Published on in Vol 27 (2025)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/68571, first published .
Sleep Quality as a Mediator of Internet Gaming Disorder and Executive Dysfunction in Adolescents: Cross-Sectional Questionnaire Study

Sleep Quality as a Mediator of Internet Gaming Disorder and Executive Dysfunction in Adolescents: Cross-Sectional Questionnaire Study

Sleep Quality as a Mediator of Internet Gaming Disorder and Executive Dysfunction in Adolescents: Cross-Sectional Questionnaire Study

1School of Psychological Sciences, Macquarie University, Sydney, Australia

2German Center for Addiction Research in Childhood and Adolescence, University Medical Center Hamburg-Eppendorf, Building W29 Martinistr 52, Hamburg, Germany

Corresponding Author:

Kerstin Paschke, PD, Dr med, Dipl-Psych


Background: Internet gaming disorder (IGD) has been associated with impairments in executive functioning, particularly inattention and impulsivity. Sleep quality has separately been linked to both gaming behavior and cognitive performance, yet its role as a mediating factor in this relationship is underexplored.

Objective: This study aimed to determine whether sleep quality mediates the relationship between IGD symptoms and executive dysfunction in adolescents, specifically focusing on the domains of inattention and hyperactivity or impulsivity. A reverse mediation model was also tested to explore the bidirectional nature of these relationships.

Methods: A representative sample of 1000 adolescents (539/1000, 53.9% males), aged between 12 and 17 years (mean 14.52, SD 1.64), completed validated self-report measures of IGD symptoms, executive dysfunction, and sleep quality. Structural equation modeling was used to test direct and indirect effects with age and gender included as covariates.

Results: Of the sample, 2.4% (24/1000) met criteria for IGD (875/1000, 87.5% males), and 22.6% (226/1000) met criteria for chronic sleep reduction. Among those with IGD, 54.2% (542/1000) also experienced chronic sleep reduction. In model A (IGD → Sleep → Executive Dysfunction), IGD symptoms were associated with poorer sleep quality (a=0.32, 95% CI 0.19-0.44), which in turn were associated with greater executive dysfunction (b=0.05, 95% CI 0.01-0.10). The indirect effect was significant (a×b=0.02, 95% CI 0.01-0.04), and sleep quality was a partial mediator. In the reverse model (model B), executive dysfunction was associated with poorer sleep quality (a=0.15, 95% CI 0.06-0.25), which subsequently was associated with higher IGD symptoms (b=0.11, 95% CI 0.07-0.16); indirect effect a×b=0.02, 95% CI 0.01-0.04. Simple slope analysis showed that IGD symptoms were associated only with executive dysfunction at average or poor levels of sleep quality. At higher levels of sleep quality, this relationship was no longer significant.

Conclusions: The results of this study suggest that sleep quality may be an important intermediary mechanism by which IGD might contribute to executive dysfunction and provide a basis for the development and implementation of strategies that target sleep issues in IGD. Prospective longitudinal research is needed to examine the directionality of the relationships between IGD, sleep quality, and executive dysfunction longitudinally.

J Med Internet Res 2025;27:e68571

doi:10.2196/68571

Keywords



Over the past few decades, gaming and screen use have surged in popularity due to technological advancements and the increasing availability and accessibility of these technologies [Twenge JM, Martin GN, Spitzberg BH. Trends in U.S. adolescents’ media use, 1976–2016: the rise of digital media, the decline of TV, and the (near) demise of print. Psychol Pop Media Cult. 1976;8(4):329-345. [CrossRef]1]. For some individuals, this rise in gaming behavior has led to problematic relationships with gaming and the internet. The inclusion of gaming disorder (GD) in the ICD-11 (International Classification of Diseases, Eleventh Revision) by the World Health Organization highlights the growing recognition of these issues, describing it as a pattern of persistent or recurrent gaming behavior that takes precedence over other life interests and activities, resulting in significant impairment or distress [Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. World Health Organization. 2024. URL: https://www.who.int/publications/i/item/9789240077263 [Accessed 2025-07-01] 2]. Similarly, the DSM-V-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision) acknowledges internet gaming disorder (IGD) as a condition warranting further study [American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association; 2013. URL: https://www.psychiatry.org/psychiatrists/practice/dsm [Accessed 2024-09-30] ISBN: 978-0-89042-576-33]. While both IGD and GD describe problematic gaming behaviors, IGD follows an addiction-based model with a focus on psychological harm, whereas GD emphasizes functional impairment [Jo YS, Bhang SY, Choi JS, Lee HK, Lee SY, Kweon YS. Clinical characteristics of diagnosis for internet gaming disorder: comparison of DSM-5 IGD and ICD-11 GD diagnosis. J Clin Med. Jun 28, 2019;8(7):945. [CrossRef] [Medline]4]. Additionally, GD is less stable over time and more associated with psychiatric comorbidities [Hong YN, Hwang H, Starcevic V, Choi TY, Kim TH, Han DH. Which is more stable and specific: DSM-5 internet gaming disorder or ICD-11 gaming disorder? A longitudinal study. Psychiatry Clin Neurosci. Apr 2023;77(4):213-222. [CrossRef] [Medline]5].

A meta-analysis exploring rates of IGD indicated a global pooled prevalence of 4.6% [Fam JY. Prevalence of internet gaming disorder in adolescents: a meta-analysis across three decades. Scand J Psychol. Oct 2018;59(5):524-531. [CrossRef] [Medline]6], with other studies estimating prevalence rates of 1.16%‐3.5% in German adolescents [Rehbein F, Kleimann M, Mössle T. Prevalence and risk factors of video game dependency in adolescence: results of a German nationwide survey. Cyberpsychol Behav Soc Netw. Jun 2010;13(3):269-277. [CrossRef] [Medline]7,Wartberg L, Kriston L, Thomasius R. Internet gaming disorder and problematic social media use in a representative sample of German adolescents: Prevalence estimates, comorbid depressive symptoms and related psychosocial aspects. Comput Human Behav. Feb 2020;103:31-36. [CrossRef]8], 3.6%‐9.4% in North American samples [Kim HS, Son G, Roh EB, et al. Prevalence of gaming disorder: a meta-analysis. Addict Behav. Mar 2022;126:107183. [CrossRef] [Medline]9,Turner NE, Paglia-Boak A, Ballon B, et al. Prevalence of problematic video gaming among Ontario adolescents. Int J Ment Health Addiction. Dec 2012;10(6):877-889. [CrossRef]10], and 2.8%‐3.1% in Australian teenagers elevated under the COVID-19 pandemic [King DL, Delfabbro PH. Features of Parent-Child Relationships in Adolescents with Internet Gaming Disorder. Int J Ment Health Addiction. Dec 2017;15(6):1270-1283. [CrossRef]11-Paschke K, Austermann MI, Simon-Kutscher K, Thomasius R. Adolescent gaming and social media usage before and during the COVID-19 pandemic: interim results of a longitudinal study. Sucht Zeitschrift für Wissenschaft und Praxis. 2021;67(1):13-22. [CrossRef]13]. This prevalence is concerning, given the particular susceptibility of adolescents to developing IGD [Karacic S, Oreskovic S. Internet addiction through the phase of adolescence: a questionnaire study. JMIR Ment Health. Apr 3, 2017;4(2):e11. [CrossRef] [Medline]14-Kuss DJ, Griffiths MD. Online gaming addiction in children and adolescents: a review of empirical research. J Behav Addict. Mar 2012;1(1):3-22. [CrossRef] [Medline]16], along with the neurological, psychological, and social consequences associated with its development [Brand M, Young KS, Laier C. Prefrontal control and internet addiction: a theoretical model and review of neuropsychological and neuroimaging findings. Front Hum Neurosci. 2014;8:375. [CrossRef] [Medline]17-Wartberg L, Kriston L, Zieglmeier M, Lincoln T, Kammerl R. A longitudinal study on psychosocial causes and consequences of Internet gaming disorder in adolescence. Psychol Med. Jan 2019;49(2):287-294. [CrossRef] [Medline]20]. Globally, IGD treatment centers have seen a steady increase in patient referrals with common presenting issues including family conflict, social isolation, and gaming-related interference with other activities [King DL, Achab S, Higuchi S, et al. Gaming disorder and the COVID-19 pandemic: treatment demand and service delivery challenges. J Behav Addict. Apr 12, 2022;11(2):243-248. [CrossRef] [Medline]21].

