers found the atmosphere exciting foreign websites (poker, casino games, and pleasant (rather than stressful or sports betting, and 'free play' modes). serious). Brunelle et al (11) concluded that Students also completed the DSM-IV-MR-J (a) poker was the most popular form of (17), a gambling screen assessing severity online gambling, (b) adolescent online of gambling and gambling-related problems. gamblers were more likely to be problem In relation to participation, Olason gamblers than those who did not gamble reported that in the first study, 62% of the online, (c) most initiation of online participants had gambled, 11% were regular gambling took place with family members, gamblers, 20% had gambled on the internet, (d) most adolescent online gamblers began and just under 4% were regular internet by playing in the 'free play' mode, and (e) gamblers. In the second study. 57% of the for many adolescents, online gambling was participants had gambled, 8% were regular a way to make money, occupied them when gamblers, 24% had gambled on the internet, they had nothing else to do, and allowed and just over 4% were regular internet them to socialize. gamblers. Table 3 outlines in more detail Olason (16) reported two studies the findings in relation to internet gambling examining gambling behavior among more specifically. In both studies, males Icelandic adolescents that included questions were significantly more likely than females relating to internet gambling. The first to gamble on the internet (32% boys vs. 9% study carried out in school classes girls in study I; 37% boys vs. 11.5% girls in Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 63 Table 3. Types of games played on the internet by Icelandic adolescents adapted from Olason (16) Study l:(n = /5/J) Study 2: (n~1537) Type of game Regular Total Regular Total Gamblers Gamblers Gamblers Gamblers Icelandic websites Lotto 0.6 2.4 0.5 8.7 Sports pools 0.7 3.4 0.9 8.5 Sports betting 0.8 2.9 1.2 6.2 Foreign websites Online poker 0.6 1.9 1.8 6.5 Casino games 2.2 15.8 1.8 12.3 Sports betting - - 0.5 1.9 'Free play' Modes 3.3 28 - - study II). The results in relation to problem to ascertain their experience of gambling on gambling showed that the prevalence of the internet, adolescents were asked 'Have problem gambling among gamblers was 3% you ever played any National Lottery game in the first study and 2.2% in the second on the internet?' Those who had done so study. However, among those who had were also asked 'Which, if any, of the gambled on the internet, the respective follo\ving games have you played in the problem gambling prevalence rates were past 7 days?' and were presented with the significantly higher at 10.1% and 7.5%. following options: (i) instant win games for Results also revealed that 11.5% had used money, (ii) free instant win games, (iii) their own credit card, 23.1% had used their lotto, and (iv) one of the other lottery draw own debit card, 15.4% had used one of the games. Those who had experience of parents' credit cards, and 50% had used gambling online were also asked how they some other method (e.g.. brother's credit played National Lottery games on the card, friends paying and then paying them internet, and presented with the options: (i) back, electronic cash, PayPal, Neteller, with the system let me register, (ii) I played bonus money, etc.). along with my parents, (iii) another adult let Griffiths and Wood (18), in the United me play, (v) I used my parent's/guardian's Kingdom, surveyed 8,017 young people online National Lottery account with their aged between 12 and 15 years of age about permission, (v) I used my parent's/ their internet gambling behavior. Like the guardian's online National Lottery account Olason studies, their survey used the DSM- without their permission, and (vi) played IV-MR-J screen to identify whether free games. respondents who gambled were problem or The results showed that approximately social gamblers. The study examined one in twelve young people aged 12 to 15 remote gambling in relation to use of the years (8%) said they had played a National National Lottery products online. In order Lottery game on the internet. Boys were Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 64 ADOLESCENT GAMBLING ON THE INTERNET more likely than girls to say they have parents. Those who had played independently played National Lottery games on the were most likely to have played free games, internet (10% vs. 6%), as were young with just 0.3% of young people having people who were Asian and black. Not played National Lottery games on their own surprisingly, young people identified as for money. 'problem gamblers' were more likely than Weite, Barnes, Tidwell and Hoffman (19) 'social gamblers' to have played a National assessed the relationship between specific Lottery game on the internet (37% types of gambling and the extent of problem compared with 9%). Of those who had gambling reported by American adolescents gambled on the internet, a quarter of the and young adults using data from the adolescents said they had played free National Survey of Youth and Gambling, instant win games on the internet (24%), with 2,274 youth aged 14 to 21 years. The nearly one in five had played instant win study found that 2% of respondents (3% games for money (19%) or Lotto (18%), males; 0% females) reported gambling and 10% had played one of the other draw online in the twelve months preceding the games. Problem gamblers were more likely interview. The authors also reported that to have played every game in the past week, these respondents gambled online an average compared with social gamblers who were of 48 days per year, the highest average of less likely to remember what games they any kind of gambling reported in the survey. had played in the last week. Young people The study also found that 65% of with parents who approve of young people respondents who gambled on the internet gambling were more likely to have played reported having at least one symptom of the online instant win games for money. Lotto, South Oaks Gambling Screen Revised for or other draw games (35% compared with Adolescents (SOGS-RA) (20), which again 19%; 40% compared with 15%: 22% was the highest of the 15 forms of gambling compared 6% respectively). The results being considered. Statistical analyses suggest parental consent or help in gaining revealed that when participation in other access to the games via the internet. forms of gambling were controlled for, the When asked which of a series of link between internet gambling and problem statements best describes how they played gambling among youth was no longer National Lottery games on the internet, significant. In other words, they concluded nearly three in ten adolescents who played that young internet gamblers were likely to online reported playing free games (29%), experience more problem gambling one in six reported that the system let them symptoms by virtue of gambling on more register (18%), slightly fewer played along forms of gambling, as opposed to the with their parents (16%), and one in ten used properties of internet gambling itself. Indeed, their parent's online National Lottery this was supported in part by the data, with account either with their permission (10%) internet gamblers engaging with an average or without it (7%). However, it should be of 6.9 different types of gambling within the noted that a third of online players said they last 12 months, the highest level of gambling 'couldn't remember' (35%). Overall, among versatility reported by players of any of the all young people (and not just players), 2% 15 gambling activities. played National Lottery games online with Ipsos MORI (21) in the United their parents or with their permission and 2% Kingdom surveyed 8,598 pupils (4,466 have played independently or without their males; 4,447 females; 45 not stated), from Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 65 201 schools. Two different class levels demonstrated in figure 1, just over a quarter (curriculum years 8 and 10) were surveyed of adolescents had played in 'money-free within each school which resulted in the mode' in the week preceding the survey, sample consisting of 11-15-year olds. The with opportunities on the social networking questionnaires included items relating sites four or five times more popular than demographic and socioeconomic informa- those presented on real gambling sites. tion; gambling attitudes and behavior Using statistical modeling to further (online and offline) and a youth-adapted examine the same data, Forrest, McHale problem gambling screen (DSM-IV-MR- and Parke (22) reported that gambling in JX17). Overall, 1% reported gambling on money-free mode was the single most the internet for money in the seven days important predictor of whether the child prior to the survey. The children reported had gambled for money and one of the most that they were most likely to spend their important predictors of children's problem money on the internet during this time gambling. However, it should be noted that frame on clothes, music, video games and this relationship is correlational and not DVDs (10%, 9% 8% and 5%, respectively) causal. The possibility and extent to which with 68% not spending any of their own money-free gambling is responsible for real money online within that period. Children gambling participation and gambling- were also asked about 'gambling-like related risk and harm could only be experiences' which included play-for free confirmed using longitudinal data. or practice modes of real gambling sites and A study by Byrne [23; cited by gambling-type games for play money or Derevensky & Gupta (24)] in Canada of points on social networking sites. As 2,087 adolescents and young adults (43% 80% , 70% 67% 60% -i I 50% 40% 28% 30% 19% 20% 10% 6% 3% 3% 2% 2% 0% BEI FS31 Yes. Any Bebo Facebook An> other Online Online Online Online Games Poker money- Blackjack Poker Bingo Roulette free (other) gambling Fig. 1: Money-free gambling in the last 7 days (n=8,598) adapted from Ipsos MORI (21) Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 66 ADOLHSCHNT GAMBLING ON THE INTERNET males; 57% females) reported some data on money. Poulin and Elliot (30) reported that youth internet gambling. The study found in the past year, 4.2% of adolescents had that more individuals under the age of 18 gambled for money online in Atlantic years than 18 to 24 years played 'free play' Canada, and in Montreal, almost one in ten games on internet gambling sites (43% vs. teenagers (9%) reported as having gambled 33% for males; 42% vs. 29% for females). online for money (24). The most popular form of 'free play' activity for those both under and over the ONLINE GAMBLING-LIKE EXPERIENCES age of 18 years was card playing (poker and Over the last decade, a number of papers blackjack), with less frequent gamblers have been published examining gambling- (i.e., those gambling less than once per like experiences engaged in by adolescents month) playing slot machines or other including instant win games in children's forms of online gambling machines. snacks like crisps and chocolate (31) and Over the past year, almost one in twenty money-free gambling which could include (4.6%) of the participants (7.8% males; 'free play', 'practice' and 'demo' games on 2.3% females) had gambled online with internet gambling sites (18). As noted their own money. When examined by age, above, Ipsos MORI (21) reported that 28% those under 18 years were more likely to be of their sample of 8,598 children had male (8.6%; over 18 years 6.8%) than participated in money-free gambling of female (3.2%; over 18 years 1.3%). The some description in the week preceding the two most popular forms of internet survey. The study also found that those gambling for both those under 18 years and children who reported: being male; having over 18 years were card playing (online a black or white ethnic background; earning poker) and sports betting. For those who or receiving £30 in the last week; and that gambled online for money, Byrne reported their parents were gamblers were all that many did so with a family member significantly more likely to have gambled (i.e., parent or older sibling). For those who in money-free mode in the specified time gambled on the internet, the prevalence rate period. of problem gambling was almost 19%. Some clinical researchers have asserted Although very high, similar rates of that youth gambling in money-free mode problem gambling prevalence among self- may be a cause for concern (18,24,32-34). selected samples have been reported by For example, a number of North American other research studies on student gambling studies have reported that anywhere (25-28). Byrne reported no significant between 25% to 50% of teenagers have gender differences but did note that the played 'free play' games via internet younger the person gambling online, the gambling sites (24,30,35). It has been more likely they were to exhibit problem alleged that such opportunities encourage gambling. teenagers to practice before 'graduating' to In addition to the study of Byrne, there playing for money games at online casinos have also been some smaller more locally (36) and that a 'precautionary principle' based studies done in various parts of should be applied which prevents Canada. For instance, Meerkamper (29) adolescents from being exposed to reported that more than one in twenty gambling-like experiences. However, the teenagers in Nova Scotia aged 15 to 17 specific impact of money-free play remains years reported playing online poker for unclear. Despite the strong correlation of Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 67 money-free play with both gambling the game the social networking utilities can participation and problem gambling (22) present gambling as a viable route for the and there is currently no conclusive acquisition of scarce virtual goods. According evidence to suggest that money-free play to Downs' pilot research there were 25 causes individuals to start gambling for Poker applications on Bcbo (and over 500 actual money or to be more at risk of separate poker groups) and in excess of 100 experiencing gambling related harm, poker applications on Facebook (and over although there is a growing body of 1.000 separate poker groups). These poker correlational evidence. sites featured some with real prizes, some The use of 'free play' sites is not the with cash-play options, and all easily only type of online gambling-like downloadable by those under 18 years experience that adolescents can now engage along with many free trial games. The in. Griffiths, King and Delfabbro (37) largest of these poker groups had over identified other types of gambling-like several thousand members and in one group experience including (i) gambling via social surveyed, 15% of those in the group networking sites and (ii) gambling via declared they were under the age of 18 online penny auction sites. These are briefly years. Furthermore, gambling applications examined below. typically contain sidebar advertisements and hyperlinks to real gambling sites. GAMLING VIA SOCIAL NETWORK SITES Downs also reported a type of pseudo- Across the world, the social networking gambling among 'Fluff Friends' that has phenomenon has spread rapidly. Despite over 100,000 active users per month. In this the minimum age for most major social social networking forum, users (typically networking sites usually being 13 years young girls) create 'Fluff' Art. To do this (and 14 years on My Space), a study by the they have to earn 'munny' (sic)—a type of Office of Communications (38) in the virtual money through pet racing". Pet racing United Kingdom reported that just over a costs 1-point per race and winnings can be quarter (27%) of 8 to 11 year olds who are up to 4000 points. Clearly no money is aware of social networking sites said that changing hands, but young children are they had a profile on a social networking learning the mechanics of gambling and site. The most popular social networking Downs asserts there are serious questions site used by children was Bubo (63%). about whether gambling with virtual money Recently, Downs (39) noted that content- encourages positive attitudes toward gambling generated risks from this new leisure in young people. For instance, does activity have not been investigated in any gambling with virtual money lead to an detail, yet young people using these sites increased prevalence of actual gambling? are able to gain access to gambling. She also asks to what extent are gambling- Downs claimed that the potential of related groups on social networking sites social networking sites to 'normalize' being used by those under 18 years of age, gambling behaviors may change social and whether membership of such a groups understandings of the role of gambling facilitates access to commercial gambling amongst young people. For example, while sites? It also seems natural for youth to socially responsible gambling emphasizes question whether they should game on that money spent gambling may not offer a internet sites if they are winning 'play return other than the pleasure gained from money'. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 68 ADOLESCENT GAMBLING ON THE INTERNET GAMBLING VIA ONLINE PENNY AUCTION majority of .teenagers) can participate in SITES such and activity and it could be argued that Another gambling-like activity is the many of the items in the auctions appeal participation in online penny auctions such particularly to teenage audiences (video as 'Madbid', 'Swoopo', Bid Boogie', 'Rapid game consoles, MP3 players, laptops, etc.). Bargain' and 'Hudson' (40). In order to To what extent this very new form of online participate in an online penny auction, the activity with gambling-like experiences is person needs to place a bid in an ongoing affecting the youth population is as yet auction. Bids can be made only in one undetermined but this is one area where penny (or one Euro cent) increments. The further research is needed. participants can do this by (a) placing a bid by sending a text message from their AGE VERIFICATION: PREVENTION AND mobile phone (at £1.50 or €1.50 a bid plus REGULATION operator's costs) or (b) placing a bid Given the cross-border nature of internet through the creation of an online account gambling, the conceptualization and where the person purchases a 'bundle' of evaluation of regulatory issues regarding bids (at 75 pence/75 cents to £1.40/61.40 a underage internet gambling is a difficult bid, depending on how big a bundle they task. Age verification can take a variety of buy in advance). To bid by text message, a forms with cross-referencing with official person sends a message with the code for data sources (e.g., electoral register) fast the specific product that they want to bid becoming one of the most common. on. There is no limit to how many bids that Additionally, operators may ask for the can be submitted on the same auction initial deposit to be made using a credit card product or on how many different products (given that credit can only be enforced for can be bid on at any one time individuals aged 18 years and over) in order For example, here is an example of a to verify age and then permit the customer to real winning bid outlined by Griffiths (40). revert to debit card as a payment method on A PlayStation videogame console (retail subsequent transactions. price of £310) was won in a penny auction The British Gambling Commission (41) for £8.34. To the winner of the auction this recently reported the findings of an online was won at a hugely discounted price. mystery shopping exercise which was However, what this really means is that designed to assess the effectiveness of there were 834 separate bids for this item underage gambling prevention protocols of all costing up to £1.50 per bid (depending internet gambling operators who are whether it was done online or via mobile licensed in the United Kingdom, and those phone). Looking at the 'bid history', most operators who may be regulated overseas, of the final 50 bids were made by just two but who advertise their products to the individuals who at a minimum spent at least United Kingdom market. The Gambling £30 in those final bids trying to secure the Commission used 16-year old volunteers item. Although one person won the console, (with parental consent) and a category of the other person spent a considerable bank account which is available to amount of money and received nothing in customers under the age of 18 years. return. Griffiths (40) has argued that this is Volunteers registered their details and a internet gambling under another name. false date of birth and continued to try to Anyone with a mobile phone (e.g., the vast gamble and withdraw funds. Of the 37 Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 69 license holders tested, 13 (accounting for the United States and English speaking 2.2% of active customer accounts) were Canadian provinces, with higher rates being identified as having weaknesses which reported for Quebec and Europe. could permit underage internet gambling. In Adolescent internet gamblers were also other words, while just over one in three found significantly more likely to be problem were identified as having problems with gamblers (12,16). Possibly, problem gamblers underage prevention protocols, these were are more susceptible and/or vulnerable to operators with a relatively small customer gambling online, and because the internet base (together accounting for just over 2% provides convenience gambling it is a cause of active player population). for concern in this particular sub-group of Although these results represent a gamblers. However, it may also be that potential cause for concern, they compare adolescent problem gamblers gravitate to favorably with an offline mystery shopping the internet, adding it as an additional mode exercise undertaken by the Gambling of gambling to their general repertoire of Commission testing all major betting gambling behaviors (as suggested by Wood operators in Great Britain. Initial findings and Williams (46) in relation to their large indicate that an underage individual was sample of adult gamblers). Consistent with permitted to place a bet in 98 out of the 100 findings reported in this review. Wood and betting shops visited (42). Of course, the Williams reported (46) a higher rate of circumstances and protocols for age problem gambling among the internet verification and prevention of underage gamblers compared with non-internet gambling are different between offline and gamblers. Importantly, the authors noted online operations (e.g., checks may be that as other modes of gambling (other than limited to the first visit in an online internet) were reported by participants as the environment, but must be attempted on main cause of their gambling problems, it every visit to an offline operator). was most likely that internet gamblers were Nevertheless, these findings do suggest that already heavy gamblers to begin with and access to online relative to offline gambling this was simply a new mode of play to opportunities is more difficult to gain for compliment their existing gambling would-be underage customers. activities. This is also consistent with initial conclusions by Weite and colleagues (19) DISCUSSION who suggested the increased risk to be the Although there is some variation in the consequence of wide-ranging participation participation rates reported in the studies in gambling activities rather than a direct considered in this review, the small number causal link between internet gambling and of surveys showed that a small but problem gambling. significant minority of adolescents can and Given the complexity of the available do gamble on the internet. Several studies evidence, the role of internet gambling in reported a past year internet gambling creating adolescent problem gamblers prevalence rate of around 4% (23,29,30). should be treated with caution. However, it However, some reported a lower figure (19) is clear that research that can help to and others report the rate as being identify the impact of internet gambling on considerably higher (12,24) e.g., 8% (12), either creating or facilitating gambling- 9% (24) and 20%-24% (16). Interestingly, related harm among adolescents should be lower rates of participation were found for made a research priority. Such research Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 70 ADOLESCENT GAMBLING ON THE INTERNET should consider the potentially different permitting access to underage players it is roles that internet gambling may play in clear that there is still much work to do. creating new forms of harm and in Some operations must tighten their age exacerbating current forms of harm. verification systems by using more cross- Another interesting theme to emerge referencing options and stricter criteria, from this review was that friends and even at the risk of losing customers aged 18 family were reported to play an important years and over. Also, even though there is role in the online gambling experience some evidence, at least in the United among adolescents. For example, Brunelle Kingdom, that access to gambling online et al (12) reported that only 2% of internet may prove more difficult relative to gambling was done with the adolescent securing offline access, underage internet playing alone. That 57% of the gambling gamblers may only need to get through the was done with a family member and 37% hurdles once. In other words, once an done with friends emphasizes the social adolescent has managed to get through age nature of internet gambling among adoles- verification systems and register, they can cents, an activity that has been traditionally gamble again repeatedly. This differs from noted as being an asocial activity. Similar offline facilities, where adolescents would findings were also reported by Griffiths and have to deceive the 'gatekeepers' on each Wood (18). These figures appear to be separate visit. significantly different to trends among We should emphasize that regulator)' adults with one study reporting that 59% of performance and compliance is only one adult respondents reported that they always aspect of preventing underage internet gambled alone (45). There are two potential gambling. It seems that with only 23% of implications of these findings. Firstly, underage internet gamblers using their own future research must explore the nature and debit cards to register and pay for their the specific impact of the social processes gambling, most are being assisted in some in adolescent internet gambling. The role of way with their payment (i.e. using friends, family may be particularly important in this family or sponsored credit cards). In one regard. Secondly, parents need to be survey (18), 17% of those that had played educated about gambling (and its potential the lottery on the internet had accessed their problems) in the same way as other parents' accounts (either with or without potentially addictive behaviors (for example, their permission). This places a significant drinking, smoking, drug taking, etc.). level of responsibility with older friends In terms of regulation, there seem to be and family members, either in terms of significant developments in preventing refusing assistance in accessing real underage individuals gambling online with gambling opportunities or in closely clear licensing conditions and codes of monitoring the use of credit cards for which practice being implemented and regular they have ultimate responsibility. compliance checks being performed (for There appears to be two challenges here example, see guidelines by the Global in relation to parents preventing underage Gambling Guidance Group [G-f; http:// internet gambling. Firstly, parents must www.gx4.com/], or e-Commerce Online have the appropriate attitudes, awareness, Gaming Regulation and Assurance [e- and intentions to prevent underage COGRA; http://www.ecogra.org/}). Yet, gambling. Although parents may have the with at least one in three regulated sites still ability to prevent underage gambling Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 71 online, they may permit or assist their child 'demo' modes of real gambling sites) that as result of viewing such behavior as children are being introduced to the harmless and/or as a fun activity. Secondly, principles and excitement of gambling even if parents are motivated to prevent without experiencing the consequences of underage internet gambling, they must be losing money. Early research has shown it prepared to monitor their child's behavior, is significantly more commonplace to win and where made available, children's while "gambling" on the first few goes on a spending on credit and debit cards and other 'demo' or 'free play' game (43), although forms of account should be monitored. this is not the case for all games (e.g., UK Educating parents should be one of the key National Lottery games). The same study components of any strategy aimed at also reported that it was commonplace for preventing or minimizing underage internet gamblers to have extended winning streaks gambling. Innovative anti-gambling software during prolonged periods while playing in has been developed and in some the 'demo' modes. However, there have jurisdictions has been offered without costs been significant regulatory developments in (for example, the BetStopper program in recent years with improved codes of Nova Scotia). practice requiring that age verification also The issue of payment is perhaps one of applies to 'demo modes' and that such the most important areas for further modes should be an accurate representation research. More work is needed to explore of the real playing experience including the the relationship between underage payment chances of winning and the rate of return to mechanisms and the development of the player (for an example, see Gambling problem gambling. For example, if an Commission) (44). adolescent is gambling using someone Based on the available literature, it may else's credit or debit card, and they are not be important to distinguish between the winning or losing their own money, will different types of money-free gambling this have the same implications for being made available—namely social developing or facilitating problem gambling? networking modes and 'demo' or 'free Factors the have been linked to the play' modes. Initial considerations suggest development and facilitation of problem that these may be different both in nature gambling (e.g., the big win; chasing; and in impact. For example, as Downs (39) arousal) could be argued to be dependent on argues, players gambling in social the extent to which a gambler is winning or networking modes may experience a losing their own money. different type and level of reinforcement Finally, evidence- suggests that 'money than those gambling in 'demo' mode. For free' gambling plays an important role for example, on some social networking sites adolescents in conceptualizing and the accumulation of 'play money' or experiencing internet gambling. Over one 'points' may have implications for buying in three adolescents have been reported to virtual goods or services or being eligible gamble in money-free mode (12,23) with for certain privileges. This may increase the Ipsos MORI (21) reporting that 28% of 11- value and meaning of the gambling event to to 15-year olds in a United Kingdom the individual. Secondly, when considering sample had done so within the last week. It the 'flow' and intention of individuals is argued that it is through money-free accessing such sites, it could be argued that gambling (using social networking sites or individuals accessing money free gambling Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 72 ADOLESCENT GAMBLING ON THE INTERNET through social networking sites may be to parents, teachers, health professionals more likely to be induced or persuaded to and other practitioners. play given that these web-site visitors' primary intention may have been social REFERENCES interaction (i.e., the primary function of the 1. Griffiths MD. Gambling technologies: website) as opposed to those playing in Prospects for problem gambling. J 'demo' mode where gambling is the GamblStud 1999;15:265-83. primary function of the website. 