Gambling Among Young People, 837 kB

Gambling Among
Young People
A Knowledge Review
Frida Fröberg
swedish national institute
of public health
www.fhi.se

Gambling Among Young People
A Knowledge Review
swedish national institute
of public health
www.fhi.se

© swedish national institute of public health r 2006:20
issn: 1651-8624
isbn: 91-7257-471-2
author: frida fröberg
illustrator: lotta persson
graphic production: ab typoform
print: edita, stockholm, 2006

Contents
Foreword ____________________________________________________________________ 5
Summary ____________________________________________________________________ 6
1. Introduction ________________________________________________________________ 7
Background __________________________________________________________________ 8
Aim ________________________________________________________________________ 9
Method______________________________________________________________________ 9
Definitions __________________________________________________________________ 10
Gaming in Sweden ____________________________________________________________ 11
2. Young people and gambling __________________________________________________ 13
Introduction ________________________________________________________________ 14
How much do young people gamble? ____________________________________________ 14
Popular games ______________________________________________________________ 15
Why children and young people gamble __________________________________________ 15
Children’s and young people’s perceptions of gambling ____________________________ 17
Differences between the gambling habits of girls and boys____________________________ 18
Summary __________________________________________________________________ 18
3. Pathological gambling – the assessment tools __________________________________ 21
Introduction ________________________________________________________________ 22
The most common tools ______________________________________________________ 22
The quality of the tools ________________________________________________________ 24
Summary __________________________________________________________________ 28
4. Pathological gambling in young people ________________________________________ 29
Introduction ________________________________________________________________ 30
The prevalence of pathological gambling in young people ____________________________ 30
Prevalence at different ages ____________________________________________________ 32
The gambling habits of young pathological gamblers ________________________________ 32
Other problems in young pathological gamblers __________________________________ 35
Pathological gambling – not a chronic state ______________________________________ 37
Summary __________________________________________________________________ 38
5. Risk factors of pathological gambling in young people ____________________________ 39
Introduction ________________________________________________________________ 40
Individual factors ____________________________________________________________ 41
Social network factors ________________________________________________________ 43
Differences between girls and boys ______________________________________________ 45
Summary __________________________________________________________________ 45

6. Prevention ________________________________________________________________ 47
Introduction ________________________________________________________________ 48
Evaluated primary preventive (universal) measures ________________________________ 48
Treating adult pathological gamblers ____________________________________________ 49
Practical experience of treating young pathological gamblers ________________________ 49
Theoretical prevention models __________________________________________________ 50
Summary____________________________________________________________________ 51
Appendix: Table 1. A list of the proportion of adolescents who
have gambled or who have some type of gambling problem __________________________ 54
References __________________________________________________________________ 55

Foreword
Our habits, both positive ones and the ones with destructive qualities, are established already at a
young age. Living conditions during childhood have an impact not only on the living situation of
children and young people but also on their habits and way of life. This also applies to young people’s
attitudes to gambling. Public Health Objective 11 includes the aim of reducing the damaging effects
of too much gambling.
In 1999, the Swedish National Institute of Public Health was commissioned to continually follow the
development of pathological gambling and to strive to reduce the damaging effects of too much gambling.
Since 2003, the Institute has been able to carry out parts of a proposed action plan on pathological
gambling that was submitted to the Government in January 2003. One of the main aspects in the
action plan deals with examining the gambling habits of young people and developing methods to
reduce the damaging effects of gambling.
Despite the fact that young people gamble less than adults, a greater proportion of young people
suffer from gambling-related problems. We have, however, not as much knowledge about the gambling
habits and problems of children and young people as we do about the gambling of adults.
This review of young people’s gambling habits forms part of the work being carried out to achieve
the aims set out in the action plan. The Maria Ungdom Clinic (an addiction clinic for adolescents) in
Stockholm has also started working on a development project this year. The aim is to produce suitable
treatment measures for adolescents with gambling problems and to create preventive measures. The
intention for the long term is to create a centre of knowledge for adolescents with gambling problems.
This review is based on articles that have been published in scientific periodicals, a couple of
unpublished reports and presentations at international conferences. Knowledge gained from study
visits to research centres and treatment clinics for adolescents who are pathological gamblers is also
included.
The review has been written by public health planner Frida Fröberg at the Swedish National
Institute of Public Health. Dr. Anders Tengström from the Research Centre for the Psychosocial
Health of Young People at the Maria Ungdom Clinic and the Karolinska Institutet (FORUM) was the
scientific supervisor. Anders Tengström has also co-authored the sections on the quality of the assessment
tools and the risk factors of pathological gambling in young people.
Professor emeritus Sten Rönnberg and Professor Håkan Stattin have also contributed valuable
input to an early version of the report. The author has, however, the sole responsibility for the final
wording of the report.
A special thank you also to Dr. Rina Gupta and Dr. Jeffrey Deverensky and the staff at the
International Centre for Youth Gambling Problems, as well as Geneviève Siebes and Christian
Carpenter at the Centre Dollard-Cormier, who have kindly shared their experience of treating young
people with gambling problems.
Stockholm 16th October 2006
gunnar ågren
5