Although the research field still lacks a clear consensus on the precise operationalization of IGD and its diagnostic parameters [D Griffiths M. Internet addiction disorder and internet gaming disorder are not the same. J Addict Res Ther. 2014;05(4):04. [CrossRef]22-Quandt T. Stepping back to advance: why IGD needs an intensified debate instead of a consensus. J Behav Addict. Jun 1, 2017;6(2):121-123. [CrossRef] [Medline]25], evidence increasingly indicates that IGD and other disordered screen use behaviors are associated with cognitive impairments in clinical populations [Moshel ML, Warburton WA, Batchelor J, Bennett JM, Ko KY. Neuropsychological deficits in disordered screen use behaviours: a systematic review and meta-analysis. Neuropsychol Rev. Sep 2024;34(3):791-822. [CrossRef] [Medline]26-Shin YB, Kim H, Kim SJ, Kim JJ. A neural mechanism of the relationship between impulsivity and emotion dysregulation in patients with internet gaming disorder. Addict Biol. May 2021;26(3):e12916. [CrossRef] [Medline]29]. A recent meta-analysis on neuropsychological performance in individuals with problematic gaming behaviors and broader disordered screen use found decreased cognitive performance, with small to medium effect sizes compared with healthy controls [Moshel ML, Warburton WA, Batchelor J, Bennett JM, Ko KY. Neuropsychological deficits in disordered screen use behaviours: a systematic review and meta-analysis. Neuropsychol Rev. Sep 2024;34(3):791-822. [CrossRef] [Medline]26]. The most affected cognitive domains were attention and executive functioning [Moshel ML, Warburton WA, Batchelor J, Bennett JM, Ko KY. Neuropsychological deficits in disordered screen use behaviours: a systematic review and meta-analysis. Neuropsychol Rev. Sep 2024;34(3):791-822. [CrossRef] [Medline]26].

This paper focuses on executive functioning, specifically on 2 key facets: attentional control (inattention) and behavioral inhibition (hyperactivity or impulsivity). While executive functioning also encompasses working memory, cognitive flexibility, and higher-order processes such as decision-making and problem-solving [Anderson V. Assessing executive functions in children: biological, psychological, and developmental considerations. Pediatr Rehabil. 2001;4(3):119-136. [CrossRef] [Medline]30,Strauss E, Sherman EMS, Spreen O. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary. Oxford University Press; 2006. ISBN: 019515957831], this study specifically examines the regulatory control of attention and behavior as core components of executive dysfunction in IGD. Moreover, these subdomains align closely with attention-deficit/hyperactivity disorder (ADHD) symptomology, a condition widely regarded as a disorder of executive dysfunction [Brown TE. Executive functions and attention deficit hyperactivity disorder: implications of two conflicting views. Intl J Disabil Dev Educ. Mar 2006;53(1):35-46. [CrossRef]32,Silverstein MJ, Faraone SV, Leon TL, Biederman J, Spencer TJ, Adler LA. The relationship between executive function deficits and DSM-5-defined ADHD symptoms. J Atten Disord. Jan 2020;24(1):41-51. [CrossRef] [Medline]33], and one that shows strong comorbidity with IGD [Dalbudak E, Evren C, Aldemir S, Coskun KS, Ugurlu H, Yildirim FG. Relationship of internet addiction severity with depression, anxiety, and alexithymia, temperament and character in university students. Cyberpsychol Behav Soc Netw. Apr 2013;16(4):272-278. [CrossRef] [Medline]34-Park JH, Lee YS, Sohn JH, Han DH. Effectiveness of atomoxetine and methylphenidate for problematic online gaming in adolescents with attention deficit hyperactivity disorder. Hum Psychopharmacol Clin Exp. Nov 2016;31(6):427-432. [CrossRef]37]. Specifically, higher GD symptom severity is related to higher symptoms across the hyperactivity or impulsivity and inattention subdomains [Koncz P, Demetrovics Z, Takacs ZK, Griffiths MD, Nagy T, Király O. The emerging evidence on the association between symptoms of ADHD and gaming disorder: a systematic review and meta-analysis. Clin Psychol Rev. Dec 2023;106:102343. [CrossRef] [Medline]38]. This overlap highlights the nature of executive dysfunction across both disorders, providing a theoretically and clinically grounded rationale for focusing on these executive function domains in this study.

Impairments in healthy executive functioning, a crucial part of brain development during childhood and adolescence [Xu F, Han Y, Sabbagh MA, Wang T, Ren X, Li C. Developmental differences in the structure of executive function in middle childhood and adolescence. PLoS One. Oct 2013;8(10):e77770. [CrossRef]39], can have far-reaching implications for socioeconomic status, including academic success, school dropout rates, overall health, and quality of life [Warburton WA, Tam P, Cantali R. Screen addiction among consumers. In: The Importance of Media Literacy: Getting the Most From the Digital World. Cambridge Scholars Publishing; 2024:204-225. ISBN: 1-5275-5630-140-Hackman DA, Gallop R, Evans GW, Farah MJ. Socioeconomic status and executive function: developmental trajectories and mediation. Dev Sci. Sep 2015;18(5):686-702. [CrossRef] [Medline]43]. Adolescents with IGD exhibit neurobiological changes, such as reduced orbitofrontal cortex thickness, a structural abnormality also seen in substance use disorders [Kuss DJ, Pontes HM, Griffiths MD. Neurobiological correlates in internet gaming disorder: a systematic literature review. Front Psychiatry. 2018;9:166. [CrossRef] [Medline]44], as well as abnormal glucose metabolism and white matter fiber consistency in the orbitofrontal regions [Wei L, Zhang S, Turel O, Bechara A, He Q. A tripartite neurocognitive model of internet gaming disorder. Front Psychiatry. 2017;8:285. [CrossRef] [Medline]45]. Indeed, Ioannidis et al [Ioannidis K, Hook R, Goudriaan AE, et al. Cognitive deficits in problematic internet use: meta-analysis of 40 studies. Br J Psychiatry. Nov 2019;215(5):639-646. [CrossRef] [Medline]46] characterize cognitive dysfunction as part of the pathophysiology of problematic internet use, including problematic gaming, particularly highlighting the existence of underlying frontostriatal dysfunction. In a systematic review, Schettler et al [Schettler L, Thomasius R, Paschke K. Neural correlates of problematic gaming in adolescents: a systematic review of structural and functional magnetic resonance imaging studies. Addict Biol. Jan 2022;27(1):e13093. [CrossRef] [Medline]47] examined problematic gaming—a term encompassing both IGD and GD—and found that adolescents exhibiting problematic gaming behaviors showed greater cognitive-affective imbalance than age-matched controls. This imbalance was marked by alterations in brain regions associated with identity formation, social cognition, personality formation, and mentalizing—key processes during this developmental period. Although establishing a causal mechanism between problematic gaming behaviors and executive dysfunction is challenging [Thorell LB, Burén J, Ström Wiman J, Sandberg D, Nutley SB. Longitudinal associations between digital media use and ADHD symptoms in children and adolescents: a systematic literature review. Eur Child Adolesc Psychiatry. Aug 2024;33(8):2503-2526. [CrossRef] [Medline]48,Werling AM, Kuzhippallil S, Emery S, Walitza S, Drechsler R. Problematic use of digital media in children and adolescents with a diagnosis of attention-deficit/hyperactivity disorder compared to controls. A meta-analysis. J Behav Addict. May 13, 2022;11(2):305-325. [CrossRef] [Medline]49], it is possible that secondary effects resulting from gaming and executive dysfunction, such as sleep, may be mediating this relationship.