2. Griffiths MD, Wood RTA. 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Griffiths MD, King D, Delfabbro P. university students: Further findings Adolescent gambling-like experiences: from an online survey. Int J Ment Are they a cause for concern? Educ Health Addict 2010;8:82-9. Health 2009; 27:27-30. 27. Matthews N, Fanisworth WF, Griffiths 38. Office of Communications. Social MD. A pilot study of problem gambling Networking: A quantitative and quali- among student online gamblers: Mood tative research report into attitudes, states as predictors of problematic behaviors and use 2008. Accessed 2009 behavior. CyberPsychol Behav 2009; 12 July 09. URL: www.ofcom.org.uk. (6):741-5. 39. D owns C. The Facebook phenomenon: 28. Wood RTA, Griffiths MI), Parke J. Social networking and gambling. The acquisition, development, and Gambling Social Responsibility Forum maintenance of online poker playing Conf, Manchester Metropolitan Univ, in a student sample. CyberPsychol Manchester, Sep 2008. Behav 2007; 10:354-61. 40. Grif fiths MD. Online 'penny auction' 29. Meerkamper E. Decoding risk: sites: Regulation needed E-Finance Gambling attitudes and behaviors Payments Law Policy 2008;2(12):I4-6. amongst youth in Nova Scotia. Nova 41. Gambling Commission. Online mystery Scotia, Nova Scotia Gaming Corp, 2006. shopping programme. Information Note 30. Poulin C, Elliot D. Student drug use 2009. Accessed 09 Jul 2009. available at: survey in the Atlantic provinces: http://\vww.gamblingcommission.gov.uk/ Atlantic technical report. Halifax, UploadDocs/publications/Document'Onli Dalhousie Univ, 2007. ne%20mystery%20shopping%20progra 31. Griffiths MD. Instant-win promotions: mmc%20Julv%2009.pdf Part of the gambling environment? 42. Gambling Commission. Underage Educ Health 1997;15:62-3. gambling 2009. Accessed 09 Jul 2009. 32. Griffiths MD. Internet gambling: Available at: http://\v\vw.gamblingcom Issues, concerns and recommendations. mission.gov.uk/UploadDocs/publication CyberPsychol Behav 2003;6:557-68. s/Document/Under-age%20gambling% 33. Messerlian C, Byrne AM, Derevensky 20-%2Qpress%20release%20-%20Mav JL. Gambling, youth and the Internet: %20200 9.pdf. Should we be concerned? Can Child 43. Sevigny S, Cloutier M, Pelletier M, Adolesc Psychiatr Rev 2004; 13(l):3-6. Ladouceur R. Internet gambling: 34. Mitka M. Win or lose, Internet Misleading payout rates during the gambling stakes are high. JAMA "demo" period. Computers Hum Behav 2001;285(8):1005. 2005;21:153-8. 35. McBride J, Derevensky J. Internet 44. Ga mbling Commission. Remote gambling behavior in a sample of gambling and software technical online gamblers. Int J Ment Health standards. Technical standards paper Addict 2009;7:149-67. 2007. Accessed 09 Jul 2009. Available 36. Kelle y R, Todosichuk P, Azmier J.J. at: http://\vww.gamblingcommission. Gambling@home: Internet gambling gov.uk/UploadDocs/publications/Docu Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM MD GRIFFITHS AND J PARKE 75 ment/Remote%20Gambling%20and% gambling: Prevalence, patterns, 20Software%20Technical%20Standar problems, and policy options. Guelph, ds.pdf. Ontario: Ontario Problem Gambling 45. Valenti ne G, Hughes K. New forms of Research Centre, 2009. gambling participation: problem internet 47. Hyder AA, Juul NH. Games, gambling and the role of the family. gambling, and children: Applying the London, Responsibility in Gambling precautionary principle for child health. Trust, 2008. J Child Adolesc Psychiatr Nurs 2008; 46. Wood RT, Williams RJ. Internet 21:202-4. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM ©Freund Publishing House Ltd. Int J Adolesc Med Health 2010;22(l):77-93 A critical review of adolescent problem gambling assessment instruments Randy Stinchfield, PhD Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America Abstract: The field of youth gambling assessment is in its infancy. Currently four youth problem gambling instruments have been used to identify adolescent problem gamblers: a) South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA); b) DSM-IV-Juvenile (DSM-IV-J) and the related DSM-IV-Multiple Response-Juvenile (DSM-IV-MR-J); c) Massachusetts Gambling Screen (MAGS) and d) Canadian Adolescent Gambling Inventory (CAGI). Three of the four instruments are adaptations of adult instruments, and none of the four have undergone rigorous psychometric evaluation. While these instruments are used with varying populations in divergent settings, the psychometric properties for their use in these populations and settings are unknown. This review provides information about the instruments and makes suggestions for further instrument development and refinement. Each instrument is described in terms of its development, content, intended purpose, psychometric properties, administration method, scoring instructions, and interpretation. Strengths and limitations of each instrument are compared for both research and clinical purposes. Existing instruments are used to make clinical, scientific, and public policy decisions, and therefore, it is critical that these instruments demonstrate evidence of reliability, validity and accuracy. It is recommended that the field adopt testing standards for the development and use of adolescent problem gambling scales, and generate a body of rigorous psychometric research that demonstrates reliability, validity, and classification accuracy. Ultimately, the goal is to improve measurement precision in identifying youth problem gamblers. Keywords: Adolescent gambling assessment instruments; youth gambling assessment instruments Correspondence: Randy Stinchfield, PhD. Department of Psychiatry. University of Minnesota Medical School, 689 Fairmount Avenue, Saint Paul, MN 55105, United States. E-mail: [email protected] Submitted: July 15,2009. Revised: September 01,2009. Accepted: September 17,2009. INTRODUCTION Oaks Gambling Screen-Revised for This paper describes the instruments currently Adolescents (SOGS-RA); 2) DSM-1V- used to identify adolescent problem gamblers, Juvenile (DSM-IV-J) and its revision, DSM- compares the advantages and disadvantages IV-Multiple Response-Juvenile (DSM- IV- of existing instruments, and makes MR-J); and 3) Massachusetts Gambling recommendations for future instrument Screen (MAGS). A fourth instrument refinement and development. Three instru- currently under development is the Canadian merits are commonly used to measure Adolescent Gambling Inventory (CAGI). adolescent problem gambling. All three are The South Oaks Gambling Screen adaptations of adult instruments: 1) South (SOGS) is the most commonly used adult Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 78 PROBLEM GAMBLING ASSESSMENT INSTRUMENTS problem gambling screening instrument. The gambling has a different appearance in SOGS is a 20-item instrument developed to youth than among adults and therefore screen for probable pathological gambling in neither of these approaches seem ideal. adult clinical samples that has demonstrated Both investigators studying problem satisfactory reliability, validity, and classifi- gambling and mental health professionals cation accuracy (1-3). Winters, Stinchfield need to select from among existing and Fulkerson (4,5) adapted the SOGS for an instruments, which have little, if any, adolescent gambling survey in Minnesota in psychometric information for the adoles- 1990. The DSM-IV (6) lists 10 diagnostic cent population or the settings in which criteria for Pathological Gambling (PG), they are administered. with 5 or more of these criteria being present The primary aim of evaluating any to diagnose PG. Fisher (7) adapted the DSM» instrument (see table 1 for the description IV diagnostic criteria for adolescent surveys of each instrument) is to determine whether in the UK and developed two forms, one it measures accurately the characteristics of with a yes/no response option, DSM-1V-J (7) interest (14). Therefore, the instrument is and one with a multiple response option, considered satisfactory if the scores are DSM-IV-MR-J (8). Shaffer. LaBric. Scanlon, shown to reflect important features of and Cummings (9) attempted to improve gambling behavior. Instrument evaluations upon the existing instruments and developed are dependent upon the adequacy of their the MAGS. While not specifically an psychometric properties, including reliability, adolescent instrument, the MAGS was validity, and classification accuracy. developed on an adolescent sample and Reliability is often defined as consistency, adapted items from the Short Michigan repeatability, and stability (15). Reliability Alcoholism Screening Test (SMAST), an can be influenced by factors such as the adult alcoholism screen (10). A fourth number of items in the scale, number of instrument, currently under development, is respondents used in the evaluation and the the Canadian Adolescent Gambling Inventory types of respondents utilized in the development and evaluation of the This review serves as a resource for instrument. There are two types of investigators and mental health professionals reliability—temporal stability and internal who are involved in the screening and consistency. Temporal stability measured assessing of adolescent problem gambling. by test-retest procedures and reported as Most adolescent problem gambling correlation coefficients, involve administering instruments have not undergone rigorous the test to the same individual at two points reliability, validity, and classification in time, typically within a fairly short time accuracy evaluation (13). The assessment of period of a few days or a week (It is adolescent problem gambling has been assumed that the characteristics of interest conducted either by assuming that existing have not changed over this brief time adult instruments are appropriate for period). This mathematical construct, adolescents (which is a questionable usually shown as V expresses the extent of assumption) or by making revisions to adult correspondence or magnitude of the instruments in order to make them relationship between two scores. It ranges developmental ly appropriate. The literature from 0, indicating no relationship, to 1, on adolescent development would suggest indicating perfect correspondence between that the phenomenology of problem the two scores. In order to demonstrate Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCHFIELD 79 Table 1. Descriptions of Instruments Name of Content Areas Number of items; Administration Time and Scoring instructions, Instrument response options; Method scorerange , cut- (year) time frame scores, interpretation of scores SOGS-RA signs and symptoms 12 items; yes/no; past 10 minute paper and Each item is one point; (1990) of problem gambling; year penal questionnaire score range 0-1 2; 0-1 negative = no problem; 2-3 = at consequences risk gambling; 4+ 1 = problem gambling; DSM-IV-J DSM-IV diagnostic 9 criteria measured 5-10 minute paper and each item is one point; andDSM- criteria by 12 items; yes/no pencil questionnaire score range is 0-9; IV-MR-J (DSM-IV-J) and score of 4 or more is (1992; multiple response classified as a problem 2000) options (DSM-IV-MR- gambler J); past year MAGS psychological and 14-items;7itemsare 5-10 minute interview or Each item is scored 0 (1994) social problems scored in a scale paper and penal for no and 1 for yes. associated with based on item questionnaire Each item score is gambling weights from a multiplied by a weight discriminant function and then summed analysis; yes/no; past along with a constant year time frame using a weighted scoring algorithm derived from a discriminant function analysis. The MAGS classifies respondents into non-pathological gambling, transitional gambling, or pathological gambling CAGI gambling frequency; 45 items measuring 20 minutes; paper and 9 item gambling (2007) time spent gambling; five domains: (a) penal questionnaire problem severity money spent gambling problem subscale has a score gambling; gambling severity; (b) range of 0 to 27 problem severity psychological (behaviors and consequences; (c) consequences) social consequences; (d)finandal consequences; and (e) loss of control; four-point multiple response options, past three months time frame Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 80 PROBLEM GAMBLING ASSESSMENT INSTRUMENTS Table 1. Descriptions of Instruments (continued) Psychometrics Classification Accuracy Indices Name of Reliability Validity Sample characteristics, criterion, base Instrument rate, sensitivity, specificity, and hit rate SOGS-RA a/pha = .80;Two gambling activity (r= .39), using a criterion of DSM-IV-J, 97% true week test-retest gambling frequency (r =.54) positive; 0.5% false negative; and 2.4% kappa = .57 and and amount of money false positives (Derevensky & Gupta, a/p/jaof.81 and .76 gambled in past year (r=.42) 2000); using two criteria of self-identified for males and need for help and receipt of help, 96% females respectively were correctly classified, however, (Poulin. 2000); sensitivity was about 60% and specificity a/p/)aof.74(Welte, was 96% for both proxies (Boudreau & et al. 2008) Poulin, 2007). DSM-IV-J alpha = .75 significantly different mean NA and DSM- scores between regular and IV-MR-J non-regular gamblers and between problem and social gamblers. DSM-IV-MR-J problem gamblers also tended to play more games regularly, spend more money, borrow to fund their gambling, and sell their possessions to fund their gambling; DSM-IV-J related to the SOGS-RA (r=. 67) and GA 20(f=.68)(Derevensky& Gupta, 2000) MAGS alpha = .83 MAGS score obtained a high Sample was 589 Boston, MA high school (1994) correlation (r= .76) with DSM- students who reported gambling in the IV score. past year. Criterion was DSM-IV diagnostic criteria as measured by a 12 item instrument. See development article for classification accuracy indices. Note that these classification accuracy indices are based on a discriminant function analysis computed on the development sample and therefore other MAGS users are not likely to obtain as high an accuracy. (CAGI) alphas range from Correlated with gambling NA (2007) .74 to .88; test-retest frequency ( r = .32 to r = .55) ranged from r = .60 and money spent gambling ( r to .91 = .12 to r =.50). Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCHFIHLD 81 satisfactory temporal stability, a test-retest Nunnally (15) and Cicchetti (17) correlation of r =.70 or higher typically suggested that validity correlations greater needs to be obtained. than r - .30, provide support for convergent Reliability is also measured by looking validity. Finally, another validity indicator at the internal consistency of the test items. is how well the instrument is able to Internal consistency is the concept that a set discriminate between two target samples. of items are all measuring the same For example, a new measure of problem construct. One way of measuring internal gambling should obtain high scores when consistency is by comparing the score on administered to a sample of gambling half of the items to the score on the other treatment clients and low scores when half of the items. This split-half reliability administered to a sample from the general is measured in terms of the correlation population. coefficient r. Another approach to Another measure of an instrument's measuring internal consistency is to utilize utility and performance is referred to as statistical techniques that measure the classification accuracy (18,19). That is, homogeneity of the scale, commonly how well does the instrument identify those measured by Cronbach's (16) alpha, a with and without the disorder. The coefficient that ranges from 0 to 1. The classification accuracy is typically assessed higher the alpha, the greater the internal with a number of coefficients, including consistency of the scale. As a criterion, sensitivity, specificity, false positive rate, Nunnally (15) recommends that an alpha of false negative rate, positive predictive .90 be used as the minimum standard and power, and negative predictive power. an alpha of .95 is desirable in applied Sensitivity is the true positive rate, that is, settings where a test score is used to make the rate of positive test results among those important decisions. with the disorder, and specificity is the true Validity is defined as whether the negative rate, that is, the rate of negative instrument measures the construct it test results among those without the purports to measure (14). One type of disorder. False positive rates represent the validity is content validity, that is, do the percent of positive test results among scale items cover the various features of the individuals without the disorder and false construct being measured. A second type of negative rate is the percent of negative test validity is criterion-related validity. results among those with the disorder. Criterion-related validity is commonly Positive predictive power is the rate of true- assessed by measuring correlations between positive results among all positive test the scale of interest and other scales that results. Negative predictive power is the measure the same construct. In order to rate of true-negative results among all demonstrate validity, a new scale should be negative test results. correlated with existing scales of the same construct that have already demonstrated South Oaks Gambling Screen—Revised satisfactory psychometric properties. For for Adolescents (SOGS-RA) example, a new scale to measure problem Given the widespread use of the SOGS, gambling may be correlated with the Winters, Stinchfield, and Fulkerson (4) SOGS, an instrument with demonstrated revised the adult SOGS for an adolescent satisfactory psychometric properties. problem gambling survey in Minnesota. At Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 82 PROBLEM GAMBLING ASSESSMENT INSTRUMHNTS the time, 1989, there was no instrument to Two scoring procedures have been used identify adolescent problem gamblers. with the SOGS-RA, yet neither system has Jacobs (20) had used the Gamblers received extensive psychometric and Anonymous 20 questions in a youth study classification accuracy analyses. These two and Lesieur and Klein (21) had used DSM- scoring systems have come to be referred to III-based questions for their adolescent as the SOGS-RA "broad" and "narrow" survey, but neither study reported detailed criteria (23). The broad criteria are based on psychometric information on either instru- a combination of gambling frequency and ment. As a result. Winters, Stinchfield and SOGS-RA score. To be classified as a Fulkerson (4) adapted the most commonly problem gambler under the broad criteria, used adult instrument, the SOGS, for the respondent has to gamble at least adolescents and referred to it as the SOGS- weekly and obtain a SOGS-RA score of Revised for Adolescents (SOGS-RA). The two or more: or gamble daily, regardless of investigators revised the original SOGS by SOGS-RA score"(5). Under the SOGS-RA changing the lifetime time frame to a past narrow criteria a cut score of four or more 12-months time frame which seemed more indicates a problem gambler, a score of 2-3 developmentally appropriate for adolescents indicates an at-risk gambler, and a score of as they do not have as much life experience 0-1 is a non-problem gambler (23). as adults and they tend to live more in the Because these two sets of SOGS-RA present than adults. Other revisions included scoring criteria have caused some changing the wording of items and response confusion, the problems associated with the options to better reflect adolescent gambling broad criteria will be addressed. The behavior and youth reading levels, SOGS-RA broad criteria are problematic eliminating two items that were viewed as for a number of reasons. First, Winters and having poor content validity for adolescents; Stinchfield (23) moved from the broad and retaining only one item for sources of criteria in 1993 to the more narrow criteria borrowed money rather than nine items as is in 1995 because of the low threshold for done with the SOGS. The SOGS-RA problem gambling of the broad criteria; and consists of 12 items and a copy of the re-analyzed the original 1990 Minnesota SOGS-RA as well as a detailed description data using the narrow criteria. Second, the of the revisions can be found in Winters, broad criteria are not exhaustive of all Stinchfield, and Fulkerson (4). Reliability patterns of gambling problem severity and validity coefficients were computed on because not all patterns were present in the 460 males aged 15-18 years, and the internal original data and that the response options consistency reliability was alpha = .80. In for gambling frequency items were limited terms of validity, the SOGS-RA was to either daily, weekly, monthly, less than correlated with gambling activity (r = .39), monthly, and not at all. Gambling more gambling frequency (/· = .54) and amount of often than weekly and less often than daily money gambled in past year (/· =.42) (4). The is missing from the broad criteria (i.e., SOGS-RA was able to discriminate between gambling between two and six days per youth who gambled regularly and those who week). Third, most recent studies that have did not. Since its development, the SOGS- used the SOGS-RA have used the narrow RA has been used in a wide number of criteria and there appears to be a consensus adolescent-gambling surveys (13,22). among most users of the SOGS-RA that the Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCHFIELD 83 narrow criteria are preferred over the broad "unreasonable estimates of problem and at criteria. risk gambling" and raised the cut score to 5 Fourth, the broad criteria are probably or more to reflect the same cut score that is "too broad". The SOGS-RA broad criteria used with the adult SOGS, however, they define problem gambling as daily gambling did not have a criterion to compare against and this is a questionable criterion for and they gave no classification accuracy problem gambling—it is not found in either information for this new cut score. the SOGS or the DSM criteria. Does daily Derevensky and Gupta (25) compared gambling indicate problem or pathological the SOGS-RA with the DSM-IV-J and GA gambling? Not necessarily. The broad 20. The authors noted some item content criteria considers a score of 2 as problem differences between these scales and found gambling and given that it is fairly easy to the DSM-IV-J to have obtained the more endorse two SOGS-RA items, particularly conservative estimate of problem gambling the subjective items, this also seems to be prevalence (3.4%) as compared to the too low a threshold for problem gambling. SOGS-RA (5.3%). There was a fairly high The narrow criteria cut-score of 4 is similar degree of classification agreement between to the SOGS and DSM-IV cut-scores of five. the SOGS-RA and DSM-IV-J. The SOGS- Fifth, the SOGS was originally intended to RA when compared to the DSM-IV-J as the correlate with diagnostic criteria for patho- criterion, yielded 97% True Positive; 0.5% logical gambling, and this is how most users False Negative; and 2.4% False Positives. interpret a SOGS cut-score, whereas, the Ladouceur et al (26) raised the question SOGS-RA broad criteria are not close to that as to whether adolescents understand level of problem severity. Sixth, although SOGS-RA items. It should be noted that some convergent validity information was there are some errors in their description of reported for the broad criteria in the original the SOGS-RA. Ladouceur et al describe the SOGS-RA study, it did not provide any SOGS-RA as having 19 scored items when classification accuracy information. Seventh, it is only 12 items, however, the Table a minor additional point about the SOGS-RA provided indicated they only scored 12 broad criteria is that the category "no items. The authors indicated that the cut problem gambling" is misleading as it score is 5 and this indicates Probable suggests that all cases in this category are Pathological Gambling, when the published gamblers when in fact this category includes cut score is 4 indicating problem gambling. non-gamblers. For these reasons, it is They found that adolescents misunderstood recommended that the SOGS-RA narrow SOGS-RA items and that after clarification criteria be used rather than the broad criteria their SOGS-RA score was lower on retest. for identifying adolescent problem gamblers, The authors conclude that this mis- at least until further research on the understanding of item content could cause classification accuracy of the SOGS-RA is inflated prevalence rates (See Derevensky, conducted. Gupta, and Winters (27) for a critical A few studies have examined the review of this study). psychometric properties and cut score of Wiebe. Cox and Mehmel (28) examined the SOGS-RA. In terms of the cut score, the psychometric properties of the SOGS- some investigators have chosen to raise it RA in a community sample of adolescents. above four. Govoni, Rupcich and Frisch The authors found over- and under- (24) rejected the broad criteria as yielding endorsement of some items by problem Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 84 PROBLEM GAMBLING ASSESSMENT INSTRUMENTS gamblers versus at risk gamblers, suggesting not hold up, but more psychometric research that item weighting, deleting items or is needed. rewriting items may improve the classifi- Langhinrichsen-Rohling. Rohling, Rohde, cation accuracy of the SOGS-RA. They and See Icy (31) examined the SOGS-RA also found a two factor solution that was cut score as it compares to the MAGS. The interpretable as gambling consequences and author found a lack of congruence between lack of control over gambling. the SOGS-RA and the MAGS for classifying Poulin (29) used the SOGS-RA in a problem gamblers. The SOGS-RA classi- survey of adolescents in the Atlantic fied 80 of 1,395 high school students who provinces of Canada and found the broad had gambled in the past year as problem criteria to be "complex and ambiguous"... gamblers using a cut score of 4 or more, and not "exhaustive and mutually exclusive". and the MAGS classified only 26 as She also found the narrow criteria to be problem gamblers. The authors concluded problematic because of the lack of an that the prevalence estimates of adolescent adequate rationale for a cut score of 4 or problem gambling vary as a function of the more to define problem gambling. Poulin instrument used. In response to this (30) also used this same survey data to disparity, they suggested creating a fourth conduct a psychometric study of the SOGS- category for the SOGS-RA, using a cut RA and found three factors, which she score of 6 or more to indicate Probable labeled "self-awareness of one's problem Pathological Gambling, which improved gambling, insight into others' assessment of the agreement rate between the SOGS-RA one's problem gambling, and expedient and MAGS. This study exhibited some measures to address the negative financial limitations, including the use of different consequences of problem gambling." Two time frames for SOGS-RA (past 12 months) week test-retest stability showed fair to