Commentary on Galanis et al.: When age could make the difference-let's not sweep violence under the keyboard.

Maladaptive impulsive aggression is a common reason for seeking help for gaming disorder in children and adolescents. Future research on stigma should consider including externalizing behaviours such as this in clinical vignettes. In an interesting meticulously designed study, Galanis et al. [1] investigated the effect of gaming health information on stigma related to gaming disorder using three different vignettes of young male adults (problem, regular and casual gamers). The effect of biomedical accounts of gaming disorders on the stigma associated to this condition is apparently scarce, while biases linked to diagnostic confirmation probably play a more important role. The problem gamer vignette depicts a young male adult mainly characterized by social withdrawal and internalization symptoms, although he is also ill-tempered and tends to argue with his girlfriend. However, this vignette could be substantially different from pre-existing representations of gaming disorder among survey participants. The population with gaming disorder is highly heterogeneous, and more than 50% of people seeking treatment exhibit externalizing behaviour [2]. Clinical presentation depends upon the person's age and living environment. Possibly due to different organization, places and settings of care for children and adults [3], and due to methodological and regulatory constraints, few data are available from mixed samples of children and adults with gaming disorder, and very few data comparing clinical presentations between children and adults are available. The two most typical profiles are adolescents living with their parents and independent young adults living by themselves [4]. In adolescents, parent–child conflict is a risk factor for gaming disorder [5]. Indeed, conflict with parents over excessive gaming activity is part of the usual description of gaming disorder in children and adolescents [6]. Maladaptive behaviour, and in particular impulsive aggression such as verbal threats and throwing objects, triggered by an ordinary request to turn off the game [7], is also a common reason for seeking help for gaming disorder in children and adolescents [8]. Comorbidities such as attention deficit hyperactivity disorder (ADHD) could be more frequent in impulsive aggressions in this context [9]. Conversely, in lay people, a long-standing concern since the 1990s is the link between violent games and aggression [10], possibly boosted by scientific sensationalistic statements [11]; however, it has gained credence in recent findings, leading the scientific community to encourage further exploration of this association [12, 13]. Stigma is frequently reported in illnesses manifesting behavioural disturbances or socially odd behaviour [14]. Moreover, the stereotype of violence is one of the pillars of stigma in mental disorders [15]. Additionally, manifestations of dangerousness through aggression in the clinical vignettes describing severe mental disorders, including addictive disorders, are associated with higher stigma, as measured by greater desire for social distance and increased support for punitive treatment [16]. Future research looking specifically at stigma in adolescents with gaming disorder is therefore warranted. In particular, externalizing behaviours and impulsive aggressions should be included in the clinical vignettes used to assess stigma so that stigma related to these manifestations of gaming disorder is not underestimated and is further explored. Amandine Luquiens: Writing—original draft (equal). Jorge Lopez-Castroman: Writing—review and editing (equal). We are grateful to Sarah Kabani for English editing. None. None. NA.