6
Summary
In 2001, the Swedish National Institute of Public Health was commissioned by the Government
(Government Communication S2001/9487/FH) to draw up a proposal for an action plan to combat
pathological gambling in Sweden. This review, which aims to systematise the scientific literature on
young people’s gambling habits, forms a basis for the development of the measures in the action plan
that are geared towards young people. The literature reviewed consists of scientific articles that have
been published in international periodicals, a number of unpublished reports and a couple of presentations
from conferences. Knowledge gained at research centres and treatment clinics for young
pathological gamblers has also been included.
Studies from Western countries indicate that gambling is common among young people, albeit
less so than among adults. It is the chance of winning or the risk of losing which are important factors
motivating young people in their decision whether to gamble or not to gamble. Gambling is also seen
as something exciting, fun, entertaining and a way to while away the time. Young people may have
trouble differentiating between the concepts luck, fate, chance and probability. Additionally, they are
used to playing TV and computer games, which makes them vulnerable consumers when it comes to
gambling. It is usual for young people to have a gambling problem. The prevalence rate of gambling
problems and pathological gambling in young people in North America is estimated at approximately
ten to fourteen percent, which corresponds to studies from Australia and Europe. In 1999, the proportion
of young problem and pathological gamblers in Sweden was estimated at approximately five
percent, compared with two percent among adults.
An analysis of the studies indicates that young people with a gambling problem also often suffer
from other problems, normally depression and anxiety disorders, crime and alcohol and/or drug
addiction. The studies also indicate that the risk factors, i.e. the factors that may increase the risk of a
gambling problem occurring in a young person, are: manifesting impulsive behaviour in childhood or
teenage years (for boys), having friends who gamble, having friends who are problem or pathological
gamblers, having parents who have introduced their children to gambling and having parents who
gamble a lot, above all together with their children. It appears that boys run a greater risk of developing
a gambling problem than girls. However, there are very few if any studies on girls and gambling. The
link between various types of problem behaviour, crime, addiction and pathological gambling is still
vague since not enough research has been carried out in this area. Moreover, there is practically no
research that has followed young people with a gambling problem over a number of years and therefore
we know currently very little about how things turn out for the young people who have had these
problems.
There is still only limited research on the prevention including treatment of pathological gambling
in young people. However, the literature suggests that work to combat gambling problems in young
people should be based on known principles for the prevention of other types of risk behaviour.
Certain conclusions as regards treatment principles can also be drawn from studies on gambling in
young people and knowledge gained from study visits at treatment clinics. Namely, that it is necessary
to inform young people and parents about gambling and gambling problems; that young pathological
gamblers usually have other problems at the same time which must treated in parallel; and that it is
important to include motivation-enhancing elements in treatment.

1.
introduction

8
Background
Adolescent Swedes gamble less and spend less money on gambling than Swedish adults, however, a
greater proportion of them are problem gamblers as compared to adults. According to one population
study, approximately five per cent of 15 to 17-year-olds gambled so much that they could be classified
as pathological gamblers or as problem gamblers, while the corresponding figure for adults was two
per cent. For some unknown reason, the risk of acquiring a gambling problem is therefore more than
twice as high for young people as for adults.
Children and young people who are growing up today are exposed to various types of gambling in
a completely different way compared to previous generations. Among other things, many hundreds of
millions of crowns are being invested on an annual basis in gaming advertising via Svenska Spel and
ATG, as well as unknown amounts by foreign gaming companies via foreign-based TV channels and
the Internet. Gambling is portrayed in the advertisements and in the mass media as a form of entertainment,
as something you do together with your friends rather than something you do to win money.
Therefore, many people, particularly young people, rarely understand the risks linked to gambling.
The effects of these campaigns are not known, but naturally they risk increasing gambling among
young people and therefore also the prevalence of gambling problems.
Furthermore, the gaming market itself has changed radically. New gambling games that are geared
towards specific groups of people are constantly being launched on the market while new media for
games has cropped up in the shape of the Internet, TV and mobile telephones, which have radically
increased accessibility. There are currently few situations or even minutes in our every day lives when
it is not possible to gamble. It is unclear how these major changes on the gaming market and the
increased exposure to gambling have affected and will affect the gambling habits of the children and
young people who are growing up today.
The Swedish National Institute of Public Health was commissioned in 2001 (Government
Communication S2001/9487/FH) to draw up a proposal for an action plan aimed at reducing the prevalence
of pathological gambling in Sweden. According to the action plan, the group children and
young people should be prioritised. Preventive measures geared towards all children and young people
must be carried out with the hope of raising the debut age for gambling and reducing gambling in the
age group. Moreover, specific measures geared towards specific risk groups of children and young
people are regarded as necessary. According to the action plan, the following measures should be
carried out:
• Informing young people, parents and the general public about the risks of children and young
people’s gambling habits.
• Informing school staff and parents about the signs of pathological gambling and what can be done
to support those who gamble too much.
• Ensuring that various social sectors are better prepared to recognise the symptoms and support
young people who are or who are becoming addicted to gambling.
• Contributing to the development of knowledge-based treatment within the framework of noninstitutional
care provided for by the psychiatric, addiction care and social services.
• Contributing to the development of knowledge centres where young pathological gamblers and
their relatives can seek treatment.
• Supporting research projects aimed at generating knowledge in the areas above.
In order to be able to carry out these measures, knowledge about the gambling of young people, about
the gambling habits of children and young people, about the risk factors of developing an addiction,
as well as knowledge about treatment and prevention are required. This review aims to map out the
existing knowledge of these areas and thus forms the first measure taken in the part of the Swedish
National Institute of Public Health action plan that is aimed at reducing pathological gambling among
young people in Sweden.

Aim
The overriding aim is to systematise existing scientific literature on the subject in order to compile
knowledge about young people’s gambling. The knowledge generated will subsequently form the
basis for the development of preventive measures for this age group. More specifically this review
will focus on the following aspects of young people’s gambling:
1. Describing the gambling habits of young people.
2. Studying the prevalence of problem/pathological gambling in young people.
3. Describing the risk and protective factors which are related to problem/pathological gambling in
young people.
4. Studying prevention programmes or specific preventive measures, including treatment.
Method
literature search
The review is broad in focus with many different sub-areas, hence the literature search was carried out
using a large number of databases in order to ensure that no literature was missed or left out. Searches
were also carried out in sociological, medical, psychological and other health-related databases:
Medline, Medline In Process, PsycINFO, SciSearch, Social Sciences Citation Index, Pascal, Cinahl,
BIOSIS Previews, Elsevier BIOBASE, New Scientist and Health Periodicals Database. The search
terms which were used either individually or in combinations were the following: (gambling OR
gaming OR gambler) AND (adolescent OR adolescence OR young OR youth OR teenager). The search
was completed in February 2006 and thus only includes articles that were published up until and
including February 2006.
selection
A first elimination/selection of articles was based on the summaries of the articles. Only articles that
dealt with gambling and children’s and young people’s gambling were selected to be read in their entirety.
Moreover, the articles had to be published in Swedish, Norwegian, Danish, English or Spanish in
order to come into question. Articles which did not highlight the aim of this review sufficiently were
rejected, for example articles that only dealt with gambling problems in adults. No specific criteria
with regard to the scientific quality of the studies were set in the selection of articles since research in
the field of young people and gambling is still limited and too strict quality rules would have rendered
the review inadequate. The scientific quality of the articles varied and this might naturally have an
impact on the conclusions that can be drawn from individual studies. These differences in quality are
commented upon throughout the text.
A complementary search for further studies was carried out based on the references in the already
identified articles, which is why further articles were included in the review. A number of reports and
a thesis on young people and gambling that were published in Sweden and Norway, but that have not
been published in any scientific periodical, have also been included. Similarly, a presentation at a
Nordic conference on gambling research in Helsinki in March 2005, organised by the Nordic Board
for Research on Alcohol and Drugs (NAD) as well as three studies that were presented at the 6th
European Conference on Gambling Studies and Policy Issues, in Malmö, Sweden in June 2005 have
also been included. Finally, knowledge gained during study visits to research centres and treatment
clinics for young pathological gamblers in Montreal, Canada has been included in the section on prevention.
9