Indeed, previous studies have highlighted the crucial role that sleep plays in cognitive functioning, particularly executive control, as well as in the development of IGD. For instance, addicted gamers reported significantly higher rates of daytime sleepiness and sleep deprivation [Achab S, Nicolier M, Mauny F, et al. Massively multiplayer online role-playing games: comparing characteristics of addict vs non-addict online recruited gamers in a French adult population. BMC Psychiatry. Aug 26, 2011;11(1):144. [CrossRef] [Medline]50], with the use of screens more generally being associated with symptoms of insomnia [Fossum IN, Nordnes LT, Storemark SS, Bjorvatn B, Pallesen S. The association between use of electronic media in bed before going to sleep and insomnia symptoms, daytime sleepiness, morningness, and chronotype. Behav Sleep Med. Sep 3, 2014;12(5):343-357. [CrossRef] [Medline]51]. Sleep quality was shown to be lowest in children who use internet gaming for more than 6 hours a day and highest for those using only 1 to 2 hours a day [Ahmed GK, Abdalla AA, Mohamed AM, Mohamed LA, Shamaa HA. Relationship between time spent playing internet gaming apps and behavioral problems, sleep problems, alexithymia, and emotion dysregulations in children: a multicentre study. Child Adolesc Psychiatry Ment Health. Aug 16, 2022;16(1):67. [CrossRef] [Medline]52]. A meta-analysis found that problematic gamers reported more adverse sleep status, including sleep duration, sleep quality, sleep problems, and daytime sleepiness, than nonproblematic gamers [Kristensen JH, Pallesen S, King DL, Hysing M, Erevik EK. Problematic gaming and sleep: a systematic review and meta-analysis. Front Psychiatry. 2021;12:675237. [CrossRef] [Medline]53]. In a longitudinal study, Barlett et al [Barlett ND, Gentile DA, Barlett CP, Eisenmann JC, Walsh DA. Sleep as a mediator of screen time effects on US children’s health outcomes. J Child Media. Feb 2012;6(1):37-50. [CrossRef]54] found that sleep mediated the relationship between media exposure (measured by screen time) and attentional problems in children, supporting the “displacement hypothesis,” which posits that screen time displaces time spent on more beneficial activities such as sleep [Neuman SB. Literacy in the Television Age: The Myth of the TV Effect in Literacy in the Television Age: The Myth of the TV Effect. Ablex Publishing; 1991. ISBN: 089391485155].

Regarding executive functioning, the effects of sleep deprivation and reduced sleep quality have also been well studied. Various meta-analytic findings show a significantly negative effect of sleep restriction on executive functioning, sustained attention, and long-term memory, with the magnitude of the effect shown to increase with age [Astill RG, Van der Heijden KB, Van Ijzendoorn MH, Van Someren EJW. Sleep, cognition, and behavioral problems in school-age children: a century of research meta-analyzed. Psychol Bull. Nov 2012;138(6):1109-1138. [CrossRef] [Medline]56-Lowe CJ, Safati A, Hall PA. The neurocognitive consequences of sleep restriction: a meta-analytic review. Neurosci Biobehav Rev. Sep 2017;80:586-604. [CrossRef] [Medline]58]. Sleep problems may also interact with ADHD symptoms via reciprocal causation, possibly sharing a common neurological etiology [Hvolby A. Associations of sleep disturbance with ADHD: implications for treatment. Atten Defic Hyperact Disord. Mar 2015;7(1):1-18. [CrossRef] [Medline]59]. Quality of sleep may be adversely impacted in ADHD with increased sleep-onset latency, shorter sleep time, sleep-disordered breathing, and nocturnal motricity [Kirov R, Brand S. Sleep problems and their effect in ADHD. Expert Rev Neurother. Mar 2014;14(3):287-299. [CrossRef] [Medline]60]. Poorer sleep quantity and quality in adolescents is associated with weaker attentiveness and poorer responses on tasks of executive functioning [Kuula L, Pesonen AK, Martikainen S, et al. Poor sleep and neurocognitive function in early adolescence. Sleep Med. Oct 2015;16(10):1207-1212. [CrossRef] [Medline]61]. Given these decrements in executive function, Anderson et al [Anderson B, Storfer-Isser A, Taylor HG, Rosen CL, Redline S. Associations of executive function with sleepiness and sleep duration in adolescents. Pediatrics. Apr 2009;123(4):e701-e707. [CrossRef] [Medline]62] recommend that pediatricians and public health officials consider sleep quality and deprivation as an important contributor regarding adolescent functioning.

With this recommendation in mind, it currently remains unclear whether sleep quality mediates the relationship between IGD and executive function, particularly in core components of inattention and hyperactivity/impulsivity. Additionally, there is uncertainty regarding the pathway of these effects: whether executive dysfunction or IGD leads to reduced sleep quality in the same way and, conversely, which condition is more considerably impacted by poor sleep quality. Identifying sleep quality as a mediator would allow researchers and clinicians to focus on it as a key factor linking IGD and executive dysfunction, making it a target for intervention. Early identification of sleep problems in individuals at risk for IGD or executive dysfunction could serve as a preventive measure and positively influence patient prognosis [Sugaya N, Shirasaka T, Takahashi K, Kanda H. Bio-psychosocial factors of children and adolescents with internet gaming disorder: a systematic review. Biopsychosoc Med. 2019;13:3. [CrossRef] [Medline]63]. This approach suggests that, rather than solely focusing on reducing gaming or directly managing executive dysfunction, interventions could include strategies to improve sleep, which could incrementally add to better overall outcomes. This is especially important given the disproportionate risk adolescents face in developing IGD, where early intervention in the developing brain is particularly crucial [Njoroge WFM, Hostutler CA, Schwartz BS, Mautone JA. Integrated behavioral health in pediatric primary care. Curr Psychiatry Rep. Dec 2016;18(12):106. [CrossRef] [Medline]64].

To the authors’ knowledge, no studies have examined sleep quality as a potential mediator between the severity of IGD and executive dysfunction. Therefore, based on prior theoretical foundations, we hypothesize that sleep quality will mediate IGD and executive dysfunction, focusing on the subdomains of inattention and hyperactivity/impulsivity. As this is a cross-sectional study and given the support for a bidirectional model of executive dysfunction and IGD symptoms as well as the uncertainty regarding pathway effects, the reverse mediational process will also be examined. The results of this study may inform future longitudinal and prospective research exploring these outcomes.


