Harnessing the Power of Gaming to Combat the Youth Mental Health Crisis by Ruderman Family Foundation

Harnessing the Power of Gaming to Combat the Youth Mental Health Crisis: A Guide For Stakeholders to Support the Mental Well-being of Youth and Young Adult Gamers

October 2023 Sierra Smith, BS Research Associate Melissa Dunn Silesky, MPH Associate Director of Research Erika Bonnevie, MA Senior Director of Research MaryJane Karp, MPH Media Monitoring Analyst

Executive Summary The escalating youth mental health crisis demands immediate attention and innovative approaches to support young people. Despite the immensity of this issue, most youth do not receive mental health treatment. Gaming provides one avenue to reaching this population, as it is a hobby that is enjoyed by the majority of U.S. youth (71%). However, there is a need for more information on how to use gaming to support the mental health of youth and young adults in a culturally competent way. To fill this gap, the Ruderman Family Foundation commissioned the Public Good Projects (PGP) to understand the role that gaming plays in the mental health of youth and young adult gamers. This report contains the findings from a multi-phased investigation that consisted of a literature review; 22 interviews with youth and young adult gamers, researchers, clinicians, and developers from across the US; and an analysis of Reddit conversations on gaming and mental health. This report identifies the role that gaming companies, mental health professionals, researchers, trusted adults in young gamers' lives, and even gamers themselves can play in making the gaming space a more supportive environment for youth and young adult gamers’ mental health. The following recommendations have been drawn from key findings across all research activities.

Recommendations for Gaming Companies Acknowledge and Prioritize Mental Health: Gaming companies wield substantial influence by shaping gamers’ experiences through their design, player interactions, live events, and the behavioral norms established within their creations. Gaming companies should use their influence to speak publicly about mental health and allocate funds specifically to support the mental health of their players. In addition to demonstrating that companies care about their players, promoting mental health can help foster a more loyal and engaged customer base, as it can support players who are trying to cope with external stressors that may impact their gameplay. Create and Share Resources: Gaming companies should share mental health tips and education and healthy gaming practices. They can utilize existing resources, such as promotions of hotlines or mental health organizations, or uniquely created resources. Gaming companies should share these resources directly in games, in content warning labels, in game or gaming systems’ lobbies, on social media, and through streamer advocacy and sponsorship. Resources should feel authentic and genuine and have an appropriately serious tone. Create a Standardized Warning System: It is important that gamers and trusted adults can make informed decisions about the type of content to which they are willing to be exposed. There is currently no standardized regulatory body overseeing video game content warning labels. Therefore, gaming companies should utilize existing systems, like the Entertainment Software Rating Board’s (ESRB) rating system, to make sure that clear descriptions of game content are consistently applied across different games. Prevent Toxicity: Because toxicity is widely believed to be encouraged by the anonymous nature of games, gaming companies can require gamers to connect profiles to real-life accounts to help hold people accountable for their actions. Companies can also incentivize positivity by rewarding players for good sportsmanship or employing a moral component to games. If appropriate, companies should also give the option for players to create private servers. Address Toxicity After It Happens: Mute features should allow users to completely block all forms of contact from a toxic player, not just direct messages. This includes blocking messages in the general chat and prewritten messages. Mute features should also be designed to make targets of harassment feel empowered, rather than like they are being punished by having to miss out on aspects of gameplay. When it comes to reporting, gaming companies need to provide a clear and easy-to-use reporting system for harassment, and take action quickly and transparently. Game companies should also avoid requiring multiple people to report a player before taking action. PAGE 1

Recommendations for Nongamers Reframe Misconceptions About Gaming: Gaming is a central hobby in the lives of many gamers. Although gaming can become a problematic distraction in some instances, for most, gaming is a healthy coping mechanism, a tool to help gamers feel accomplished and develop skills such as teamwork, leadership, and perseverance. Gaming is also a way to deepen existing relationships and meet new people. Nongamers should avoid making negative comments about gaming, as it can evoke feelings of shame, misunderstanding, and isolation. Learn About Their Games: To learn more about the games your gamer is playing, seek out resources such as the ESRB’s Family Gaming Guide and read game reviews before buying games. Caregivers should play the games with their kids to understand what they will be doing and seeing firsthand. Finally, talk about online safety to help them make their own informed decisions about gaming. Support Healthy Gaming Habits: Trusted adults play an important role in helping youth develop healthy gaming habits. When it comes to setting boundaries and limiting gameplay, adults should take a harmreduction approach, not an abstinence approach. This means setting timers, utilizing screen time controls, keeping gaming devices outside of the bedroom, allowing gaming after other priorities or activities are done, and keeping school and play computers separate, if possible. Furthermore, to help prevent toxicity, it is important to discuss the repercussions that words and behaviors can have on others, even when they are said in an online context.

Recommendations for Gamers Practice Healthy Gaming Habits: While game developers and nongamers work to make gaming a better place for youth mental health, there are immediate steps that gamers can take to safeguard their own wellbeing. Gamers can start by creating a designated time to game, such as after completing other priorities. Taking breaks is important, whether after a certain amount of time spent gaming, when emotions get heated, or from certain games altogether. This last point is especially important for esports players in their offseason to prevent burnout. Prevent and Address Toxicity: To avoid toxicity, gamers can try to play with people they know in private groups or servers. If playing with people they know is not possible, gamers can seek out new people to game with in social media spaces that have been created for people of similar demographics and life experiences. To address toxicity, gamers should speak up when they hear something and report what they witnessed. It’s also important that gamers understand what toxicity means, and avoid being the source of it.

Recommendations for Strategic Partnerships Researchers and Mental Health Professionals: Gaming companies should partner with researchers and mental health professionals to understand the experiences and mental health challenges their players face and identify the best course of action for addressing them, whether that be through providing resources, modifying existing design elements, or creating design elements. Fortunately, there are already professionals and organizations, such as Take This and Healthy Gamer, which specialize in this space. Schools and Parent Organizations: Gaming companies should partner with schools and parent organizations to help nongamers understand the important role that gaming plays in the lives of many young gamers and to combat negative stereotypes. Gamers: Gaming companies should partner with their own players to understand their perspectives, feelings, and needs related to mental health. Gamers can provide valuable perspectives on how to create supportive and accommodating game designs and experiences.

“Video gaming is a powerful tool that is in its infancy. It can be a tool for benefit and it can be a tool for detriment. The worst thing that we can do, in my opinion, is just slam the door and say, ‘Don't do it.’ And the best thing that we can do is provide more research.” -Dr. Kristy Custer PAGE 2

Table Of Contents 04

Introduction

Methods

Why Gamers Play

Gaming and Mental Health

Recommendations for Gaming Companies

Recommendations for Nongamers

Recommendations for Gamers

Recommendations for Strategic Partnerships

Conclusions

References PAGE 3

Introduction The escalating youth mental health crisis demands immediate attention. An alarming 42% of U.S. high school students report persistent feelings of sadness or hopelessness. Yet mental health treatment frequently remains underutilized– most U.S. youth experiencing major depression haven’t received any mental health treatment. This sobering reality underscores the need to find innovative ways to support the mental health of young people in places where they already spend their time. Enter the gaming community. Gaming is a global phenomenon, with over 3.2 billion people gaming worldwide, more than the number of people who use online streaming services. In the U.S. alone, there were 215.5 million active gamers in 2022, including 71% of U.S. youth under 18 years old. As the youth mental health crisis surges in tandem with the growing popularity of gaming, it's increasingly apparent that gaming has the potential to provide support for the mental well-being of players. But where should gaming companies, social platforms, gamers, and nongamers begin? In 2023, the Ruderman Family Foundation commissioned The Public Good Projects to study this question and identify opportunities in the gaming space. We undertook a multiphase investigation, including 22 interviews with gamers, researchers, clinicians, and developers from across the US. We also explored Reddit conversations on gaming and mental health, to understand the concerns, experiences, and challenges that gamers express online. Gaming has the tremendous potential to change the mental health trajectory of millions of young people, and this report serves as a starting guide for doing so.