good versus the MAGS (lifetime), however, the agreement, with a kappa for the narrow MAGS development article used a past 12 criteria of .57. Internal consistency was months time-frame (9). The authors report satisfactory with a Cronbach's alpha of .81 that the MAGS item "arrested for gambling" and .76 for males and females respectively. was the best item for discriminating the She also notes that the cut point may be too "probable pathological gamblers from all high because it only classified 26% of male the other groups", however, this raises a daily gamblers and 9% of female daily question as to the validity of this response. gamblers as problem gamblers. However, I How many high school students get would contend that there is not a perfect arrested for gambling? relationship between gambling frequency and Ladouceur et al (32) compared the problem gambling and therefore, this failure SOGS-RA to DSM-IV criteria in a sample to classify daily gamblers as non-problem of 631 adolescents. The SOGS-RA identi- gamblers should not be a concern. fied 93 adolescents as Problem Gamblers. Derevensky, Gupta and Winters (27) Of those 93, only 7 were confirmed as addressed the issue of high prevalence Pathological Gamblers through clinical rates, the arguments that they are inflated, interview conducted 1 or 2 weeks later. and the role of the SOGS-RA in this debate. While this study shows evidence of the The authors concluded that most arguments likely discordant results obtained from the against the high prevalence rates, some of SOGS-RA versus DSM-IV diagnostic which are measured with the SOGS-RA, do criteria, numerous weaknesses limit the Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCHFIELD 85 validity of the results. One of the weak- adolescents in Iceland. The authors nesses is the 1- to 2-week time delay computed a Principal Components Analysis between the administration of the SOGS- and reported a one-factor solution RA and the clinical interview, which itself accounting for 37% of the variance and a can lead to disagreement. Another weakness coefficient alpha of .81. The correlation is that the two measures were administered between the SOGS-RA and DSM-IV-MR-J by different methods (self-administered was r = .79. They reported that the SOGS- paper-and-pencil questionnaire in a class- RA identified 2.7% with problem gambling room setting versus face-to-face interview), which was slightly more than the 2% therefore the method of test administration identified by the DSM-IV-MR-J and a becomes a confound and possible alternative concordance rate of kappa = .62. explanation for the discordant results. Boudreau and Poulin (34) compared the Another weakness is the lack of details SOGS-RA cut score of 4 or more to about the clinical interview content, indicate problem gambling to two gold reliability, validity and classification standard proxies of self-identified need for accuracy. The clinical interview was help with their gambling and receipt of help deemed the criterion or gold standard for for gambling. This was a very creative this study, however, no information about study in its use of criteria other than DSM- the reliability, validity, or classification IV, however, the criteria items are of accuracy of this "gold standard" was unknown validity. The investigators found provided. Still further, the investigators the SOGS-RA, using a cut score of four, failed to score the DSM-IV criteria, but correctly classified 96% of these two rather used another party who listened to proxies, however, the SOGS-RA demon- the recorded interviews and made a strated poor sensitivity at about 60% for diagnosis. This diagnostician was not the both proxies. The SOGS-RA identified interviewer and therefore could not probe or 59% of those 80 youth who self-identified clarify any criteria that may have been as needing help (0.9%) and 62% of those 54 vague or ambiguous. While the authors' youth who received help (0.7%). In other provide a Cohen's kappa of .74, it is not words, the SOGS-RA did not identify 41% clear which two classifications are being of those youth who self-identified as compared and it is not clear how needing help; and did not identify 38% of discrepancies between diagnosticians were those jouth who reported receiving help. resolved, since the classifications were not Specificity was 96% for both proxies. To in perfect agreement. The authors call for a improve sensitivity, the authors suggest that consensus on a definition of adolescent the cut score should be lowered; however, pathological gambling. So, while this study this study was the only one that suggested raises questions about the classification lowering the SOGS-RA cut score to accuracy of the SOGS-RA, it is in no way a improve accuracy. conclusive study. The SOGS-RA is not Weite et al (35) used the SOGS-RA in a likely to match up perfectly with DSM-IV national survey of 2,274 United States (US) criteria, but this study does not rigorously respondents who were 14-21 year olds and demonstrate that likelihood. found (he SOGS-RA had a Cronbach's Olason, Sigurdardottir and Smari (33) alpha of .74, indicating satisfactory internal compared the SOGS-RA with the DSM-IV- consistency. Using the SOGS-RA and a cut MR-J in a prevalence survey of 750 score of 4 or more they reported a 2.1% rate Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 86 PROBLEM GAMBLING ASSESSMENT INSTRUMENTS of problem gambling. The authors also with satisfactory internal consistency measured DSM-1V diagnostic criteria by reliability (alpha - .75). In terms of administering the Diagnostic Interview validity, the DSM-IV-MR-J had significantly Schedule (DIS) and reported a 0.4% rate of different mean scores between regular and pathological gambling. They did not non-regular gamblers and between problem directly compare the SOGS-RA to the DIS, and social gamblers. Respondents classified but the SOGS-RA obtained a higher rate of as problem gamblers by the DSM-IV-MR-J problem gambling than the DSM-IV rate of also tended to play more games regularly, pathological gambling. spend more money, borrow to fund their gambling, and sell their possessions to fund DSM-1V-J and DSM-IV-MR-J (J=Juvenile) their gambling; no correlation coefficients (MR=MuItipIc Response) were provided however. The readability of Fisher (7) developed a 12-item questionnaire the DSM-IV-MR-J test questions were at to measure 9 of 10 DSM-IV diagnostic grade level 4.8, using the Fleisch-Kincaid criteria of PG in juvenile fruit machine Grade Level Test. players in the UK and it was the first The DSM-IV-J does not match up adaptation of DSM-IV criteria for youth. identically with the DSM-IV-MR-J in that The DSM-IV-J response options are 'yes' the DSM-IV-J is missing an item to or 'no'. The DSM-IV-J has been used in a measure the DSM-IV criterion for loss of number of studies around the world to control, that is, making repeatedly measure problem gambling among adoles- unsuccessful efforts to control, to cut back, cents, including the UK (36-41). The DSM- or to stop gambling. Furthermore, the IV-J has been revised by changing the DSM-IV-J measures the criterion for phrase "playing fruit machines" to financial bailout while the DSM-IV-MR-J "gambling" and by using multiple response does not. So. the DSM-IV-J and DSM-IV- options into the DSM-IV-MR-J (8). MR-J measure somewhat different DSM-IV The DSM-IV-MR-J also has 12 items to criteria. As such, neither scale measures all measure 9 of the 10 DSM-IV criteria, and 10 DSM-IV criteria and the scales are not the items are adapted from the DSM-IV identical, \\hich causes confusion by test criteria to reflect the developmental stage of users. Jacques and Ladouceur (43) report youth. Fisher simplified the language and that tliis limitation may have occurred omitted details that were less relevant for because Fisher was not working from the youth. She excluded criterion 10, because official DSM-IV criteria but rather a pre- "young problem gamblers tend to resolve DSM-IV version outlined by Lesieur and desperate financial situations caused by Rosentlial (43). While this was true for the gambling by illegal methods (incorporated DSM-IV-J published in 1992, Fisher did in item 8)" (8). Eleven of the twelve items have the official criteria when the DSM-IV- have four response options: 1) never; 2) MR-J article was published in 2000. once or twice; 3) sometimes and 4) often. There are four concerns about the DSM- Fisher (8) has a scoring system for the set IV-MR-J. First, item #3 does not appear to of response options for each item to match match or concur with the DSM-IV criterion the nine DSM-IV criteria. The score range it is intended to measure. The DSM-IV is from 0 to 9, and a score of 4 or more is criterion is "Made repeated unsuccessful classified as a problem gambler. A factor efforts to control, cut back, or stop analysis indicated a unidimensional scale gambling"; and the item to measure this Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCHFIELD 87 criterion is "In the past year have you ever IV-J to be related to the SOGS-RA (r = .67) spent much more than you planned to on and GA 20 (r = .68). No classification gambling?" This item appears to be more accuracy information was reported because closely aligned to the earlier DSM-III-R the DSM-IV-J was used as the criterion to criterion #2, "frequent gambling with larger test the classification accuracy of the amounts of money or over a longer period of SOGS-RA and GA 20; however, there was time than intended." Second, the exclusion a fairly high degree of agreement between of criterion 10 seems premature, given that the instruments. clinicians and the media have reported that Jacques and Ladouceur (42) examined parents have paid the gambling debts of their the confusion regarding the scoring of the children. Criterion 10 seems relevant for DSM-IV-J. The nine DSM-IV-J criteria are youth and until proven otherwise, it should measured by 12 items and some investi- not be excluded from an instrument intended gators have made the error of computing the to measure DSM-1V diagnostic criteria. cut score from all 12 items rather than from Therefore, the DSM-IV-MR-J appears to the nine criteria. This error can make a measure 8 of the 10 DSM-IV criteria and difference in the reported prevalence rate and lacks items to measure criteria 3 and 10. therefore investigators are urged to follow Third, multiple response options were the scoring instructions for nine criteria. included in the DSM-IV-MR-J, but these Olason, Sigurdardottir and Smari (33) multiple response options appear to be compared the DSM-IV-MR-J with the ignored when it comes to scoring. The SOGS-RA in a prevalence survey of 750 scoring instructions collapses the multiple adolescents in Iceland. The authors response options into a dichotomous scoring computed a Principal Components Analysis of 0 or 1 for each item and therefore does not and reported a one-factor solution accounting use the multiple response options in the for 41% of the variance and a coefficient scoring system (8). Why provide multiple alpha of .78. The correlation between the response options if they will not be used to DSM-IV-MR-J and SOGS-RA was /· = .79. score the scale? Fourth, there is a lack of They reported that the DSM-IV-MR-J evidence of validity and no estimates of identified 2% with problem gambling that classification accuracy are provided by was slightly less than the 2.7% identified by Fisher. The developer states that there is the SOGS-RA and a concordance rate of evidence of validity (significant differences kappa = .62. between groups), however, insufficient detail is provided to judge the value of this Massachusetts (.ambling Screen (MACS) evidence. For example, we do not know how Shaffer et al (9) developed the Massa- the groups (problem gamblers versus social chusetts Gambling Screen (MAGS), a gamblers) were selected or identified or what 7-item screening instrument designed to criteria were used to classify them as measure the gambling problems of excessive problem gamblers versus social gamblers. gamblers and to obtain an estimate of the Derevensky and Gupta (25) compared prevalence of problem gambling. The the DSM-IV-J with the SOGS-RA and GA MAGS was developed in 1993 on a sample 20. The authors found the DSM-IV-J to of 589 Boston high school students who yield the lowest estimate of problem had gambled in the past year. The MAGS gambling of the three measures. In terms of was not developed exclusively for adoles- convergent validity, they found the DSM- cents, but because the development sample Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM PROBLEM GAMBLING ASSESSMENT INSTRUMENTS comprised high school students and also same level of accuracy will be maintained because the "A" in the acronym MAGS has when administered to other samples. Item oftentimes mistakenly been referred to as weights can be unique to a given sample Adolescent, rather than ΜË for Massa- and therefore may not generali/e to other chusetts, the MAGS is erroneously referred samples. This issue requires further research. to as an adolescent instrument. Never- The MAGS was compared with the theless, Shaffer and colleagues indicate that SOGS-RA by Langhinrichsen-Rohling, ct the instrument was developed for both al. (31) in a survey of high school students. adolescents and adults. The MAGS inquires The MAGS and SOGS-RA were found to about behavior during the past year. The have little concordance in their classifi- MAGS includes 14 items adapted from the cations and the MAGS yielded much more Short Michigan Alcoholism Screening Test conservative estimates than the SOGS-RA. (SMASH), an alcoholism screen developed The MAGS only classified 26 as probable by Sel/.er, Vonokur, and van Rooijen (10). pathological gamblers of the 1,395 high Of these 14 items, 7 were selected as the school students who had gambled in the best discriminators in a discriminant past year as problem gamblers while the function analysis, and the MAGS comprises SOGS-RA classified 80 as problem these 7 items. In the MAGS development gamblers. The authors concluded that the study, a measure of DSM-IV diagnostic prevalence estimates of adolescent problem criteria for PG was also developed, gambling vary as a function of the consisting of 12 items, which served as the instrument used. This study exhibited some criterion. Each item is assigned a 0 for a limitations, including the use of different 'no' response and a 1 for a 'yes' response. time frames for SOGS-RA (past 12 months) Scoring is based on item weights that are versus the MAGS (lifetime), however, the multiplied by each item score and summed, MAGS development article used a past-12- along with a constant. The MAGS classifies months time frame (9). As noted above, the respondents into three categories: a) non- authors report that the MAGS item pathological gambling, b) transitional "arrested for gambling" was the best item gambling, or c) pathological gambling. Cut for discriminating the "probable patho- scores are based on a weighted scoring logical gamblers from all the other groups", equation derived from a discriminant however, this raises a question as to the function analysis. The 7-item MAGS scale validity of this response. How many high had an internal consistency reliability school students get arrested for gambling? coefficient alpha of .83. In terms of validity, the MAGS total discriminant score Canadian Attetesiteut Gambling Itneatary obtained a high correlation (/· =.76) with (CAGI) total DSM-IV score. The most recent adolescent instrument to be The brevity of the MAGS is one of its developed is the Canadian Adolescent strong points. However, one concern is the Gambling Inventor}' (CAGI) (11,12). This use of item weights for scoring that were adolescent instrument is not the typical derived from the development sample of a adaptation of an adult instrument, but rather limited number of high school students. followed an instrument development While item weights may have provided process of defining the behaviors of excellent classification accuracy in the interest, creating an item pool, pilot testing development sample, it is unlikely that this items with adolescent focus groups, and Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCIIFIELD 89 conducting procedures to obtain initial acceptable (r = .60) to excellent (r = .91). estimates of reliability, validity, and Internal consistency measured with classification accuracy. The goal of the Cronbach's alpha ranged from .74 to .88. In CAGI was to develop a scale specifically terms of convergent validity, the CAGI for adolescents, rather than revise an adult scales were correlated with gambling instrument. The intent was to develop a frequency (r = .32 to /· = .55) and money scale that represents a continuum of spent gambling (r = .12 to r = .50). gambling problem severity from low to high problem severity, rather than items CONCLUSIONS that tap into high problem severity alone, as In response to the need for instruments to is done with adult scales that have been measure problem gambling among adoles- adapted for youth, such as the DSM-IV-J. cents, a small number of instruments have The CAGI moves beyond a single, simple been developed. Most of these instruments scale to the measurement of more complex, have been developed by adapting adult multiple domains of gambling problem instruments for adolescents and this is a severity. The CAGI measures the two main questionable practice given that problem elements of youth gambling, gambling gambling among adolescents is believed to behavior itself, and gambling problem have somewhat different characteristics severity, including preoccupation and than among adults. Developers who have negative consequences. The development of adapted adult scales for adolescents have the CAGI included defining the behaviors also tended to use a lower cut score to of interest, creating an item pool, pilot indicate problem gambling in adolescents testing items with adolescent focus groups, than is used to indicate problem gambling psychometric analyses of items and scales, for adults. For example, the cut score on the and procedures to obtain estimates of SOGS is five, but the cut score on the reliability, validity, and classification SOGS-RA is four; and the cut score on the accuracy. DSM-IV is five and the cut score on the The CAGI has a past three months time DSM-IV-MR-J is four. frame and measures five areas: a) types of Large differences have been reported in gambling activities played; b) frequency of prevalence rates in epidemiological studies participation for each gambling activity; c) of adolescent problem gambling, from as time spent gambling for each activity; d) low as 0.3% to as high as 10% (13,22,44), money spent gambling, and e) gambling and at least part of this discrepancy is likely problem severity. The CAGI is available in attributable to imprecision in existing both English and French language versions. adolescent assessment tools. As this review The gambling activities section includes a has shown, these instruments have little fake gambling item to test for validity of information on their psychometric self-report. The gambling problem severity properties and in particular, there has been a items have four-point response options. lack of rigorous research on the classifica- While it is still under development, there is tion accuracy of these instruments. This a working draft of the instrument and may, in part, explain the wide range of preliminary psychometric estimates. prevalence estimates reported in gambling Temporal stability was measured with a surveys. The adult instruments from which test-retest procedure 7-14 days apart and the adolescent instruments were adapted test-retest correlations ranged from were developed for clinical purposes but Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM PROBI.I-.M GAMBLING ASSKSSMENT INSFRUMl-NTS have often been used for other purposes and youth. Is adolescent problem gambling the populations. The psychometric properties of same as or different from adult problem an instrument must be investigated for the gambling? Is youth problem gambling the different settings and the populations for same or different at \arying ages and which it is applied. The classification developmental stages? Gambling is accuracy of an instrument is affected by the exhibited by 8- and 9-year old children as base rate of the disorder within the well as young adults. How does problem population to \\hich it is being applied, and gambling display itself in \outh of varying therefore an instrument developed to ages and developmental stages? Can the measure PG in a clinical sample where the same instrument be used for youth of base rate is fairly high will have weaker varying ages and developmental stages? classification accuracy when applied to the Can the same cut score be used for youth of general population where the base rate is varying ages and developmental stages? oMremely low. The current state of Third, investigators must use scientific adolescent problem gambling assessment standards for test development. It is makes it difficult for a clinician or recommended that investigators and test researcher to select a psychometrically users follow the standards for testing set sound instrument that will measure problem forth by the American Educational Research gambling in a population of interest. Ë Association, the American Psychological number of steps must be taken to address Association, and the National Council on these issues. Measurement in Education (45). These First, existing instruments have to be guidelines describe technical standards for put to rigorous psychometric evaluation, test construction and evaluation, including and this research will build a body of reliability and validity. The use of these evidence for (or against) the reliability, guidelines will facilitate the development of validity, and classification accuracy of psychometrically sound instruments that existing adolescent problem gambling will be recognized as standards in the field. instruments. Research on the psychometric Fourth, DSM-IV diagnostic criteria for properties of these instruments has to be PG are used to make clinical, scientific, and conducted for the settings and populations public policy decisions. The DSM-IV in which they are used, such as students in a diagnostic criteria are the accepted standard school setting. This research will justify the for the identification of PG but some (or continued use of those instruments found to all) of the criteria may not be relevant for exhibit satisfactory reliability, validity, and youth. Debate continues about the adequacy classification accuracy, and will serve to of definitions and diagnostic criteria of encourage the revision and refinement of pathological gambling, particularly as it those instruments found lacking. applies to youth (11,12,13.44). Therefore, Second, for the assessment of adoles- one of the most pressing questions in the cent problem gambling, new instruments field of adolescent problem gambling is: must be developed that take into account What criteria should be used to diagnose the developmental issues of youth at adolescent PG? different ages. This effort should include Psychometric research on measures of refining the definition of problem gambling adolescent PG will lead to refinement of for youth \\ith a focus on describing the measurement tools and greater precision, phenomenon of problem gambling among which is the mark of uood science. After a Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCHFIEl.D body of research has been generated, the Stud 1994;10:339-62. goal of a "gold standard" instrument(s) to 10. Selzer ML, Vonokur A, van Rooijen measure adolescent PG, or at least one that L. A self-administered short Michigan receives favorable consensus, will be alcoholism screening test (SMAST). J achieved. Stud Alcohol I975;36:117-26. ll.Wiebe J, Wynne H, Stinchfield R, REFERENCES Tremblay J. Measuring problem 1. Lesieur HR, Blume SB. The South gambling in adolescent populations: Oaks Gambling Screen (SOGS): Ë Phase I report. Canadian Centre on new instrument for the identification Substance Abuse, 2005. of pathological gamblers. Am J 12. Wiebe J, Wynne H, Stinchfield R, Psychiatry 1987;144:l 184-8. Tremblay J. The Canadian Adolescent 2. Lesieur HR, Blume SB. Revising the Gambling Inventory (CAGI): Phase II South Oaks Gambling Screen in Final Report. Canadian Centre on different settings. J Gambl Stud 1993; Substance Abuse, 2007. Available at: 9:213-23. hltp://ww\v. gamblingresearch.org 3. Stinchfield R.Reliability, validity, and 13. National Research Council. Patho- classification accuracy of the South logical gambling: A critical review. Oaks Gambling Screen (SOGS). Washington, DC: Natl Acad Press, Addict Behav 2001;27:1-19. 1999. 4. Winters KC, Stinchfield R, Fulkerson 14. Alle n MJ, Yen WM. Introduction to J. Towards the development of an measurement theory. Monterey, CA: adolescent gambling problem severity Brooks/Cole, 1979. scale. J Gambl Stud 1993; 9:63-84. 15. Nu nnally JC. Psychometric theory (2'ul 5. Winters KC, Stinchfield R, Fulkerson Ed.). New York: McGraw-Hill, 1978. J. Patterns and characteristics of 16. Cronbach L. Coefficient alpha and the adoles-cent gambling. J Gambl Stud internal structure of tests. Psycho- 1993;9: 371-86. metrika 1951 ;16:297-334. 6. American Psychiatric Association. 17. Cicche tli DV. Guidelines, criteria, and Diagnostic and statistical manual of rules of thumb for evaluating normed Mental Disorders. Fourth Edition. and standardized assessment instru- Washington, DC: Author, 1994. ments in psychology. I'sychol Assess 7. Fisher SE. Measuring pathological 1994;6:284-90. gambling in children: The case of fruit 18. Baldess arini RJ, Finklcstcin S, Arana machines in the UK. J Gambl Stud GW. The predictive power of 1992;8:263-85. diagnostic tests and the effect of 8. Fisher S. Developing the DSM-IV- prevalence of illness. Arch Gen MR-J criteria to identify adolescent Psychiatry 1983;40: 569-73. problem gambling in non-clinical 19. Fleis s JL. Statistical methods for rates populations. J Gambl Stud 2000;16: and proportions (2nd ed.). New York: 253-73. Wiley, 1981. 9. Shaffer HJ, LaBrie R, Scanlon KM. 20. Jacobs DF. Illegal and undocumented: Cummings TN. Pathological gambling A review of teenage gamblers in among adolescents: Massachusetts America. In: Shaffer HJ, Stein SA, Gambling Screen (MAGS). J Gambl Gambino B, Cumminss TN, eds. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM PROBLEM GAMBLING ASSESSMENT INSTRUMENTS Compulsive gambling: Theory, 2000; 16:53-78. research and practice. Lexington, MA: 30. Poulin C. An assessment of the Lexington Books, 1989:249-92. validity and reliability of the SOGS- 21.Lesieur HR, Klein R. Pathological RA. J Gambl Stud 2002; 18 (l):67-93. gambling among high school students. 31. Langhinrichsen-Rohling J, Rohling ML, Addict Behav 1987; 12:129-35. Rohde P, Seeley JR. The SOGS-RA vs. 22. Shaffer HJ, Hall MN. Estimating the the MAGS-7: Prevalence estimates and prevalence of adolescent gambling classification congruence. J Gambl Stud disorders: Ë quantitative synthesis and 2004;20(3):259-8I. guide toward standard gambling 32. Ladouce ur R, Ferland F, Poulin C, nomenclature. J Gambl Stud 1996; 12 Vitaro F, Wiebe J. Concordance (2): 193-214. between the SOGS-RA and the DSM- 23. Win ters KC Stinchfleld R Kim L. IV criteria for pathological gambling Monitoring adolescent gambling in among youth. Psychol Addict Behav Minnesota. J Gambl Stud 1995;! 1: 2005;19(3):271-6. 165-83. 33. Olason DT, Sigurdardottir KJ, Smari 24. Govoni R, Rupcich N, Frisch GR. J. Prevalence estimates of gambling Gambling behavior of adolescent participation and problem gambling gamblers. J Gambl Stud 1996; 12: 305- among 16-18 year old students in Ϊ7. Iceland: A comparison of the SOGS- 25. Dereven sky JL, Gupta R. Preva-lence RA and DSM-IV-MR-J. J Gambl Stud estimates of adolescent gambling: A 2006;22(l):23-39. comparison of the SOGS-RA, DSM- 34. Boudreau B, Poulin C. The South Oaks IV-J, and the G A 20 questions. J Gambling Screen-revised Adolescent Gambl Stud 2000; 16:227-51. (SOGS-RA) revisited: A cut-point 26. Ladouce ur R, Bouchard C, Rheaume analysis. J Gambl Stud 2007;23:299- N, Jacques C, Ferland F, Leblond J, 308. Walker M. Is the SOGS an accurate 35. Weite JW, Barnes GM, Tidwell MO, measure of pathological gambling Hoffman JH. The prevalence of among children, adolescents and problem gambling among U.S. adults? J Gambl Stud 2000; 16:1-24. adolescents and young adults: Results 27. Dereven sky JL, Gupta R, Winters K. from a national survey. J Gambl Stud Prevalence rates of youth gambling 2008;24:119-33. problems: Are the current rates 36. Fis her SE. Gambling and pathological inflated? J Gambl Stud 2003; 19(4): gambling in adolescents. J Gambl Stud 405-25. 1993;9:277-87. 28. Wiebe J, Cox BJ, Mehmel BG. The 37. Fis her SE. The amusement arcade as a South Oaks Gambling Screen Revised social space for adolescents. J Adolesc for Adolescents (SOGS-RA): Further 1995;18:71-86. psychometric findings from a 38. Fis her SE. A prevalence study of community sample. J Gambl Stud gambling and problem gambling in 2000; 16:275-88. British adolescents. Addict Res 29. Poulin C. Problem gambling among 1999;7:509-38. adolescent students in the Atlantic 39. Wood RTA, Griffiths MD. The acqui- provinces of Canada. J Gambl Stud sition, development and maintenance Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM RANDY STINCIIFIELD 93 of lottery and scratchcard gambling in literature (Prepared for the American adolescence. J Adolesc 1998;21:265-73. Psychiatric Association Task Force on 40. Becona E. Pathological gambling in DSM-IV Committee on Disorders of Spanish children and adolescents: An Impulse Control Not Elsewhere emerging problem. Psychol Rep 1997; Classified). J Gambl Stud 1991;7:5-39. 