10
Definitions
what is meant by gambling games?
In this review, the term “games” will only be used in the sense of gambling games, i.e. a game where
you bet money and where you can win money. All other types of games are excluded, for example role
play, computer games and TV games. Amusement arcade games like flipper are also not included, even
if you pay to play them because the aim is not to win money. The reason for this narrow use of the term
“game” is because gambling is treated as a separate phenomenon, separate from other types of games,
in research and the clinical context. In literature written in English the terms gaming and gambling are
used for “playing a game” (a direct translation of the Swedish term for gambling). Gambling only has
to do with playing a game for money and can be associated with taking risks and with luck, while
gaming might also apply to other types of games and is more associated with playing for fun. Those
who manufacture, sell and organise gambling games tend to use the term gaming while those who
work with pathological gambling tend to use the term gambling.
children and adolescents/young people
In this review, children and adolescents/young people includes everyone between the ages of 8 and
20.
what is meant by gambling problems and pathological gambling?
Various terms are used to describe problems with gambling in literature, research and the clinical
context; anything from a gambling dependency, pathological gambling, problematic gambling, and
gambling addiction to taking risks. Generally, you differentiate between those who have serious gambling
problems and those whose problems are not quite so serious. The terms gambling addiction and
pathological gambling refer to people who fulfil the diagnosis criteria for a clinical diagnosis. The
other terms indicate that only certain criteria have been fulfilled, not sufficient for a diagnosis but that
the gambling still has a serious negative impact on the individual.
Terms used in research
Research on pathological gambling has mainly been conducted in English and the most commonly
used terms are:
• Pathological gambler, probable pathological gambler, serious problem gambler and problem
gambler, for the more serious state.
• At risk gambler, risk gambler, in transition gambler and problem gambler, for those who have less
serious problems.
This means that the term problem gambler may refer to both these states. This in turn means that you
have to check which sense is being referred to in any literature in English.
The clinical definition of pathological gambling
The clinical definition of a gambling addiction that is used in the healthcare sector, in accordance
with the American Psychiatric Diagnosis System DSM-IV (1), is “pathological gambling” in the
English edition. However, in the Swedish translation the term “spelmani” (gambling mania) is used.
According to DSM-IV the definition pathological gambling is based on the fulfilment of at least five
of the following criteria:
1. Preoccupied. You are preoccupied with gambling, plan your gambling, get money for gambling
and so on.

2. Tolerance. You have to gamble with ever-greater sums of money to get the same buzz of excitement.
3. Loss of control. You are unable to control how much you money you spend on gambling, to cut
back your gambling or to stop gambling.
4. Withdrawal symptoms. You suffer from various symptoms when you manage to keep away from
gambling, for example restlessness and irritation.
5. Escapism.You gamble to stop thinking about problems, depression, anxiety, debts etc.
6. Chasing your losses. After having lost money you go back to try to win back what you have lost.
7. Lies.You lie to others to conceal your gambling.
8. Crime.You commit crimes, for example embezzlement, fraud or theft in order to be able to gamble.
9. Social consequences. You put your personal relationships, work or similar at risk because of your
gambling.
10. Financial dependence.You depend on others in a financial crisis.
In the World Health Organisation (WHO) diagnosis system ICD-10 (2) the term pathological gambling
is translated into gambling addiction in Swedish. ICD-10 defines pathological gambling in the
following way:
1. The gambling has had negative consequences. Over a one-year period, a person has had at least
two or more gambling episodes that have lead to financial losses and personal worries, and where
their every day life has been affected.
2. Loss of control. The person has an intense desire to gamble which is difficult to control and
he/she is unable to stop gambling despite his/her efforts.
3. Preoccupied. The person in question is preoccupied with gambling.
There is no specific diagnosis for people with a less serious problem in either the DSM or the ICD
system. Nor is there a special diagnosis or has a specific adjustment been made for gambling problems
in young people. The criteria are based on adult pathological gambling and it is unclear to what
extent they are applicable on young people.
In this review, the term pathological gambler will be used to refer to those with a serious problem
and the term problem gambler for those with a less serious problem; as well as pathological gambling
and problem gambling respectively.
Gaming in Sweden
In Sweden we currently have a regulated gambling market which means that only certain actors may
organise and run gambling events in Sweden. These actors are the state, the horse-racing organisations
and popular movements as well as other non profit-making organisations. The surplus made
from lotteries and gaming is allocated to public interest use. The Swedish state is the sole owner of
Svenska Spel, the horse-racing organisations own AB Trav och Galopp (ATG) while the popular
movements and various non profit-making organisations organise many different games, above all
traditional lotteries. The most important is Bingolotto which is a national lottery. Bingo in halls is an
important source of income for many local associations. Restaurant casinos and games and lotteries
at amusement parks and funfairs are the only gambling games that are exempt from the rule that the
surplus must benefit the public good. These games are, on the other hand, the only ones apart from
horse-racing that are taxed.
11