What is Gaming? “Gaming” refers to the activity of playing video or electronic games using a console, phone, computer, or other device. “Gamer” is a nuanced term that refers to people who play single-player, multiplayer cooperative, or competitive games, and those who watch games. In multiplayer games, people can interact with each other through voice or chats within games or on external social platforms like Discord. People can play various roles in the gaming world: moderators are hired or volunteer to ensure gamers adhere to the standards and rules of the game, and streamers broadcast gameplay through a recorded video or live stream for others to watch on platforms like Twitch and YouTube (6). “Esports” is an increasingly popular form of gaming and has many similarities to traditional youth and professional sports leagues. Esports are competitive, have set rules, and are organized by a rule-enforcing body (7). There are now over five hundred collegiate esports programs in the U.S., with many of them offering scholarships to esports players (6). *For the purpose of this paper, we use “gaming companies” to refer to game developers (who design and create games) and game publishers (who sell and market games). We use “social platforms” to refer to streaming and social media platforms.

PAGE 4

Methods To understand current perspectives on gaming and mental health, we undertook a mixed methods approach using qualitative interviews and quantitative analysis of social listening data from Reddit. We conducted 22 semi-structured virtual interviews with individuals in two priority groups gaming professionals, including leaders in the field of gaming research, professionals working at gaming organizations and gaming companies, psychologists, and those involved in esports; and youth and young adult gamers, or those who play online multiplayer games at least two times a week, are between the ages of 13 and 30 years old, and are currently enrolled in school. Interviews focused on various aspects of gaming and mental health including the roles that gaming and the gaming community play in mental health; how the mental health of gamers can be better supported; and challenges, risks, and opportunities to engage in mental health-related work in this space. Interviews were conducted between June - August 2023. The interviewees consisted of 12 gamers and 10 gaming professionals. Gamers included those who play multiplayer games and esports. For the context of this report, “multiplayer games” refers to multiplayer games played in a casual or recreational context (not professional). Of gamers, 58% were male-identifying, 34% were female-identifying, and 8% were non-binary identifying. Of gamers, 67% were in college, 17% were in high school, 8% were in middle school, and 8% were in trade school. Interviewees ranged from 13 to 29 years old. Among professionals, 40% were maleidentifying, 50% were female-identifying, and 10% were non-binary identifying. Professionals had expertise from across the gaming industry, including clinical psychology (30%), research (60%), working for a game development studio or had experience in game design (40%), esports coaching (10%), developing a school esports program (20%), professional esports gaming (10%), streaming (20%), and working at a gamer-focused nonprofit (70%). Most professionals had multiple affiliations; therefore, percentages exceed 100%. To complement qualitative data, we used PGP’s established social listening methods to analyze publicly available conversations about gaming and mental health on Reddit. We chose Reddit specifically because of its large community of young adult gamers and popular subreddits dedicated to open conversations about gaming and mental health. While much of the conversation on Reddit shows positive views towards gaming’s impacts, we focused specifically on identifying negative conversations concerning gaming and mental health. To analyze data, we created a complex search query to collect public conversations on Reddit that discussed both gaming and mental health. We then hand-coded the top 200 conversations related to worsening mental health and gaming to understand young adults’ top concerns around their own gaming and mental health and to raise potential solutions to address those concerns.

PAGE 5

Why Gamers Play Before delving into the opportunities for gaming to positively impact mental health, we must first step back and examine the motivations behind gaming, and the broader implications that it has on overall well-being. Most of the gamers we interviewed told us that they gamed to have fun, relax, and be immersed in something. Their mood is often a key factor in deciding which game to play on a given day. Some like to play building games when they’re feeling creative, others prefer games with mundane elements like farming or exploring when they want to decompress, and some play high-intensity multiplayer games when they want to feel challenged or release frustration. Dr. Kelli Dunlap, Community Director at Take This and a video game psychologist and game designer, explained, Whatever it is that somebody is seeking, is the kind of game they're going to go find. If they're bored, they're going to seek a more action and adventure type of game. If they're overwhelmed, they're going to seek more cozy games where everything's calm. If their life is chaotic, they're going to try and find a game where they can have a lot of control. If their real life is incredibly controlling, they're probably going to go to games that have more escapist, free-form expression. Consistent with previous research, in most interviews and 25% of Reddit posts, we found that games are also important coping mechanisms for challenges outside the gaming world. Our interviewees said gaming was a coping mechanism to deal with everything from stress about tests at school to feelings of rejection to family members arguing. Gaming as a coping mechanism was especially prevalent during the COVID-19 pandemic. As Andrew Phelps, Professor & Director of the American University Game Center, explained,

“When we locked everybody in their houses for two years they really needed some social connection. And cohesion and playing online together became a way for a lot of people to deal with some of the loneliness, panic, and anxiety that was being caused by [COVID-19].” Collin*, a 29-year-old gamer, also said that gaming had helped him get through his military deployments, “It’s just a way of passing time to deal with the mundane nature of living in a ship, day in, day out, working 12 hours on 12 hours off. Games helped a lot.” The immersion and consuming focus that games demand allows gamers to disconnect from their present concerns, and focus on something other than their daily life. While many of the gamers we spoke with use gaming as a productive means of managing negative emotions or eliciting positive ones, it's important to note not all gamers are aware of the ways that games impact them. Max, a 21-year-old-gamer, talked about how self-reflection is important in deciding whether to game and which games to play: “If you played the game for 3 hours, but you didn't have fun the entire time and just came out of it angry, it wasn’t the escape it was supposed to be and that's something you need to talk about, or at least reflect on.” Some Reddit users talked about how they rage quit gaming, or that they were experiencing ‘rank anxiety,’ associated with maintaining their in-game ranking status. *For the sake of anonymity, we have assigned pseudonyms to all gamers we interviewed. Their demographic information, such as age and gender, are unchanged. We have used the real names and affiliations of the professionals we interviewed, with their permission.

PAGE 6

Regardless of whether gamers are aware of the positive or negative emotional impacts of gaming, it holds an important place in the lives of young people. The current task at hand is understanding how to harness this immensely popular platform as a positive force in their mental well-being.

Skill Development Both the existing research and our own investigation show the pivotal role that games can play in fostering personal growth. Previous studies have found gaming to be an effective tool in helping gamers improve their teamwork and leadership skills. Repeated failures encourage problem-solving, develop resiliency, and help gamers learn how to manage difficult emotions like frustration. Gaming can also result in

“I've never seen anything like it. Kids fail, and fail, and fail, and what do they keep doing… they keep getting up, and they keep trying again.” -Dr. Kristy Custer

feelings of accomplishment and higher self-esteem. Alyssa, a 15-year-old gamer, told us, “I felt really good about completing the Pokemon game because I didn’t know I was the person who could do things. It's the same as completing a project… It's that feeling that really boosts your confidence in yourself and it makes you feel good knowing you did something.” These skills– resilience, leadership, and commitment– are essential elements of a young person’s growth, learned and honed through experience. Dr. Kristy Custer, President of Educational Innovation for Generation Esports, sees gaming as an ideal medium to teach these skills, “I've never seen anything like it. Kids fail, and fail, and fail, and what do they keep doing… they keep getting up, and they keep trying again.”