Ethical Considerations

This study is part of a large ongoing study on adolescent media usage [Paschke K, Laurenz L, Thomasius R. Chronic sleep reduction in childhood and adolescence. Dtsch Arztebl Int. Oct 2, 2020;117(40):661-667. [CrossRef] [Medline]65-Paschke K, Sack PM, Thomasius R. Validity and psychometric properties of the internet gaming disorder scale in three large independent samples of children and adolescents. Int J Environ Res Public Health. Jan 26, 2021;18(3):1095. [CrossRef] [Medline]67] for which ethical approval (no. LPEK-0307) has been obtained by the local psychological ethics commission at the Center for Psychosocial Medicine of the University Medical Center Hamburg-Eppendorf. Verbal informed consent was obtained from both parents and adolescents prior to their participation in the study. Participants were informed of their right to withdraw from the study at any time without any consequences. Compensation was offered for participation in the form of charity vouchers. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Declaration of Helsinki of 1975, as revised in 2008.

Participants

Data were collected by Forsa, a market and opinion research institute, using computer-assisted telephone interviews (forsa.omniTel). Participants were children and adolescents aged 12-17 years, selected through a multistage systematic random sampling process based on the German Arbeitskreis Markt- und Sozialforschungsinstitute e.V. (ADM; a business association representing private sector market and social research agencies) telephone master sample. Sampling occurred in 2 stages: first, geographically distributed sampling points were identified across Germany; second, households within these points were selected via a random-route method, with 1 eligible adolescent randomly chosen per household. A total of 2075 households were contacted, and after obtaining verbal consent from parents and participants, the final participation rate was 48.2%, yielding a sample of 1000 participants. The dual-frame sampling method (landline and mobile numbers) ensured broad coverage of the population. The sample was stratified by age, gender, and region to align with national demographic distributions based on microcensus data from the Federal Statistical Office of Germany. Data were also collected on educational and occupational status (school student, apprentice, and voluntary service), school attainment (desired or achieved school-leaving certificate), and recent attendance patterns (absences from school, apprenticeship, or work within the preceding 4 weeks). A rolling sample approach was used, meaning that there was no fixed gross sample; instead, previously processed numbers were continuously replaced with new numbers following a systematic call plan. Representativity using this approach has been established in prior research [Zwar L, König HH, Hajek A. Conspiracy mentality among informal caregivers as a risk factor for caregiver burden, mental health, perceived loneliness and social isolation during the COVID-19 pandemic: findings of a representative online study from Germany. Qual Life Res. Nov 2022;31(11):3139-3151. [CrossRef] [Medline]68-Zwar L, König HH, Hajek A. Mental health, social integration and support of informal caregivers during the second wave of the COVID-19 pandemic: a population-based representative study from Germany. Arch Gerontol Geriatr. Nov 2023;114:105085. [CrossRef] [Medline]71]. Participants were informed that their participation was voluntary, the data were collected anonymously, and would not be passed on to third parties. Due to the nature of telephone interviews, there were minimal missing responses, which were recorded as NA or “don’t know” responses. A comprehensive description of the data collection methods and demographic characteristics can be found elsewhere [Paschke K, Sack PM, Thomasius R. Validity and psychometric properties of the internet gaming disorder scale in three large independent samples of children and adolescents. Int J Environ Res Public Health. Jan 26, 2021;18(3):1095. [CrossRef] [Medline]67].

Measures

To evaluate IGD symptoms as defined by DSM-V, we used the well-established Internet Gaming Disorder Scale (IGDS). This scale is a single-factor, polythetic tool comprising 9 questions with a binary response format (no/yes), with higher scores reflecting greater risk for IGD. It has been frequently used with German adolescent samples, showing good psychometric properties [Paschke K, Sack PM, Thomasius R. Validity and psychometric properties of the internet gaming disorder scale in three large independent samples of children and adolescents. Int J Environ Res Public Health. Jan 26, 2021;18(3):1095. [CrossRef] [Medline]67]. For the purposes of the descriptive results, the cutoff indicating disordered gamers is a score of at least 5 [Pontes HM, Griffiths MD. Measuring DSM-5 internet gaming disorder: development and validation of a short psychometric scale. Comput Human Behav. Apr 2015;45:137-143. [CrossRef]72]. In this sample, the Cronbach α score was 0.58. Potential reasons for this low score are provided in the “Strengths and Limitations” section in the “Discussion” section.

Sleep quality was assessed by administering the 9-item, validated Sleep Reduction Screening Questionnaire (SRSQ) [van Maanen A, Dewald-Kaufmann JF, Oort FJ, et al. Screening for sleep reduction in adolescents through self-report: development and validation of the Sleep Reduction Screening Questionnaire (SRSQ). Child Youth Care Forum. Oct 2014;43(5):607-619. [CrossRef]73]. The SRSQ measures chronic sleep reduction including its associated consequences, affecting everyday life across 9 questions with a 3-step ordinal scale. The SRSQ has been validated and used in various populations, including German adolescents, with good psychometric properties [Paschke K, Laurenz L, Thomasius R. Chronic sleep reduction in childhood and adolescence. Dtsch Arztebl Int. Oct 2, 2020;117(40):661-667. [CrossRef] [Medline]65,van Maanen A, Dewald-Kaufmann JF, Oort FJ, et al. Screening for sleep reduction in adolescents through self-report: development and validation of the Sleep Reduction Screening Questionnaire (SRSQ). Child Youth Care Forum. Oct 2014;43(5):607-619. [CrossRef]73]. Higher scores indicated more pronounced indications of poor sleep quality, with scores above 17.3 indicating chronic sleep reduction according to the Youden criterion reported elsewhere [Paschke K, Laurenz L, Thomasius R. Chronic sleep reduction in childhood and adolescence. Dtsch Arztebl Int. Oct 2, 2020;117(40):661-667. [CrossRef] [Medline]65]. In this sample, the Cronbach α score was 0.71.

The Strengths and Difficulties Questionnaire (SDQ) is a widely used screening tool for assessing behavioral and emotional difficulties in children and adolescents as well as a sensitive screener for ADHD-combined subtype [Pritchard A. The Strengths and Difficulties Questionnaire hyperactivity-inattention subscale is more sensitive for the ADHD-combined subtype than other subtypes in 7-9-year-old school children. Evid Based Ment Health. May 2012;15(2):34. [CrossRef] [Medline]74,Ullebø AK, Posserud MB, Heiervang E, Gillberg C, Obel C. Screening for the attention deficit hyperactivity disorder phenotype using the Strength and Difficulties Questionnaire. Eur Child Adolesc Psychiatry. Sep 2011;20(9):451-458. [CrossRef] [Medline]75]. In this study, we used the hyperactivity-inattention subscale of the SDQ to assess 2 core components of executive functioning: attentional control (inattention) and behavioral inhibition (hyperactivity or impulsivity). These domains are commonly impaired in individuals with IGD and are also core symptoms of ADHD, which is itself widely recognized as a disorder of executive dysfunction [Brown TE. Executive functions and attention deficit hyperactivity disorder: implications of two conflicting views. Intl J Disabil Dev Educ. Mar 2006;53(1):35-46. [CrossRef]32,Silverstein MJ, Faraone SV, Leon TL, Biederman J, Spencer TJ, Adler LA. The relationship between executive function deficits and DSM-5-defined ADHD symptoms. J Atten Disord. Jan 2020;24(1):41-51. [CrossRef] [Medline]33]. Executive dysfunction, in the context of this study, is operationally defined as difficulty regulating attention and behavior, as measured by self-reported inattentiveness and hyperactivity. While this subscale does not capture the full spectrum of executive functioning, it targets 2 key subdomains most relevant to an IGD population. Responses were rated on a 3-point Likert scale: “not applicable,” “partially applicable,” and “clearly applicable.” Higher scores indicate greater executive functioning problems. This subscale has been used in child psychiatric diagnostic settings and demonstrates satisfactory to good psychometric properties [Carballo JJ, Rodríguez-Blanco L, García-Nieto R, Baca-García E. Screening for the ADHD phenotype using the Strengths and Difficulties Questionnaire in a clinical sample of newly referred children and adolescents. J Atten Disord. Sep 2018;22(11):1032-1039. [CrossRef] [Medline]76-Muris P, Meesters C, van den Berg F. The Strengths and Difficulties Questionnaire (SDQ). Eur Child Adolesc Psychiatry. Feb 1, 2003;12(1):1-8. [CrossRef]78]. In this sample, the Cronbach α score was 0.62.

