Acceptance and Commitment Group Therapy for Problematic Gaming in Adolescents: A Randomized Controlled Trial

Abstract

Objectives

Internet Gaming Disorder (IGD) is associated with emotional distress and functional impairment in adolescents. This study evaluated the effectiveness of Acceptance and Commitment Group Therapy (ACGT) in reducing problematic gaming symptoms and associated depression, anxiety, and stress among high school students.

Methods

In this randomized controlled trial, 40 adolescents with problematic gaming symptoms, identified using a prespecified 7-item Game Addiction Scale (GAS-7) screening threshold of ≥14, were randomly assigned to either ACGT (n=20) or a control group (n=20). Participants in the intervention group received eight weekly sessions of ACGT, whereas the control group received no structured intervention. Outcomes were assessed at baseline, post-intervention, and three-month follow-up using GAS-7 and the Depression Anxiety Stress Scale–Youth version.

Results

Participants who received the intervention demonstrated reductions in problematic gaming symptoms that were maintained at follow-up. The median GAS-7 scores decreased from 16.5 at baseline to 11.0 post-intervention and 11.5 at the three-month follow-up, whereas scores increased in the control group (all p<0.001). In the adjusted analyses, a significant “treatment group×baseline GAS-7” interaction was observed at both post-intervention (F[1,33]=10.36; p=0.003) and follow-up (F[1,33]=6.79; p=0.014), indicating that between-group differences varied according to baseline problematic gaming severity. Secondary emotional outcomes were exploratory and should be interpreted with caution.

Conclusion

A group-based intervention that incorporated Acceptance and Commitment Therapy was associated with a sustained reduction in problematic gaming symptoms among adolescents. These findings support the need for further evaluation of this approach in larger randomized trials with active control conditions and diagnostic confirmation of IGD.

INTRODUCTION

Internet Gaming Disorder (IGD) has emerged as an important mental health concern among adolescents. Although gaming is a common recreational activity, a minority of adolescents develop persistent problematic gaming characterized by impaired control, increased priority given to gaming over other activities, and continued gaming despite negative consequences [1,2]. Meta-analytic evidence suggests that IGD affects approximately 4%–9% of adolescents, although estimates vary substantially according to diagnostic criteria, assessment instruments, and study populations [3-5]. IGD is associated with poor academic performance, interpersonal difficulties, anxiety, depression, emotional distress, and other psychosocial problems [4,6].

Adolescence may represent a particularly vulnerable period for problematic gaming due to developmental, psychological, and social factors. Heightened reward sensitivity, still-maturing executive control, impulsivity, emotional distress, and stronger reinforcement from gaming may contribute to persistent problematic gaming behavior [7]. Gaming may also function as a coping strategy for stress, anxiety, depressed mood, or other difficult emotional experiences [8]. These factors suggest that interventions addressing both gaming behavior and the psychological processes that maintain it may be clinically relevant [7,8].

Psychological flexibility is a central therapeutic target in Acceptance and Commitment Therapy (ACT). ACT seeks to reduce experiential avoidance and promote adaptive responses to difficult thoughts, emotions, and urges through acceptance, cognitive defusion, present-moment awareness, self-as-context, value clarification, and committed action [9]. Emerging intervention evidence has extended ACT to problematic gaming. A pilot randomized controlled trial of an ACT-based self-help intervention in young adults with excessive gaming behavior reported reductions in gaming-related symptoms and gaming time, as well as improvements in psychological flexibility and inhibitory control [10]. More recently, an intervention study among adolescents with gaming disorder found that ACT was associated with improvements in emotion regulation and gaming-related outcomes [11].

Other psychological approaches have also shown benefits for problematic gaming. A systematic review and meta-analysis found that cognitive behavioral therapy reduced IGD symptoms and associated depressive symptoms, although evidence for sustained effects remains limited [12]. Randomized studies have also reported benefits from preventive cognitive-behavioral interventions and multidimensional family therapy among adolescents with problematic gaming [13,14]. However, randomized studies specifically evaluating group-based ACT among adolescents remain sparse, particularly in school settings and Southeast Asian populations. This randomized controlled trial therefore evaluated an eight-session school-based Acceptance and Commitment Group Therapy (ACGT) program in Indonesian adolescents with problematic gaming, examining changes in gaming symptoms and exploratory emotional outcomes over a three-month follow-up period.