12
types of games
You can divide the most common games into the following categories:
• Lotteries. Traditional lotteries with lottery tickets where the draw is made after the purchase are
included as well as scratch cards where you know immediately whether you have won anything or
not, for example Triss and Tian.
• Betting games. Betting on different sport events, for example athletic contests, horse-racing
(horse-racing and harness racing) and greyhound-racing are the most common betting games.
Tipset, V75, Oddset, Måltipset, Dagens Dubbel and Greyhoundracing belong to this category.
• Fruit machines. The term “fruit machine” is used in this report to refer to all kinds of gambling
machines, including poker machines. Most modern gambling machines are Video Lottery
Terminals (VLTs) and are completely electronic. In Sweden all legal gambling machines are
VLTs. The Swedish fruit machines are called Jack and Miss Vegas and are placed in restaurants
and in bingo halls around the country. Jack and Miss Vegas are the equivalent to what used to be
called one-armed bandits, but today they are totally electronic.
• Number games. In the number games, for example Keno, you bet that one or several numbers will
be drawn.
• Bingo in bingo halls. There are hundred-odd bingo halls around the country.
• Casinos. A few years ago four state casinos were opened in Sweden where you can, for example,
play on fruit machines, play roulette, poker and Black Jack.
• Restaurant casinos.There are casinos in 730 restaurants, usually Black Jack or roulette. Their bets
and winnings are more limited compared to the four casinos where international rules apply.
• Private games. Games organised privately, for example playing cards or placing bets.
It is possible to play several of these games via the Internet, on your mobile telephone, in a gaming
shop or for example at a racecourse. There are often several different variations of the games where
the person gambling can, for example, choose combinations of numbers or let the computer make a
random selection. For some of the games the draw is only once a week, while for others the feedback
is immediate. In addition to the games that are organised on the Swedish market there are also other
games that are available via the Internet and are organised from other countries. You can play poker,
roulette, scratch cards, place bets etc on thousands of games sites all over the world.
age limits
Most of the above-mentioned games are not permitted for children and adolescents under the age of
18. Games with an age limit include all casino games, fruit machines, greyhound-racing and horseracing,
most sport betting games and bingo in a bingo hall. You also have to be 18 to be able to play on
the Swedish companies’games on the Internet; this is checked when you register as a player. The rules
vary on the foreign websites depending on the legislation in the country in question, but you do require
some type of credit card, which in practice makes it more difficult for adolescents to participate.

2.
young people
and gambling

14
Introduction
Most surveys on the gambling habits of young people are questionnaires that have been carried out in
Western countries. Normally, young people have been asked about how often they gamble, how much
money they normally bet and what games they bet on. In this review, studies that represent a larger group
of young people, for example Swedish adolescents of a certain age, are presented. One problem with
these studies is that nearly all of them have been carried out in schools, which means that there is no data
available as regards young people who do not go to school. A further problem with school surveys is that
a large proportion of pupils are away from school everyday, often those that have problems and who
might be in a risk group as regards pathological gambling or other addictions. Moreover, knowledge
about how the gambling habits have developed over time is lacking since in school surveys the questions
have only been put with regard to the adolescents’gambling habits at a particular point in time.
How much do young people gamble?
Most studies on the gambling habits of young people have been carried out in the USA and Canada,
with a few studies from Europe and Australia. What all these studies have in common is the fact that a
majority, 60 – 90 per cent, of all the young people in the studies have at some time in their lives
gambled and that young people gamble less than adults (3–14). The American researcher Jacobs has
reviewed studies on the gambling habits of Canadian and American adolescents. This review indicates
that over 60 per cent of the adolescents in these countries at the end of the 1990s had gambled (7).
Two regional studies have been carried out in Australia indicating that gambling is fairly established
among young Australians. At the end of the 1990s, 90 per cent of adolescents in Melbourne, 15 to 18
years old, said that they had gambled at one time or other (15), while approximately 70 per cent of the
young people aged between 11 and 19 in the Australian Capital Territory (that includes urban and
rural areas as well as small towns) said that they had gambled in the last year (16).
Studies from the Nordic countries indicate that games are as common a phenomena here as in the
rest of the Western world. Rossow and Hansen conducted a major study in Norway which indicates
that almost 80 per cent of Norwegian adolescents, aged between 12 and 18, have gambled in the last
year (12). Swedish adolescents gamble nearly as often according to the only Swedish population study
on gambling that has been conducted; 75 per cent of Swedish adolescents aged between 15 and 17 said
that they had bet money on a game in the last year (17). One difference between Sweden and Norway is
that fact that Norwegian adolescents gamble more often, more regularly and for greater sums than their
Swedish counterparts. This does not, however, apply to all Norwegian adolescents, most play only
sporadically and for smaller sums, while 10 per cent of Norwegian adolescents represent 50 per cent of
the gambling (12). The Swedish study indicates that only a fairly small proportion, 16 per cent, of
adolescents gamble regularly (every week) compared to just over 40 per cent of adults (17).
The Swedish Council for Information on Alcohol and other Drugs (CAN) conduct an annual drug
habit study of pupils in ninth grade, which has included questions about gambling since 2000, and
since 2004, adolescents in their second year of upper secondary education have been asked about
their gambling habits. These studies indicate that gambling is a common spare time activity above all
among boys. Approximately 40 per cent of boys both in grades seven to nine and in upper secondary
education gamble once a month, 20 per cent of girls do so (18, 19, 20).
According to Jacobs’ review of studies conducted in the USA and Canada, gambling among
young people in North America increased during the 1980s and 1990s. At the beginning of the 1980s,
45 per cent of North American adolescents had gambled, while 66 per cent said that they had done so
by the end of the 1990s (7). According to the CAN’s studies, gambling has neither increased nor
decreased among Swedish ninth graders during the period 2000–2004 (18, 19). Questions with regard
to gambling on the Internet were included in the latest study from 2005, but it is still impossible to
distinguish a change in how much ninth graders gamble (18). These results, however, do not mean to
say that no changes have occurred as regards adolescent’s gambling since young people who are
younger or older than those in the ninth grade have not been included in these studies (only figures
from 2004 and 2005 are available as concerns pupils at upper secondary school level).