Social Connection Although gaming has been historically plagued by antisocial stereotypes, the overwhelming majority of U.S. gamers (83%) play with others. Gaming creates a space that gathers people who have similar interests and goals, which can foster new relationships and deepen existing ones. Everyone we interviewed said that games are a tool for social connection, often with friends or family. Gamers said that conversations they have during games are comparable to, or even better than, their in-person conversations. This could be because of the unique environment that gaming provides, and the freedom gamers have to bond and express their emotions within the context of the game, instead of face-to-face conversations which can leave them feeling vulnerable. This point is also supported by research which found that 55% of gamers said that gaming has helped them develop deeper relationships with others. Gaming also creates new connections: 61% of U.S. gamers say that they have met people through gaming that they otherwise would not have met. Two interviewees brought up that many of their gaming friends are their closest friends, despite living across the country from each other and having only met in person a few

PAGE 7

times. Likewise, Reddit users often said that they game specifically as a way to make new friends. According to Max, “If I didn't have video games as that outlet, I wouldn't have all of the friends or the relationships that I have today.” Gaming allows players to bond over something common, despite being in separate locations. This can be particularly important for specific groups, like those who are LGBTQIA+ or differently abled, who

“If I didn't have video games as that outlet, I wouldn't have all of the friends or the relationships that I have today.” -Max

may have a hard time finding people with similar life experiences in their area. Most interviewees said that the gaming community is inclusive and supportive when people are playing with others they don’t know. They attributed this feeling to gaming’s relatively low barrier to entry. People of various ages, backgrounds, physical abilities, and neurodivergence can have a shared experience without being in the same location. As Dr. Custer indicated, “It's a very diverse demographic that plays video games. You got your goth kids with your jock kids, with your popular kids, and your unpopular kids. Everybody fits in when it comes to video games.” Gaming allows people to be identified more by their achievements in the game than by their differences outside of it.

Gaming and Mental Health About half of interviewees reported hearing discussions about mental health within the gaming community. These conversations mostly happened outside of the game itself, taking place on social platforms like Twitch and YouTube. On these platforms, streamers in particular are starting to use their influence to raise awareness about mental health conditions and share their personal experiences. Annie, a 21-year-old gamer felt that, “Nowadays a lot of streamers are pretty open about their mental health, and even people that I know face to face. A good eight out of ten of my friends have it [mental health struggles].” In 2018, Twitch called on streamers to talk about mental health and share resources with their viewers for Mental Health Awareness Month. Several streamers have also hosted charity streams, which typically involve streamers playing a game or completing a challenge to raise awareness and funds for a charity of their choice. In 2021, streamers Harpo Gaming and J03 Live founded Streamers for Mental Health, which is an organization that encourages streamers to use their channels to raise funds and awareness for emotional and mental health. Interviewees felt that people were generally supportive of these disclosures, though there were occasional negative reactions. According to interviewees and previous studies, there are various factors that can influence reactions and acceptability of streamers’ discussions of mental health. First, different streamers have different topics that they focus their channels on. Like video games, viewers often choose which streams to watch based on their mood. This means that a channel or segment that is primarily focused on mental health is more likely to receive positive feedback about a mental health discussion than a channel or segment that is dedicated to gameplay and strategy because viewers are aware or are intentionally choosing to enter a space where they know mental health will be discussed. However, this is nuanced as one study found that some viewers didn’t mind when streamers discussed mental health, as long as it did not negatively affect their gameplay, while others did not want to see mental health discussed on certain channels at all. PAGE 8

Third, previous research and our own study found that people often feel put off if they believe a streamer is being generic or inauthentic in their discussion of mental health. Annie told us about a time when she witnessed a streamer playing happy music in the background while discussing a serious mental health topic: “It just doesn't feel real or genuine… This one streamer was talking about mental health and had the chirpiest music in the background. And I was like, ‘This does not fit the conversation right now.’” Within the esports realm, in particular, interviewees felt that mental health is regularly discussed. Two of the three esports players we interviewed had seen esports organizations and players talk about the importance of mental health and share resources. They also shared that their esports coaching staff encouraged conversations about the topic. AJ Hammond, Head Coach of Esports at the University of Mount Union, shared that “I can pull up my

“It just doesn't feel real or genuine… This one streamer was talking about mental health and had the chirpiest music in the background. And I was like, ‘This does not fit the conversation right now.’” -Annie

Twitter page right now and look at the esports people that I'm connected with, and I guarantee you at least three of the tweets I read today are going to be like, ‘Hey, if you're struggling, please reach out to someone, here are some resources.’” This growing attention to mental health in recent years may stem from several deaths by suicide among high-profile streamers and esports players, some of whom had previously spoken about their own mental health struggles. This conversation has potentially prompted a heightened awareness of mental health, specifically in esports and streaming.

Toxicity and Harassment While the gaming community has made strides in addressing mental health, toxicity, and harassment are critical issues that must be addressed. While people we interviewed noted that toxicity and harassment are perpetrated by a minority of people in the gaming community, these can have devastating consequences at the individual level. Dr. Rachel Kowert, a research psychologist and the Research Director of Take This, a non-profit mental health organization that provides tailored resources for gaming companies, explained that “hate and harassment is associated with a range of short- and long-term mental health challenges. It can be things such as feeling uncomfortable for a short amount of time, that can move on to things like long-term

“Hate and harassment is associated with a range of short- and long-term mental health challenges. It can be things such as feeling uncomfortable for a short amount of time, that can move on to things like long-term posttraumatic stress disorder symptomology, which impacts every area of your life for a significant amount of time. So it runs the gamut from short to long-term, mild to severe.” -Dr. Rachel Kowert

PAGE 9

post-traumatic stress disorder symptomology, which impacts every area of your life for a significant amount of time. So it runs the gamut from short to long-term, mild to severe.” Other research has shown that toxicity and bullying within gaming can cause feelings of helplessness, depression, damaged self-esteem, and stress– similar to the consequences of in-person bullying. Our Reddit analysis showed various examples of gamers saying that they quit specifically because of toxicity or harassment within a game. One Reddit user explained her own personal experience of harassment, writing, “It feels as if these individuals hold the power to determine my destiny. Their words have a profound impact on me, whether they declare that ‘You won't amount to anything,’ belittle my achievements by saying ‘Anyone could have done what you did,’ or personally insult me." These issues are especially prevalent among female and LGBTQ+ gamers, who are more likely to be targets of toxic behavior. Throughout our research, female Reddit users and interviewees shared various experiences and fears of gender discrimination in the gaming community. For example, one Reddit user shared, “Being female just makes my anxiety worse because I would feel like I need to prove that girl gamers don't suck.” While nearly half of video gamers in the U.S. are female, stereotypes about gender and gaming persist. Much has been written about the issue of toxic masculinity and gaming culture, including stereotypical portrayals of gender roles and gender-based harassment within games. Researchers have found that female gamers are less likely to participate in voice chat, which is often a key part of the socialization and strategic aspects of the multiplayer gaming experience, for fear of harassment when others realize they are female. Likewise, two interviewees talked about the importance of quickly addressing any form of discrimination towards LGBTQ+ people, including the general use of homophobic language. These comments can make players feel unsafe and unwelcome, even if they were not directed toward a specific individual. The confluence of in-game toxic masculinity and misogyny is particularly critical to address because toxicity and trolling can escalate to harassment outside of the game. Two of our interviewees specifically referenced Gamergate, in which prominent female-presenting gamers were harassed, doxxed (had their personal information, such as address and phone number, posted online without their consent), and received threats, both online and offline. The Gamergate movement attracted widespread attention not only because of the severity of the gamers’ experiences but also because no one was ever held accountable. Instead, as is often the case with toxicity and harassment online, the targets of the harassment were the ones who experienced the brunt of the punishment. Several news outlets have argued that the failure to hold people accountable during Gamergate helped to pave the way for growing extremism within gaming. Gamergate highlighted the need for improved measures to protect people from harassment and reprimand those who inflict it. Almost a decade later, this issue hasn’t been appropriately resolved. Any efforts to support the mental health of players need to place toxicity and the experiences of female and non-binary gamers front and center. Many of the online platforms associated with the gaming community have established community guidelines, which users are expected to follow. These guidelines typically place restrictions on hate speech, sharing others' personal information, and more. However, most interviewees felt that gaming companies and social platforms weren’t doing a good job of enforcing these protections. Because there are no standard guidelines or regulations across the gaming industry, it’s difficult for gaming companies and social platforms to learn from each other or be held accountable by the community. Some of the professionals we interviewed brought up the Fair Play Alliance, which aims to address toxicity and harassment by establishing best practices that encourage positive gaming experiences and sharing resources for gamers and professionals. While a starting point in creating an inclusive experience for all gamers, their recommendations are voluntary and not legally enforceable. PAGE 10