METHODS

Study design

This was a parallel-group randomized controlled trial conducted in a public senior high school in Surabaya, Indonesia. Participants were assessed at baseline (week 0), immediately after completion of the intervention (week 9), and at follow-up (week 21). This study was designed to evaluate the effectiveness of ACGT for problematic gaming and associated emotional symptoms. This randomized controlled trial was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.

Participants and recruitment

Students in grades 1 and 2 were screened for problematic gaming using the Indonesian version of the 7-item Game Addiction Scale (GAS-7) [15,16]. Of 184 students screened, 40 met the prespecified GAS-7 screening criterion of ≥14 and were eligible for enrollment, representing 21.7% of the screened population. The ≥14 threshold was adopted as a study-specific screening threshold for elevated problematic gaming symptoms. This threshold was adapted from previous Indonesian research using the Indonesian Online Game Addiction Questionnaire, an instrument different from the GAS-7; scores of 14–21 on this questionnaire were categorized as mild online game addiction [17]. The threshold was used for participant screening rather than for diagnostic confirmation of IGD.

Eligible students were invited to participate in the study and provided written assent, with written informed consent obtained from their parents or legal guardians before enrollment. All enrolled participants completed the intervention and follow-up assessments.

Participants were eligible if they were enrolled in grade 1 or grade 2 of senior high school, had a GAS-7 score of ≥14, were able to communicate in Indonesian, and provided written assent with parental or guardian consent. Students were excluded if they had a severe or chronic medical illness requiring ongoing treatment, had a previously diagnosed psychiatric disorder, or were currently receiving psychiatric medication based on the information obtained from their parents or guardians during the screening process.

The a priori sample size calculation was based on post-intervention gaming scores from a previous Indonesian study, with mean±standard deviation values of 47.26±21.99 in the intervention group and 65.22±11.82 in the control group [18]. Using a two-sided α of 0.05, 80% power, and a 1:1 allocation ratio, the minimum required sample size was 16 participants per group (32 participants in total). To account for potential attrition, the target sample size was increased by 25% to 40 participants, with 20 participants allocated to each group.

Randomization and allocation

Participants were randomly assigned in a 1:1 ratio to the intervention or control group using a simple lottery. No additional allocation-concealment procedures were used. Allocation was performed after participant enrollment and baseline assessment. Owing to the nature of the intervention, neither the participants nor the therapists could be blinded to group assignment. However, outcome assessments were conducted by psychologists who were unaware of treatment allocation.

Intervention

Participants assigned to the intervention group received ACGT delivered in eight weekly sessions over eight consecutive weeks. Each session lasted approximately 90–120 minutes and was conducted in a group format. The principal investigator developed the therapy module based on formal training in ACT for children and adolescents, established ACT protocols, and international certification workshops. Prior to implementation, supervisors and three experts in psychotherapy and child and adolescent psychiatry reviewed the module.

The intervention targeted six core ACT processes: present-moment awareness, self-as-context, acceptance, cognitive defusion, value clarification, and committed action. Sessions incorporated mindfulness exercises, experiential activities, group discussions, structured worksheets, metaphor-based learning, and relapse prevention strategies. Two clinical psychologists assisted with the sessions to facilitate participation and support group processes. A summary of the intervention content is presented in Table 1.

Table 1.