Popular games
The most popular games among adolescents in the USA and Canada are cards, dice and board games
played together with friends and family as well as betting games in sport and bingo. Despite age
limits, it does happen that young people play on fruit machines and at casinos as well as via the
Internet. Adolescents in North America tend to play privately with friends and family while adults
tend to play the games offered by the gaming companies (7, 11). Young people in Australia prefer
playing private card games, buying scratch cards, putting money on horse-racing and dog-racing,
Internet poker and sport games. Young people also play on fruit machines where these are available
despite the fact that they are not allowed to (15, 16).
Young people in Europe are no different to their North American or Australian counterparts as
regards the type of games they play. British adolescents for example, tend to play on fruit machines
and scratch cards. When fruit machines were first introduced in the United Kingdom everyone was
permitted to play on them regardless of age. However, after it had been reported that the gambling
caused some adolescents problems, it was decided that all new machines would have age limits.
Young people are still today allowed to play on the older machines and 60–75 per cent of young
people say that they have played on these, usually in pubs or in amusement arcades (14, 21–24).
In Norway, the most popular game among young people is also fruit machines; followed by card
games, scratch cards and lotteries. 13–28 per cent of Norwegian adolescents say that they play on fruit
machines once a week despite the age limit of 18(10, 12). There are many fruit machines in Norway,
many more than in other European countries. The fact that the machines are easily accessible since
they are also placed in shopping centres and shops as well as in restaurants and amusement arcades,
contributes to the broad use of fruit machines among young people.
Trisslotter (scratch card) is the most commonly played game among Swedish ninth graders, both
girls and boys, but fruit machines are also played a lot despite the fact that there is an age limit of 18.
In the CAN study from 2005, 20 per cent of the boys and 10 per cent of the girls said that they had
played on a fruit machine in the last year. Moreover, 4 per cent of 15-year-old boys had played on fruit
machines several times a month or even more often. Sports related games like Oddset and Stryktipset
were also common, mainly among boys. Furthermore, 10 per cent of the boys and 1 per cent of the
girls said that they had played poker on the Internet in the last year, and 4 per cent of the boys in the
last week. Young people, mainly boys, play other games via the Internet as well to a certain extent.
Boys at upper secondary school level play Oddset more than younger boys and 10 per cent play poker
via the Internet several times a month or more often, while girls’gambling habits seem to be the same
both in the seventh to ninth grade and at upper secondary school level (20, 18).
Why children and young people gamble
Results from studies on what motivates children and young people to gamble are presented in this
section. The studies have been carried out in the United Kingdom, Canada and the USA and are based
on interviews, questionnaires and an experimental study on children and young people aged between
10 and 20. The studies indicate that there are a number of reasons why young people choose or choose
not to gamble; everything from the possible winnings to the pleasure, the social context and escapism.
gains and losses
Both children and young people in these studies say that the main reason for gambling is that they
want to win money. According to an experimental study, money has a particular value for children of
pre-school age. When choosing between a game where you win points or sweets and one where you
win money, it is the possibility of making a financial gain that makes more children want to play the
latter, to play for longer and to come back and play again. Younger adolescents, aged between 11 and
15, say in interviews that they may decide not to gamble because of the risk of losing money involved,
they feel that it is difficult to deal with losing money, they do not have so much money and they have
15

16
few possibilities of obtaining more. Also some say that they are afraid of getting into debt and that
they therefore do not dare gamble (25–28).
pleasure and spare time
Another reason why children and adolescents gamble, regardless of age, has to do with pleasure, it is
entertaining, fun and a way to while away the time. They often play together with others, parents or
friends, as a social activity that provides a sense of belonging. Scratch cards are often bought together
with friends, or you go to amusement arcades together after school as a spare time activity (25, 26).
parents who gamble
In the UK it is common for the whole family to sit and watch the national lottery draw together at the
weekend, and for many children and adolescents it is an important family activity (25, 26). Parents
have an impact on their children’s gambling habits in many ways.
Studies indicate that it is usually parents who have
introduced their children to gambling and
that children whose parents gamble
start gambling at a younger age and
gamble more later on in life compared
to other children (21, 29).
excitement
Gambling is exciting to children and
young people. The moment you scratch
your lottery ticket or when the wheels
on the fruit machine are turning is associated
with immediate physiological
excitement, which leads to a “tingling
feeling” in your body (25, 26).
competition
Many young people, above all boys, say that
the reason they gamble is that they want to
control the game, be good at it or win over the
machine. It also has to do with being a winner,
showing your friends how good you are at the game. If you have lost money you
prefer not to tell them, but if you win, well then that is something you happily tell them about
(25).
flight and fantasy
Others gamble to put their minds on other things, to forget what things are like at home or how they
feel. These children and adolescents prefer to play alone than with their friends and describe the
gambling activity as repetitive behaviour that helps them block out reality and keep unpleasant
thoughts at bay (25). Fantasy is another form of escapism, for example dreaming about the jackpot
when you are bored, “being able to buy anything you want”. Unlimited access to money seems to be a
dream scenario for many children and young people (26).

Children’s and young people’s perceptions of gambling
Results from studies conducted in the UK and Canada based on interviews and questionnaires with
children and adolescents aged between 11 and 16 are presented below. The terms behind gambling,
i.e. that it is chance that determines the outcome, the difference between chance and probability, the
actual possibility of winning and the importance of skill in gambling, these are all concepts that are
difficult for children and adolescents to grasp and distinguish between.
probability, fate, luck, chance
It is difficult to distinguish between the concepts of probability, fate, luck and chance. Interviews
indicate that children and adolescents use these terms as synonyms. They may for example say that
winning or losing has to do with fate. Most adults understand the difference between these terms
cognitively speaking, and while they can be drawn into the game and “forget” the rationality behind it,
children and adolescents simply have not learnt the difference yet which means that the fundamental
terms behind gambling remain unclear to them (26).
skill
Children and adolescents tend to overestimate the importance of ability and skill in gambling; boys to
a larger extent than girls (30). They believe, for instance, that if you practise, you can become a good
gambler and similarly if you lose, then you are a bad gambler. Gambling reminds them of other types
of games that they have been used to playing from a young age and which they can actually become
good at, for example flipper or TV and computer games. This means that it is logical for them to
believe that gambling works in the same way.
17

18
the possibility of winning
Children and adolescents, above all boys, tend to overestimate the possibility of winning. If the chance
of winning a certain game is one in five hundred, younger children may think that this means that you
can win five hundred times, or that you can win five hundred crowns. Children think that a reimbursement
rate of 75 per cent, i.e. that the gamblers on average lose 25 per cent of the stakes, means that you
can win 75 times more money or that you can win 75 times. Younger children also seem to think that
the chance of winning is greater if the winnings are high (26, 30, 31).
magical thoughts
Gamblers, both young and old, tend to indulge in magical thoughts when they gamble. They might for
example think to themselves that: “If I think of my lucky number, the wheel will stop on it”. The
concept “magical thoughts” refers to the propensity of young children to attribute occurrences and
reasons why things happen to them selves. Most adults understand that they cannot influence the outcome
of the game through their thoughts or through superstitious behaviour, but for many children
and adolescents it is still natural to believe that you can influence your surroundings in this way (26, 30).
the illusion of control
The illusion of control entails a gambler believing that he/she, rather then chance, is in control of the
game. The difference between the illusion of control and magical thoughts is that the latter has to do
with influencing the outcome through your thoughts and superstitions, while the latter has to do with
believing in your ability to manipulate the game through various tricks. This might mean that you
believe that you can throw a six with the dice if you throw it loosely rather than hard. Children and
adolescents seem to have a fairly realistic view about not being able to control the game, the more so
the older they get. Despite this, they tend to “forget” this when they are gambling. When they are gambling,
a majority say that they are able to influence the game in a number of ways. This applies above
all to when they are playing on fruit machines and particularly to those adolescents who regularly play
on fruit machines (30).
Differences between the gambling habits of girls and boys
Separate analyses of girls and boys are included in most studies on the gambling of young people. The
results indicate without exception that boys and girls in the Western world differ markedly as regards
their gambling habits. Boys start gambling at a younger age and thereafter gamble more often and for
longer periods than girls. This also applies to Swedish and Norwegian boys. The CAN school study
from 2005 indicates that no girls in the ninth grade said that they gambled as regularly as several times
a week on any game, while for each type of game there were a couple of per cent of boys who said that
they played several times a week (4–10, 12, 19, 31–37). Moreover, girls and boys tend to choose to put
their money on different types of games. On the whole, boys tend to gamble on riskier games, such as
putting bets on sports, while girls go for lotteries (4, 14, 33). This also applies to Swedish adolescents
where boys choose sports games like Oddset and Stryktipset as well as games on the Internet to a
greater extent than girls (17–19).
Summary
Studies from Western countries indicate that gambling is a common activity among children and
young people; 60–90 per cent of young people in Europe, Australia and North America have at some
time or other bet money on a game. However, young people still gamble far less than adults, and even
if most have tried, relatively few gamble on a regular basis. In North America gambling among young