Recommendations for Gaming Companies Acknowledge and Prioritize Mental Health Gaming companies wield substantial influence in the gaming world, shaping people’s experiences through their design, player interactions, live events, and the behavioral norms established within their creations. Because of this, these companies bear a responsibility for acknowledging and prioritizing the mental wellbeing of their players. Interview responses varied when it came to whether gaming companies are even cognizant of their community's mental health. About half of the interviewees believed that companies are indeed aware, but hesitate to address mental health concerns due to perceived costs, resource allocation, or legal considerations. Others suggested that companies are aware but struggle to initiate conversations on the subject. Dr. Peter Etchells, an author and professor of psychology and science communication at Bath Spa University, speculated that, “I think the sort of bigger games development companies are more aware of this sort of stuff and care about it. But I think it's something that they need to be more comfortable and confident talking about. My impression that I get from my looking at public conversations is that games companies are generally very hesitant to talk about this sort of stuff, and that makes them look like they don't care.” About 25% of interviewees thought that gaming companies are completely unaware of the mental health of their players. Professionals that we interviewed felt that rates of mental health conditions in the gaming community are probably comparable to the rates among the general public. However, there isn’t strong research to support this assertion– few rigorous studies dive into the prevalence of mental health conditions among gamers, let alone among players of specific games. To begin to address the mental health needs of their players, and provide the appropriate game modifications and resources we discuss in the following sections, gaming companies should prioritize identifying the types of mental health conditions that their players are experiencing. To gain this information, gaming

“I think the sort of bigger games development companies are more aware of this sort of stuff and care about it. But I think it's something that they need to be more comfortable and confident talking about. My impression that I get from my looking at public conversations is that games companies are generally very hesitant to talk about this sort of stuff, and that makes them look like they don't care.” -Dr. Peter Etchells

companies and social platforms could partner with researchers and clinicians who are already working to understand the implications of gaming in youth mental health. We discuss more opportunities for such collaborations in Partnerships below. Gaming companies might actually be addressing mental health matters internally within their organization, or seeking solutions behind the scenes. However, when they fail to directly communicate these efforts to their players, their public silence can create the perception that they don’t care about the mental health of their community. Gaming companies possess a strong and influential voice, which they frequently employ to market their products and captivate the attention and engagement of their players. As a result, their perceived or actual absence of action and commentary on mental health issues becomes even more PAGE 11

pronounced. Stanley, a 22-year-old gamer said, “My honest opinion is that because they're so marketing and player-base focused, it is not a real concern that they have. But I also really don't know what they know about it. Like, I haven't heard or seen anything about these companies even discussing that sort of thing.” This sentiment was corroborated by others, as half of the interviewees proposed that game developers allocate specific funding to actively promote mental health resources. This proactive investment not only underscores

“My honest opinion is that because they're so marketing and player-base focused, it is not a real concern that they have. But I also really don't know what they know about it. Like, I haven't heard or seen anything about these companies even discussing that sort of thing.” -Stanley

a commitment to player well-being but also makes business sense: our analysis of Reddit discussions revealed that around a quarter of users reported having to discontinue gaming due to external mental health struggles which impacted their overall gaming experience and enjoyment. Prioritizing gamers’ mental health both enhances player retention and fosters a more loyal and engaged consumer base.

Create and Share Resources Interviewees provided various practical suggestions for integrating mental health education and resources within gaming platforms. They proposed that gaming platforms share mental health tips and healthy gaming practices, like practicing relaxation techniques, or reminders to stay hydrated. Within the game environment itself, interviewees supported the idea of incorporating pop-up reminders with this messaging. While more of a game design suggestion, Reddit users also suggested that games have a "relaxing mode," allowing people to enjoy games without the pressure of completing quests. Some games are already taking these steps– interviewees noted specific games that encourage gamers to take breaks or leave their character in a specific place, or reduce the rewards for completing tasks as a gaming session goes on. Despite gamers’ growing comfort with discussing mental health, most of the gamers we interviewed were unaware of the existing mental health resources tailored for gamers. For example, many gamers weren’t aware of organizations like Healthy Gamer, which are already working in this space to create mental health resources and coaching for gamers. As a result, interviewees suggested that gaming companies start by raising awareness of existing resources. Although organizations such as the Trevor Project, the AKKOMA Project, and the JED Foundation are not specifically tailored toward gamers, these organizations have resources that are tailored to youth and young adults that gaming companies can amplify. If a gaming company needs or prefers to make original content, interviewees offered some suggestions for them to follow. Interviewees stressed the importance of approaching mental health with seriousness and sensitivity. Content related to mental health shouldn’t trivialize people’s challenges and should refrain from appearing overly casual; young people possess a keen awareness of inauthentic content. The emphasis should be on creating materials that are authentic and relatable. Interviewees also highlighted the nuances in using the term “gamer,” given that it can describe both someone who plays relaxing farming games and someone who plays competitive esports games. The word “gamer” can carry negative stereotypes, especially if used in an

PAGE 12

inauthentic way. Content should be tailored for the specific type of gamer it’s trying to reach. Once resources are selected or created, they must be made available, visible, and accessible. Dr. Kowert advised, “It doesn't necessarily have to be in-game, so to say, on the platform level. I think there is opportunity constantly just have a thing, have a tab, have a page about ‘Here's a link to hotlines and resources and information.’” Making resources readily accessible not only helps direct people where to go, but it also gives them a constant reminder that there’s help available when they’re ready to use it. Interviewees suggested posting resources in various locations, including 1) directly in the games in loading screens as a menu option or in a character’s speech bubble; 2) in content warning labels; 3) in the game or gaming systems’ lobby where companies often market upcoming events and game updates; 4) on social media through gaming companies’ or companies’ handles; and 5) through streamer advocacy and sponsorship.

Create a Standardized Warning Label System No standardized regulatory body currently oversees video game content warning labels. In North America, many video games utilize the ESBR’s (Entertainment Software Rating Board) rating system which includes age ratings, descriptions of game content, and information on types of interactive elements. While all console manufacturers and certain retailers require ESRB ratings, these labels are voluntary and not all games use them. Though ESRB ratings are a valuable resource to vet a game before playing it, previous research has found that the warning labels are often inadequate or poorly regulated. These findings were reaffirmed by our research, with interviewees discussing the need for more detailed content warning labels and the ability to turn off potentially triggering parts of a storyline or feature. Alex, a 13-year-old gamer suggested, “...have it somewhere, like in the title or description, like, ‘Warning: This is gonna be here’…. If a game has blood in it, have a warning and a setting where you can turn it on and off.” Reddit users also noted that the absence of trigger warnings in certain games had contributed to the deterioration of their mental health.