Content of the eight session acceptance and commitment group therapy program

Session	Core ACT process	Key components	Duration
1	Introduction and orientation	Psychoeducation on Internet Gaming Disorder and ACT model; group agreement; initial functional analysis	90-120 min
2	Mindfulness and present moment awareness	Mindful breathing; experiential exercises; awareness of urges and gaming triggers	90-120 min
3	Self as context	Observer self exercises; perspective taking activities	90-120 min
4	Acceptance	Experiential exercises addressing avoidance; metaphor-based work including quicksand and control paradox	90-120 min
5	Cognitive defusion	Techniques to distance from unhelpful thoughts; metaphor exercises; experiential restructuring activities	90-120 min
6	Values clarification	Identification of personal values; value exploration worksheets; group discussion	90-120 min
7	Committed action	Goal setting aligned with values; behavioral planning; barrier analysis	90-120 min
8	Relapse prevention and consolidation	Review of skills; self-evaluation; individualized relapse prevention plan	90-120 min

ACT, Acceptance and Commitment Therapy.

Participants assigned to the control group continued their usual school activities and did not receive structured psychological interventions, training, or study-related educational modules during the study period. Their contact with the research team was limited to completing the GAS-7 and Depression Anxiety Stress Scale–Youth assessments at baseline (week 0), week 9, and week 21. After completion of the study, participants in the control group were offered the intervention.

Measures

Problematic gaming symptoms were assessed using the Indonesian version of GAS-7, an established instrument originally developed by Lemmens et al. [15] for the assessment of gaming-related problems in adolescents. The GAS-7 consists of seven items representing salience, tolerance, mood modification, relapse, withdrawal, conflict, and problems. Each item is rated on a 5-point response scale, yielding a total score ranging from 7 to 35, with higher scores indicating more problematic gaming symptoms [15]. The validated Indonesian language version was used without modification and has demonstrated acceptable internal consistency (Cronbach’s α=0.770) and good concurrent validity [16]. Total GAS-7 scores were analyzed as continuous variables.

Depression, anxiety, and stress were assessed using the Indonesian version of the Depression Anxiety Stress Scale for Youth (IDASS–Y), an adolescent-adapted version of the DASS-21. This 21-item instrument evaluates symptoms across three domains: depression, anxiety, and stress. The Indonesian version has demonstrated good reliability and construct validity, with Cronbach’s alpha and McDonald’s omega exceeding 0.80 across all subscales and confirmatory factor analysis supporting its three-factor structure [19]. Total scores for each subscale were analyzed separately.

Ethical considerations

This study was approved by the Health Research Ethics Committee of the Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia (No. 55/EC/KEPK/FKUA/2025). Written informed consent was obtained from parents or legal guardians, and written assent was obtained from all participants prior to enrollment. Participation was voluntary, and students were informed that they could withdraw from the study at any time without academic consequences. Confidentiality of participants’ information was maintained throughout the study. Participants requiring further mental health evaluation were referred according to institutional procedures. However, the trial was not prospectively registered.

Statistical analysis

Data were analyzed using IBM SPSS Statistics, version 27 (IBM Corp.). Continuous variables were assessed for normality using the Shapiro–Wilk test and were presented as mean±standard deviation or median (range), as appropriate. Baseline characteristics were compared using independent samples t-test, Mann–Whitney U test, chi-square test, or Fisher’s exact test, as appropriate. Within-group changes over time were evaluated using paired t-tests or Wilcoxon signed-rank tests according to data distribution, whereas between-group comparisons were performed using independent samples t-tests or Mann–Whitney U tests.

To determine whether the association between treatment group and problematic gaming outcomes remained after accounting for baseline psychological symptoms, additional analyses of covariance (ANCOVA) were performed separately for post-intervention and three-month follow-up GAS-7 scores. The treatment group was entered as a fixed factor, while baseline GAS-7, depression, anxiety, and stress scores were included as covariates. The homogeneity of regression slopes was evaluated by testing the interactions between the treatment group and each covariate. Because the treatment group×baseline GAS-7 interaction was significant, this interaction term was retained in the final model. Thus, the final models included treatment group, baseline GAS-7, baseline depression, baseline anxiety, baseline stress, and treatment group×baseline GAS-7 interaction. F statistics, p values, and partial eta squared (η²) were reported for each model term. Because the treatment group×baseline GAS-7 interaction was significant, conditional treatment effects were estimated at representative baseline GAS-7 scores of 14, 17, and 20, corresponding to low, intermediate, and high scores, respectively, within the observed baseline range.