81:275-87. 44. Sha ffer HJ, Hall MN, Vander Bill J. 41. Gupta R, Derevensky J. Adolescent Estimating the prevalence of gambling behaviour: A prevalence disordered gambling behavior in the study and examination of the correlates United States and Canada: A meta- associated with excessive gambling. J analysis. Boston: Harvard Med Gambl Stud 1998; 14:319-45. School, Div Addict, 1997. 42. Jacques C, Ladouceur R. DSM-1V-J 45. A merican Educational Research criteria: A scoring error that may be Association, American Psychological modifying the estimates of patho- Association and National Council on logical gambling among youths. J Measurement in Education. Standards Gambl Stud 2003; 19(4):427-31. for educational and psychological 43. Lesieur HR, Rosenthal RJ. Patho- testing. Washington, DC: Am Psychol logical gambling: A review of the Assoc, 1985. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM ©Freund Publishing House Ltd. Int J Adolesc Med Health 2010;22(1):95-111 Adolescent gambling: Current trends in treatment and future directions Becky L Nastally, MS and Mark R Dixon, PhD Behavior Analysis and Therapy Program. Rehabilitation Institute, Southern Illinois University. Carbondale, Illinois, United States of America Abstract: Adolescent problem gambling is a growing cultural concern and this paper reviews the \arious research findings and treatment options that are available. Scientists have discovered a number of biological factors that may contribute to the development of adolescent gambling, including specific brain states, neurochemical levels, physiological arousal tendencies, and genetic predispositions. Additionally, a number of psychological processes have been revealed, including the need to escape from psychological stress, the possession of certain cognitive fallacies, and the construction of incorrect rules about the gambling event itself. Effective treatment can be developed through the incorporation of empirically-based research into the clinical approach. Current treatment options include pharmaceutical prescriptions, changing cultural practices, and the delivery of psychodynamic, cognitive, and behavioral therapy models. An analysis of the gap between science and practice is described, and possible solutions to bridge this gap are provided. Keywords: Childhood gambling, pathological gambling, gambling treatment, gambling research, acceptance and commitment therapy Correspondence: Mark R Dixon, PhD, Behavior Analysis and Therapy Program, Rehabilitation Institute. Southern Illinois University. Carbondale, II. 62901, United States. K-mail: mdixon'i/.siii.cdu Submitted: September 05, 2009. Revised: October 10. 2009. Accepted: October 18. 2009. INTRODUCTION person they are in adulthood. Middle-aged The imagination of a boy is healthy, and adults will look at their children and the mature imagination of a man is \vonderifanythinghaschanged.Theywill healthy; but there is a space of life wonder whether their kids will test the same between, in which the soul is in a limits or experiment with the same risky ferment, the character undecided, the behaviors the parents once engaged in wm· of life uncertain, the ambition thick- during childhood. Society must also ask sighted: thence proceeds mmvkishness. itself the question: where do 'normal' John Keats (1795-1821) adolescent impulsive behaviors stop and potentially harmful addictive patterns Musings about adolescence often involve begin? Perhaps it is the increased recalling a time of self-discovery and accessibility, technology, and real threat of freedom. Maybe teenage trials of alcohol, harm surrounding these behaviors today drugs, or free love result in regrets for that makes actions that were once innocent some, but most would agree that without rites of passage a cause for alarm. It is those experiences, they would not be the difficult to argue that things like the rise in Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM CURRENT TRENDS IN TREATMENT sexually transmitted diseases and the PHYSIOLOGICAL AND PSYCHOLOGICAL widespread social endorsement of gambling PROCESSES have had no effect on the current generation. The key to successful treatment of the Within an analysis of the etiology and problem adolescent gambler begins with an treatment of problem or pathological under-standing of how body and mind are gambling, researchers, as well as the public, affected by the gambling event itself. can no longer ignore this issue as it applies Additionally, it is important to understand to adolescents. The numbers are staggering that there are observed differences between and hard to believe, so perhaps awareness is problem and non-problem gamblers, both the first goal. Participation in adolescent biologically and psychologically. Certain gambling (among middle and high school individuals may be more prone to gamble students) has steadily increased, and in than others based on their biological examining this problem more closely, some makeup, as well as their reaction to researchers have pointed to the greater gambling activities. Understanding how availability and social approval of gambling. each contributes to the manifestation of a For example, 30 years ago only 2 states in gambling problem is critical for the United States (US) allowed any determining the most effective possible legalized form of gambling, but today treatment options. gambling is now legal in 48 out of 50 US Although research into the physiology states (exceptions are Utah and Hawaii) (1), involved in pathological gambling is in its and internet gambling allows residents to early stages, much research has been wager virtually anywhere. Because it conducted on the biological processes and appears that gambling regulation at least from the neurocognitive perspective in the reduces the forms of gambling that last decade. As with other impulse control adolescents can participate in, some may be disorders, it appears there is some evidence quick to assume this is a social problem that to suggest that abnormal serotonin levels is adequately controlled. However, even exist in pathological gamblers (2). These though youth are not permitted in casinos, findings have come from basic, neurobio- adolescents are still finding ways to logical investigations (3), as well as from gamble. In this article, a review of research on pharmacological treatments of treatment approaches for adolescent pathological gambling (4). The release of problem gambling is presented. The dopamine, believed to be associated with underlying premise is that effective behaviors that produce rewards or treatment should be developed and guided reinforcement (5), also may be involved in by psychometrically sound assessments that the physiology of pathological gambling detect the presence of the disorder and (6). Growing research has also found an empirically validated research on physio- onset of problem gambling in older adults logical and/or psychological processes that following introduction of pro-dopaminergic contribute to the manifestation or drugs for Parkinson's disease (7). maintenance of the disorder. The review Recently, technology in functional will focus on both the processes at work magnetic resonance imaging, or fNIRI, that may sustain or reduce adolescent assessment has also made it possible to problem gambling and outline various examine the neural correlates of behavior treatment options that are currently related to pathological gambling. A study available. by Potenza and his colleagues (8) found Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM BL NASTALLY AND MR DIXON 97 that viewing videotapes depicting gambling processes of adolescent problem gamblers scenarios evoked greater gambling urges consists of correlational analyses that relate for male pathological gamblers when the gambling population to another clinical compared with matched controls, and that disorder, behavioral excess or deficit, or such urges were associated with changes in demographic condition (16-24). From this patterns of activity in the frontal, research has come a better understanding of paraljmbic, and limbic structures of the the adolescent gambler profile and has shed brain. The results were supported by those light on what makes a young person at risk of a similar study that employed gambling- for developing a gambling problem. For related visual cueing and showed signifi- example, adolescents with a gambling cantly greater activity in the prefrontal problem are more likely to engage in region of the brain in participants who were substance use (16,21), have parents with problem gamblers compared with matched gambling problems (17), show signs of controls (9). Further support for a neural depression (18), attempt suicide (20), and basis of pathological gambling, similar to engage in sexual activity (22) than their other impulse control disorders such as non-gambling counterparts. Many studies substance abuse, was provided in a study by have concluded that problem gambling Reuter et al. (10) that also found increased occurs more often in males (17,20,22) and prefrontal activation in a pathological that adolescents tend to gamble more as gambling participant sample when exposed they get older (23). to a guessing task. Similar results have been Interestingly, some studies have found a noted by Habib and Dixon (11), whereby relationship between the reasons why pathological gamblers viewed actual slot adolescents gamble or their beliefs and their machine spins and outcomes while in the level of pathology (21,23). For example. fMRI scanner. Lynch and colleagues (21) found that In addition to work done on the neuro- adolescents were more likely to report biological chemistry involved in gambling, gambling for social reasons than to actually early biological conceptualizations of win money. It has also been found that, like gambling include the role of subjective adult problem gamblers, adolescent arousal (12). For example, a study by gamblers hold illogical beliefs about the Anderson and Brown (13) on the independence of random events and their differences between gambling in real chances of winning as it relates to gambling casinos and analogue settings recorded (23). These findings are often linked with elevated heart rates during gambling. The theory-driven models that attempt to elevated heart rates were comparable to explain the development of a gambling those observed with considerable exercise problem in adolescents (18,25-27). One and were associated with riskier bets among example is that certain individuals possess high sensation seeking individuals. These personality traits that make them more findings have been supported in more susceptible to becoming problem or recent research that has investigated pathological gamblers. A recent study by increased arousal as measured by heart rate Gupta. Dercvnesky, and Ellenbogen (19) in gamblers specifically when winning found that high levels of disinhibition, compared with when losing (14) and in the boredom susceptibility, cheer-fulness, and context of treatment (15). Ë large portion of excitability combined with low levels of the research conducted on psychological conformity and self-discipline were Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM CURRENT TRENDS IN TREATMENT associated with predictors of severity level ment approaches based on hunches, in problem gambling among adolescents. personal experiences, or ideological or In recent years, some researchers have religious beliefs. Treatment has not waited been exploring experimental methods that for science, yet effective treatment must be may be able to recreate various aspects of guided by science. As more researchers the gambling experience, with hopes of embrace the challenge of conducting isolating a small number of factors that experimental research on adolescent problem could be responsible for the development of gamblers, better care providers will be able problem gambling. Simulated gambling to deliver effective treatments. environments have been created (28), actual Perhaps one of the most logical gaming devices have been brought into assumptions for why a young person would experimental laboratories (20), and child- want to gamble is that there is an hood analogues to actual gambling have opportunity to actually win money. With been developed (30). If certain triggers can little to no effort, the child may be able to be identified, then such variables should be acquire a relatively large sum of money targeted for elimination in treatment. from another. Winning seems to be an Additionally, by teaching the problem outcome that could sustain gambling (32). gambler how such variables are triggering However, with the odds of winning in most their desire to gamble, coping strategies can gambling games being against the player, be trained to minimize these urges. something seems to be missing in an Despite such attempts to measure analysis that simply assumes that wins, or gambling behavior directly, direct experi- reinforcement, is \\hat keeps someone mentation involving independent variable gambling. Most problem gamblers manipulations using adolescent problem experience financial losses and not wins. gamblers remains a challenge. There are Maybe the possibility or the opportunity to various logistical hurdles and ethical win is enough to keep someone gambling, considerations when conducting gambling even when the odds of winning are not in experiments with adults who demonstrate their favor. In attempts to understand if gambling pathology (31), and these issues winning jackpots are crucial to sustain apply to adolescents as well and most likely gambling, researchers have often tested a to a greater degree. If researchers use player's ability to detect which game will adolescents with current gambling problems produce more wins (33), or have pitted two in a gambling experiment, then it may be identical games against each other that viewed as contributing to a clinical differ only on irrelevant characteristics, disorder; which is akin to a study on drug such as color or pre-experimental history abuse that provides drugs to drug addicts. If (knowing that 'blue' is better than 'yellow') one uses adolescents with no known (28). It has been repeatedly shown that problems \\ith gambling, then the investi- gamblers cannot always detect great gation may be viewed as lacking external differences in pa\back percentages and that validity. However, if researchers simply choices among available games are often remain concerned about limitations instead made for esoteric, self-constructed, and of moving forward to generate a body of illogical reasons. Subsequent reports have evidence about the causal factors that noted that various additional non- contribute to gambling problems, then the reinforcing characteristics of the gambling therapy community is left to create treat- game itself are able to cause increases in Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM BI. NASTAI.LY AND MR DIXON gambling. Thee characteristics include the results of this experiment could be applied in presentation of non-winning displays that treatment programs, whereby clients are resemble wins (i.e., near-misses) (34) and allowed to gamble in a controlled the availability of multiplier options (35). In environment while being made aware of the short, winning does not always matter. The illogical choices. Reflection on choices could cognitions and language processes of the be targeted in treatment with alternative gambler do matter (36). decision strategies along with learning the Additional psychological mechanisms objective nature of many casino games. have been suggested to control the problem Another study by Mui and Dixon (39) behavior of the gambler. The adolescent exposed some gamblers to a brief mindful- gambler may find him/herself continuing to ness exercise that sought to teach the client gamble for access to tangible items, such as about values in their life and if gambling was vouchers and prizes, attention and sociali- consistent with such values, and other zation from peers, sensory· stimulation, or gamblers with illogical strategies on how to the escape from Stressors or psychological win when gambling. Those individuals given conflict in life. To date, escape from stress the mindfulness intervention reduced their seems to be the most commonly reported subsequent gambling duration significantly. cause for excessive gambling (37). In a Other bridge studies have demonstrated an survey of over 100 gamblers, escaping from elimination of the near-miss effect in slot the stress of life was overwhelming machine players (34), and how discounting reported as the most frequent cause for of delayed rewards by pathological gamblers excessive gambling (38). · may be improved upon (40). The niche of 'bridge-research' related to problem gambling has great potential for TREATMENT APPROACHES easy translation into clinical practice. The Minimal research has investigated the 'bridge' is a metaphorical -term used to evidence-based treatment of adolescent describe research that oftentimes attempts to problem gamblers (41). Experts in the field balance the demands for experimental rigor have offered possible explanations for the with the. need for direct application in the lack of empirical findings, including few clinical setting. As more researchers develop treatment centers are adequately equipped empirical investigations designed to relate to to treat adolescent problem gamblers, treatment directly, the gap between the gamblers at this developmental stage rarely laboratory and practice may begin to shrink. recognize the need and express a desire for An example of such a bridge approach is that treatment, poor funding for this type of of Johnson and Dixon (29), who showed that research, and a general lack of awareness of when given the opportunity to do so, two the scope of the problem (42,43). As a pathological gamblers would engage in result, treatment providers are being forced irrelevant choice making (picking numbers to adapt typical paradigms used with adults. at roulette; selecting one of two identical slot machines to play) at various casino games. Pharmaceutical interventions However, when the experimenters required Pharmacological treatments for patho- these individuals to pay additional money logical gambling generally fit into the (response cost) for the opportunity to engage categories of various SSRIs (selective in their illogical choice making, both serotonin reuptake inhibitors), opioid gamblers tended to act more rationally. The antagonists, and mood stabilizers (44). Such Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 100 CURRENT TRENDS IN TREATMENT medical interventions work to normalize the balanced attitudes through the dissemi- levels of brain chemistry or to address nation of information, and to protect those comorbid psychiatric conditions to reduce groups that have been adversely affected by the symptoms of gambling addiction. gambling-related policies. Specific strategies Currently no medication has been approved in implementing this prevention model have by the Food and Drug Administration, and included informational videos (48) or more no randomized controlled trial has been comprehensive programs that include conducted on the use of anti-psychotics information about the legality of gambling (44) to treat pathological gambling among and development of coping skills conducted adolescents. However, increased efficacy in public high schools (49). research is being conducted. In some cases, Gamblers Anonymous, or GA, can also successes have been reported. For example, be conccptuali/cd as a contemporary Grant and colleagues (45) investigated the community intervention. GA is based on use of the opioid antagonist, nalmefene, as the 12-step model of Alcoholics Anony- an outpatient treatment for gambling mous that heavily emphasizes spirituality symptoms. A 16-week, randomized double- and encourages members to meet each blind, placebo-controlled trial was conducted 'step' with the ultimate goal of completely using 207 pathological adult gamblers. The abstaining from gambling. GA has included results indicated a difference in gambling adolescent as well as adult problem severity among the groups, and few side gamblers (50). Although readily available effects were reported using low doses of the to many community members, the efficacy drug. Another example of the use of of such an approach for adolescents is pharmacological treatments for excessive indeed limited. gambling was a study that used similar methodology, but the effect of the SSRI, Psychoanalytic Models fluvoxamine was evaluated (46). This study The psychod\namic approach toward the was on a smaller scale (n = 10) and the treatment of gambling problems has been results were also less direct. A significant around for almost 100 years. In 1920, interaction effect was observed for the order Simmel (cited in 50) conceptualized of administration of the drug and placebo. pathological gambling as a manifestation of The reader is referred to the article in this a narcissistic fantasy spurred by intense volume by Grant and Potenza (45) for the feelings of entitlement. In a brief review of most current pharmacological treatments. psychoanalytic approaches to gambling, Lopez Viets and Miller (51) note that earh Community interventions psychoanalysts claimed that gambling Along the lines of prevention, recent behavior was a result of extreme descriptions of what can be referred to as deprivation during childhood or an community interventions within a public indi\ idual's unconscious desire to lose. In health perspective may also be of his essay, Doesloevsky ami Patricide, Freud importance in the present discussion of briefly theori/cd that gambling was closely treatment approaches for pathological related to masturbation. He argued that gambling. Korn and Shaffer (47) outline the since both gambling and masturbation goals of this approach adequately: to involve overt motor activity followed by prevent gambling-related problems in at- feelings of relief and guilt, compulsive risk populations, to promote knowledge and gambling often becomes a substitution for Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM BL NASTALLY AND MR DIXON 101 compulsive masturbation (52). Aversion therapy was used for a variety of Perhaps the best known psychoanalytic addictions in the early days of behaviorism model for treating pathological gambling and relies on the concept of-classical was developed by Rosenthal and Rugle (53), conditioning. In such approaches, an who assert that the immediate goal of aversive stimulus (e.g., an electric shock or treatment should be abstinence and that the a noxious substance) is paired with stimuli clinician should focus on confronting the associated with the addictive substance or gambler's denial and defenses as well as behavior. Barker and Miller (55) describe disrupting the gamblers need to chase delivering painful, electric shocks to an losses with repeated wagers. According to adult patient who reported compulsive and their model, the clinician should combat the undesirable rates of gambling while he gambler's ambivalence toward therapy by observed a video of himself in a gambling engaging the gambler as an active environment and listened to auditory contributor to the treatment process. stimuli associated with gambling. Over the Unfortunately, the authors' conceptualization course of 10 days of treatment, the patient of gambling treatment appears to be received more than 450 shocks. The authors hindered by a lack of empirical support and reported complete abstinence of gambling practical applications of their model (54). at two month follow-up. Despite the variety of psychoanalytic Another early behavioral technique for theories of gambling, little research has reducing gambling was imaginal desensiti- been published examining its effectiveness zation therapy (56). This technique also in treating pathological gambling. Most relies on the principles of classical published reports are descriptive case conditioning, but in this case antecedent studies with little or no empirical support stimuli associated with the addictive (51). The largest psychoanalytic study of behavior are paired with relaxation training compulsive gambling to date was in an attempt to reduce anxiety. In a study conducted in 1958 by Bergler. As noted by comparing the effects of aversion and Lopez Viets et al (51), Bergler reported that desensitization therapy, researchers imple- of 60 clients, 75% experienced successful mented the latter condition by asking treatment. Unfortunately, Bergler did not patients to imagine a scene that would report exactly what was meant by the term stimulate gambling urges. Then, the 'successful' and the 60 gamblers who therapist presented segments of this scene received treatment were selected from over and induced relaxation for approximately 200 referrals to the program (cited in 50). 20 seconds. When the patient was adequately- Overall, currently little evidence supports relaxed, the therapist went on to subsequent the efficacy of a psychoanalytic approach to segments of the scene until it was presented treating pathological gambling other than in its entirety. Interestingly, at one-year successful case reports (54). follow up, 70% of patients (adults) who had been exposed to imaginal desensitization Early behavioral models maintained gambling reductions as Some early treatments for pathological compared with only 30% of those exposed gambling consisted of behavior therapies to aversion therapy. However, evaluations such as aversive conditioning or systematic of such interventions for adolescents have desensitization, sometimes with exposure. not been reported. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 102 CURRI-.NT º RENDS IN TREATMENT Cognitive behavioral models experimental conditions: GA referral, GA While strictly cognitive models have shown referral plus CBT workbook, and GA promise in eliminating gambling behavior referral plus 8 sessions of individual CBT. (57-59). current trends in psychological The frequency of days gambled, as well as treatment arc suggesting that behavioral the amount of money gambled was assessed therapeutic approaches in combination with at baseline, mid-treatment (after 1 month), other traditional forms of therapy can be post treatment, 6 months following more effective. Even though aversion treatment, and I year following treatment. therapy and largely systematic desensiti- To highlight the level of gambling zation for addictive behaviors has gone out addressed in the current study, the groups of practice, behavioral principles play a combined were gambling an average of major role in one of today's most widely more than S 1,200 per month, approximately accepted treatment for pathological 14 days per month at the outset. Following gambling—cognitive behavioral therapy. treatment, all groups showed some Cognitive behavioral therapy, or CBT, improvement. Overall, however, CBT was is the most widely used intervention for found to reduce gambling compared with psychiatric conditions, including addiction GA referral alone during treatment, and disorders (60). and has recently come under some of those effects were maintained at widespread investigation in the treatment of the 6-month and 1-year follow-ups (63). problem gambling. CBT targets psycho- Other successes of CBT in treating problem logical problems from both the cognitive gambling have been reported (64,65). and the behavioral theoretical paradigm. Ladouceur, Boisvert, and Dumont (66) This model, as it applies to gambling, reported the effect of CBT for the treatment involves the existence and manipulation of of problem gambling in four adolescents intermittent reinforcement of behavior (aged 17-19 years) that utilized a "multiple emitted by the gambler, as well as cognitive baseline across participants" design. The distortions and erroneous belief patterns treatment package consisted of information (61). This goal is accomplished through, about gambling, cognitive interventions for among other things, trigger awareness. A erroneous beliefs, problem-solving training, 'trigger' may be conceptualized as a simple relapse prevention, and social skills antecedent condition in which gambling training. Perceptions about their ability to takes place in the presence of, or from a control thoughts/behaviors related to cognitive perspective in that the actual gambling and the severity of their problem trigger is an increase in the level of arousal were recorded as primary dependent as gambling thoughts and urges increase measures; the results showed clinically (62). Reinforcement of behaviors that are significant changes for all adolescents incompatible or alternative to gambling also following the intervention. Furthermore, plays a major role (50). Regardless of the these measures were supplemented by theoretical framework, CBT has been reports of abstinence among all participants shown to be effective in reducing gambling. at 3- and 6-months follow up. Petry and her colleagues (63) conducted The McGill treatment paradigm (42) has a large scale, randomized control trial on been used to address adolescent gambling the effectiveness of CBT when compared problems since 2003 and has served over 80 with GA for the treatment of over 200 adolescents and young adults aged 14 to 21 gamblers. This study consisted of three years. The model encourages abstinence Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM BL NASTALLY AND MR DIXON 103 over controlled gambling and places (70), and smoking (71). There is also individuals into categories according to the evidence that certain components of ACT etiology and comorbidity of their gambling are effective in directly reducing gambling behavior to design the type and duration of behavior (72,39). Furthermore, a body of the intervention they receive. The authors research using the ACT -model with assert that most clients fall into a range that adolescents experiencing various clinical is characterized by "tending ίο gamble problems continues to grow (73-75). impulsively primarily for purposes of escape ACT is a therapeutic approach to and as-a way of coping with their stress, psychological problems that can best be depression, and/or daily problems" (42). The conceptualized as a contemporary model of goals of treatment include understanding the behavioral and cognitive therapies, with its motivations of gambling, increasing self- roots in functional contextualism (76). ACT awareness, addressing cognitive distortions, differs from the early behavioral models and encouraging a decrease in gambling noted above in its emphasis on verbal among other objectives. learning and language as the key to The clinical technique termed "motiva- behavior change. ACT is also distinct from tional enhancement" has been noted to traditional cognitive-behavioral approaches strengthen the results of typical cognitive in its requirements of clients to "accept" behavioral approaches to treatment of their thoughts or urges to gamble rather problem gamblers (67). Such approaches than attempting to eliminate or remove such typically provide feedback to the individual cognitions. ACT claims that cognitive regarding the treatment process, making events cannot be analyzed as causal entities. them aware of their current state of Instead, thoughts, feelings, and emotions recovery, while providing additional are behavioral constructs. ACT is not incentives for treatment compliance. considered to be part of traditional Successes of incorporating motivational behavioral approaches. Rather, ACT is enhancement appear promising (65). considered a distinct post-Skinnerian Adoption into childhood therapeutic approach (77) claiming that language and approaches might also include feedback cognition are at the root of human suffering. mechanisms to parents and caregivers about At the core of ACT are six basic progress of their child, assuming consent psychological processes that include has been given, that may allow for the acceptance, defusion, self as context, development of additional contingency contact with the present moment, values, arrangements outside of the therapy context and committed action (78). These processes (i.e., going to a movie, earning opportunities are said to be responsible for the ultimate for preferred activities or tangible items). outcome, which, in the case of ACT, is psychological flexibility. Psychological Contemporary behavioral models flexibility is an individual's ability to An additional model is based on the acknowledge and accept maladaptive rules psychological treatment approach called or contingencies, while not restricting their Acceptance and Commitment Therapy behavior to the extent that it keeps them (ACT) (68). ACT has been documented as from living a valued life. The Acceptance successful for the treatment of many and Action Questionnaire-II (AAQ-I1) (79) psychological problems including obsessive is the standardized assessment tool that compulsive disorder (69), substance abuse serves as the primary measure of this Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 104 CURRENT TRENDS IN TREATMENT outcome. The processes are presented here experience certain thoughts and actually sit in a particular order; however the order in with them, especially if the behavior pattern which they are presented and moved, as of avoidance is longstanding; however this well as which processes are targeted within is precisely what occurs during the a therapeutic context is entirely determined therapeutic exchange. by the case conceptualization of the The process of defusion works against individual client (80). literal language (thoughts and other verbal The process of acceptance is perhaps behavior) serving as causal entities to u hat most sets this therapy apart from behavior. For example, just because a traditional cognitive therapy—instead of person has the thought, º will die if 1 do not controlling, restructuring, or attempting to play a slot machine', does not mean that eliminate unwanted thoughts, emotions, or they will actually die and that because they urges. The term 'experiential avoidance,' a had this thought, they must in fact play the central tenet of the ACT perspective, is the slot machine. The term •defusion' of opposite of acceptance in that "a person is thoughts suggests that the individual can unwilling to remain in contact with have the thoughts but the painful or difficult particular private experiences (e.g., bodily functions are reduced. In essence, the client sensations, emotions, thoughts, memories, learns to interact differently with thoughts. behavioral dispositions) and takes steps to This is done through exercises in \\hich the alter the form or frequency of these events client may be asked to say, instead of "I'm and contexts that occasion them" (68). This weak," "I'm having the thought that I'm strategy to avoid painful stimuli, however, \\eak." The therapist might also ask the is inherently illogical because through client to say "I'm weak" over and over language, it only makes the stimuli more again quickly for two minutes straight, to salient (78). for example, if an individual sing the \\ords "I'm weak" like an opera tries to adhere to the rule "Don't think singer, or to describe what the thought "I'm about gambling," then the simple formation weak" looks like by asking what color it is, of this rule includes at least a verbal how big is it, and \\hat is its texture. A host reminder of the stimuli they seek to avoid— of other defusion exercises are used as well gambling. (82), and these exercises are done to under- For behaviors that could be termed as mine the literalization and believabilily of addictive, the act of engaging in the the thoughts. This is done in an accepting behavior itself creates an avenue for and respectful manner as it attempts to experiential avoidance (81). Gambling has create a gentle space that exists between the the potential of being an avoidant or escape thought and thinker, the feeling and the maintained behavior in that by silting at a feeler. slot machine and playing for 45 minutes, Work on the process, self as context, for example, experiencing any other focuses on getting in touch with a cognitive or emotional content is delayed or transcendent sense of self that is ever avoided altogether. For the gambler, this present, rather than defining or labeling may include thinking or worrying about the oneself by dynamic thoughts, feelings, or amount of debt they have accumulated or emotions. Ë person with an addiction often any other source of psychological stress defines themselves as an addict. This self- from marital problems to dealing with the labeling and admitting powerlessness o\er a loss of a loved one. It is often painful to certain substance or behavior is done in Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM BL NASTALLY AND MR DIXON 105 traditional 12-step models. However, if this that have occurred as a result of excessive is the only self conceptualization one has, gambling can become more salient. then there may be potential harm in the Acceptance and defusion could be used to long run. For example, a person with a help experience the painful or negative gambling problem who relapses may blame emotions related to those consequences. oneself or this very rigid definition of Recognizing personal values is the oneself for their behavior and act in process that promotes living a life that is accordance with it. Such a person may have important. Meaningful areas of a client's the thought "I'm an addict and I'll always life such as family, friends, career, be just an addict so I might as well continue education, and spirituality arc assessed and to gamble." Ë diffusion exercise using that evaluated within the context of the present thought may be helpful in this situation moment. The client is asked how much they such that the client can examine their value each of these areas and how much thoughts. they are living in accordance with these Contact with the present moment values in the here and now. Values and reinforces the idea that much of living a valued life are the backdrops on psychological suffering can be concept- which the therapeutic approach unfolds. For ualized as maladaptive preoccupation with example, when acceptance is low and the either the past (as is often the case with problem gambler indicates, "/just can't depression) or the future (often the case think about those things and gambling is with anxiety). Living in the present moment the only thing that helps," the therapist asks and letting experience rather than thoughts questions like, dictate behavior is offered as a solution to "What if it meant that von could be these fixations. This approach means living for something again'.' What if becoming an active participant in the world your life could have a clear purpose around us even when that world brings that you were proud of? Would you be about pain. It is often the problem with willing to experience those thoughts for addiction that clients are looking for a good just a little while? " 'quit' date or they complain that it is just too hard to quit now; they'll quit when they The extent to which a client is living a find a job, when they stop feeling bad, etc. life that he/she values is a primary goal or From an ACT perspective, the therapist measure of treatment in ACT. It is also challenges this avoidant behavior by important to highlight the difference emphasizing the importance of the present between values and goals. Goals are moment and noticing or showing up for objectives that can be met and forgotten what is going on without trying to evaluate, about; values are life directions, things that plan, or analyze it. still remain present even when goals are Likewise, the behavior of 'chasing met. For example, a client may say they wins' or adhering to the gambler's fallacy really value getting married. This statement (the player is 'due' to win following a is more like a goal because if the client gets string of losses) could be conceptualized as married, they've satisfied that desire. The discounting the present moment to obtain role of the ACT therapist is to help the probable outcomes in the future. By client see that getting married may be a becoming more aware of the present goal in the service of the value of having moment, perhaps the negative consequences love in their life. This is something that will Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 106 CURRl-NT TRKNDS IN TRKATMHNT always be true which is why values work is no doubt be advantageous. While some may done prior to the next process. Once a client argue that traditional CBT models could can identify true values then the goal setting accomplish this just as well, there is process can begin. evidence to suggest that avoiding or Committed action is the process in averting an individual's attention from which a client obligates to behave in urges or cravings can actually be counter- patterns that are consistent with (heir values productive (83). For this reason, an right now. The therapist posits that there are acceptance based therapy may be preferable. actions, sometimes tiny, that can be done Based on this assumption, recently a now in the semce of living a life that is protocol using ACT for the treatment of important. After work is done on all of the adolescent problem gambling has been other processes, the client then has to "vote developed by Dixon and Nastally (84). The with his or her own feet" (82). The client protocol uses the ACT processes described and therapist devise goals that, although above to conceptualize and treat adolescent may start out small, lead to effective, gambling as a psychological problem that is personally significant behavioral change. similar to other forms of addiction and stems The fact that the process \\ill not be easy from a lack of acceptance, fusion with literal and setbacks will occur is also emphasized. language, escapism or avoidant behavior, The 'Hikers on a Path' (82) metaphor is and a lack of values direction and committed often used in therapy as a committed action action (81). Work is done on each process in process move. The therapist likens the the ser\-ice of assisting the client in client's journey to a hiker on a mountain in abstaining from gambling behavior. For that even though the hiker is convinced he example, work on the process of values is may never get there, a person across the done early on in the treatment of adolescent valley can see they are moving in precisely gambling because it is likely that these the right direction. Committed action also things have been neglected for some time. means engaging when thoughts, feelings, or By assessing the clients' values, possible emotions stand to disrupt valued patterns of directions for therapy can be gained. living. For the individual who gambles this Acceptance and diffusion work is also may mean that the intensity of the urge to incredibly relevant for adolescent problem gamble seems unbearable. By using the gamblers. Since gambling may be a form of processes of acceptance and defusion, the experiential avoidance for many clients, it is client will hopefully be able to engage in the role of the therapist to prepare them to the chosen course of action with those urges come into contact with undesirable thoughts, and thoughts. feelings, and other psychological content in Given this description it seems logical the absence of gambling. This may consist of that ACT may be beneficial in the area of actual urges or thoughts about wanting to treating adolescent gambling problems for gamble or content related to daily problems many reasons. Perhaps the most glaring that gambling has allowed them to escape potential benefit is the focus on thoughts as from. For example, one defusion exercise determinants of behavior. Breaking down that may be used with an adolescent who the causal relationship between common feels a very strong urge to gamble would be cognitive distortions of some pathological to 'physicalize' that urge by giving it gamblers, such as the illusion of control and physical properties. The use of the the gambler's fallacy, and behavior would adolescent imagination is key here. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM BL NASTALLY AND MR DIXON 107 Lastly, the process of committed action treatment models should be contacted for when dealing with addiction is two-fold; copies of their protocols so that independent clients make the commitment of staying field work can be tested. Component abstinent from gambling in the service of analyses of the key principles of the making other commitments (81). Abstaining treatment package might be attempted to from gambling represents the first goal to understand the basic mechanisms that are work toward. It is also important to responsible for positive therapeutic anticipate with the client some barriers they outcomes. With the foundations-that have may encounter while trying to meet this been laid, the next decade of gambling goal and reiterate strategies to deal with research will be promising for underage these barriers. persons that are either at risk for or are suffering from pathological gambling. By CONCLUSION improving our knowledge base about the Many researchers are attempting to find treatment of adolescent gambling, the answers to the reasons why some widespread proliferation of gambling will adolescents may become interested in and not be such a risk. addicted to gambling. Effective assessments have been constructed and more elaborate REFERENCES and comprehensive ones will surely 1. Black DM, Moyer T. 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Int J Adolesc Med Health 2010;22(1):113-128 Internet-based interventions for youth dealing with gambling problems Sally Monaghan, BPsych and Richard TA Wood, PhD School of Psycholog)', University ofSydne)', Australia and GamRes Research and Consultancy, Quehec, Canada Abstract: Ë substantial proportion of adolescents and joung adults gamble and rates of problem gambling amongst youth are significantly higher than found in adult populations. Despite this, few >outh seek treatment suggesting that traditional services are failing to help this vulnerable population. Youth are progressively active online and use the Internet for social networking, recreation, and increasingly, to seek help for health and mental health issues where they would not be comfortable seeking traditional forms of professional help. In recognition of this, Internet-based therapy and guided interventions have been launched specifically for adolescents and young adults in an attempt to reduce high-risk behaviors and increase program utili/ation. Research has demonstrated that online therapeutic support is perceived to be acceptable and useful by youth. Furthermore, online interventions have demonstrated success in reducing smoking and heavy drinking amongst this typically hard to reach population. Given the success of similar programs, online problem gambling services are predicted to be effective in increasing youth awareness of their potentially problematic gambling behavior and assist adolescents and young adults in retaining control and minimizing and reducing gambling-related problems. Keywords: Internet therapy, problem gambling, youth, online counseling, adolescents, young adults Correspondence: Sally Monaghan, School of Psychology, Brennan MacCallum Building (Ë18). The University of Sydney, Sydney NSW 2006, Australia. Tel: Phone: +1514-803-3665; E-mail: sallvnv3> psych usvd cdu.au Submitted: July 15. 2009. Revised: September 08, 2009. Accepted: September 16. 2009. INTRODUCTION cohort (5-7). Gambling amongst youth is Although typically seen as an adult pursuit, particularly disconcerting as young gamblers increasing numbers of adolescents and are more likely to engage in alcohol and young adults are engaging in gambling and drug use and abuse/dependence, develop experiencing gambling-related problems. significant psychiatric problems including Studies from Australia, Canada, the US and pathological gambling, substance use and UK that have assessed the rate of problem mood disorders (8). gambling among adolescents (aged 12-17 Despite the high rates of problem years) have found rates of problem gambling amongst youth, this age group gambling typically 2-3 times that found in rarely recognizes their problems or seeks adults (1-4). Young adults aged 18-24 also treatment. One reason for this is that youth appear to have significantly more gambling- gamblers are typically not suffering from related problems than any other adult age life-changing experiences, such as losing Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 114 INTERNET-BASED INTERVENTIONS one's house, job, or family, that are often available, the present paper is focused upon associated with problem gambling given active interventions involving interactive that they do not have these to lose. self-help programs including personalized However, youth gamblers may still exper- feedback or Internet-based interactions with ience significant psychosocial problems therapists or peers through email, chat or including financial losses, anxiety, guilt or discussion forums. depression, disruption and neglect of work, school, and relationships, lost opportunities INTERNET USE and engagement in illegal activities (9). Results from the Pew Internet and Reluctance to seek help is not limited to American Life Project found that in 2007- young problem gamblers. It has been noted 2008, 93% of teenagers between the ages of that young people have specific barriers 12 and 17 reported using the Internet, an \shen it comes to accessing mental health increase from 73% in 2001 (15,16). Thirty- services (10). These include both structural seven percent of the respondents indicated barriers including time, costs, and travel, that they used email, instant messaging, and personal barriers such as being and/or chat rooms to discuss subject matter overwhelmed by unfamiliar issues, lack of that they would not have discussed with confidence in seeking help, or not someone in person (16). Similar access recognizing the extent of their problem. rates have been found worldwide with a There is also evidence that adolescents survey of adolescents in 13 countries often prefer to seek help from informal observing that 100% of 12-14 year olds sources, such as family and friends, rather have Internet access in the United than formal support including school Kingdom, followed by 98% in the Czech counselors and mental health professionals Republic, 96% in Macau, and 95% in (11). Given the failure of traditional Canada (17). Even in the countries with the treatment programs to recruit clients in least Internet access usage was still need of help new interventions must be common with 70% of adolescents in developed that are accessible to adolescents Hungary and Singapore reporting regular and young adults. Internet use. In a similar study of 9 to 19 Interest in online therapeutic interventions year olds in the UK, 47% of adolescents has gained momentum with the emergence used email, chat or instant messaging and of increasing research that online programs users indicated that talking to people online for health and mental health problems have was the same or more satisfying as talking efficacy equal to or better than traditional to people in real life (18) demonstrating the programs including face-to-face therapy and high comfort levels that adolescents have brief interventions and educational and self- with Internet use. help options (12-14). The current paper The Internet is rapidly becoming a discusses the feasibility of using online major source of health information for therapeutic support for helping young people adolescents and young adults (19,20). experiencing gambling issues. Although a Preliminary findings indicate that youth number of youth-focused informational regard the Internet as appealing as it is an websites aimed at preventing gambling- accessible and anonymous method of related harms (e.g., w\\w.friends·!fricnds.ca seeking help (19,21). For example, a study and www. wannabet. org) are currently by Mission Australia (22) found that young Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM S MONAGHAN AND RTA WOOD 115 people aged 11-19 years rated the Internet A further advantage of online inter- as the fourth most important source of ventions is the ability to assess a large and advice and support after friends, parents vulnerable population in a cost-effective and relatives/family friends. Furthermore, and confidential manner and provide Kids Help Line client data reveals that relevant resources to those in need. For compared to telephone support, young those without Internet access in their people are five times more likely to seek homes, websites can be easily accessed help for mental health concerns, three times from computers in schools, colleges, more likely to seek help about suicide and libraries and Internet cafes. Adolescents and eating behavior issues, and twice as likely young adults can complete online screening to seek help for self image, sexual questionnaires in private and at their orientation and sexual assault online (23). convenience and receive automatic and Similarly amongst older teenagers (15-17 personalized feedback to determine their years old), 21% reported searching the need for further intervention and be directed Internet for information on sensitive to relevant resources. There is evidence that subjects, which they found difficult to talk brief online feedback that sets an about face-to-face (24). individuals' gambling behavior against social norms is perceived as being useful RATIONALE FOR INTERNET for non-problem and problem gamblers and INTERVENTIONS may encourage behavioral change (31). High rates of Internet use amongst young Although youth may be skeptical about adults and college students (25) have discussing high-risk and illegal behaviors prompted the trial of several online with a health practitioner, parent, or other interventions for smoking and alcohol use. adult, they are interested in how their There are several reasons that make online behavior compares with that of their peers interventions advantageous in seeking to (32). Online feedback interventions appeal treat high-risk behaviors amongst youth. to this curiosity while reducing appre- Firstly, the confidentiality and nonjudg- hension associated with talking to a mental quality of the Internet may increase professional. Furthermore, research indicates the potential for youth to divulge personally that youth respond better to electronic relevant information, which may facilitate feedback than to in-person feedback knowledge, attitude or behavioral changes regarding high-risk behaviors such as (26). Compared with paper-and-pencil drinking (33-35). questionnaires, computerized programs for Internet interventions can be tailored to young people increase self-disclosure in be relevant for the individual accessing it, sensitive areas, such as risky sexual providing customized information, exercises behavior, excessive alcohol use, marijuana and support based on their reported use, and family problems (27,28). The problems, age, gender, stage of readiness anonymity and accessibility of the Internet and needs. This is particularly useful for may allay young people's concerns about problem gambling interventions given the seeking help, especially their fears about variety of forms (e.g. electronic gaming being personally identifiable (29,30), which machines, sports wagering, online gambling) is particularly important for interventions for and reasons for gambling (e.g. risk-taking, illegal activities such as underage gambling. boredom, social pressure, emotional escape). Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 116 INTERNET-BASED INTERVENTIONS Tailoring program content is more likely to commented on the particular benefit of be read, remembered, and viewed as Internet therapy for teenage boys, who used personally relevant (36,37), which may the Internet as much as females, but arc ultimately increase program utilization and much less likely to seek help in person. effectiveness. This hypothesis is supported by further Internet-based interventions also enable research demonstrating that about one in users to control their learning environment, three adolescents were more able to self- move at their own pace, and receive disclose online than offline (40). information on demand (38). This may Kids Help Line (www.kidshelp.com.au) encourage youth to access the interventions is a free confidential 24-hour online at a time convenient to them and \\hen they counseling service (provided in real-time, are at the appropriate stage of readiness for chat-based text exchange) specifically for change. The convenience of online programs Australians aged between five and 18 years allo\\s youth to access therapeutic support (typically used by adolescents). Online from experts or peers at any time if they focus groups reported that the online need advice, counseling, or have any environment was less confronting than questions. Online programs overcome traditional forms of counseling, with barriers to traditional treatment including responses indicating that it was less geographical isolation, inability to attend "intimidating" and "scary", that counselors individual or group sessions due to timing, wouldn't think they were "weird" and transport or conflicting commitments, fears couldn't see if they cried (11). Additional of Stigmatisation and/or privacy concerns. advantages included privacy issues, particularly that the children would not be INTERNET INTERVENTIONS FOR overheard and being able to take time in ADOLESCENTS writing replies, which increased feelings of Interventions for adolescents concerning control and comfort with the counseling high-risk behaviors are very important as process. Participants indicated that they this is a critical developmental period in were comfortable with text communication \\hich behavioral experimentation occurs, and felt online counselors were more peer pressure is high, and maladaptive supportive than telephone counselors, behavioral patterns can be formed. indicating that the reduced emotional range Although research is still emerging, there is in Internet counselor communication was increasing evidence to support the use of an advantage. The most commonly reported online interventions for youth during this challenges with text communication were difficult period of emerging adulthood. In concerns that counselors might not be able one large-scale study, 17,000 year 10 to adequately understand the participants' students from South Australia were emotions, that miscommunications could surveyed about their use of the Internet to occur and that it was more difficult to build seek counseling and advice for personal a therapeutic alliance. Kids Help Line problems (39). The results revealed that the online services had limited hours of adolescents surveyed were seeking help availability (closed at 9 pm) and ended from the Internet at the same rate they sessions after approximately one hour. sought help from other mental health Participants reported waiting for up to three professionals such as school counselors, hours to chat with a counselor or missing psychiatrists and psychologists. The authors out altogether, which highlights the Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM S ΜΟΝΛΟΗΛÍ AND RTA WOOD 117 importance of having an adequate number specially designed web site for adolescents, of counselors available, extending hours of along with proactive phone calls from the operation, and the possibility of having group facilitator to the participant (42). repeated sessions. Significant positive effects were found for Ë further study of Kids Help Line by the online intervention with 57% of King and colleagues (41) directly compared participants reporting visiting the website, one online counseling session with one which was rated positively on several telephone counseling session. Significant dimensions. Website utilization was pre-existing differences were found between associated with positive smoking cessation the groups as the online counseling group outcomes. In contrast, proactive phone calls contained significantly more females, were did not increase quit rates or abstinence, older and reported high pre-counseling which may be because it was difficult to distress compared with the telephone reach the adolescents and engage them in counseling group. The higher distress levels conversation at the time of the call and in were consistent with reported internal their home where they may be overheard. findings that young people using online An important component of online counseling are more likely to be coded with interventions may be tailored emails that mental health problems, suicidality, and provide personalized feedback, relevant sexual abuse than youth seeking telephone cognitive and behavioral strategies and support. Results indicated that while both promote self-efficacy. Classroom-based interventions had a substantial positive web-assisted tobacco interventions found overall effect on distress levels, telephone high school student smokers who counseling had a much more substantial participated in an interactive smoking effect than online counseling. Telephone cessation website and received tailored counseling also generated greater thera- emails were significantly more likely to peutic alliance, lower resistance, and higher reduce their intentions to smoke and were collaboration as compared to online more resistant to cigarette use at 6-month counseling, however, these variables did follow-up than those in an interactive not predict counseling outcomes. The control condition (43). The intervention authors' hypothesized that \\hile the also significantly reduced the likelihood of duration of the telephone and online cigarette use by non-smokers. sessions were equivalent, due to the time Similarly, promising outcomes have involved with composing and typing been demonstrated with a "virtual world messages, youth using the telephone were chat room" for adolescent smoking able to address their problems more cessation. The Internet therapy program effectively because of the greater speed and allows young smokers to interact with a efficiency of communication. However, the trained cessation counselor and other teen authors argue that increasing the duration of smokers in a real-time "virtual world". In a online sessions would enhance the impact randomized controlled trial smokers of this form of intervention. participated in 45-minute sessions weekly Internet interventions may act as an for seven weeks (44). Those participating in adjunct to existing programs for adolescents the online program were significantly more to reduce risky behaviors. A trial of a web- likely than controls to report weekly based addiction to a high school-based abstinence, reduced smoking and quit rates smoking cessation program included a at the conclusion of the program. Only the Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 118 INTERNET-BASED INTERVENTIONS number of times quit was statistically determines the level to which the forum is significant at the one-year follow-up, monitored for potentially damaging or suggesting booster sessions may be insensitive content. In a study of online necessary to increase program effective- bulletin boards for adolescents who self- ness. Participants rated the intervention harm the most common type of exchange positively in terms of its ease of use. appeal were users providing informal support to and usefulness; however, only 9% logged other members (46). Members also on to receive all seven sessions with most discussed potential triggers for self-harm participants receiving three online sessions. behavior, and formal help-seeking, with Less promising results were found for a mainly positive attitudes. These themes can home-based self-guided online smoking be construed as positive for adolescents cessation program for adolescents, \vhich often dealing \vith significant life issues and resulted in lower abstinence rates than face- engaging in dangerous behavior and to-face therapy sessions, although the indicate that youth were attempting to use treatment differences were not significant online forums in a helpful way to manage (45). Adolescents were randomly allocated their concerns and problems. The study to conditions, regardless of their intention to found positive correlations between quit and while attendance rates were high for informal support, encouraging disclosure, the brief office interventions, there was and advising formal treatment, suggesting relatively low utilization of the website that the online interactions may be indicating that it did not sufficient keep providing self-injurers support and meaning teenagers engaged. The program attempted outside a clinical setting. to use a non-directive, impersonal, patient- Troublingly, the third largest category education approach, without professional of posts was in relation to concealment of guidance or prompting. The failure of this the practice and its effects, and users shared program suggests that online interventions details about specific techniques used to may be more effective as an adjunct to face- self-injury. Such posts are potentially to-face or online therapy, be coupled with damaging as they may be suggestive of reminders and prompts to use the site, and adolescent self-harm. The potential impact offer personalized, directive and interactive of such exchanges may be to expose content and feedback to engage teenage vulnerable adolescents to a subculture in smokers. Adolescents \\lio used the online which harmful behavior is normali/cd and site made greater progress in reducing the encouraged. The authors concluded that number of days smoked compared to the Internet discussion forums provide a powerful face-to-face condition suggesting that the vehicle for bringing together adolescents self-help site may be used as a self- dealing with significant difficulties, yet, management tool for those not ready to quit. greater involvement from adults and treatment One modality of online support that providers as moderators is necessary to could potentially help young people is prevent increases of maladaptive behaviors. discussion forums. These are an electronic This may be particularly important for a venue in which individuals register a user- problem gambling-based discussion forum to name and are allowed to post thoughts, ask prevent users swapping tips and encouraging questions, and respond to posts made by misinformation, including irrational beliefs other users. Web-based discussion forums and misunderstanding how outcomes are have differing levels of moderation, which determined. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM S MONAGHAN AND RTA WOOD 119 INTERNET INTERVENTIONS FOR YOUNG encouraged to reply by email to their ADULTS counselors with questions and comments, Due to the propensity for young adults to and to update their counselors on their engage in high-risk behaviors, the cessation progress. Emails were sent ineffectiveness of traditional interventions weekly for the first month and then monthly and high use of the Internet amongst this for the following five months. Additional cohort, online interventions are becoming emails were sent around the participant's increasingly used for college students and quit date. Although all participants received young adults. As with adolescent Internet the same cognitive and behavioral interventions, research is at early stages, but techniques from the self-help guide and in- positive effects have been found for person session, those in the online condition Internet-based programs for high-risk were more likely to have adopted these and behaviors including smoking and alcohol have made a quit attempt. The majority of consumption (47-49). Online interventions participants (92%) read "most" or "all" or may also be more appealing to young adults their emails indicating that this is an than traditional programs. In an online appropriate medium to communicate with survey of a random sample of 1,564 young adults. university students. Kypri and colleagues Another online smoking cessation (33) found significantly greater support program incorporated content of general (82%) among hazardous drinkers for online interest to young adults, weekly reminder interventions than for health education emails, interactive quizzes with tailored seminars (40%) or practitioner-delivered feedback, behavioral monitoring, peer- interventions (58%). Similar positive results support via weekly emails from peer were found in an evaluation of an online coaches, and weekly incentives ($10 gift smoking cessation program for young card) (48). Compared with a control group, adults (50) and Internet-based counseling participants had increased short-term services for general mental health amongst abstinence rates. Although long-term quit college students (51), indicating Internet- rates were not found, given that this study based therapy programs may reach a wider included participants who had no population at need of assistance, who would immediate plans to quit, an emphasis on not seek traditional services. taking breaks from smoking may encourage Ë trial of an Internet-based smoking quitting attempts in the future. cessation program amongst young adults Online interventions have also been found participants were more engaged in shown to be effective in reducing hazardous the program activities, rated their treatment drinking amongst college students (26,49, more favorably and had quit for more 52). Trials have demonstrated that online consecutive days at 3- and 6-month follow- interventions that include personalized ups compared to participants \vho received feedback with tailored motivational an in-person counseling session and information about high-risk drinking are traditional print-based self-help materials more effective than assessment only, (47). The online intervention was intro- educational websites, and interactive online duced in an in-person session and consisted interventions that do not include tailored of a self-help kit, but was augmented by ΙΟ- feedback (26,32,49,52). Of significant note, Ι 2 counseling emails tailored to the these effects have also been shown for individual participant. Participants were subgroups of heavy drinkers including Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 120 ΙΝº l-RNl-T-BASFO INTI-RVI-NTIONS women, persistent heavy drinkers, those Internet interventions \\ould be an who intend to drink heavily for a particular acceptable form of treatment for gambling- occasion (e.g., 2Ã' birthday), and those with related issues and preferred to traditional low-motivation to change (26,52), face-to-face or self-help alternatives. demonstrating the usefulness of an online Internet therapy has been introduced to treat approach amongst a typically hard to reach individuals with gambling problems in population. Australia, Canada, Finland, New Zealand. Importantly, brief online interventions Sweden, Norway and the U.K. Although have also been found effective for reducing evidence is preliminary, positive results high-risk behaviors amongst young adults have been found indicating that Internet (32). Ë trial of an Internet alcohol reduction therapy, using self-guided interactive intervention for college students found that exercises combined with therapeutic students who completed a brief online support via telephone or email, is effective screener for problem drinking and received compared to wait-list controls, reaches personal izcd feedback found it easy to use, individuals who would not otherwise present personally relevant and would recommend for treatment and is viewed positively by it to friends (53). The intervention prompted clients (55-60). help-seeking behavior with 30% of Two qualitative studies examining participants accessing additional information online support forums for adults dealing with on support services through the website. gambling-related problems have indicated Online peer-support may also be useful the usefulness of such an approach. A in assisting \outh dealing with various North American study of the Gambler issues. Reach Out! (http://www.reachout. Anonymous forum "GA ll'eh* (61) and a conuui) is an Australian Internet-based study of two UK based forums 'Gainhling mental health service for young people Therapy^ and the 'GaniCare* forum (62) (aged 16-25) that receives approximately found similar results. They noted that the 230,000 individual visits a month (54). An majority of members had previously online community forum enables youth to avoided seeking face-to-face treatment discuss various issues and is supported and because of an unwillingness to disclose monitored by clinical staff. Anecdotal information about themselves. Lurking (i.e., evidence suggests that it is a positive, visiting but not registering presence to other unique, and helpful online experience users) at a problem gambling support group although little is known about the actual website made it easier for many to seek impact of the service (54). further help including face-to-face help and this appeared particularly true for the INTERNET INTERVENTIONS FOR female clients in the study. Furthermore, GAMBLING Wood and Griffiths (63) found that the Although Internet interventions are being online virtual therapist service 'GamAiif increasingly implemented and evaluated to was used by far more female problem reduce some high-risk behavior amongst gamblers (relative to males) than any other youth, there is little to no empirical comparable UK service, indicating that evidence supporting the use of online online therapeutic support may be perceived interventions for gambling-related problems as more accessible to females who are for youth. Based on the evidence presented typically reluctant to present for treatment above, it is reasonable to conclude that at typically male dominated services. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM S MONAG1 IAN AND RTA WOOD 121 Both Cooper (61) and Wood and Wood 2007 the site received 1,999,778 hits. (62) found that for many members the Although the website received a large forum was reported as the only support that number of visitors, and strong endorsement they could access, due to financial, geo- from the clinical and educational community, graphical, transportational, and'or emotional the number of adolescents and young adults constraints. Wood and Wood (62) also who engaged in this service was minimal. reported that the forums helped most Upon completion of the pilot project funding members to avoid the urge to gamble by was not continued and the websites are no posting and reading forum messages longer operational. The chief reason cited instead. Overall, it was reported that the for the project termination was a lack of forums helped the majority of members clients and sustained funding to warrant maintain better control over their gambling service continuation. One reason for the behavior. Given that Internet gambling is limited success of the intervention may be the fastest growing form of gambling, insufficient effective advertising and online support forums may prove to be an recruitment methods. extremely useful way of helping those who Although the pilot project described develop problems with online gambling. above was not successful, lessons from the To date, there have not been any development of online smoking cessation published studies that have looked at the and hazardous drinking sites aimed at utility of online therapeutic support for adolescents and young adults may aid in the helping youth with gambling problems. development of a more effective youth- This is likely due to the fact that at this oriented online problem gambling inter- point in time there do not appear to be any vention. In an evaluation of an online online services specifically aimed at >outh smoking cessation site, focus groups with with gambling problems. However, there college students indicated that a lack of has been a pilot project that aimed to time and interest discouraged use of social provide online help for adolescents and support features (50). Yet, other interventions young adults with gambling problems. The with demonstrated effective-ness have pilot was conducted in Canada by the incorporated peer-support into a wider International Centre for Youth Gambling program (48). Alternate apparently successful Problems and High-Risk Behaviors at components include tailored feedback McGill University. An online platform directing clients to relevant information and offered individual and group chats for 28 resources, interactive exercises and quizzes hours per week run by graduate psychology with automatic feedback, email reminders students and supervised by psychological and prompts, email communication with staff with various topics focusing on therapists and content and formatting «ambling and problems associated with relevant to a youth audience (whether gambling. Separate teen and young adult adolescent or young adult). Due to the sites widely promoted throughout Canadian apparent reluctance of youth to recognize high schools, universities, and health care the seriousness of their gambling-related providers, and in popular media. From problems, an important component of an January through June, 2007 the site had online gambling treatment for youth may be 2,161 different visitors; 4,102 visits; and an Internet-based assessment with 1,031.893 hits. In total, from inception automatic personalized normative feedback. (November 2005) through the end of June Receiving feedback on how their own Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 122 INTERNET-BASED INTERVENTIONS gambling behavior compares with their young adults. The privacy offered by the peers may encourage adolescents and Internet also prohibits therapists knowing young adults to consider taking steps to the identity of the client which poses modify their gambling involvement. potential concerns in the case of suicidal Furthermore, recruitment strategies can be ideation. An Israeli online forum used to encourage all youth to complete specifically for youth suicide support has online assessments and these can be been shown to be very successful in helping acti\cl\ encouraged or •mandated within adolescents dealing with suicide issues schools and universities and by health care (65). The program has successfully inter- providers. vened in several suicide attempts and The absence of youth from treatment received positive user feedback (65). services suggests both the perceived However, Internet interventions may not be inaccessibility of existing services for youth suitable for all youth and more intensive and the reluctance to recognize gambling- treatment may be required for some related problems (64). To overcome these problems. Therapists should be trained to barriers to help-seeking online support recogni/e serious mental health problems services may be used in educational settings (e.g. personality disorders, psychosis) and whereby youth use the services as part of recommend clients seek additional help as structured school or college class activities. required. In educational terms, the Internet is being Issues surrounding cross-jurisdictional increasingly used as a media for therapy must also be considered. Most progressive learning that appears to have licensing bodies require therapists to some advantages over traditional teaching practice only in states or provinces where methods. For example, groups of online they are licensed. If a client is located in a learners can motivate and support each state other than where the therapist is other's learning experiences. Such an located this could be considered a breach of approach can communicate gambling this agreement. To avoid such difficulties prevention information to under-aged online interventions may be limited to \outh, as well as information on how to accepting members from the province they spot the signs of a gambling problem and are located in if therapist contact is how/where to seek, help involved in the program. Given the limited evidence on the utility Despite the apparent advantages of an of providing online support for youth online gambling treatment program, caution gambling problems it is premature to is required particularly for youth whose main determine whether such a program would be problematic form of gambling is Internet effective. However, based on the successful gambling. There is increasing evidence that implementation of online interventions for internationally adolescents and young adults other high-risk behaviors, this treatment are gambling online at higher rates than option deserves further consideration and adults (66-74). Online problem gambling research, particularly given the success of treatment services may not be suitable for this approach with adults. youth who are unable to resist the urge to access online gambling sites. However, as an ISSUES FOR CONSIDERATION increasing proportion of school and Some concerns have been raised over the university research, learning and general use of Internet therapy with adolescents and activities are conducted online it mav be Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM S MONAGHAN AND RTA WOOD 123 useful to assist online gamblers with should become familiar with the online techniques to overcome urges to engage in language (textese) of adolescents (e.g. lol, Internet gambling without prohibiting all bbs, pos) in order that they do not miss such Internet use. An online support site may act important tonal inflections. as s safe place youth can go online when they are tempted to gamble and recommend CONCLUSIONS specific tips and techniques to reduce Online therapeutic support services appear problematic gambling behavior as well as to have a great deal of potential to assist offering online gambling blocking software youth in dealing with gambling related to prevent youth from accessing Internet problems given their access to and gambling sites. As Internet-based treatment familiarity with the media, and the services are not intended to replace existing anonymous capabilities of such services. interventions it is predicted that offering This is evidenced in their use of online online support \\ill be highly useful for therapeutic support for other health related some youth gamblers and not prohibit others issues and high risk behaviors. In particular, from seeking alternate help if needed. this type of support may be one way that It is important for both counselors and could potentially help to bridge the gap youth clients to take care in transferring the between the few youth that seek help and high levels of comfort that youth have with the much larger number identified as Internet use into a therapeutic relationship. experiencing problems overall. Certainly, Over familiarity with the Internet appears to existing evidence suggests that Internet- have lead adolescents to view Internet- based interventions do already appear to based communications as not 'real writing', help youth reduce smoking and heavy but rather the same as phone calls and drinking. Furthermore, adult problem casual conversations (75). However, in gamblers, who are often otherwise reluctant focus groups, teenagers said they are to seek support., have experienced positive motivated to write when they can select effects of online gambling therapy The key topics that are relevant to their lives and challenge lies in designing appropriate interests and survey results show that the online services and communication majority of youth enjoy writing for personal strategies that will appeal to and be enjoyment, including writing in a journal, accessible by youth. Whilst at the same blogging, and writing music or lyrics (75). time, ensuring that youth are aware of both The results indicate that teenagers are able the problems they may face in relation to to write expressively and appropriately, and their gambling behavior and the availability enjoy writing about their own lives, of such online services to assist them. thoughts, and emotions. This suggests that Important design elements include ease of Internet-based therapy may be successful access (e.g. via emailed hyperlinks to a amongst this age group. Care should be target population, hyperlinks on other highly taken to ensure that emails between a accessed websites or easily searchable), therapist and client are carefully considered reduced length, ease of navigation, non- and worded, rather than terse and unedited. judgmental language, brief assessments The lack of non-verbal cues in text-based with personalized normative feedback, communications can lead to misunder- tailored content where appropriate and links standings regarding the tone and content of to other services. Programs should the message. Furthermore, counselors emphasize the anonymity and privacy of Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 124 INTERNIT-BASKD INTERVENTIONS users by encouraging non-identifiable user Tidwell M, Parker J. Alcohol and names and anonymous emails (e.g. gambling pathology among U.S. Hotmail, Yahoo, or Gmail accounts) to be adults: prevalence, demographic used. Only careful attempts at engaging patterns and comorbidity. J Stud youth in this way will ultimately Alcohol 2001;62: 706-13. demonstrate the utility of online therapeutic 8. Lynch WJ, Maciejewski PK, Potenza support for helping youth overcome MN. Psychiatric correlates of gambling gambling problems, paired with evaluation in adolescents and young adults grouped studies to help further shape \shat does and by age at gambling onset. Arch. Gen doesn't work in this emerging branch of Ps> chiatry 2004:611:1116-22. therapeutic support. 9. 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MORI/International Gamin« Research http:Vww.pewinternet.org/ Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM ©Freund Publishing House Ltd. Int J Adolesc Med Health 2010;22(1):129-138 Pharmacological treatment of adolescent pathological gambling Jon E Grant, JD, MD, MPH and Marc N Potenza, MD, PhD Department of Psychiatry. University of Minnesota Medical School, Minneapolis, Minnesota and Departments of Psychiatry and Child Study Center, Yale University School of Medicine. New Haven, Connecticut. United States of America Abstract: Adolescents as a group appear to constitute a high-risk population for gambling problems. (ii\en the rates of adolescent problem gambling and its impact on affected individuals and their families, effective treatments are important. There are. however, no pharmacological treatments for pathological gambling in children, adolescents, or adults that are currently approved by the United States Food and Drug Administration (FDA). Additionally, no studies have investigated directly the safety and efficac\ of pharmacological treatments for pathological gambling in adolescents. This article reviews the literature on effective treatments in adults with pathological gambling, describes the safety data for the use of these drugs in adolescents, and provides a rationale for future studies to investigate the efficacj and tolerability of pharmacotherapies for pathological gambling in adolescents. Keywords: Adolescence, impulse control disorders, pathological gambling, pharmacotherapy Correspondence: Professor Jon Ii Grant. JD. MD. MPH. Department of Psychiatry. University of Minnesota Medical School. 2450 Riverside Avenue. Minneapolis. MN 55454 U.S.A Tel: 612-273- 9736: Fax: 612-273-9779; E-mail: grant045gumn.edu Submitted: August 15, 2009. Revised: September 28, 2009. Accepted: October 06. 