“...have it somewhere, like in the title or description, like, ‘Warning: This is gonna be here’…. If a game has blood in it, have a warning and a setting where you can turn it on and off.” -Alex

These labeling systems should also be frequently updated to reflect the most recent research on the ways that certain aspects of gaming can negatively impact young people. In recent years there has been a growing concern about the relationship between loot boxes (in-game boxes that have random in-game objects and prizes) and gambling. Dr. Dunlap suggested supporting children’s mental health by not exposing them to things like gambling in the first place. She explained that, “Instead of

saying, ‘Let's have better mental health and games,’ maybe we can talk about ‘Okay games that specifically target this group of children between 8 and 12.’ What are things that we can make recommendations to developers for? For example, if it is a T-rated game or lower, there should not be loot boxes in it. There should be no kind of references to gambling whatsoever.” Interviewees also brought up microtransactions (in-game-purchases), and advertisements as things that should be avoided in games targeting children.

PAGE 13

Prevent Toxicity Almost all interviewees believed that as the facilitators of these communities, gaming companies should bear some responsibility for curbing toxicity and bullying. Many interviewees believe that toxicity is encouraged by the anonymous nature of games. Yiyi Zhang, PR + Community Manager at Heart Machine, Inc. said, “I would create more accountability structures for people to not be able to run their mouths under anonymity. If you create a user profile, it has to somehow be tied to a real-life profile before you're able to freely post anywhere. I think that goes a long way to preserving safety.” De-anonymizing accounts, even if identifiable information is not made visible to other players, would help hold bullies accountable for their actions, which may prevent them from perpetuating toxicity in the future. We acknowledge that for gaming companies, this suggestion may mean the additional responsibility of storing and safeguarding players’ personal information and potentially add friction to new players’ onboarding. However, the tradeoff is fostering a more positive and less toxic gaming community– which could ultimately increase their player base. Within the game design, interviewees recommended that games incentivize positive behavior and interactions by offering rewards for good sportsmanship. Story-driven games can employ a moral component that rewards gamers for choosing positive behaviors. They also advocated for companies to allow gamers to create their own private servers, especially for gamers of specific ages, sexual orientations, gender identities, etc., to help them find supportive communities. Companies that already allow this feature should focus on raising awareness of these servers and connecting gamers to these niche communities.

Address Toxicity After It Happens Games and social platforms must enhance their mute features so players are able to stop bullying as it occurs. Gamers should have the ability to comprehensively mute all communications if they are experiencing harassment. While some games and social platforms permit users to block private messages from harassers, very few provide options to also conceal their messages from the general chat. Even in games that limit communication to a list of pre-written messages, perpetrators can still harass others by inundating them with messages and interrupting their gameplay. While critical to supporting players, mute features should also be designed in a way that doesn't make targeted players feel punished or excluded from the game. Games and social platforms should take an active role in moderating conversations or messaging behaviors by leveraging AI technology to identify and address toxic players. This would alleviate some of the burden off players who experience harassment. Games and social platforms typically offer users the ability to file reports when experiencing or witnessing toxic behavior. However, our interviewees highlighted various shortcomings in the current systems. First, gamers must often select a category from predetermined options to describe the type of toxicity they've experienced or observed, which might not accurately capture their specific situation. Second, two of the clinicians stressed the importance of taking immediate action to support the people who experience harassment and address the perpetrators. Yet some platforms can take weeks to respond to reports, and there’s little transparency in the process. Raymond Lancione, CEO of QWEERTY Gamers, illustrated, “I’ll

PAGE 14

find accounts that have harassed us, and they've been on Discord for four years. They're saying the F. word, they're dropping explicit images, and Discord doesn't do anything about it. We make the reports. Nothing happens.” Some platforms also require reports from multiple gamers before they act, causing further delay and making individuals feel helpless, invalidated, or like they are being punished. Annie provided an example of how challenging it can be to acquire multiple reports:

“I'll find accounts that have harassed us, and they've been on Discord for four years. They're saying the F. word, they're dropping explicit images, and Discord doesn't do anything about it. We make the reports. Nothing happens.” -Raymond Lancione

“In some games, a certain number of players need to report a person for them to get kicked out, even if you have proof that person is saying these things to you. What if I just go to a random session - it's a group of friends playing, and one player says all these things? And I have to convince their own friends to report them? It's not going to happen. I'm going to be the one to leave instead of that person being kicked out.” In this scenario, the person experiencing the harassment gets no justice or support: they leave the game to protect themselves while the perpetrator continues playing and faces no consequences.

“Xbox did release a Transparency Report, which has been a really great step forward in terms of having insight on the scope of the problem. So I would give them some kudos for releasing Transparency Reports. I would say nobody is doing it in a super effective way, but the Transparency Reports give this baseline of like, ‘Here's here's where we're at right now.” -Dr. Rachel Kowert

As such, interviewees recommended fostering communities that encourage gamers to speak up when they hear something– and when they report incidents, they should receive a compassionate and timely response, along with resources for people who have experienced online harassment. As a starting point for increasing their own transparency, companies can look to Xbox’s Transparency Report which shares information on the actions that Xbox takes to moderate content and create safer experiences. Dr. Kowert gave kudos to the company for their efforts to provide

a real scope of toxicity and bullying on their platform: “Xbox did release a Transparency Report, which has been a really great step forward in terms of having insight on the scope of the problem. So I would give them some kudos for releasing Transparency Reports. I would say nobody is doing it in a super effective way, but the Transparency Reports give this baseline of like, ‘Here's here's where we're at right now.” When players do report harassment, games shouldn’t require multiple reports to respond to a single instance of documented toxicity. Enforcing zero-tolerance policies against toxicity and harassment should be the standard in gaming communities. Hammond, who is also a former professional Halo player, shared anecdotal experience of seeing less toxicity in the collegiate and professional esports spheres after the implementation of zero-tolerance policies: “What happens is, you have kids like me who grew up watching some of the best Halo players in the world verbally demolish the other team. And you're like 12 watching this on Youtube, and thinking ‘I want to be just like him,’ because those are your idols. It wasn't

PAGE 15

until very recently, within the last two years that everyone as a collective in esports has come to realize that ‘Hey, maybe that's not very cool to do.’ So, I think it's getting better, and it's taking a step in the right direction.” Many professional leagues now issue monetary fines for players who violate community guidelines. In order to more comprehensively monitor guideline violations, additional moderators can be added to games.

Advice For Gaming Companies Acknowledge and prioritize mental health: Speak publicly about mental health, and allocate funds specifically to support the mental health of players Create and share existing resources: Share mental health tips and education, and healthy gaming practices Create a standardized warning labeling system: Using existing systems, make sure that game content has clear descriptions that are consistently applied across games Prevent toxicity: Require gamers to connect profiles to real-life accounts and incentivize positivity Address toxicity after it has happened: Provide a clear and easy-to-use reporting system for harassment and take action quickly and transparently Invest in partnerships: Create cross-sector partnerships with researchers, mental health professionals, schools, parents, and players to de-silo conversations about mental health

Recommendations for Nongamers Reframe Misconceptions about Gaming Trusted peers and adults form a crucial support system in the lives of today's youth and young adults. However, nongamers commonly hold misconceptions and negative attitudes toward gaming. These biases often arise from a lack of understanding about what video games entail, the media's tendency to focus solely on the potential drawbacks of gaming, or a person’s own negative experiences with gaming. Half of the people we interviewed argued that nongamers should treat video games no differently than any other hobby. As Dr. Daniel Kaufmann, (@DrGameology), Associate Professor at Grand Canyon University, said, “If [gamers] were in the garage playing guitar this much, and then they got excited about something they put together in the song they're writing with their friends, and they wanted to share that with you, would you shut them down and remind them how uninteresting that is and how it's a waste of time?’” Part of the disconnect may stem from the fact that the outcomes of gaming can often be intangible or unclear to nongamers. While nongamers can grasp the value of mastering a musical instrument (because they comprehend the end product– music), the achievements in a video game can seem amorphous, trivial, or meaningless to a nongamer. As a result,