Data Analysis

We followed recommendations for hypothesizing and constructing mediation models and interpreting effects [Fairchild AJ, McDaniel HL. Best (but oft-forgotten) practices: mediation analysis. Am J Clin Nutr. Jun 2017;105(6):1259-1271. [CrossRef] [Medline]79-Zhang Z, Wang L, Tong X. Mediation analysis with missing data through multiple imputation and bootstrap. In: van der Ark L, Bolt DM, Wang WC, Douglas JA, Chow SM, editors. Quantitative Psychology Research Springer Proceedings in Mathematics & Statistics. Vol 140. Springer, Cham; 2015:341-355. [CrossRef]82]. To examine whether sleep quality mediates the effect of IGD symptoms on executive dysfunction, we used structural equation modeling and a nonparametric bootstrap method with bias-corrected CIs. Figure 1 shows the path diagram of the mediation models. As shown in Figure 1A, we tested the following effects: (1) effect of IGD symptoms on sleep quality (path a), (2) effect of sleep quality on executive function (path b), (3) indirect effect of IGD symptoms on executive functioning through sleep quality (path a×b), (4) direct effect of IGD symptoms on executive functioning, controlling for sleep quality (path c′), and (5) total effect, representing the overall effect of IGD symptoms on executive functioning (path a×b+c). An additional mediation model was run, reversing the predictor and outcome variables (Figure 1B).

Bootstrapping was used because it does not require the indirect effect (a×b) to be normally distributed, making it the preferred method to determine whether the indirect effect is different from zero [Zhang Z, Wang L, Tong X. Mediation analysis with missing data through multiple imputation and bootstrap. In: van der Ark L, Bolt DM, Wang WC, Douglas JA, Chow SM, editors. Quantitative Psychology Research Springer Proceedings in Mathematics & Statistics. Vol 140. Springer, Cham; 2015:341-355. [CrossRef]82,Zhang Z, Wang L. Methods for mediation analysis with missing data. Psychometrika. Jan 2013;78(1):154-184. [CrossRef] [Medline]83]. A significant indirect effect suggests at least partial mediation, meaning that sleep quality explains part of the relationship between IGD symptoms and executive functioning. If the direct effect is nonsignificant in the presence of a significant indirect effect, this indicates that the effect of the predictor on the outcome variable occurs entirely through mediating variables (ie, sleep quality). If the direct effect remains significant, sleep quality only partially explains this relationship (partial mediation).

Software R (version 4.2.2; R Foundation for Statistical Computing) was used for data cleaning and analysis. To account for missing data, multiple imputation was used for each model. We used 60 imputations as recommended by Zhang and Wang [Zhang Z, Wang L. Methods for mediation analysis with missing data. Psychometrika. Jan 2013;78(1):154-184. [CrossRef] [Medline]83] for the 21.6% missing data of 1 variable (IGDS) considered to be missing at random. The multiple imputation and mediation analyses were conducted using the bmem package (version 2.1; Comprehensive R Archive Network), which imputes missing data and runs the structural equation modeling in each of the 1000 bootstrap samples that were used in the analysis. To speed up the imputation, we recruited parallel computing with the number of cores set to 8. After obtaining the mediation effect estimates, bias-corrected CIs for the model parameters and mediation effects were constructed. To investigate the nature of the indirect effect, a simple slope analysis was conducted using the ggeffects package (version 1.6.0; Comprehensive R Archive Network), estimating marginal means (EMM) for different levels of sleep quality.

Figure 1. Hypothesized mediational models. In the first hypothesized mediation model (A), a represents the impact of Internet gaming disorder symptoms on sleep quality, while b represents the effect of sleep quality on executive functioning. The direct effect of Internet gaming disorder symptoms on executive functioning is denoted as c′. In model (B), the direction between Internet gaming disorder and executive functioning is reversed.

Table 1 displays descriptive results using complete data. Given nonnormality, bivariate correlations were used for gender and IGD. All main variables were positively related to each other, except for age (with no association with IGD and a negative association with executive functioning) and gender (with no association with executive functioning and a negative association with sleep quality). Along with the theoretical support of age and sex effects in IGD [Wartberg L, Kriston L, Zieglmeier M, Lincoln T, Kammerl R. A longitudinal study on psychosocial causes and consequences of Internet gaming disorder in adolescence. Psychol Med. Jan 2019;49(2):287-294. [CrossRef] [Medline]20,Marraudino M, Bonaldo B, Vitiello B, Bergui GC, Panzica G. Sexual differences in internet gaming disorder (IGD): from psychological features to neuroanatomical networks. J Clin Med. Feb 16, 2022;11(4):1018. [CrossRef] [Medline]84-Wang M, Hu Y, Wang Z, Du X, Dong G. Sex difference in the effect of Internet gaming disorder on the brain functions: evidence from resting-state fMRI. Neurosci Lett. Apr 17, 2019;698:44-50. [CrossRef] [Medline]86], this suggested that gender and age should be regarded as covariates in the next stage of analysis.

Of note, 2.4% (24/1000) of the sample met criteria for IGD, 87.5% (875/1000) who were male, consistent with research in the German adolescent population [Rehbein F, Kleimann M, Mössle T. Prevalence and risk factors of video game dependency in adolescence: results of a German nationwide survey. Cyberpsychol Behav Soc Netw. Jun 2010;13(3):269-277. [CrossRef] [Medline]7,Wartberg L, Kriston L, Thomasius R. Internet gaming disorder and problematic social media use in a representative sample of German adolescents: Prevalence estimates, comorbid depressive symptoms and related psychosocial aspects. Comput Human Behav. Feb 2020;103:31-36. [CrossRef]8]. Additionally, 22.6% (226/1000) of the sample met criteria for chronic sleep reduction according to Youden criteria. Of those who met the criteria for IGD, 54.2% (542/1000) also had chronic sleep reduction. A more detailed description of the demographic characteristics has been reported elsewhere [Paschke K, Laurenz L, Thomasius R. Chronic sleep reduction in childhood and adolescence. Dtsch Arztebl Int. Oct 2, 2020;117(40):661-667. [CrossRef] [Medline]65].

First, to evaluate the potential influence of missingness of data, we tested the same models with no imputations. We found negligible differences between the 2 analyses (ie, between missing and complete data). In the first model (Figure 2A), parameter estimates indicated that higher IGD symptoms were associated with poorer sleep quality. Poorer sleep quality was associated with reduced executive functioning. The indirect effects of sleep quality of IGD symptoms on executive functioning were different from zero with 95% CI. Controlling for the indirect effect of sleep quality, IGD remained associated with executive functioning.

In the reverse mediation model (Figure 2B), where executive dysfunction might lead to reduced sleep quality, which in turn could worsen IGD symptoms, the same variables remained significant. Of note, executive dysfunction had a greater association with poor sleep quality. Higher executive dysfunction scores remained associated with IGD symptoms when controlling for the indirect effect of sleep, although this effect was less pronounced compared with the first model. Overall, the results indicated that sleep quality partially mediates the relationship between executive dysfunction and IGD, given that both the indirect and direct effects were significant.