people increased during the 1980s and 1990s. The gambling habits of young people in Sweden have
only been studied from 2000 onwards and during this period gambling has neither increased nor
decreased. Studies also indicate that young people play the games that they have access to regardless
of whether they are allowed to do so or not.
The chance of winning and the risk of losing money are important motivators for children and
young people when they decide whether to gamble or not. Gambling is, however, also seen as an exciting
and fun activity, a form of entertainment and a way to while away the time. It is usually parents
who introduce their children to gambling and children often gamble together with their families and
then when they are older they gamble with their friends. For some young people gambling is a way to
escape problems and worries, a way of thinking about other things or keeping worrying or unpleasant
thoughts at bay.
Many children and young people have trouble understanding concepts like chance, fate, luck, probability,
chance of winning and size of winnings, concepts you need to be able to distinguish if you
are going to grasp the underlying terms of gambling. Gambling appeals to magical thoughts; most
have at some time or other said to themselves that “if I just look at the dice, I’ll get a six” or something
similar. It is natural for younger children to think that they are able to influence occurrences and
events outside of their control. Children can therefore be regarded as vulnerable consumers when
it comes to gambling, not least because most of the children growing up today are used to TV and
computer games which they can practise on and become good at, and which might make them think
that this also applies to gambling.
The motivation to gamble may increase depending on certain aspects in the design of the games.
These aspects are ones which to a large extent can be associated with magical thoughts in games, the
illusion of control over the game or the gambler being able to win thanks to his/her skill.
The gambling habits of boys and girls differ in a number of ways; boys gamble at a younger age,
more often, for longer periods of time and for with higher stakes than girls. They also tend to go for
riskier games compared to girls.

3.
pathological gambling
– the assessment tools

22
Introduction
Assessment tools in the shape of questionnaires, so-called self-assessment screens, are used in research
and in the clinical context to assess the prevalence of gambling problems in young people. The most
common screens for the gambling problems of young people are the South Oaks Gambling Screen
(SOGS-RA), DSM-IV-MR-J, Gamblers Anonymous (GA), Massachusetts Gambling Screen
(MAGS) and Lie/Bet. A new tool for young people has also been developed in Australia, the Victorian
Gambling Screen, VGS.
Screens generally differentiate between those who do not gamble, those who gamble but do not
have a problem; those who probably have a gambling problem and those who are probably pathological
gamblers. Sometimes a further category of gamblers is included, those who are presumed to lie in
the risk zone for developing a problem. When these screens have been designed, the clinical criteria
for pathological gambling have usually formed the basis of the conceptualisation of what a gambling
problem actually entails. Despite this clinical point of departure it is not possible to diagnose a gambling
addiction solely based on these self-assessment tools. In order to be able to clinically diagnose an
addiction a more extensive clinical interview is required.
The different categories or degrees of gambling problems
are partly based on the fact that we have seen
that young people can have a less or more serious
gambling problem and this in turn means more or
less serious negative consequences for the individual.
The different screens, however, use different categories.
Some only differentiate between people “with”
or “without” a problem, while others include many
more categories for the varying degrees of a gambling
problem.
It is difficult to categorise different types of problem
gamblers and risky gambling habits because
there are currently very few studies on different
groups of problem gamblers indicating possible
disparities between the groups as regards gambling
or how the gambling in any particular group will
develop in the future. However, the main problem
when it comes to judging the prevalence of pathological
gambling is the lack of an external standard criterion for young gamblers. There is no agreement as to
what is meant by adolescent pathological gambling and researchers tend to use different tools. The
screens and what they measure are presented in the following section, followed by a description of the
quality of the tools.
The most common tools
DSM-IV-MR-J is based on the psychiatric criteria for pathological gambling in DSM-IV (see clinical
definition of pathological gambling) and has been used by Fisher in the UK for adolescents aged
between 12 and 15. The first version of the tool, DSM-IV-J, was presented already at the beginning of
the 1990s and subsequently modified in the year 2000. DSM-IV-J was designed for a clinical population,
while the later version was adapted so that it could be used on ordinary groups of adolescents.
The questionnaire consists of 12 items 1 corresponding to nine criteria, four or more of which must
be fulfilled to be classified as pathological gambling. (The test designer, however, uses the term
1 Item = question/statement included in an assessment tool.