PAGE 16

nongamers can perceive gaming to be a waste of time. To counteract this, Dr. Custer discussed the importance of framing gaming as “purposeful play” to make parents and trusted adults understand that gaming can actually be a very intentional act to socialize, improve skills, or blow off steam. Loved ones making negative comments about gaming can evoke feelings of shame, “Parents think their kid is lonely and sad, and, misunderstanding, and isolation– which can exacerbate gamers' existing mental health issues. ‘Oh, it must be the games he's playing 20 hours a week.’ It must be the games that you take This issue is particularly important given that away. What you could actually be taking away is nearly every interviewee emphasized that the tool that they were using to mitigate the excessive gaming often serves as a symptom of underlying depression and anxiety and deeper challenges that gamers are grappling with loneliness, and whatever else that they may in their real lives, as discussed in Why Gamers Play. As Dr. Kowert stated, “Parents think their struggle with.” kid is lonely and sad, and, ‘Oh, it must be the -Dr. Rachel Kowert games he's playing 20 hours a week.’ What you could actually be taking away is the tool that they were using to mitigate the underlying depression and anxiety and loneliness, and whatever else that they may struggle with.” Removing someone's chosen coping mechanism can exacerbate their difficulties, as it casts the very tool they relied upon as something shameful. Dr. Hannah Dam, Strategic Partnerships Manager at Healthy Gamer, recommended that to support the gamers, nongamers start by asking themselves, “How do you have a conversation that's not fighting with them? If they feel like you're coming in with an agenda, they're going to get defensive, and they're going to want to shut the door. They're going to shut down.” In parents’ efforts to help their children, they may be inadvertently causing harm.

Learn About Their Games As discussed above in Why Do Gamers Play, there’s a line between healthy escapism and complete avoidance of life outside of a game. Additionally, as discussed above in Create A Standardized Warning Labeling System, there are aspects of certain games that can be harmful or inappropriate for certain ages. But while gaming companies work to harness the power of their product to support youth mental wellbeing, there are steps that nongamers can take now to support their gamers. First, nongamers must educate themselves about the potential risks and benefits of video games by reading content labels or seeking out game reviews. Several gaming organizations have compiled resources specifically for nongamers, such as the ESRB’s Family Gaming Guide. Entire media outlets, like Destructoid, are dedicated to breaking down games, gaming platforms, and gaming events. We urge parents and trusted adults to educate themselves using resources like these that don’t sensationalize the harms of games– finding articles that reaffirm preexisting biases against games is easy to do. Using only these resources does a disservice in their efforts to better understand the role of gaming in their loved one’s life.

PAGE 17

Support Healthy Gaming Habits Games are designed to keep players engaged. As Alyssa reflected, “It's hard to keep track of time while gaming, you just get so absorbed.” As a result, half of interviewees said trusted adults are critical in helping youth develop healthy gaming habits by enforcing the amount of time spent playing and ensuring that other priorities are being completed. When it comes to setting boundaries, parents can set timers, utilize screen time controls, try to keep gaming devices outside of the bedroom, allow gaming after other priorities or activities are done, and keep school and play computers separate, if possible. Research shows that parental monitoring of gaming serves as a significant protective factor against the development of unhealthy gaming habits. In a demonstration of the important role that parents play in helping gamers develop healthy gaming habits, two of the people we interviewed said their parents are the reason they have healthy gaming habits now. For example, Annie told us, “I learned young. It was a big thing when my parents were around. They were kind of like, ‘Hey, like you've been playing for too long. You've been sitting at the screen for hours. Go walk.’” One-third of professionals we interviewed stated that parents and educators should take a harmreduction approach to game time regulation versus banning games, to avoid inadvertently exacerbating mental health concerns in gamers who use gaming for mood regulation, decompression, and socialization. Our Reddit analysis found posts from youth saying their parents had unanimously forbidden gaming due to concerns about their mental health effects, with users posting questions like, “How to convince my mom video games are not causing me depression?” While abstinence from gaming seems like a step to protect their loved one, a ban on gaming can be disempowering and delegitimizing to the gamer. Likewise, their child may perceive that there is no safe amount of time to be game. Instead, parents should talk with their loved one about reasonable limits and expectations for gaming, and work together to come up with healthy habits and boundaries that both can agree on. Additionally, parents and trusted adults can play an important role in preventing toxicity and bullying within games. Half of the interviewed professionals thought that tackling toxicity in gaming had to start with societal changes that nurture positive behaviors in youth. Raising

“How to convince my mom video games are not causing me depression?” -Reddit User

awareness about the repercussions of words and actions, both online and offline, is pivotal to addressing toxicity in gaming since online bullying has many parallels to in-person bullying. Resources like StopBullying.gov have guides on identifying and addressing bullying in gaming, and provide information on how to prevent their loved one from bullying others.

Advice For Nongamers Reframe misconceptions about gaming: Gaming can be a healthy coping mechanism, help gamers feel accomplished, and connect with others Learn about their games: Seek out resources, read game reviews, play games with your kids, and talk about online safety to help them make informed decisions about gaming Support healthy gaming habits: Use existing resources to learn how to set appropriate time limits on gaming and prevent bullying PAGE 18

Recommendations for Gamers Practice Healthy Gaming Habits While game developers and nongamers work to make gaming a better place for youth mental health, there are immediate steps that gamers can take to safeguard their own well-being. Interviewees suggested using separate rooms and devices for work and play if they have the resources. They noted that it may help to have a designated time for gaming, and planning breaks from gaming to “stretch it and do yoga, or breathing exercise, or something before you return” said Zhang. As a benefit, research has found that taking breaks during prolonged gaming sessions can increase “processing speed and executive function,” meaning breaks can actually improve a gamer’s abilities. Gamers may also benefit from thinking of gaming as a reward or incentive after completing other tasks, like homework or chores. Additionally, Reddit users suggested taking a break from certain games or communities if gamers are experiencing toxicity and harassment or negative feelings related to gameplay. Interviewees suggested that gamers intentionally take time to reflect on how a game is making them feel, which can help them decide whether to play and which games to play. Gamers who play on esports teams may face unique pressures, including the need to constantly practice. Interviewees suggested that they avoid playing the games they play competitively when they’re not in practice, or in the off-season. Implementing better gaming and self-care habits alone can’t mitigate the impact that gaming has on mental health. Instead, they are a piece of the puzzle– along with game design changes, messaging, access to resources, and the de-stigmatization of gaming by nongamers– to ensure gaming is not only a better place for youth mental health, but is a tool for mental health empowerment.

Prevent and Address Toxicity and Harassment When it comes to preventing toxicity and harassment, gamers should be aware that words are harmful, whether they are said face-to-face, over a headset, or through in-game chat, given that online bullying has the same negative consequences as in-person bullying. Although we acknowledge that this solution depends on the game, gamers can try to avoid toxicity by playing games that allow them to play in private groups or servers. Additionally, there are various Subreddits, Discord groups, Facebook groups, and organizations dedicated to helping gamers of specific demographic groups find people like them to play with. For example, the subreddit r/gaymer is for LGBTQ+ gamers and the subreddit r/girlgamers is for female-identifying gamers to talk about games and find people like themselves to play with. Gamers can also help encourage positive and supportive communities by speaking up when they witness someone being bullied, whether it is to let the perpetrator know that their actions are harmful or to support the person who was targeted. Although imperfect, gamers can also report perpetrators through a game’s reporting mechanism or block/mute the perpetrator in the game.