To investigate the nature of the indirect effect, a simple slope analysis was conducted. Participants were divided based on sleep quality levels, categorized as 1 SD above and below the mean. As shown in Figure 3, for those with poorer sleep quality (eg, higher scores), IGD symptoms predicted executive dysfunction (EMM 9.13, 95% CI 0.05-0.22). This prediction remained significant for those with average sleep quality, although the effect was reduced (EMM 0.09, 95% CI 0.02-0.17). In contrast, for those with better sleep quality, IGD symptoms no longer predicted executive dysfunction (EMM 0.06, 95% CI −0.05 to 0.17). Thus, the mediating effect of sleep quality between IGD and executive dysfunction diminished as sleep quality improved. Conversely, as sleep quality decreased, its contribution to mediating the relationship between IGD and executive dysfunction increased.

Table 1. Descriptives and correlation table.
VariableMean/%SDGender (male)AgeSDQaIGDSbSRSQc
Gender (male)53.9%
(539/1000)
d
r0.030.040.22e−0.03
P value.82.24<.001.001
Age14.521.64 – – – –
r0.03−0.13e0.030.15e
P value.82<.001.21.001
SDQa4.651.52
r0.04−0.13e0.13e0.10e
P value.24<.001<.001.001
IGDSb0.861.28
r0.22e0.030.13e0.13e
P value<.001.21<.001<.001
SRSQc16.022.28
r−0.030.15e0.10e0.13e
P value.001.001.001<.001

aSDQ represents the hyperactivity-inattention subscale of the Strengths and Difficulties Questionnaire.

bIGDS measures the severity of symptoms on the Internet Gaming Disorder Scale.

cSRSQ represents the Sleep Reduction Screening Questionnaire.

dNot available.

eCorrelation is significant at the .01 level (2-tailed).

Figure 2. Bootstrap mediation effects of hypothesized models. (A) The model with internet gaming disorder symptoms as the predictor and executive dysfunction as the outcome. (B) The model with executive dysfunction as the predictor and internet gaming disorder symptoms as the outcome. Path coefficients (in boldface) represent parameter estimates, with bootstrap SEs within parentheses. All models were adjusted for age and sex. The 95% CIs were derived from 1000 bootstrap samples, with 60 imputations used to account for missing data. a = Internet gaming disorder symptoms’ effect on sleep quality; b = Sleep quality’s effect on executive dysfunction; a×b = The indirect effect; c′ = Direct effect, controlling for sleep quality; and a×b+c = Total effect.
Figure 3. Exploring the indirect effect. Sleep quality categorized as 1 SD above and below the mean, mediating the relationship between IGD symptoms and executive dysfunction. IGD: internet gaming disorder.

Principal Findings

Research has demonstrated a relationship between IGD and executive dysfunction, indicating that IGD is associated with specific cognitive deficits in attention and hyperactivity or impulsivity. Additionally, both have been linked with poor sleep [Lowe CJ, Safati A, Hall PA. The neurocognitive consequences of sleep restriction: a meta-analytic review. Neurosci Biobehav Rev. Sep 2017;80:586-604. [CrossRef] [Medline]58,Wolfe J, Kar K, Perry A, Reynolds C, Gradisar M, Short MA. Single night video-game use leads to sleep loss and attention deficits in older adolescents. J Adolesc. Oct 2014;37(7):1003-1009. [CrossRef] [Medline]87-Zheng H, Wang M, Zheng Y, Dong GH. How sleep disturbances affect internet gaming disorder: the mediating effect of hippocampal functional connectivity. J Affect Disord. Mar 2022;300:84-90. [CrossRef]89]. However, the role of sleep as a potential mediator in the relationship between IGD and executive dysfunction remains unclear. We proposed that the current treatment models’ failure to consider sleep as a mediating factor limits their efficacy and overlooks a crucial link in this relationship. Therefore, the aim of this study was to investigate how sleep quality is related to IGD and executive dysfunction. Given the high prevalence of IGD among adolescents and the critical role of executive functioning in their development [King DL, Delfabbro PH, Zwaans T, Kaptsis D. Clinical features and axis I comorbidity of Australian adolescent pathological Internet and video game users. Aust N Z J Psychiatry. Nov 2013;47(11):1058-1067. [CrossRef] [Medline]15,Diamond A, Ling DS. Conclusions about interventions, programs, and approaches for improving executive functions that appear justified and those that, despite much hype, do not. Dev Cogn Neurosci. Apr 2016;18:34-48. [CrossRef] [Medline]41,Hackman DA, Gallop R, Evans GW, Farah MJ. Socioeconomic status and executive function: developmental trajectories and mediation. Dev Sci. Sep 2015;18(5):686-702. [CrossRef] [Medline]43,Paulus FW, Ohmann S, von Gontard A, Popow C. Internet gaming disorder in children and adolescents: a systematic review. Dev Med Child Neurol. Jul 2018;60(7):645-659. [CrossRef] [Medline]85], addressing potential negative impacts remains a key priority.

First, in comparing the strength of the parameter estimates of the 2 models (Figure 3), IGD symptoms appeared to be more strongly linked to sleep quality than executive dysfunction. When controlling for sleep quality, the association between executive dysfunction and IGD was stronger than the reverse. In both models, sleep quality partially mediated the relationship between executive dysfunction and IGD. Partial mediation suggests that while sleep quality accounts for some of the variance in executive dysfunction among individuals with IGD, additional factors—such as reward system dysfunction [Li Q, Wang Y, Yang Z, et al. Dysfunctional cognitive control and reward processing in adolescents with internet gaming disorder. Psychophysiology. Feb 2020;57(2):e13469. [CrossRef] [Medline]90], psychological inflexibility [Yang X, Ebo TO, Wong K, Wang X. Relationships between psychological flexibility and internet gaming disorder among adolescents: mediation effects of depression and maladaptive cognitions. PLoS One. Feb 2023;18(2):e0281269. [CrossRef]91], and attentional biases [Kim M, Lee TH, Choi JS, et al. Dysfunctional attentional bias and inhibitory control during anti-saccade task in patients with internet gaming disorder: an eye tracking study. Prog Neuropsychopharmacol Biol Psychiatry. Dec 20, 2019;95:109717. [CrossRef] [Medline]92]—may also contribute to this relationship. The results of this study indicated that sleep quality may be an important mediatory mechanism when considering the relationship between IGD and executive dysfunction. This is especially relevant, given that more than half of the participants who met criteria for IGD had comorbid chronic sleep reduction, consistent with other research findings [Kristensen JH, Pallesen S, King DL, Hysing M, Erevik EK. Problematic gaming and sleep: a systematic review and meta-analysis. Front Psychiatry. 2021;12:675237. [CrossRef] [Medline]53].

Overall, these findings suggest that the relationship between IGD, executive dysfunction, and sleep quality may operate via a reciprocal feedback loop, with each affecting the other. In other words, IGD can produce poor sleep quality, which in turn can lead to worse executive dysfunction, resulting in a feedback loop. This aligns with previous research demonstrating the reciprocal nature of executive dysfunction and IGD [Thorell LB, Burén J, Ström Wiman J, Sandberg D, Nutley SB. Longitudinal associations between digital media use and ADHD symptoms in children and adolescents: a systematic literature review. Eur Child Adolesc Psychiatry. Aug 2024;33(8):2503-2526. [CrossRef] [Medline]48,Ioannidis K, Grant JE, Chamberlain SR. Problematic usage of the internet and cognition. Curr Opin Behav Sci. Apr 2022;44:101104. [CrossRef]93,Vally Z. Symptoms of internet gaming disorder, inattention, and impulsivity: a cross-sectional study conducted in the United Arab Emirates. Psychiatr Q. Mar 2021;92(1):301-310. [CrossRef] [Medline]94], and, novelly, highlights the role of sleep as a significant mediator.