Additional ANCOVA models were used for the secondary emotional outcomes. Depression, anxiety, and stress scores at weeks 9 and 21 were analyzed separately, with treatment group entered as the fixed factor and the corresponding baseline score as the covariate. Homogeneity of regression slopes was assessed by testing the interaction between treatment group and the corresponding baseline score. When a significant interaction was identified, the interaction term was retained, and the between-group difference was interpreted as conditional on baseline symptom severity. Depression, anxiety, and stress were considered exploratory secondary outcomes. No adjustment for multiple comparisons was prespecified or applied; therefore, p values for these outcomes were interpreted descriptively and should not be considered confirmatory.

A two-sided p<0.05 was used as the nominal significance threshold.

RESULTS

Participant flow and baseline characteristics

Of the 184 students screened, 40 met the prespecified GAS-7 screening criterion of ≥14 for elevated problematic gaming symptoms and were randomly assigned to the intervention group (n=20) or control group (n=20). All participants completed the intervention and follow-up assessments, resulting in a 100% retention rate (Fig. 1).

Fig. 1.

CONSORT flow diagram of participant recruitment, allocation, follow-up, and analysis. A total of 184 students were screened, 40 eligible participants were randomized in a 1:1 ratio to the intervention or control group, and all randomized participants completed the post-intervention and three-month follow-up assessments and were included in the analysis.

The baseline characteristics are presented in Table 2. GAS-7 scores were comparable between the groups at baseline (p=0.606). Baseline depression and anxiety scores were also similar between the groups, while the between-group comparison for anxiety yielded p=0.050. Stress scores were higher in the intervention group than in the control group (7.30±1.52 vs. 6.15±1.69, p=0.030).

Table 2.

Baseline characteristics of study participants

Variable	Intervention	Control	p
	(n=20)	(n=20)
Age (yr)	16.75±0.55	17.15±0.75	0.279
Sex, female	10 (50.0)	6 (30.0)	0.333
GAS-7 score	16.5 (14-20)	15.5 (14-21)	0.606
Depression score	5 (1-10)	5 (3-7)	0.273
Anxiety score	4.5 (1-10)	4 (1-7)	0.050
Stress score	7.30±1.52	6.15±1.69	0.030

Values are presented as mean±standard deviation, median (range), or number (%), as appropriate. GAS-7, Game Addiction Scale-7.

Primary outcome: problematic gaming symptoms

Within-group changes

Participants who underwent ACGT showed a reduction in problematic gaming symptoms over time. The median GAS-7 score decreased from 16.5 (14–20) at baseline to 11.0 (10–14) at week 9 (p<0.001), with the improvement maintained at week 21 (11.5 [10–15]).

In contrast, the control group showed progressive increases in GAS-7 scores, with the median rising from 15.5 (14–21) at baseline to 17.0 (12–21) at week 9 and 18.0 (15–25) at week 21 (p<0.001) (Table 3).

Table 3.

GAS-7 scores over time

Time point	Intervention median (range)	Control median (range)	Between-group P
Week 0	16.5 (14 to 20)	15.5 (14 to 21)	0.606
Week 9	11.0 (10 to 14)	17.0 (12 to 21)	＜0.001*
Week 21	11.5 (10 to 15)	18.0 (15 to 25)	＜0.001*

^*p＜0.05. GAS-7, Game Addiction Scale-7.

Between-group comparisons

No significant difference in GAS-7 scores was observed between the groups at baseline. However, significant differences emerged at week 9 (p<0.001) and remained evident at week 21 (p<0.001), favoring the intervention group (Table 3 and Fig. 2).

Fig. 2.

Distribution of GAS-7 scores in the intervention and control groups at baseline (week 0), post-intervention (week 9), and three-month follow-up (week 21). Boxes represent the interquartile range, horizontal lines indicate the median, and whiskers represent the observed minimum and maximum values. Individual points represent participant-level scores. ***p＜0.001. GAS-7, Game Addiction Scale-7.