PAGE 19

Advice For Gamers Set a designated time to game: Planned breaks from gaming can even improve your gaming Read ratings and reviews: Before playing, find out if there are any things that might be triggering Reflect on your mood: Identify how a game makes you feel after playing it Avoid certain games: Especially for esports or team players, try new games in the off-season Prevent Toxicity: Try to play with people you know and consider spaces that have been created for people of similar demographics and life experiences. Learn about what toxicity is, and avoid being the source of it. Address toxicity: Speak up and report instances of toxicity that you witness. If you are experiencing harassment, consider utilizing mute and blocking features

Recommendations for Strategic Partnerships Gamers and professionals both advocated for strategic partnerships to address the mental health needs of players. As Dr. Dunlap explained, “The silos need to break down because right now, research is over here and game developers are over there, and mental health professionals are going, ‘Well, I can't hear either of you.’ They're very segregated spaces, and they speak really different languages.” Three distinct categories of collaborations emerged as key priorities to break down these silos.

“The silos need to break down because right now, research is over here and game developers are over there, and mental health professionals are going, ‘Well, I can't hear either of you.’ They're very segregated spaces, and they speak really different languages.” -Dr. Kelli Dunlap

Researchers and Mental Health Professionals First, gaming companies should partner with researchers, mental health professionals, and mental health organizations. There are numerous professionals and organizations, such as Take This and Healthy Gamer, that are actively working to understand the implications and opportunities that gaming has on youth mental health. In partnering, these professionals can help gaming companies understand the experiences and mental health challenges their players face, and identify the best course of action for addressing them, whether that be through providing resources or modifying design elements. Additionally, gaming companies can collaborate with researchers and mental health professionals on new game design elements. Zhang said that this collaboration should happen “well before a game has come out– during the PAGE 20

feedback process when the game is still being prototyped, when the game design is not set.” The goal of this collaboration isn’t to constrain game developers’ creative freedom but to ensure that if potentially detrimental elements are added to games, they are counterbalanced by evidence-based resources, messaging, and

“How to convince my mom video games are not causing me depression?” -Reddit User

features that do support gamers, which mental health professionals can help inform. Partnering with mental health organizations can help games connect players to existing mental health resources, such as guides, videos, and counseling.

School and Parent Organizations Second, gaming companies should partner with schools and parent organizations. By fostering a deeper understanding of the role gaming plays in the lives of young gamers, these partnerships can dispel misconceptions and stereotypes about video games. This collaboration can pave the way for more meaningful educational programs and supportive youth leagues, further enriching the gaming experience for young people.

Gamers Third, gaming companies should partner with their own players to understand their perspectives, feelings, and needs related to mental health. Players are “stakeholder[s] by participating in these games,” Ryan, one 23-year-old male gamer explained, adding that gaming companies should “bring more people on board, especially people with mental health issues, to focus on the user experience interface and make it accommodating to everybody.” Players have a vested interest and invaluable insights into how the games they love can be improved; gaming companies lose out by not engaging them in these conversations.

PAGE 21

Conclusions Society’s efforts to support the mental health of youth have been critical, but our attention is often fixated on the physical world. However, protecting and nurturing children is equally vital in the virtual realm. Youth and young adults, like Max, think “games are a very important part of people's lives” because they have been a part of their lives “for the entirety of it.” Instead of villainizing, trivializing, and blaming games for the youth mental health crisis we face, we need to leverage their ubiquity to help. We started this investigation with a question: Where should gaming companies, gamers, and nongamers begin if they want to harness the power of gaming for youth mental well-being? This report highlights gaming’s potential as a powerful tool to support the well-being and mental health of today's youth and young adults. Gaming offers a unique platform for fostering social connections, honing valuable life skills, and imparting essential life lessons. Games hold enormous and largely untapped potential to serve as bridges, connecting young people with crucial mental health resources and supportive communities. Every stakeholder– gaming companies, mental health professionals, researchers, trusted adults in young gamers' lives, and gamers themselves– has a vital and urgent role to play in supporting youth mental health in this virtual realm.

Limitations While the interviews and Reddit analysis provide valuable insights into the topic of gaming and mental health, several limitations may impact the generalizability and interpretation of the results. Findings are based on 22 interviews and analysis of specific Reddit channels, which may not capture the full range of perspectives on the topic. A larger sample of interviewees and an analysis of additional Reddit channels could yield additional insights and potentially different themes. Additionally, we reached out to employees of several large game developer companies and did not receive a response from any, so the perspective of these organizations is not included in this report. According to researchers we did interview, this is a common limitation when conducting research in this field, as the gaming industry can be competitive and wary of legal concerns associated with participating in research. Additionally, all interviews were conducted in English, which means we could be missing insights unique to non-English speaking youth and young adults. While we tried to ensure a diverse mix of interviewees from different geographies, racial and ethnic groups, and ages, it is possible that our sampling methods have excluded the perspectives and identities of valuable groups. Despite these limitations, we did reach thematic saturation within our gamer and professional interviewee groups, suggesting a thorough sample and sound thematic results.

PAGE 22

References Introduction Alexander, G. A. (2023). College Esports: Grassroots Hobby Turned Unregulated Industry. Bonnevie, E., Gallegos-Jeffrey, A., Goldbarg, J., Byrd, B., & Smyser, J. (2021). Quantifying the rise of vaccine opposition on Twitter during the COVID-19 pandemic. Journal of communication in healthcare, 14(1), 12-19. Bonnevie, E., Goldbarg, J., Gallegos-Jeffrey, A. K., Rosenberg, S. D., Wartella, E., & Smyser, J. (2020). Content themes and influential voices within vaccine opposition on Twitter, 2019. American journal of public health, 110(S3), S326-S330. Centers for Disease Control and Prevention. (2023, April 27). YRBSS Data Summary & Trends. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_summary_and_trends.htm NPD Group. (2022, June 10). 2022 Essential Facts About the Video Game Industry. https://www.theesa.com/resource/2022-essential-factsabout-the-video-game-industry/ Orme, S. (2022). “Just watching”: A qualitative analysis of non-players’ motivations for video game spectatorship. New Media & Society, 24(10), 2252–2269. https://doi.org/10.1177/1461444821989350 Reinert, M, Fritze, D. & Nguyen, T. State of Mental Health in America 2023. Mental Health America. (2022, November 29). https://mhanational.org/research-reports/state-mental-health-america-2023 Stojanovic M. (2023, March 9). Gamer demographics from 2023: No longer a men-only club. PlayToday. https://playtoday.co/blog/stats/gamer-demographics/ Zhong, Y., Guo, K., Su, J., & Chu, S. K. W. (2022). The impact of esports participation on the development of 21st century skills in youth: A systematic review. Computers & Education, 104640.

Why Gamers Play Arbeau, K., Thorpe, C., Stinson, M., Budlong, B., & Wolff, J. (2020). The meaning of the experience of being an online video game player. Computers in Human Behavior Reports, 2, 100013. Barr, M., & Copeland-Stewart, A. (2022). Playing video games during the COVID-19 pandemic and effects on players’ well-being. Games and Culture, 17(1), 122-139. Blasi, M. D., Giardina, A., Giordano, C., Coco, G. L., Tosto, C., Billieux, J., & Schimmenti, A. (2019). Problematic video game use as an emotional coping strategy: Evidence from a sample of MMORPG gamers. Journal of behavioral addictions, 8(1), 25-34. Hewett, K. J., Zeng, G., & Pletcher, B. C. (2020). The acquisition of 21st-century skills through video games: Minecraft design process models and their web of class roles. Simulation & Gaming, 51(3), 336-364. NPD Group. (2022, June 10). 2022 Essential Facts About the Video Game Industry. https://www.theesa.com/resource/2022-essential-factsabout-the-video-game-industry/ Quwaider, M., Alabed, A., & Duwairi, R. (2019). The impact of video games on the players' behaviors: A survey. Procedia Computer Science, 151, 575-582. Zhong, Y., Guo, K., Su, J., & Chu, S. K. W. (2022). The impact of esports participation on the development of 21st century skills in youth: A systematic review. Computers & Education, 104640.