Categorizing the level of sleep quality allowed us to qualify the nature of its mediation. Specifically, we found that at higher levels of sleep quality, IGD symptoms did not significantly predict executive dysfunction. Conversely, at lower levels of sleep quality, the prediction stood. This suggests that good sleep quality appears to mitigate the impact of IGD on executive dysfunction. Therefore, improving sleep quality may potentially buffer against the negative effects of IGD and executive dysfunction. By extension, identifying poor sleep quality early can help target those at greater risk of compounded symptoms.

Implications

These findings have several practical and theoretical implications. Previous studies have linked poor sleep status, including reduction in sleep quality, with IGD [Kristensen JH, Pallesen S, King DL, Hysing M, Erevik EK. Problematic gaming and sleep: a systematic review and meta-analysis. Front Psychiatry. 2021;12:675237. [CrossRef] [Medline]53]; however, few current treatment programs include sleep as a factor for improvement [Paschke K, Cloes JO, Thomasius R. Res@t: resource-strengthening training for adolescents with problematic digital-media use and their parents. Sucht. Apr 2023;69(2):75-85. [CrossRef]95-Zajac K, Ginley MK, Chang R, Petry NM. Treatments for internet gaming disorder and internet addiction: a systematic review. Psychol Addict Behav. Dec 2017;31(8):979-994. [CrossRef]98]. Similarly, sleep issues may not always be generally considered in screening procedures. This is despite the evidenced sleep issues among individuals with IGD, including disruptions to the circadian clock [Touitou Y, Touitou D, Reinberg A. Disruption of adolescents’ circadian clock: the vicious circle of media use, exposure to light at night, sleep loss and risk behaviors. J Physiol Paris. Nov 2016;110(4 Pt B):467-479. [CrossRef] [Medline]99], increased sleep latency, and decreased total rapid eye movement sleep [Higuchi S, Motohashi Y, Liu Y, Maeda A. Effects of playing a computer game using a bright display on presleep physiological variables, sleep latency, slow wave sleep and REM sleep. J Sleep Res. Sep 2005;14(3):267-273. [CrossRef] [Medline]100].

From a preventative standpoint, patients presenting with IGD may benefit from a routine assessment of sleep quality during triage, such as the SRSQ or the Sleep Screening Questionnaire Children and Adolescents [Paulsrud C, Thorsen SU, Helms P, et al. Validation of the newly developed Sleep Screening Questionnaire Children and Adolescents (SSQ-CA) with objective sleep measures. Sleep Med. Dec 2023;112:359-367. [CrossRef] [Medline]101]. Regarding treatment, interventions aimed at improving sleep quality, such as cognitive-behavioral therapy for insomnia, sleep hygiene education, and relaxation techniques, may be particularly beneficial for individuals with IGD and executive dysfunction [Chung KF, Lee CT, Yeung WF, Chan MS, Chung EWY, Lin WL. Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis. Fam Pract. Jul 23, 2018;35(4):365-375. [CrossRef] [Medline]102-Rossman J. Cognitive-behavioral therapy for insomnia: an effective and underutilized treatment for insomnia. Am J Lifestyle Med. 2019;13(6):544-547. [CrossRef] [Medline]105]. For instance, programs such as Res@t (Resource-Strengthening Training for Adolescents with Problematic Digital-Media Use) include structured guidance on optimizing sleep routines, such as minimizing screen exposure before bedtime, establishing consistent sleep-wake schedules, and implementing behavioral techniques to reinforce healthier sleep habits [Paschke K, Cloes JO, Thomasius R. Res@t: resource-strengthening training for adolescents with problematic digital-media use and their parents. Sucht. Apr 2023;69(2):75-85. [CrossRef]95]. Ensuring adequate and restful sleep may also reduce the risk of developing or exacerbating IGD and executive dysfunction. The bidirectional nature of these relationships underscores the importance of considering multiple factors in management and treatment of IGD.

Ensuring that patients and their families receive psychoeducation regarding the importance of good sleep hygiene and its impact on mental health may help prevent the exacerbation of IGD symptoms and executive dysfunction. Encouraging healthy lifestyle habits that promote better sleep (eg, regular sleep schedules, reduced screen time, physical activity, and blue light filters before bed) can serve as preventive and mitigating measures [Brown TM, Brainard GC, Cajochen C, et al. Recommendations for daytime, evening, and nighttime indoor light exposure to best support physiology, sleep, and wakefulness in healthy adults. PLoS Biol. Mar 2022;20(3):e3001571. [CrossRef] [Medline]106-Perrault AA, Bayer L, Peuvrier M, et al. Reducing the use of screen electronic devices in the evening is associated with improved sleep and daytime vigilance in adolescents. Sleep. Sep 6, 2019;42(9):zsz125. [CrossRef] [Medline]109]. This can be in addition to psychoeducation regarding the impacts of the sedentary lifestyle, repetitive microtrauma, and obesogenic environment that can accompany excessive gaming and may lead to pathological musculoskeletal injury and a decline in general health status [Satish Kumar C, Sharma MK, Amudhan S, et al. Digital gaming, musculoskeletal, and related health hazards among adolescents and young adults. Indian J Psychiatry. 2023;65(6):698-700. [CrossRef]110].

Finally, impacts on executive functioning are a common finding across addictions. Dysregulated reward processing, diminished impulse control, and aberrant reward-based learning linked to IGD have been similarly found in individuals with gambling disorder [Dieter J, Hoffmann S, Mier D, et al. The role of emotional inhibitory control in specific internet addiction—an fMRI study. Behav Brain Res. May 1, 2017;324:1-14. [CrossRef] [Medline]111-Luijten M, Meerkerk GJ, Franken IHA, van de Wetering BJM, Schoenmakers TM. An fMRI study of cognitive control in problem gamers. Psychiatry Research: Neuroimaging. Mar 2015;231(3):262-268. [CrossRef]114] and substance use disorders [Warburton WA, et al. Submission to the joint select committee on social media and Australian society. 2024. URL: https:/​/www.​mentalhealthcommission.gov.au/​sites/​default/​files/​2024-07/​submission-to-the-joint-select-committee-on-social-media-and-australian-society.​pdf [Accessed 2025-06-17] 19,Kuss DJ, Pontes HM, Griffiths MD. Neurobiological correlates in internet gaming disorder: a systematic literature review. Front Psychiatry. 2018;9:166. [CrossRef] [Medline]44]. Given the partial mediation observed, interventions should consider a multipronged approach that not only addresses sleep hygiene but also directly targets executive function impairments. This ensures that improvements in sleep are supplemented by interventions that target the residual cognitive deficits that persist even when sleep is optimized. Future research could also investigate whether sleep quality, like its role in IGD and executive function, may serve as a potential mediator in other types of addictions.