Adjusted analysis

Additional ANCOVAs were performed to examine whether the association between the treatment group and GAS-7 outcomes remained after accounting for baseline GAS-7, depression, anxiety, and stress scores. In the final models, a significant treatment group×baseline GAS-7 interaction was observed at both post-intervention (F[1,33]=10.36; p=0.003; partial η²=0.239) and three-month follow-up (F[1,33]=6.79; p=0.014; partial η²=0.171), indicating that the difference in follow-up GAS-7 scores between treatment groups varied according to baseline problematic gaming severity. Conditional analyses showed that at baseline GAS-7 scores of 14, 17, and 20, the estimated intervention-control differences at week 9 were -3.49 (95% confidence interval [CI], -5.06 to -1.93), -5.86 (95% CI, -6.90 to -4.83), and -8.23 (95% CI, -10.28 to -6.19), respectively, all p<0.001. Corresponding differences at week 21 were -4.33 (95% CI, -6.37 to -2.29), -6.83 (95% CI, -8.18 to -5.48), and -9.34 (95% CI, -12.01 to -6.67), respectively, all p<0.001. Thus, lower follow-up GAS-7 scores were observed in the intervention group across the representative baseline severity levels examined, with larger between-group differences observed at higher baseline GAS-7 scores. Baseline depression, anxiety, and stress levels were not significant predictors in either model. The complete model and conditional effect estimates are presented in Tables 4 and 5.

Table 4.

ANCOVA models for GAS-7 scores at week 9 and week 21

Model term	Week 9	p	Partial η2	Week 21	p	Partial η2
	F (1,33)			F (1,33)
Treatment group	3.48	0.071	0.095	1.93	0.174	0.055
Baseline GAS-7	27.62	＜0.001	0.456	12.50	0.001	0.275
Baseline depression	0.07	0.790	0.002	0.56	0.461	0.017
Baseline anxiety	0.37	0.545	0.011	0.27	0.606	0.008
Baseline stress	0.06	0.815	0.002	0.64	0.428	0.019
Treatment group×baseline GAS-7	10.36	0.003	0.239	6.79	0.014	0.171

Separate ANCOVA models were fitted for week 9 and week 21 GAS-7 scores and included treatment group, baseline GAS-7, depression, anxiety, and stress scores, and the treatment group×baseline GAS-7 interaction. The treatment group main effect is evaluated at baseline GAS-7=0 because the model includes a treatment group×baseline GAS-7 interaction. Because a GAS-7 score of 0 lies outside the possible score range of 7 to 35, this main effect should not be interpreted as an overall treatment effect. ANCOVA, analyses of covariance; GAS-7, Game Addiction Scale-7.

Table 5.

Conditional intervention-control differences in GAS-7 scores at week 9 and week 21

Baseline GAS-7 score	Week 9 difference (95% CI)	p	Week 21 difference (95% CI)	p
14	-3.49 (-5.06 to -1.93)	＜0.001	-4.33 (-6.37 to -2.29)	＜0.001
17	-5.86 (-6.90 to -4.83)	＜0.001	-6.83 (-8.18 to -5.48)	＜0.001
20	-8.23 (-10.28 to -6.19)	＜0.001	-9.34 (-12.01 to -6.67)	＜0.001

Conditional differences are intervention minus control and were estimated from the ANCOVA models at representative baseline GAS-7 scores within the observed range. Negative values indicate lower follow-up GAS-7 scores in the intervention group. ANCOVA, analyses of covariance; CI, confidence interval; GAS-7, Game Addiction Scale-7.

Secondary outcomes

Depression

Depressive symptoms were evaluated as an exploratory secondary outcome. In the unadjusted analysis, no significant between-group differences were observed at week 9 or week 21. After adjustment for baseline depression, scores were lower in the intervention group at week 9 (adjusted mean 4.07 vs. 5.03; adjusted mean difference -0.97, 95% CI -1.65 to -0.29; F[1,37]=8.36; p=0.006) and week 21 (4.04 vs. 5.06; adjusted mean difference -1.03, 95% CI -1.75 to -0.31; F[1,37]= 8.47; p=0.006).