Gaming and Mental Health Carpenter, N. (2021, May 15). Streamers aren’t therapists. but some therapists are streamers. Polygon. https://www.polygon.com/22432479/twitch-therapy-livestream-mental-health-access Gandhi, R., Cook, C. L., LaMastra, N., Uttarapong, J., & Wohn, D. Y. (2021). An exploration of mental health discussions in live streaming gaming communities. Frontiers in Psychology, 12, 575653. Keller, E. (2023, June 8). Esports Star Karel “Twisten” Asenbrener dead at 19 after chilling final tweet: “good night.” New York Post. https://nypost.com/2023/06/07/esports-star-karel-twisten-asenbrener-dead-at-19-after-chilling-final-tweet/ NPD Group. (2022, June 10). 2022 Essential Facts About the Video Game Industry. https://www.theesa.com/resource/2022-essential-factsabout-the-video-game-industry/ WTSP. (2022, July 12). Gaming community cooperates to raise money for mental health. wtsp.com. https://www.wtsp.com/article/news/health/gaming-community-raise-money-mental-health/67-b5c13bf9-9ab2-49f7-9e95-a2b2b4fa1caf Twitch. Streamers, help us spread Mental Health Awareness this month. Twitch Blog. (2018, May 1). https://blog.twitch.tv/en/2018/05/01/streamers-help-us-spread-mental-health-awareness-this-month/ Take This. (2022, October 13). About take this. https://www.takethis.org/about/

PAGE 23

Todd, P. R., & Melancon, J. (2019). Gender differences in perceptions of trolling in livestream video broadcasting. Cyberpsychology, Behavior, and Social Networking, 22(7), 472-476. Zsila, Á., Shabahang, R., Aruguete, M. S., & Orosz, G. (2022). Toxic behaviors in online multiplayer games: Prevalence, perception, risk factors of victimization, and psychological consequences. Aggressive Behavior, 48(3), 356-364.

Recommendations for Gaming Companies Community Guidelines. Twitch Safety Center. (2023). https://safety.twitch.tv/s/article/Community-Guidelines?language=en_US Dockterman, E. (2014, October 16). #GamerGate sexism and Anita Sarkeesian death threats explainer. Time. https://time.com/3510381/gamergate-faq/ Duffy, S., & Derevensky, J. (2022). Helping parents understand the content of video games: updating the ESRB rating system. Journal of Children and Media, 16(4), 606-612. FAQ. Fair Play Alliance. (2022, September 30). https://fairplayalliance.org/faq/ Fox, J., & Tang, W. Y. (2016). Women’s experiences with general and sexual harassment in online video games: Rumination, organizational responsiveness, withdrawal, and coping strategies. New Media & Society, 19, 1290-1307. Frequently asked questions. ESRB Ratings. (2021, September 9). https://www.esrb.org/faqs/#how-does-the-esrb-know-companies-havefully-disclosed-all-of-the-content-in-their-game-or-app-and-what-happens-if-they-dont Garrett, E. P., Drummond, A., Lowe-Calverley, E., & Sauer, J. D. (2023). Current loot box warnings are ineffective for informing consumers. Computers in Human Behavior, 139, 107534. Harris, B. J. (2022, November 30). About Us. ESRB Ratings. https://www.esrb.org/about/ Lynch, T., Tompkins, J. E., van Driel, I. I., & Fritz, N. (2016). Sexy, strong, and secondary: A content analysis of female characters in video games across 31 years. Journal of Communication, 66(4), 564–584. doi:10.1111/jcom.12237 Massanari, A. L. (2020). Gamergate. The International Encyclopedia of Gender, Media, and Communication, 1-5. Microtransactions (in-game purchases) (Steamworks documentation). Steamworks. (2023, June 10). https://partner.steamgames.com/doc/features/microtransactions NPR. (2019, August 30). How Gamergate became a template for malicious action online. NPR. https://www.npr.org/2019/08/30/756034720/how-gamergate-became-a-template-for-malicious-action-online Primi, C., Sanson, F., Vecchiato, M., Serra, E., & Donati, M. A. (2022). Loot boxes use, video gaming, and gambling in adolescents: Results from a path analysis before and during COVID-19-pandemic-related lockdown in Italy. Frontiers in Psychology, 13, 1009129. Ratings Guide. (n.d.) Entertainment Software Ratings Board. https://www.esrb.org/ratings-guide/#int_elems Review the Epic Games community rules. Epic Games. (2022, September 7). https://www.epicgames.com/site/en-US/community-rules Romano, A. (2020, January 20). What we still haven’t learned from Gamergate. Vox. https://www.vox.com/culture/2020/1/20/20808875/gamergate-lessons-cultural-impact-changes-harassment-laws Saputra, D., & Sawitri, H. (2023). Virtual Communication to Every Valorant Online Game Player in Developing Game Strategy. International Journal of Education, Information Technology, and Others, 6(2), 44-61. The Healthy Gamer. Dr. K’s Guide. (n.d.). https://www.healthygamer.gg/about/guide Todd, P. R., & Melancon, J. (2019). Gender differences in perceptions of trolling in livestream video broadcasting. Cyberpsychology, Behavior, and Social Networking, 22(7), 472-476. Xbox Community standards: Xbox. Xbox.com. (2023, March 15). https://www.xbox.com/en-US/legal/community-standards Xbox Transparency Report: Xbox. Xbox.com. (2023). https://www.xbox.com/en-US/legal/xbox-transparency-report

Recommendations for Nongamers Donati, M. A., Guido, C. A., De Meo, G., Spalice, A., Sanson, F., Beccari, C., & Primi, C. (2021). Gaming among children and adolescents during the COVID-19 lockdown: The role of parents in time spent on video games and gaming disorder symptoms. International Journal of Environmental Research and Public Health, 18(12), 6642. Entertainment Software Association. (2022, November 22). Family gaming guide. ESRB Ratings. https://www.esrb.org/tools-forparents/family-gaming-guide/ Home. Destructoid. (2023, August). https://www.destructoid.com/ Johnson, L. (2016, October 9). “League of Legends” pro fined $2,000 for “racially insensitive language.” VICE. https://www.vice.com/en/article/ezpq8j/league-of-legends-pro-fined-2000-for-racially-insensitive-language

Recommendations for Gamers DiFrancisco-Donoghue, J., Jenny, S. E., Douris, P. C., Ahmad, S., Yuen, K., Hassan, T., ... & Sousa, A. (2021). Breaking up prolonged sitting with a 6 min walk improves executive function in women and men esports players: A randomised trial. BMJ Open Sport & Exercise Medicine, 7(3), e001118. StopBullying.gov. How to Prevent Cyberbullying: A Guide for Parents, Caregivers, and Youth. (2021). https://www.stopbullying.gov/sites/default/files/documents/Cyberbullying%20Guide%20Final%20508.pdf

PAGE 24

https://www.facebook.com/RudermanFamilyFoundation https://www.instagram.com/rudermanfamilyfoundation/ https://twitter.com/RudermanFdn https://www.linkedin.com/company/ruderman-family-foundation https://www.youtube.com/@therudermanfamilyfoundation

https://www.facebook.com/PublicGoodProjects/ https://www.instagram.com/publicgoodprojects/ https://twitter.com/PublicGoodProj https://www.linkedin.com/company/the-public-good-projects/