2009. INTRODUCTION observation that these age-specific trends Problem gambling among adolescents can are seen in both males and females in be conceptualized as belonging to a larger epidemiological studies performed during constellation of "developmental addictions". different eras and involving different Data support a relationship between cultures suggests the existence of gender- 'bchavioral' and drug addictions in independent factors in the developmental adolescents (1-2) and gambling, substance onset of addictive disorders (8). use, and other impulsive behaviors frequently Research on developmental biology co-occur in adolescents (3-4). The co- suggests that the adolescent brain is a aggregation of impulsive behaviors appears changing organ, and this Unding has several particularly frequent in adolescent males. important correlates. First, it suggests that Arguably the most consistent and robust treatments for adults might not work in the finding across youth gambling studies is same manner in adolescents. Second, it that boys are more involved in gambling suggests that treatments within adolescents than girls and have higher rates of problem might differ according to their brain gambling than do girls (e.g., 5-7). Similarly, maturational stage, and that within subjects, adolescent males have a greater likelihood the effectiveness of specific treatments of developing a substance use disorder than might vary over time. Third, treatments adolescent females. Nonetheless, the during specific developmental epochs in Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 130 I'HARMACOTIH-RAPIES FOR ADOLESCKNTGAMBLING adolescence may have an enduring impact evidence of either safety or efficacy of on the presence or manifestation of adult these treatments in adolescents \\ith the psychiatric syndromes. These points disorder is available. Developmental issues highlight the importance of studying are important to consider when prescribing directly the efficacy and tolcrability of medication for adolescents. Because adoles- specific treatments among adolescents. cents may metabolize medications more Adolescents as a group appear to rapidly than do adults, some adolescents constitute a high-risk population for may require higher doses relative to body gambling problems. Although most weight compared with adults. On the other adolescents gamble occasionally and do so hand, because adolescents may have less responsibly, approximately 3%-8% have a adipose tissue than adults, more bioactive significant gambling problem (9-10). Given drug may be available and, therefore, a the rates of adolescent problem gambling greater likelihood of adverse events or a and its impact on affected individuals and need for lower doses. Differences in central their families, effective treatments are nervous system functioning and hormonal important. There are, however, no pharma- changes may further influence adolescents' cological treatments for pathological responses to various medications. gambling in children, adolescents or adults that are currently approved by the United Opioid antagonists States (US) Food and Drug Administration Gi\en their ability to modulate dopaminergic (FDA). Thus, it is important for patients, transmission in the mesolimbic pathway, parents and guardians to understand that opioid receptor antagonists have been any use of medications for pathological investigated in the treatment of pathological gambling is off-label, and a review of the gambling. Evidence suggests that naltrexone, benefits and risks of pharmacotherapy and a mu-opioid receptor antagonist, is effective other treatment options is warranted when in reducing gambling and gambling urges devising an appropriate treatment plan. No in adults with palhological gambling. An study has investigated directly the safety initial double-blind study suggested the and efficacy of pharmacological treatments efficacy of naltrexone, an FDA-approved for pathological gambling in adolescents. treatment for alcohol dependence and Therefore, we will review briefly the opioid dependence, in reducing the literature on effective treatments in adults, intensity of gambling urges, gambling describe safety data for the use of these thoughts, and gambling behavior (11). In an drugs for adolescents, and provide a 11-week, double-blind, placebo-controlled rationale for future studies to investigate the study of 45 subjects with pathological efficacy and tolcrability of pharmaco- gambling, significant improvement was therapies for pathological gambling in found in 75% of naltrexone-treated subjects adolescents. (mean dose 188 mg.'d) compared with 24% of those treated with a placebo. In PHARMACOTIIKRAPY particular, individuals reporting higher The empirical literature indicates that intensity gambling urges responded pharmacological treatments have been preferentially to treatment (II). examined using randomized clinical trial Findings from the initial naltrexone methodologies only in adults with patho- study were recently replicated in a larger, logical gambling, and, therefore, no direct longer study of 77 subjects randomized to Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM JR GRANT AND MN ΡΟΤΠΝΖÁ 131 either naltrexone or placebo over an 18- Naltrexone has been used in the week period. Those individuals treated with treatment of autism and appears to be well naltrexone had significantly greater tolerated in young patients (14). Although reductions in gambling urges and gambling not clearly beneficial for the social deficits behavior and greater improvement in of autism, naltrexone has demonstrated psychosocial functioning compared with efficacy in controlling the hyperactivity of those receiving a placebo. By the study autistic children and adolescents (14). endpoint, 39.7% of those on naltrexone Preliminary results in the treatment of were able to abstain from all forms of alcoholic adolescents support the efficacy gambling for at least one month, whereas of naltrexone in promoting abstinence when only 10.5% pf those individuals receiving a combined with traditional psychotherapy placebo attained complete abstinence for (15). the same time period (12). Naltrexone has demonstrated some Another opioid antagonist, nalmefene, efficacy in adolescents with autism and has also shown promise in the treatment of alcohol use disorders when used at pathological gambling. Although nalmefene 50 mg/d. The findings from studies of is currently not available in oral form in the adults with pathological gambling suggest US, in a large, multi-center trial, using a that naltrexone may be a promising double-blind, placebo-controlled, flexible- treatment for adolescents with the disorder. dose design, 207 subjects were assigned to The safety of naltrexone at the higher doses receive either nalmefene at varying doses or used in the adult studies (up to 200 mg/d), placebo. At the end of the 16-week study, however, has not been examined in an 59% of those receiving nalmefene showed adolescent population. Doses of naltrexone significant reductions in gambling urges, greater than 50 mg/d have warranted a thoughts, and behavior compared with only 'black box' warning due to the 34% receiving a placebo (11). medication's propensity for hepatotoxicity, Using the data from the nalmefene and particularly at higher doses. Therefore, naltrexone trials described above, analyses more research on both the efficacy and were performed to identify the factors safety of naltrexone in adolescent patho- associated with a positive treatment outcome logical gambling is needed to inform (13). Consistent with the influence of opiate prescribing guidelines. antagonists on alcohol consumption, a familial history of alcoholism was associated Antidepressants with a positive treatment response, as were Clomipramine. Serotonin reuptake inhibitors strong gambling urges at treatment onset. In (SRIs), drugs blocking the action of the placebo-treated patients, younger age was serotonin transporter and thus increasing the factor most closely associated with a the synaptic availability of serotonin, have positive placebo response. This finding, in been used with varying degrees of success conjunction with high placebo response in treating adults with pathological rates observed in clinical trials involving gambling. Clomipramine, a relatively non- adults with pathological gambling, suggests selective SRI, was administered in a that placebo responses in adolescents with double-blind, placebo-controlled trial to one pathological gambling warrant consideration female patient who reported a 90% and that the findings from open-label trials improvement in gambling symptoms when should be considered cautiously. treated with 125 mg of Clomipramine (16). Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 132 PHARMACOTHERAP1HS IOR ADOLESCENT GAMBLING Gambling behavior remitted at week 3 of and generally safe in the treatment of the trial, and improvement was maintained adolescents with OCD. for the next 7 weeks of the trial. Paroxetine. Two studies examining Clomipramine is currently FDA-approved paroxetine in the treatment of adults with for the treatment of obsessive-compulsive pathological gambling have revealed mixed disorder (OCD) in adolescents. Three studies results. The first 8-week study demonstrated have found the medication safe and significantly greater improvement for efficacious in treating adolescent OCD. In individuals assigned to paroxetine compared one double-blind study, a mean dose of with placebo (61 % of subjects on paroxe- 141 mg/d resulted in a significant decrease tine showed improvement versus only 23% of OCD symptoms compared with placebo on placebo) (11). A 16-\\eek, multi-center (17). A later study comparing clomipramine study of paroxetine, however, failed to find with desipramine found that a mean dose of a statistically significant difference between 150 mg/d resulted in a significantly greater active drug and placebo, perhaps in part due improvement in OCD symptoms compared to the high placebo response rate (48% to with desipramine (18). Still further, a placebo, 59% to active drug) (11). multiccnter study of clomipramine supports Although never formally tested in the efficacy and safety of clomipramine in adolescents with pathological gambling, the treatment of adolescents with OCD (19). paroxetine has been studied in adolescents The most common adverse effects observed suffering from major depressive disorder in adolescents, including dry mouth, somno- and OCD. In a double-blind study of lence, and dizziness, are comparable to those adolescent depression, paroxetine was both found in adults. Adverse cardiac effects are safe and efficacious at doses equivalent to possible and patients should be followed those used in adults (20-40 mg'd) (21). with blood levels and IZKGs for safety Other studies, however, found paroxetine purposes. Although these studies suggest treatment in adolescents to be associated clomipramine may be safe for adolescents positively with suicidality (22). As such, with pathological gambling, the effectiveness the off-label use of paroxeline in the of the drug requires further study. treatment of adolescent pathological FhiYoxamiite. Fluvoxamine, a selective gambling should be carefully considered SRI (SSR1), has demonstrated mixed results and closely monitored. in two placebo-controlled, double-blind Sertraline. In a double-blind, 6-month, studies of adults with pathological placebo-controlled trial using sertraline for gambling, with one 16-week, crossover pathological gambling in adults, a mean stud\· supporting its efficacy at an average dosage of 95 mg'd demonstrated no end-of-study dose of 207 mg'd (11). and a advantage over placebo in a group of 60 second six-month parallel-ami study with pathological gamblers (II). Sertraline, FDA- high rates of drop-out finding no significant approved for OCD in children and difference in response to active or placebo adolescents age 6-17 years, has not been drug (11). Fluvoxamine was the first SSRI studied in adolescents with pathological to gain FDA approval for the treatment of gambling. adolescent OCD. A double-blind study (20) Escilalopram. Escitalopram was used in has demonstrated that fluvoxamine at doses a 12-week, open label trial with an 8-\\eek ranging from 50mg to 300 mg'd is effective double-blind discontinuation phase for Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM JE GRANT AND MN POTF.NZA 133 respondcrs in 13 subjects with pathological Data supporting the efficacy of SRls in gambling and co-occurring anxiety disorders the treatment of adult pathological (11). At the completion of the open-label gambling, albeit mixed, suggest that these phase (mean dose 25.4 mg/d), six individuals medications may be beneficial for were considered responders, with concurrent adolescents with pathological gambling decreases in gambling and anxiety severity problems. However, given changes during observed. Gambling and anxiety improve- adolescence in serotonergic neuronal ment was maintained for those randomized structure and function in such brain regions to continue receiving active escitalopram, as the prefrontal cortex, direct investigation whereas receiving placebo was associated of the efficacy and tolerability of specific with a resumption of gambling and anxiety SRIs in adolescents with pathological symptoms. The FDA recently granted gambling remains warranted. The use of approval to escitalopram for the treatment of these medications in adolescents suffering adolescent depression. Double-blind studies from mood disorders or OCD suggests that found it safe and efficacious in treating many of these medications may be safe in depression in adolescents aged 12-17 years adolescents with pathological gambling. (23). These medications, however, carry a Bupropiou. A recent study in 39 adults warning about the possible increase in with pathological gambling used bupropion suicidality in young people and therefore in a 12-week, double-blind, placebo- should be used cautiously. controlled design. When individuals with at last one post-randomization visit were Mood stabilizers assessed, nearly 36% of those receiving Lithium Sustained-release lithium carbonate bupropion and 47% of placebo subjects were was used in a 10-week, double-blind, classified as responders. However, high placebo-controlled study of 40 adults with treatment discontinuation rates of nearly bipolar spectrum disorders and pathological 44% were observed, thus making definitive gambling. Lithium (mean level 0.87 mcq/ conclusions difficult to make regarding the liter) was found to be superior to placebo in efficacy of bupropion in the treatment of reducing the thoughts and urges associated adult pathological gambling (24). with pathological gambling. No significant The response of adult gambling differences between groups were found in symptomatology to medications approved the frequency of gambling per week, time for depression and anxiety, particularly in spent per gambling episode, or the amount the placebo-controlled trials of SSRIs, of money lost (II). Lithium has been FDA- usually results in decreased thoughts about approved for the treatment of bipolar gambling, reductions in gambling behavior, disorder in adolescents and has demonstrated and improvement in social and educational safety' in this population (25). The common or occupational functioning As these adverse effects of lithium appear similar to studies have often excluded individuals those in adults: nausea, polyuria, tremor with significant depression or anxiety, the and acne. Given its general safety profile in data suggest that modulation of serotonin adolescents and its efficacy in treating adult function in adults with pathological pathological gambling, lithium may be a gambling may mediate improvement in potentially useful treatment for adolescent s\mptoms specifically related to gambling. pathological gambling. Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 134 I'HARMACOTHI-RAPIliS FOK ADOI.KSCHNT GAMBLING Atypical antipsychotics emerging data regarding the long-term risk- Atypical antips\chotics, including drugs benefit ratio may influence the decision to like risperidone. olanzapine, and ziprasidone, use these drugs in adolescents in general. generally share the ability to antagonize Given the lack of support for the use of serotonin 5HT2 and dopaminc D2-likc (D2, atypical antipsychotics in treating adults D3, and D4) receptors (26). These drugs with pathological gambling and the have been explored as monotherapics and potential risks of using these drugs with augmenting agents in the treatment of non- regard to adverse effects e.g., weight gain psychotic disorders and behaviors, including and impaired glucose regulation), their use pathological gambling. Two recent studies in adolescents with pathological gambling have examined the use of olanzapine in the would have to be well justified and carefully treatment of pathological gambling. monitored over time. In a 12-\veek, double-blind, placebo- controlled trial of 42 adults with patho- Glutamutcrgic agents logical gambling, olanzapine (mean dose Because improving glutamatergic tone in 8.9 [5.2] mg) resulted in a 35% or greater the nucleus accumbens has been implicated reduction in PG-YBOCS (Yale-Brown in reducing the reward-seeking behavior in Obsessive Compulsive Scale modified for addictions (30), N-acet\ 1 cysteine (NAC), a Pathological Gambling) scores in 66.7% of glutamatc-modulating agent, was admini- the olan/apine group. Howe\ er, as 66.7% of stered to 27 adults with pathological the placebo group had the same reduction in gambling over an 8-week period, with PG-YBOCS scores, no statistically responders randomized to receive an significant treatment effect was noted for additional 6-week double-blind trial of olanzapine (27). In yet another study using NAC or placebo. Overall, 59% of olan/apine, (28) Fong and his colleagues individuals in the open-label phase (28) assessed 21 adults with pathological experienced significant reductions in gambling in a 7-week, double-blind, pathological gambling symptoms and were placebo-controlled trial. All subjects identified as responders. At the completion reported their primary' form of gambling as of the double-blind phase. 83% of those video poker. Reductions in cravings to assigned to receive NAC were still gamble and gambling behavior were noted responders compared with only 28.6% of in both the olanzapine and placebo groups, those assigned to the placebo (31). The only and no statistically significant difference reported side effects included mild nausea between groups was observed. or flatulence. In studies of marijuana Currently several atypical antipsychotic dependence and autism in children and are FDA-approved for use in adolescents adolescents, similar doses of NAC have (e.g., schizophrenia, bipolar disorder, and been examined with side-effect profiles autism). Although atypical antipsychotic similar to that seen in adults. drugs have been found to be well-tolerated in short-term trials involving adolescents FUTURE DIRKCTIOXS (29), increasing concerns have been raised Attention deficit hypcractivity disorder is regarding their adverse effect profile, among the most common mental illnesses particularly regarding their propensity for in adolescents, with prevalence estimates in impaired glucose control and weight gain in this population of 3%-7% (32). Adolescents adults and. adolescents (29). As such, suffering from ADHD often present with Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM JE GRANT AND MN POTENZA 135 impulsivity, and ADHD appears to confer a adolescents with pathological gambling, risk for the development of substance use particularly those with co-occurring ADI ID. and gambling disorders (33). Interestingly, Future studies should also address the an early study found that 24% adults with extent to which the observed ADHD pathological gambling suffered from co- findings extend to girls with the disorder occurring ADHD (34). and how the findings might then relate to The high rate of comorbidity between the treatment of girls with pathological pathological gambling and ADHD may gambling. suggest shared neuropathology. Evidence suggests that both pathological gambling CONCLUSIONS and ADHD are associated with alterations Despite the high prevalence of pathological in the function of the prefrontal cortex gambling in adolescents, research on this (PFC) and in the PFC's connections to the disorder, particularly with respect to striatum and cerebellum (35-36). The PFC pharmacological therapies, is in its relative is important for sustaining attention over a infancy. Our understanding of the neuro- delay, inhibiting distraction, and allocating developmental changes that occur during attention. The PFC in the right hemisphere, adolescence and their influence on particularly in the right inferior frontal adolescent behaviors is at an early stage. gyrus, may be especially important for Longitudinal studies involving neuro- behavioral inhibition (37). Lesions to the imaging, genetics, and behavioral PFC may produce a profile of assessments should help advance our distractibility, forgetfulness, impulsivity, understanding of adolescents, and with this poor planning, and locomotor hyperactivity. understanding should come advances in Given the high rates of comorbidity and prevention and treatment strategies for possible shared neuropathology between problems frequently experienced by pathological gambling and ADHD, adolescents, including risk behaviors such medications that enhance decision-making as pathological gambling. in ADHD may also benefit the impulsivity The available data on pathological underlying gambling behavior, given their gambling in adults suggest several possible similar deficits in impulse control. A recent pharmacological interventions. At present, study compared the impact of stimulant arguably the best evidence suggests the use medication on decision making in ADHD of naltrexone and lithium in treating patho- by examining performance on the logical gambling in adults. However, no Cambridge Gamble Task between boys data exist directly evaluating the efficacy with and without ADHD. In comparison and safety of pharmacological treatments with healthy controls, the ADHD group for pathological gambling in adolescents. made poorer decisions, placed their bets The pharmacological treatment of other more impulsively, and adjusted their bets disorders in adolescents suggests that less according to the chances of winning. certain medications—SRIs, mood stabilizers, The study found that the ADHD group bet naltrexone—appear safe and effective at more conservatively on the methylphenidate certain doses and for certain indications. session than on the placebo session (38). Although the data suggest potentially Based on this research, future pharma- promising pharmacological treatments for cological studies may wish to examine the adolescent pathological gambling, definitive effects of stimulant medication on treatment recommendations await the Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 136 PHARMACOTHHRAPIES FOR ADOLESCENT GAMBLING completion of controlled treatment studies Gambling Disorders, and Forest Labora- in this population. As the combination of tories, Ortho-McNeil. Oy-Control·'Biotie and behavioral and drug therapies in other GlaxoSmithKline pharmaceuticals; has addictive disorders has been demonstrated participated in surveys, mailings or to be superior to either treatment alone (39), telephone consultations related to drug future investigations in the treatment of addiction, impulse control disorders or pathological gambling in adolescents and other health topics; has consulted for law adults should consider empirically validating offices and the federal public defender's such combined treatment approaches. office in issues related to impulse control disorders; provides clinical care in the ACKNOWLEDGMENTS Connecticut Department of Mental Health This work \vas supported by NIH grants and Addiction Services Problem Gambling from the National Institute on Drug Abuse Services Program; has performed grant (N1IM) KOI DAOI9139 (MNP), RC1 reviews for the National Institutes of Health ÐË028279 (JEG), the VA VISN1 MIRECC and other agencies; has given academic (MNP), and the Minnesota and Yale lectures in grand rounds, CME events and Centers of Excellence in Gambling other clinical or scientific venues; and has Research that are supported by the National generated books or book chapters for Center for Responsible Gaming and its publishers of mental health texts. 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Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM ©Freund Publishing House Ltd. Int J Adolesc Med Health 2010;22(1):.139-151 Prevention of problem gambling in Chinese adolescents: Relevance of problem gambling assessment and positive youth development frameworks Daniel TL Shek, PhD, FHKPS, BBS, JPIAJand Jik J Lee, BSocSc, PhD1 'Department of Applied Social Sciences and "Public Policy Research Institute. The Hong Kong Polytechnic University, Hong Kong, P.R.C.; 3Department of Sociology, East China Normal University, Shanghai, PRC and 3Kiang Wu Nursing College of Macau, Macau, PRC Abstract: Although research findings show that adolescent gambling behavior is a growing problem, there are not many theory-driven prevention programs in the Chinese context. In this paper. t\vo approaches of developing Chinese adolescent prevention program are described. In the first approach, it is argued that related programs should be developed with reference to the risk factors of problem gambling based on problem gambling assessment tools and frameworks. The modified Chinese G-ΜΛΡ is used as an example to illustrate this approach. In the second approach, it is argued that programs incorporating positive youth development constructs would help adolescents develop positive qualities which would prevent them from developing problem gambling. The Project P.A.T.H.S. is given as an example. The issues related to the application of positive youth development constructs to adolescent problem gambling prevention are discussed. Keywords: Gambling problems, adolescents, positive youth development, intervention programs, G-MAP Correspondence: Daniel TL Shek, PhD, FHKPS, BBS, JP, Professor of Applied Social Sciences, Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong. P.R.C. E-mail· daniclshck'u}pol\u.edu.hk Submitted: April 01, 2009. Revised: April 30, 2009. Accepted: May 09. 2009. INTRODUCTION gamblers, 6.6% were gamblers at-risk, and A survey of the Western literature 54% were social gamblers. Dickson, showed that adolescent gambling behavior Derevensky and Gupta (4) reported that 4% is a growing problem. Shaffer and Hall (1) to 8% of the adolescents were problem reported that 10% to 14% of the young gamblers, which was as high as two to four respondents were at-risk for problem times that of the adult population. Hardoon. gambling. Griffiths and Wood (2) revealed Gupta and Derevensky (5) suggested that that high levels of adolescent gambling 4.9% of the respondents were pathological were found in Europe, USA, Canada and gamblers, whereas 8.0% of them were at- Australia. Gupta and Derevensky (3) risk. In Hong Kong, very few studies have showed that 63% of underage adolescents examined problem gambling in adolescents, in Grade 7 to Grade 12 were found The Chinese Young Men's Christian gambling; out of the total population, 2.7% Association of Hong Kong (6) found that were found to be probable pathological 3.5% of the young respondents were Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 140 PREVENTION OF ADOLFSCENT GAMBLING pathological gamblers and 0.8% of them the problem: 1) primary prevention (elimi- were probable pathological gamblers. nation of the occurrence of problems), Although the reported prevalence rates of 2) secondary prevention (early identification problem gambling in adolescents among of high-risk groups and early intervention), different countries and/or cities may not be and 3) tertiary prevention (prevention of directly comparable because of different further deterioration of the problem). The operational definitions of problem gambling, second approach adopts the "changing" these figures do give us some idea about the conception (10). which includes three target seriousness of the problems in adolescents. groups: 1) universal prevention (targeting All governments should therefore find all adolescents regardless of their risk means to tackle the problem. status), 2) selective prevention (targeting This paper attempts to examine the issue adolescents who have above-average risk of of how adolescent problem gambling behaviors but no indication that their programs could possibly be developed. The participation in risky behaviors is a first approach that we can adopt is to problem), and 3) indicated prevention examine the risk factors associated with (targeting adolescents with noticeable signs adolescent problem gambling and to and markers of a behavioral problem even develop prevention programs attempting to they are not diagnosable). The focus on reduce the influence of the risk factors. primary prevention and universal prevention Within this context, prevention programs initiatives have been commonly used to based on gambling assessment tools, such prevent adolescents' risky behaviors such as the Maroondah Assessment Profile for as substance abuse. Problem Gambling (G-MAP), will help to It is noteworthy that prevention programs develop the related programs and to regarding problem gambling are under- identify adolescent problem gamblers. The developed. As pointed out by Dickson, second approach we can consider is to Derevensky, and Gupta (4), make use of the positive youth development "despite increased awareness of the (PYD) approach to develop PYD programs need to hegin educating young children by applying PYD constructs. The basic about the potential dangers of logic of this approach is that with the gambling, empirical knowledge of the strengthening of adolescent development, prevention of adolescent gambling and adolescent development problems would be its translation into science-based reduced. prevention initiatives is scarce " (p. 97), and the authors argued that PREVENTION OF PROBLEM GAMBLING "the field of prevention of youth In \ iew of the growing problem gambling gambling problems can drtnv upon the in adolescents, one obvious question is how substantial research on adolescent problem gambling in adolescents can be alcohol and substance abuse prevention prevented (7,8). From the prevention which has a rich history of research, science perspective, there are two program development and implementa- approaches dominating the development of tion, and evaluation " (p. 99). preventive strategies. The first approach adopts the "traditional" conception (9), Currently, a majority of intervention which includes three levels of dealing with programs are developed by applying the Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM DTL SHEK AND JJ LEE 141 risk-factor concept. For example, the coping skills; and common strategy used in adolescents' 12. relative to non-problem gamblers, substance abuse prevention programs is to problem gamblers display increased identify the risk and protective factors in delinquency and crime. substance abusers. The purposes are to minimize the risk- factors and to maximize RELEVANCE OF PROBLEM GAMBLING the protective factors in young people ASSESSMENT (2,11). This strategy being used in problem It is argued that understanding of the risk gambling prevention is critical because it factors involved in adolescent problem helps identify the risk factors involved in gambling would help to develop adolescent problem gambling and reduce them while problem gambling prevention programs. A strengthening the protective factors at the survey of the literature showed that same time. researchers have developed different assess- Gupta and Derevensky (12) have done ment tools to identify risk factors in an excellent job in summarizing some of problem gambling. The G-MAP developed the major risk factors for young people with by Loughnan, Pierce, and Sagris-Desmond serious gambling problems. The risk factors (13) is one of such examples. According to are listed below: the G-MAP, the common risk factors 1. problem gambling is more popular identified in problem gambling are as among males; follows: 2. risk-takers have greater risk for problem • Problematic beliefs about winning (i.e., gambling; faulty cognitive problems): faulty belief 3. prevalence rates of adolescents' problem in the efficacy of one's cognitive system gambling are 2 to 4 times those of (control factor), use of intuition and ideas adults; about luck to achieve successful out- 4. problem gamblers have relatively lower comes (prophecy factor), and belief that self-esteem; gambling is a reasonable way to make 5. problem gamblers have higher rates of money (uninformed factor). depression; • Emotional and coping problems: use of 6. dissociation during gambling frequently gambling to lift their mood (good occurs in problem gambling; feelings factor), use of gambling to 7. high risk of suicidal ideation and control stress (relaxation factor), use of suicidal attempts exist in problem gambling to alleviate boredom (boredom gamblers; factor), and dissociation as well as 8. loss of quality friendship and relation- disconnection from emotional responses ship are common in problem gamblers; when engaging in gambling (numbness). and problem gamblers have more • Problem situations: using gambling gambling associates than do non- behavior as an "escape" from the problem gamblers; perceived demands in life (oasis), and 9. problem gamblers have increased risk gambling as a result of the dire to be for multiple addictions; "naughty" or rebellious (mischief factor). 