problem gambler since she believes that it is not a matter of pathological gambling if it is based on a
self-assessment screen. The term pathological gambling is, however, used in this review). As I said,
the criteria are based on DSM-IV but have been modified to a certain extent to better fit in with the
reality and vocabulary of adolescents.
As regards lies about gambling – this entails having lied to your family and friends in order to
protect and to hide the extent of your gambling. Included in theft is gambling with money that was
earmarked for bus tickets or food for example, jeopardising social relationships has been changed to
disputes with family and friends. In other words, the questions attempt to narrow down pathological
gambling rather than problem gambling. The tool has above all been used in the UK, but also to a
certain extent in Canada and Norway (38).
SOGS-RA is an adolescent version of SOGS, the most commonly used self-assessment instrument for
adults. It is also the most commonly used tool for young people. It has above all been used in studies
in the USA and Canada. The tool was first tested on adolescents aged between 15 and 18 in Minnesota
in 1993. It differs from SOGS in that certain terms have been replaced because they were not suitable
for young people, for example “concerning” was replaced with “planning” and “spouse, child or
other important person” was replaced with “family and friends”. Questions that are specific to SOGS-
RA have to do with the gambling habits and possible gambling problems of parents and the gambling
habits of the young people themselves.
The tool consists of 16 items which just like DSM-IV-J are based on the clinical pathological gambling
criteria. SOGS-RA also includes further dimensions with regard to gambling problems, namely
gambling habits and behaviour, how gamblers pay for their gambling (for example through theft or by
borrowing money), the type of game played and how the frequency. Only 12 of these questions are
graded, 1 point for each affirmative answer, in other words a maximum of 12 points. Problem
gamblers scoring at least 3 are differentiated from those without problems with 0 – 2 points. All the
items that are graded refer to the last 12 months.
The screen was first tested on adolescents aged between 15 and 18; a majority were boys since
very few girls in the selection said that they gambled a lot (39). After having used the tool in a further
study, two groups of young people with gambling problems were perceived – those who were probable
pathological gamblers and problem/risk gamblers – as well as two ways of defining these groups, one
narrow definition and a broad one. In the narrow definition, 4 points or more corresponded to
probably a pathological gambler, 2–3 points to problem/risk gamblers and 0 or 1 point to without
problems. Questions with regard to gambling frequency, how he/she paid for his/her gambling were
included in the broad definition. This means that a young person can be classified as a problem gambler
based on the gambling frequency without him/her having reported any negative consequences, i.e. any
symptoms of pathological gambling. This still mainly applies to boys aged between 15 and 18 (40).
MAGS is a tool that is intended for clinical use and that is rarely used in studies. Its focus is biological,
psychological and social problems that may be related to problem gambling and consists of 26
questions divided into two scales. You are classified as a pathological, risk or non-pathological gambler.
There is also a shorter version, MAGS-7, which only consists of seven questions and which can be
used to screen gambling problems (41).
GA-20 is a tool that was developed by the self-help association Gamblers Anonymous and consists of
20 items describing situations and behaviour typical for problem gamblers. The instruments are used
clinically above all by Gamblers Anonymous.
Lie/Bet is a very short screening tool. It consists of two questions – “Do you lie about your gambling?”
and “Do you gamble for more and more money”, have you in other words lost control over your
gambling. It has been developed to be able to rapidly establish in a clinical context and above all
in adults whether a person has a gambling problem, and the idea is that if a person answers in the
affirmative to one or both questions, then this is an indication that you should go further and ask more
questions. It has, however, also been used in studies since it seems very good at distinguishing people
with a gambling problem (42, 43)
23

24
VGS, Victorian Gambling Screen, is a tool that was developed in Australia for both adults and young
people. It is primarily intended for clinical use to assess the need for care. It has, however, been used
in a couple of prevalence studies. The tool can be used as a self-assessment questionnaire or as a basis
for a structured interview. It consists of 21 questions divided into three scales that are presumed to
measure different dimensions related to pathological gambling:
• Gambling behaviour and negative consequences of gambling on the individual.
• The negative consequences of gambling on near ones and dear ones.
• How much you like to gamble, i.e. the degree of pleasure or the positive consequences of gambling
on the individual.
Individuals are divided into the following groups: gamblers without problems, risk gamblers
(Borderline Problem) and problem gamblers (44).
The quality of the tools
Some of the tools described above have never been studied from the quality point of
view. SOGS-RA, DSM-IV-MR-J, MAGS and Lie/Bet have, however, been studied and
studies indicate that the tools have both their merits and their shortcomings. The quality
of a screen is described using the terms reliability and validity.
validity
By validity we mean the degree to which a tool measures what it aims to measure, i.e. in
this case gambling problems and pathological gambling. One yardstick for validity is
conceptual validity which entails studying the extent to which a tool corresponds to the
theory of what you wish to measure. Another is criteria validity where test results are
compared with another external measurement (criterion) of the same behaviour in
order to establish how well these tally. One problem with all the self-assessment tools
used in this area is the lack of criteria validity, i.e. the results obtained for gambling problems
in a specific population cannot be compared with an external standard criterion.
There is currently no generally accepted standard criterion for gambling problems in
young people. It is therefore not possible to say that a prevalence rate of 5 per cent as
regards gambling problems measured using for example SOGS-RA or DSM-IV-MR-J
in a given population is a “true” or “false” prevalence rate since there is no agreement
on what it is that is being measured. Most tools use the clinical definition of pathological
gambling in accordance with DSM-IV as a criterion, but it is unclear whether a clinical
diagnosis is a suitable external criterion for gambling problems in normal populations.
It is also unclear the extent to which the clinical criteria are applicable to the group
“young people” since they have been developed to diagnose pathological gambling in
adults.
Several studies have studied the validity of SOGS-RA. The conceptual validity of
SOGS-RA has both weaknesses and strengths. The original study (39) established that
there was a significant correlation in the number of SOGS-RA points between how
much you gamble throughout your lifetime (r = .39), the gambling frequency in the last
year (r = .54) and how much you have spent on gambling in the last year (r = .42). The
study also found that of the adolescents who scored 3 or more points, 92 per cent said
that they gambled at least once a month. The corresponding figure for the adolescents