Strengths and Limitations

Whereas previous studies investigating IGD are often hindered by small and heterogeneous samples with a lack of focus on possible mediation [Moshel ML, Warburton WA, Batchelor J, Bennett JM, Ko KY. Neuropsychological deficits in disordered screen use behaviours: a systematic review and meta-analysis. Neuropsychol Rev. Sep 2024;34(3):791-822. [CrossRef] [Medline]26,Thorell LB, Burén J, Ström Wiman J, Sandberg D, Nutley SB. Longitudinal associations between digital media use and ADHD symptoms in children and adolescents: a systematic literature review. Eur Child Adolesc Psychiatry. Aug 2024;33(8):2503-2526. [CrossRef] [Medline]48], the large sample size in this study is representative of the general population of children and adolescents. Second, the application of bootstrap structural equation modeling to examine mediation, along with multiple imputation to address missing data, follows the latest recommendations for using advanced statistical methods for mediation models [Fairchild AJ, McDaniel HL. Best (but oft-forgotten) practices: mediation analysis. Am J Clin Nutr. Jun 2017;105(6):1259-1271. [CrossRef] [Medline]79-Zhang Z, Wang L, Tong X. Mediation analysis with missing data through multiple imputation and bootstrap. In: van der Ark L, Bolt DM, Wang WC, Douglas JA, Chow SM, editors. Quantitative Psychology Research Springer Proceedings in Mathematics & Statistics. Vol 140. Springer, Cham; 2015:341-355. [CrossRef]82].

Along with its strengths, there are several limitations to consider in this study. The Cronbach α scores for 2 implemented measures (IGDS and SDQ) were lower than usual. As the alpha coefficient reflects both the properties of the scale and the attributes of the sample, unique characteristics in the sample may have contributed to these lower coefficients [Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Res Sci Educ. Dec 2018;48(6):1273-1296. [CrossRef]115]. For example, it is possible that because the questionnaire was administered over the phone instead of being self-administered, which is the more typical method, respondents might have answered more cautiously to the interviewers in an effort to appear more socially normative or desirable. Supporting this, Jeong et al [Jeong H, Yim HW, Lee SY, et al. Discordance between self-report and clinical diagnosis of Internet gaming disorder in adolescents. Sci Rep. Jul 4, 2018;8(1):10084. [CrossRef] [Medline]116] found a significant discrepancy between self-reported measurements and clinically verified IGD diagnoses among adolescents, with a false-negative rate of 44%. Thus, while the internal consistency of the scales should be interpreted with some caution, it may also be that effects of interest were understated in this sample, and that future studies may find stronger effects. It should also be noted that these 2 scales are widely and successfully used. For example, the IGDS has good established psychometric properties in similar populations [Wartberg L, Kriston L, Zieglmeier M, Lincoln T, Kammerl R. A longitudinal study on psychosocial causes and consequences of Internet gaming disorder in adolescence. Psychol Med. Jan 2019;49(2):287-294. [CrossRef] [Medline]20,Wartberg L, Kriston L, Kramer M, Schwedler A, Lincoln TM, Kammerl R. Internet gaming disorder in early adolescence: associations with parental and adolescent mental health. Eur Psychiatry. Jun 2017;43:14-18. [CrossRef] [Medline]117], and the SDQ, one of the most widely used measures of child mental health globally, has been translated into 80 languages [Strengths and difficulties questionnaire (SDQ). Child Outcomes Research Consortium. URL: https://www.corc.uk.net/outcome-experience-measures/strengths-and-difficulties-questionnaire-sdq/ [Accessed 2024-09-30] 118]. Although the hyperactivity-inattentive subscale on the SDQ has shown promise as a short and efficient screener for executive dysfunction [Ullebø AK, Posserud MB, Heiervang E, Gillberg C, Obel C. Screening for the attention deficit hyperactivity disorder phenotype using the Strength and Difficulties Questionnaire. Eur Child Adolesc Psychiatry. Sep 2011;20(9):451-458. [CrossRef] [Medline]75,Algorta GP, Dodd AL, Stringaris A, Youngstrom EA. Diagnostic efficiency of the SDQ for parents to identify ADHD in the UK: a ROC analysis. Eur Child Adolesc Psychiatry. Sep 2016;25(9):949-957. [CrossRef] [Medline]119], future research should also consider using more comprehensive measures such as full neuropsychological batteries that test a range of executive components. Given that ADHD-related symptoms are typically assessed through teacher or parent reports, future studies should incorporate multi-informant assessments. Additionally, future research should also include objective measures of sleep quality, such as actigraphy or polysomnography, instead of relying solely on self-reports, as was the case in this study. The cross-sectional nature of the data limits the ability to infer longitudinal relationships between variables. Therefore, it remains unclear, for instance, whether executive dysfunction leads to the development of IGD or vice versa; only that a relationship exists between these variables. Future longitudinal studies incorporating multimethod sleep assessments will be needed to establish causality. The generalizability of these results is limited to teenagers. Given the vulnerability of children to IGD and the importance of early intervention [Werling AM, Kuzhippallil S, Emery S, Walitza S, Drechsler R. Problematic use of digital media in children and adolescents with a diagnosis of attention-deficit/hyperactivity disorder compared to controls. A meta-analysis. J Behav Addict. May 13, 2022;11(2):305-325. [CrossRef] [Medline]49,Sugaya N, Shirasaka T, Takahashi K, Kanda H. Bio-psychosocial factors of children and adolescents with internet gaming disorder: a systematic review. Biopsychosoc Med. 2019;13:3. [CrossRef] [Medline]63,Paulus FW, Ohmann S, von Gontard A, Popow C. Internet gaming disorder in children and adolescents: a systematic review. Dev Med Child Neurol. Jul 2018;60(7):645-659. [CrossRef] [Medline]85], it would be beneficial to determine the strength of the tested mediation models in a younger population.

Conclusions

Recent years have seen a rise in the prevalence of problematic digital media behaviors among adolescents. Executive dysfunction has been associated with IGD, and sleep impairment is also common among adolescents with IGD. The findings of this study align with previous research linking these variables. However, this study’s novelty lies in suggesting that sleep quality can act as a partial mediator between IGD and executive dysfunction. This has significant clinical implications, emphasizing the need to screen for sleep issues as a preventative strategy and to address sleep quality in intervention approaches. Future research is needed to determine the temporal directionality of the relationship between IGD, sleep, and executive functioning incorporating objective sleep measures and comprehensive neuropsychological batteries. Experimental research could also test the effectiveness of sleep-focused interventions in improving cognitive outcomes and reducing IGD symptoms.

Acknowledgments

The authors declare no competing financial interests. They acknowledge financial support from the Open Access Publication Fund of UKE-Universitätsklinikum Hamburg-Eppendorf. Research conducted by MLM is supported by a Deutscher Akademischer Austauschdienst (DAAD) scholarship. The study was supported by funds from the German health insurance company DAK-Gesundheit, which had no influence on study design, data collection, analyses, interpretation, manuscript writing, or the decision for publication.

Data Availability

The data supporting this study are part of an ongoing large study on digital media use in adolescence. Access to the data may be granted after the study is completed and on individual request and with appropriate permissions from the relevant ethics subcommittee.

Authors' Contributions

MLM conceptualized and designed this study, analyzed and carried out the analyses, and wrote the manuscript. KP conceptualized and designed the larger study on adolescent digital media consumption this substudy, supervised the analyses and result presentations, and critically reviewed and revised the manuscript. WW and RT critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Conflicts of Interest

None declared.

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ADHD: attention-deficit/hyperactivity disorder
DSM-V-TR: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision
EMM: estimating marginal means
GD: gaming disorder
ICD-11: International Classification of Diseases, Eleventh Revision
IGD: internet gaming disorder
IGDS: Internet Gaming Disorder Scale
SDQ: Strengths and Difficulties Questionnaire
SRSQ: Sleep Reduction Screening Questionnaire


Edited by Javad Sarvestan; submitted 09.11.24; peer-reviewed by Hyunchan Hwang, Kunru Song, Valeria Saladino; final revised version received 04.04.25; accepted 04.04.25; published 09.07.25.

Copyright

© Michoel L Moshel, Wayne Warburton, Rainer Thomasius, Kerstin Paschke. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 9.7.2025.

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