10. problem gamblers have higher excita- • Attitudes to self (cognitive/psychological bility than the non-problem gamblers; problem): belief that others see them as 11. problem gamblers have poorer general 'losers' and wish that gambling can help Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 142 PREVENTION Ol: ADOLESCENT GAMBLING them to be 'winners' (low self-image when engaging in gambling factor), gambling as a result of the desire Relaxation: use of gambling to cope with to maintain self-image of being a stress 'winner' (winner factor), belief that Situations domain (life situations gambling is a disease or affliction that related to pathological gambling) can only be solved by life-long Desperation: gambling as a result of abstinence (entrenchment), and conscious desperation use of gambling to punish or hurt oneself Rebellion: gambling as a result of the (harm to self factor). desire to be rebellious • Social problem: social factors that may Oasis: use of gambling to reward oneself contribute to gambling (systems factor) Transition: relation between gambling and use of gambling to satisfy the desire and transitional events in lives to be around people but minimize the Attitudes to self domain (self-concept pressure to interact with them (shyness and psychological problem) factor). Low Self-image: belief that one as a 'loser' and wish that gambling can help To help to assess and develop inter- one to be a 'winner' vention programs in the Chinese context, Winner: gambling as a result of the desire Shek, Chan, and Tung (14) translated and to maintain self-image of being a validated the G-MAP in Hong Kong. As the 'winner' G-ΜΛΡ developed in the West may not be Low Self-Efficacy: belief that one is suitable for people in Asian countries due to capable to control his/her gambling cultural differences, Shek et al (15) behavior developed the modified Chinese version of 5. Social Domain (Social Influences) the G-MAP (Chinese G-ΜΛΡ) for the • Friendship: use of gambling to increase assessment of problem gambling. The social encounter modified Chinese G-MAP has 10 domains Shyness: use of gambling to satisfy the and 23 scales resembling 8 groups of factors desire to be around by people but related to pathological gambling. Detailed minimize the pressure to interact with information of the Chinese version G-MAP them is provided in the following section. Behavior domain (behavioral 1. Beliefs about winning domain influences) (cognitive problems) Habit: gambling in familiar cnviron-ment • Control: belief in the efficacy of one's or with familiar people system in winning money. Leisure: gambling as a hobby or an • Prophecy: use of intuition and ideas interest about luck to achieve successful Spirituality domain (spiritual outcomes influences) 2. Feelings domain (emotional problems) Lack of Life Goal: belief that gambling • Boredom: use of gambling to alleviate and winning money are meaningful in boredom one's life • Good Feelings: use of gambling to lift Self-Worth: gambling as a way to search one's mood for one's value • Numbness: dissociation and dis- Family domain (family influences) connection from emotional responses Reinforcements: gambling for the sake of Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM DTLSHl-XANDJJLEE 143 one's family problems, such as learning disabilities and • Escape: gambling as a way to escape substance abuse. Many researchers and from family problems intervention program developers believe 9. Attitudes to financial management that the effort on identifying and promoting domain (attitudinal influences) young people's talents and strengths will • Attitudes to Financial Management: . raise their self-esteem, self-image, and life gambling as a way to deal with one's goals. As a result, the use of PYD debts constructs should be used to promote 10. Culture domain (cultural influences) development of adolescents. • Chinese Beliefs about Gambling: beliefs There are many PYD programs in the in the Chinese proverbs about gambling West. Catalano, Berglund, Ryan, Lonczak, and Hawkins (18,19), based on their Shek et al (15) showed that the Chinese revision of 77 PYD programs, concluded G-MAP is valid and reliable. Obviously, that there are 25 successful programs the G-MAP dimensions can be used to involving 15 identified PYD constructs. develop adolescent prevention programs in From a prevention of problem gambling's the Chinese culture. For example, it would point of view, these 15 constructs are useful be helpful to train adolescents to deal with in developing adolescent problem gambling Chinese beliefs about gambling. Furthermore, prevention programs. The meaning of these the modified Chinese G-MAP can be used PYD constructs and the rationales for to identify Chinese adolescent problem including them in problem gambling gamblers who may need early intervention. prevention programs are explained below. l) Promotion of bonding: Promotion of ALTERNATIVE COMPLEMENTARY bonding means to develop strong affective APPROACH: POSITIVE YOUTH relationship with and commitment to people Although the prevention science approach (healthy adults and positive peers) and focusing on risk and protective factors of institutions (school, community and culture). high-risk adolescent behaviors generated It is believed that strong linkages with much research finding and produced many healthy adults and significant others are prevention programs in the past few important to prevent problem gambling in decades, this approach has been criticized adolescents. Researchers found that many as taking a negative view about adolescent adolescent gamblers are negatively impacted development. Based on the belief that by the following situations: a) many parents adolescents are assets to be developed and friends of adolescent gamblers are rather than problems to be solved, an gamblers; b) perceived family support in alternative approach to tackle adolescent adolescent problem gamblers is poor (5), gambling problem is in order. and c) quality friendships and relationships Some researchers (16) look upon the are lost and replaced by gambling PYD to accomplish this goal. Damon (17) associates among problem gamblers (12). stated that the field of PYD focuses on According to family theories, adolescents' adolescents' talents, strengths, interests, and developmental problems are regarded as future potentials. This focus is in sharp outcomes of their problematic family contrast to the prevention science processes. In a longitudinal study approach's focus on adolescents' personal examining the linkage between parental disadvantages, disabilities and behavioral behavioral and psychological control and Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 144 I'KKVr.NTION OF·' ADOLKSCFNT (ΪΛΜΙ)Ι.ΙΝ(ί adolescents' adjustment, Shek (20-22) making inferences, self-reflection, and showed that parental psychological and coordination of multiple views). The behavioral control are related to the cultivation of cognitive competence as a children's psychological well-being (such preventive strategy is important because as life satisfaction, mastery, life satisfaction researchers have found that there are and hopelessness). This construct is illusions of control and unrealistic intimately linked to adolescents' gambling perceptions of luck in adolescent problem behavior. gamblers (23). The control factor (belief in 2) Promotion of social competence: the efficacy of their system), the prophecy Social competence refers to interpersonal factor (use of intuition and ideas about luck skills (such as communication, assertive- to achieve successful outcomes), and the ness, conflict resolution, and interpersonal uninformed factor (belief that gambling is a negotiation), the ability to build up positive reasonable way to make money) in the human relationships, and the provision of G-MAP also suggest that cognitive opportunities to practice such skills. There dysfunction is a source of concern in are several rationales to develop social problem gamblers. According to cognitive competence as a means to prevent problem theories of problem gambling, cognitive gambling: a) the social competence in dysfunction and irrational thoughts about adolescent gamblers is poor (e.g., outcomes problem gambling are the basic factors of the G-ΜΛΡ assessment), b) many friends conducive to problem gambling. and peers in adolescents with gambling 5) Promotion of behavioral competence: problem are gamblers, and c) there is a This PYD construct includes the ability to poorly perceived peer support among use nonverbal and verbal strategies to adolescent problem gamblers (5). perform socially acceptable and normative 3) Promotion of emotional competence: behavior in social interactions and to make Emotional competence includes awareness effective behavior choices. The basic of one's own emotions, ability to under- justification for including this construct in stand others' emotions, ability to use the the prevention toolbox is that peer pressure vocabulary of emotion, capacity for plays an important role in adolescent empathy, ability to differentiate internal problem gambling (24). A significant subjective emotional-experience from proportion of adolescent gambling activities external emotional-expression, capacity to take place in friends' homes. I low to help control emotional distress, awareness of adolescents resist negative peer influence emotional messages within relationships, has become a central focus in many of the and capacity for emotional management. current programs on the prevention of The justifications for including this PYD adolescents' high risk behaviors. construct is that there are greater emotional 6) Promotion of moral competence: problems (such as depression and suicidal Moral competence refers to the orientation ideation) in adolescent gamblers (3) and to perform altruistic behavior, ability to emotional problems in problem gamblers. judge moral issues, as well as to promote 4) Promotion of cognitive competence: the development of justice and altruistic Cognitive competence includes cognitive behaviors in adolescents. It is argued that abilities, processes or outcomes (such as the promotion of this PYD construct is logical thinking, problem-solving, and goal important because problem gamblers are setting), and critical thinking (such as unable to judge the negative consequences Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM DTL SHEK AND JJ LEE 145 of pathological gambling. Adolescent process for an individual to recover) or a problem gamblers have weak moral result (positive outcomes after going constraint as reflected by the findings that through stressful events). Cultivation of they usually have a history of delinquency resilience means fostering adolescents' such as stealing money to fund their capacity against unconstructive develop- gambling (2). mental changes and life stresses in order to 7) Development of self-efficacy: Self- 'bounce back' from stressful life experience efficacy refers to beliefs in one's ability to and achieve healthy outcomes. The organize and execute the courses of action inclusion of resilience as a PYD construct is required to produce given attainments as important for two reasons. First, research well as techniques to change negative self- studies have showed that coping behaviors defeating cognitions to positive ones. There in adolescent gamblers are poor (3) and that are two reasons to support the inclusion of problem gambling may occur after negative this PYD construct in problem gambling life events (G-MAP). Second, there are prevention programs. First, problem studies showing that resilience is negatively gamblers may either have very low self- related to adolescent high-risk behaviors. efficacy (so that they wish to attain control 10) Cultivation of self-determination: via gambling) or over-estimate their ability Self-determination refers to an adolescent's to control the outcomes of gambling. ability to set goals and make choices Second, as increasing research evidence according to his/her own thinking. shows that self-efficacy is negatively Regarding skills and strategies which related to substance abuse, it is argued that promote self-determination, they include development of self-efficacy will reduce the self-awareness of strengths and limitations, likelihood of problem gambling. goal setting and action planning, problem 8) Fostering prosocial norms: Prosocial solving, choice-making, and self- norms are clear and healthy standards, evaluation. There are two justifications for beliefs, and behavior guidelines which promoting self-determination as a strategy promote socially desirable behavior. to prevent problem gambling. First, Prosocial norms often include altruism, problem gambling represents poor choice- solidarity, and volunteerism leading to making in adolescent behaviors. Second, as prosocial behaviors, such as cooperation impulsivity is involved in adolescent and sharing. As pointed out by Hardoon, problem gamblers, cultivation of self- Gupta, and Derevensky (5), adolescent determination is important (24). gambling is closely related to delinquency 11) Cultivation of spirituality: Cultivation and conduct problems. Because prosocial of spirituality refers to promotion of the norms and behaviors can be viewed as development of beliefs in a higher power or incompatible with aggressive or deviant a sense of spiritual identity, meaning or behaviors, it is expected that the promotion practice. Two arguments support the use of of prosocial behaviors, i.e., the PYD this PYD construct in the prevention of construct, will be conducive to the adolescent problem gambling. First, there reduction of high-risk behaviors. are research findings showing that purpose 9) Cultivation of resilience: Resilience in life is negatively related to adolescents' can be conceived as a capacity (the ability high-risk behavior and psychological well- of an individual for adapting to changes in a being (25). Second, according to the healthy way), a process (a reintegration existential theory of Victor Frankl, psycho- Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM I "46 PREVENTION OF ADOLESCENT GAMBLING pathological behavior, such as problem because adolescent problem gamblers may gambling, is a result of existential vacuum attempt to derive achievement from that is created by a lack of meaning in an excessive gambling and many adolescent individual. problem behaviors occur as a result of the 12) Promotion of beliefs in the future: lack of proper recognition for their positive Beliefs in the future refers to hope and behaviors. optimism, including valued and attainable goals, positive appraisal of one's capability POSITIVE YOUTH DEVELOPMENT and effort (a sense of confidence), and PROGRAMS IN HONG KONG positive expectancies of the future. As The development of positive youth problem gamblers have heightened risk for development programs is at its infancy in suicidal ideation and attempts (4). it is Hong Kong. In order to promote a holistic assumed that such negative views about the development among adolescents in Hong future are antecedents of problem gambling, Kong. The Hong Kong Jockey Club promotion of beliefs in the future will Charities Trust has approved HKS400 reduce the likelihood of problem gambling. million (note: the official exchange rate 13) Development of clear and positive between USS and HKS is 1:7.8) to launch a identity: This PYD construct refers to the project entitled "P.A.T.H.S. to Adulthood : building of self-esteem and facilitation of A Jockey Club Youth Enhancement exploration and commitments in self- Scheme". The word "P.A.T.H.S." denotes definition. As many studies have shown Positive Adolescent Training through that the self-esteem of adolescent problem Holistic Social Programmes. The Trust gamblers is lower than that of the control invited academics of five universities in participants (4), it can be argued that Hong Kong to form a Research Team to promotion of self-esteem in adolescents develop a multi-year universal PYD will prevent the development of problem program to promote holistic adolescent gambling in adolescents. development in Hong Kong, with Shek as I-I) Opportunity for prosocial involve- the Principal Investigator. Besides ment· This PYD construct refers to events developing the program, the Research and activities that promote adolescents' Team also provides training for the teachers participation in prosocial behaviors and and social workers who implement the maintenance of prosocial norms. As program, and carries out longitudinal prosocial involvement is negatively related evaluation of the project. There are two to delinquency and psychological problems tiers of programs (Tier 1 and Tier 2 (26,27), it can be argued that providing Programs) in this project. The Tier 1 opportunities for prosocial involvement Program is a universal PYD program in would prevent the development of problem which students in Secondary I to gambling. Secondary 3 will participate, normally with 15) Recognition for positive behavior· 20 hours of training in the school year at This construct refers to the development of each grade. Because research findings systems for rewarding or recognizing suggest that roughly one-fifth of adolescents participants' positive behaviors such as will need help of a deeper nature, a Tier 2 prosocial behaviors or positive changes in Program will generally be provided for at behaviors. This PYD construct is important least one-fifth of the students who have Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM DTL SHEK AND JJ LEE 147 greater psychosocial needs at each grade DISCUSSION (i.e., selective program). Although the utilization of PYD programs The overall objective of the Tier 1 represents a reasonable approach to prevent Program is to promote holistic development adolescent problem gambling, several among junior secondary school students in issues should be considered for developing Hong Kong. To achieve this objective, adolescent prevention programs in Hong program elements related to PYD Kong. constructs are included in the Tier 1 First, it is important to examine the Program (28). These elements include: goal(s) of problem gambling prevention promotion of bonding, cultivation of programs. Basically, there are two possible resilience, promotion of social competence, goals of such prevention programs: promotion of emotional competence, abstinence of gambling vs. harm minimiza- promotion of cognitive competence, tion or harm reduction of problem gambling promotion of behavioral competence, (7,8). With specific reference to the Chinese promotion of moral competence, cultivation culture of Hong Kong, parents basically do of self-determination, promotion of not tolerate gambling in adolescents. As spirituality, development of self-efficacy, such, abstinence of gambling is regarded as development of a clear and positive the legitimate objective of gambling identity, promotion of beliefs in the future, prevention programs. This goal is clearly provision of recognition for positive exemplified by the anti-gambling program behavior, provision of opportunities for initiated by the Hong Kong Education City. prosocial involvement, and fostering On the other hand, gambling prevention prosocial norms (28,29). Both Chinese and programs in the West are commonly English curriculum manuals have been designed within the context of harm produced with reference to all PYD reduction or minimization. constructs except the recognition for The second issue is whether specific positive behavior. For the recognition for gambling prevention programs or generic positive behavior, it is argued that this PYD programs should be designed. While element should be implemented as a regular the former has the advantage of having principle inside and outside classrooms. As specific focus on problem gambling as well such, no specific curricula are needed. as spending fewer manpower and financial For the evaluation of the program, resources, the stigmatizing effect of such objective outcome evaluation, subjective programs should not be underestimated. For outcome evaluation, secondary data analyses, example, for schools admitting "better" process evaluation, interim evaluation, students, most schools tend to deny any qualitative evaluation based on focus gambling problems among their students. groups, student weekly diaries and case These schools will not join such prevention studies have been used. Based on these programs as a defense mechanism. On the strategies, existing research findings other hand, as 'generic' PYD programs generally revealed that different stake- targeting the total youth population are non- holders have positive perceptions of the stigmatizing in nature, school administrators, program, workers, as well as benefits the teachers, and parents will accept the program, and that the program is effective prevention programs more readily. Never- in promoting holistic PYD among Chinese theless, the basic question that should be adolescents in Hong Kong (28-33). asked is whether the PYD program should Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM 148 PREVENTION OF ADOLESCENT GAMBLING be a panacea to all adolescents with high- designing the prevention programs. risk behaviors. The fifth issue concerns the universality Third, while it is reasonable to propose of problem gambling prevention programs. that researchers can apply the elements and A survey of the literature shows that most principles of substance abuse prevention of the existing gambling prevention programs to problem gambling prevention programs are designed in Western programs, one query that should be raised is countries. If one assumes that knowledge whether there are any meaningful transcends culture and prevention theories similarities between substance abuse are universally applicable, one can simply prevention programs and problem gambling translate the English version of such prevention programs. Basically, one has to programs and apply them in different identify the lowest common multiples of cultures. Nevertheless, as the meaning of both types of prevention programs. gambling has different meanings under Although many common risk factors are different cultures, there are researchers involved in substance abuse and problem arguing for the design of indigenous gambling (e.g., sensation seeking and gambling prevention programs utilizing the higher predisposition in males), there are 'emic' approach rather than the 'etic' some differences involved. For example, as approach. parents generally do not tolerate problem Sixth, although it is conceptually gambling behavior in adolescents, their desirable to have problem gambling tolerance for substance abuses in their prevention programs, whether such children is even less. programs are really effective in reducing Fourth, to ensure that problem gambling problem gambling behavior in adolescents prevention programs are effective, one is an empirical question to be considered. should ask what theoretical mechanisms are As such, evaluation of the effectiveness of intrinsic to those programs that can the gambling prevention program is an contribute to the effectiveness of the important issue to be addressed. programs (34). ll is noted that the theory of Unfortunately, program evaluation is not a reasoned action, self-concept theories, and simple and straightforward task and there cognitive theories have been applied to are many types and approaches of many existing gambling prevention programs. evaluation (36). In his discussion of the Hardoon and Derevensky (35) also pointed major strategics of evaluation, Patton (37) out different theories of gambling outlined three basic types of evaluation: behaviors, including personality, cognitive, quantitative evaluation, qualitative evaluation, learning/behavioral, general addiction, and and utilization-focused evaluation. Ginsberg social learning theories of gambling (38) summarized the major forms of behaviors. With reference to the ecological evaluation, including quantitative and approach, there can be different personal qualitative approaches, cost-benefit analyses, and environmental risk and protective satisfaction studies, needs assessment, factors that may contribute to the success of single-subjects designs, experimental problem gambling prevention programs. approaches and models, utilization-focused Hence, it is important to argue for the use evaluation, empowerment evaluations, fraud of theoretical mechanisms in problem and abuse detection, client satisfaction, and gambling prevention programs because journalistic evaluation. Using starting these theories will serve as the backbone in alphabets as the bases of classification, Brought to you by | Nahum Gelber Law Library (Nahum Gelber Law Library) Authenticated | [email protected] Download Date | 7/3/12 3:09 PM DTL SHEK AND JJ LEE 149 Patton (37) suggested that there are more In summary, with the growing severity than 100 types of evaluation. Because of of the problem of adolescent problem the complexity of the nature of evaluation gambling, prevention of adolescent problem and because different paradigms are gambling is an urgent issue that should be involved, researchers are confronted with addressed by researchers, professional the task of developing appropriate workers, prevention program developers, evaluation approaches and strategies in the and policy-makers. It is argued that the field of gambling prevention. utilization of the G-MAP findings as well Finally, it would be exciting if the key as the application of PYD constructs is a elements of prevention approach and promising approach for the problem positive youth development approach could gambling prevention field in the West as be integrated. According to Catalano et al well as in Hong Kong. (18), there are several attributes of the prevention science perspective. These ACKNOWLEDGMENTS include: 1) identification of risk and The preparation of this work was protective factors; 2) adoption of a financially supported by The Hong Kong developmental perspective; 3) assertion that Jockey Club Charities Trust and Wofoo problem behaviors share many common Foundation. The findings on the impact of antecedents; and 4) assertion that risk and parental psychological and behavioral protective factors change youth outcomes. control on adolescent psychological well- On (he other hand, several characteristics being are based on a study funded by the associated with the positive youth develop- Research Grants Council of the ment approach were identified: 1) emphasis Government of the Hong Kong Special on integrated youth development (i.e., Administrative Region, Hong Kong (Grant focusing on a range of youth developmental CUHK4293/03II). possibilities and problems) rather than dealing with a single youth problem; REFERENCES 2) upholding the belief that "problem-free 1. Shaffer IIJ, Hall MN. 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