Anxiety

Anxiety was analyzed as an exploratory secondary outcome. In the unadjusted analysis, anxiety scores were lower in the intervention group at week 9 (p=0.023), whereas the between-group difference at week 21 was not statistically significant (p=0.057). In the baseline-adjusted analysis, anxiety scores were lower in the intervention group at week 21 (adjusted mean 3.67 vs. 5.48; adjusted mean difference -1.82, 95% CI -2.70 to -0.93; F[1,37]=17.35; p<0.001). At week 9, the treatment group×baseline anxiety interaction was significant (F[1,36]=6.57; p=0.015), indicating that the between-group difference varied according to baseline anxiety severity.

Stress

Stress was analyzed as an exploratory secondary outcome. In the unadjusted analysis, stress scores showed a significant between-group difference at week 21 (p=0.029), whereas the difference at week 9 was not statistically significant (p=0.217). After adjustment for baseline stress, the between-group difference remained non-significant at week 9 (adjusted mean 5.15 vs. 6.05; adjusted mean difference -0.89, 95% CI -2.07 to 0.28; F[1,37]=2.36; p=0.133), but was present at week 21 (4.89 vs. 7.11; adjusted mean difference -2.23, 95% CI -3.31 to -1.15; F[1,37]=17.38; p<0.001).

Because these secondary emotional outcomes were exploratory and no adjustment for multiple comparisons was applied, the corresponding p values should be interpreted cautiously. Detailed outcome data for depression, anxiety, and stress are presented in Table 6.

Table 6.

Depression, anxiety, and stress scores in the intervention and control groups at baseline, week 9, and week 21

Outcome	Time	Intervention	Control	p (between groups)
Depression	Week 0	5 (1-10)	5 (3-7)	0.273
	Week 9	4.45±2.43	4.75±1.11	0.620
	Week 21	4.5 (1-8)	5 (3-8)	0.385
Anxiety	Week 0	4.5 (1-10)	4 (1-7)	0.050
	Week 9	3.45±1.27	4.65±1.87	0.023*
	Week 21	4 (1-7)	5 (3-10)	0.057
Stress	Week 0	7.30±1.52	6.15±1.69	0.030*
	Week 9	5.40±2.06	6.15±1.69	0.217
	Week 21	5.30±1.97	6.70±1.92	0.029*

Values are presented as mean±standard deviation or median (range). *p＜0.05.

DISCUSSION

This randomized controlled trial demonstrated that ACGT is associated with a significant and sustained reduction in problematic gaming symptoms among adolescents. Participants who received the intervention showed improvements immediately after treatment, and these benefits were maintained at the three-month follow-up. By contrast, participants assigned to the control group demonstrated a progressive increase in problematic gaming symptoms over time. Taken together, these findings are consistent with emerging evidence suggesting potential benefits of ACT-based approaches for problematic gaming [10,11].

The progressive increase in problematic gaming symptoms in the control group contributed to the observed between-group differences. Because the control condition involved no structured intervention and participants were aware of their group assignment, this pattern should be interpreted cautiously. Possible explanations include assessment reactivity, changes in academic demands during the study period, and demoralization associated with remaining in the untreated control condition. These possibilities were not directly assessed and therefore cannot be distinguished from a true worsening of problematic gaming symptoms.

Adjusted analyses identified a significant interaction between the treatment group and the baseline GAS-7 score at both post-intervention and three-month follow-up. Conditional analyses indicated lower follow-up GAS-7 scores in the intervention group across the representative baseline severity levels examined, with larger between-group differences among participants with higher baseline GAS-7 scores. This finding suggests that the baseline problematic gaming severity may moderate the association between the intervention and subsequent problematic gaming symptoms. However, given the small sample size relative to the number of parameters included in the adjusted models, this moderation finding should be considered exploratory and requires confirmation in larger studies.

One possible explanation for these effects is that the intervention targeted psychological flexibility, the central therapeutic process of ACT [9]. Problematic gaming may function as a maladaptive coping response to stress, emotional distress, interpersonal difficulties, or other negative experiences [4,7,8]. From the ACT perspective, persistent reliance on gaming to avoid or regulate unwanted internal experiences can be understood within the broader process of experiential avoidance [9]. By encouraging the acceptance of difficult emotions, cognitive defusion, present-moment awareness, and engagement in value-consistent activities, ACT may reduce reliance on gaming as an emotional regulation strategy [9]. This interpretation is consistent with emerging ACT intervention studies on problematic gaming [10,11].

These findings are also consistent with evidence implicating cognitive control and reward processing in problematic gaming among adolescents. Adolescents with IGD demonstrate reduced inhibitory control and altered reward-related processing compared with controls [20]. These processes may increase vulnerability to repetitive and reinforcing gaming behaviors. ACT may be relevant in this context because it seeks to strengthen psychological flexibility and value-guided behavior, rather than focusing solely on restricting gaming time [9].

The secondary emotional outcomes were exploratory and should be interpreted cautiously because no adjustment for multiple comparisons was pre-specified. Baseline adjusted analyses suggested lower depression scores in the intervention group at weeks 9 and 21, lower anxiety scores at week 21 and lower stress scores at week 21. The week 9 anxiety analysis also identified an interaction with baseline anxiety severity, indicating that the between-group differences varied according to baseline anxiety symptoms. These findings are compatible with the emphasis of ACT on acceptance, present-moment awareness, and more flexible responses to emotional distress [9], but they do not provide confirmatory evidence that the intervention independently improves depression, anxiety, or stress. Larger trials with pre-specified secondary outcomes and appropriate controls for multiple comparisons are needed to determine whether these emotional effects are reproducible.

The group-based format may have also contributed to the observed effects. The group sessions provided opportunities for shared reflection, normalization of experiences, peer interaction, and mutual encouragement. These nonspecific components may have influenced the treatment response alongside the structured ACT content. Because the study did not include an active control group, their contributions cannot be separated from the specific effects of ACT.

This study extends the emerging literature on ACT for problematic gaming [10,11]. Existing studies include an online pilot randomized trial on excessive gaming and an intervention study among adolescents with gaming disorders; however, randomized evidence for group-based ACT delivered in school settings remains limited [10,11]. The present findings provide preliminary evidence for the feasibility and potential benefits of a school-based group intervention that incorporates ACT for adolescents with problematic gaming. Given the prevalence of problematic gaming among adolescents [3-5], school-based approaches warrant further investigation in larger, controlled studies.

This study had several limitations. The study was conducted at a single school with a relatively small sample size, which may have limited the generalizability of the findings. Baseline stress differed between the groups, and depression, anxiety, and stress outcomes were exploratory secondary outcomes without prespecified adjustments for multiple comparisons. Outcomes were based on self-reports, objective gaming measures were unavailable, and participants were identified using a study-specific GAS-7 screening threshold rather than a structured diagnostic interview. The ≥14 threshold was adapted from previous Indonesian research using a different gaming measure and has not been validated as a cutoff for the GAS-7; therefore, the findings should be interpreted in relation to the study-specific screening criterion used. Participants and therapists could not be blinded, and the absence of an active control group meant that specific ACT effects could not be separated from non-specific influences such as facilitator attention, peer interaction, expectancy, or Hawthorne effects. Follow-up was limited to three months.

Despite these limitations, the consistency and persistence of the primary outcome support further evaluation of group-based ACT interventions for adolescents with problematic gaming. Larger multicenter trials with active control groups, diagnostic confirmation, longer follow-up, and objective behavioral measures are needed to confirm these findings and clarify the underlying treatment mechanisms.

CONCLUSION

In this randomized controlled study, a group-based intervention incorporating ACT was associated with a sustained reduction in problematic gaming symptoms among adolescents. The exploratory findings also suggest improvements in some emotional outcomes, although these should be interpreted with caution. Because the study did not include an active control condition, the observed effects could not be attributed exclusively to the specific therapeutic components of ACT. Larger studies incorporating diagnostic confirmation, active control groups, longer follow-up periods, and objective behavioral measures are warranted to confirm these findings and clarify the mechanisms underlying treatment response.

Funding Statement

Funding Statement None

Availability of Data and Material

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.