who had scored 0 points was 54 per cent. In another study, Poulin (45) found that young
people of both sexes who reported 3 or more alcohol-related problems ran six times the
risk of being a problem gambler compared to young people who had fewer alcoholrelated
problems. In the exact corresponding analysis for drugs, it was found that the
risk increase for boys was times nine and for girls times ten. All the connections and
correlations above indicate that the conceptual validity is probably relatively good.
On the other hand, shortcomings with regard to conceptual validity have been found
in SOGS-RA. The 12 items in the questionnaire, for instance, are not equally important
when it comes to describing who has a gambling problem. Certain items are much
more prevalent than others in people who are described as having gambling problems
(45, 9, 46). There are also gender differences in how the 12 items in SOGS-RA measure
gambling problems and pathological gambling. There are, for example, differences in
prevalence between boys and girls who self-report a gambling problem and moreover,
there are differences between how boys and girls answer different items (45). This has a
negative impact on the conceptual validity since in the presentation of the tool there is
no theory with regard to gender differences or differences in the items in this respect. A
lack of conceptual validity has also been established since data in SOGS-RA has been
factor analysed. Apparently, the 12 items included are spread over 2 to 3 moderately
correlated factors. These factors differ to a certain extent depending on the data sets
and the factors that only partly include the same items when the studies are compared
(9, 39, 45).
The validity of DSM-IV-MR-J was studied by Fisher in 2000. The study only includes
gambling on fruit machines, and only adolescents aged between 12 and 15.
Adolescents who regularly play on fruit machines obtained a higher score in the study
compared to those who play less often, which confirms the conceptual validity. A
further difference between those who gamble but do not report a problem and those
who report problems caused by their gambling is that those with a problem have more
commonly played on fruit machines in the last week. There is a tendency among problem
gamblers compared to other gamblers of having played at least three different
types of games in the last week, and of having sold belongings in order to pay their
gambling debts in the last year. The young people who self-reported problems with
gambling on fruit machines also had problems with scratch cards to a greater extent.
Factor analyses indicate that all the items in DSM-IV-MR-J are equally good at differentiating
between social and problem gamblers, which is an improvement compared
with the original version, DSM-IV-J, where one of the ten items was also common in
young people without a gambling problem. On the other hand, DSM-IV-MR-J also has
shortcomings as regards conceptual validity in that there are gender differences in the
responses to different items and in the test results as a whole since gambling problems
are more prevalent in boys as compared to girls (38).
Lie/Bet consists of two questions. Two questions were selected from all the DSM
criteria that best identified the people in the pathological gambling group based on
a criteria group of male pathological gamblers from Gamblers Anonymous and a
“problem-free” control group (also only men). The Lie/Bet questions had a sensitivity
of .99 and a specificity of .91 in the original study, i.e. most people who were classified
as pathological gamblers or problem free were in the criteria group and the control
group respectively. Women were included in the follow-up study, albeit still with the
Gamblers Anonymous tool as a criterion for addiction. In this study, all those who were
classified in Lie/Bet as pathological gamblers were found in the pathological gambling
group, i.e. the sensitivity was 1.00 (the maximum). On the other hand, more were
wrongly classified as problem free in the follow-up study (specificity .85) (42, 43).
Lie/Bet has been tested on two normal populations in Norway, adults and young
people, with DSM-IV (10 items) as the external standard criterion. The sensitivity was
25

26
.92 for adults and .93 for young people and the specificity was .96 for adults and .85 for
young people. In the Norwegian study, Lie/Bet did not identify as many of the adult
pathological gamblers as DSM-IV, only 20.4 per cent, while the tool managed to find
99.9 per cent of those who according to DSM-IV were problem free. As regards young
people, Lie/Bet identified 63.4 per cent of those who according to DSM-IV were
classified as pathological gamblers and 97.8 per cent of those who were problem free.
The total prevalence of risk gamblers and pathological gamblers hardly differed at all
between the tools. For young people the prevalence of risk gamblers/pathological
gamblers was 5.56 per cent with DSM-IV and 5.22 per cent with Lie2/Bet and for
adults 0.54 and 0.45 per cent respectively (47).
There is also a problem with criteria validity in Lie/Bet. To begin with the external
criterion was based on men identified as pathological gamblers by the Gamblers
Anonymous screen and in the Norwegian study by the DSM-IV criteria. None of these
external measurements can really be said to be suitable for the full assessment of pathological
gambling in young people. Generally speaking though, Lie/Bet indicates a
good validity as regards the ability to differentiate between people with a gambling
problem/addiction and those without.
MAGS consists of two sub-scales. One is called MAGS and consists of 14 items and
the other is called DSM-IV and consists of 12 items that are presumed to measure the
DSM criteria for pathological gambling. In a study conducted by Shaffer (41), the
DSM-IV scale was used as a criteria to compare with MAGS and Shaffer found that
MAGS differentiated between the young people who according to the DSM-IV scale
were classified as pathological gamblers and others. In seven items the connection with
pathological gambling was particularly clear and these were subsequently selected to
be used as a shorter screening tool, MAGS-7. However, a later study of MAGS-7 carried
out by Langhinrichsen in 2004 (48), found that one of the seven items included in the
scale did not contribute as much to the total outcome and this has a negative impact on
the conceptual validity.
The validity of VGS, the Victorian Gambling Screen, was studied in an Australian
study, but the selection consisted only of adults. There is no available data for young
people.
reliability
The stability of a tool is a measurement of its reliability, i.e. the extent to which a person
obtains the same results in several screens (test-retest). Conformity between the first
and the second test is calculated in accordance with Cohen’s Kappa and moderate to
good conformity lies between .40 and .75 (49). Another measurement is the internal
consistency, how well items in a tool correlate with each other and the entire test result.
The internal consistency is expressed using the measurement Cronbach alpha, whose
value should be 0.7 or higher (maximum 1).
The first version of Fisher’s tool for young people, DSM-IV-J, obtained a lightly higher
Cronbach alpha value, .78, than was measured in the latest version, DSM-IV-MR-J,
where the Cronbach alpha value was .75. Both these values are, however, acceptable. On
the other hand, the reliability of the test-retest has not been studied in either of the
versions. This means that we do not know the stability of the tool (14, 38). SOGS-RA has
displayed good reliability in several studies. Good internal consistency is measured in the
original study with a Cronbach alpha value of .80 (39). Poulin (45) reported a reliability
test via the test-retest carried out on 225 young people. In the study in point, Kappa values
of .57 and .58 were measured for the narrow and the broad definition of SOGS-RA for
gambling problems respectively, which indicates an acceptable reliability. In the study

that first presented the tool, the two MAGS scales had an internal consistency with
Cronbach alpha values of .83 and .87 (41). In a later study that only included the first
scale the internal consistency was much lower at .65 (compared to .83) (48). The stability
has not been tested. Finally the reliability of Lie/Bet has been proved to be good. Kappa
values of .81 have been measured in the test-retest (43).
general comments on the validity of the instruments
The most commonly used questionnaires, SOGS-RA and DSM-IV-J, have been criticised
by the Canadian researcher Ladouceur, who says that their estimates of gambling problems
in young people are too high. One explanation for this might be that children do
not understand the meaning of the questions. This has been tested by letting children
and young people appreciate their gambling problems with and without an explanation
of the meaning of the questions. With an explanation of the meaning of the questions,
children, in particular those under the age of 12, reported fewer negative gambling consequences
than they did before the questions had been explained to them. The decrease
in the prevalence of pathological gambling was 50–73 per cent for SOGS-RA and
20–29 per cent for DSM-IV-J (50, 51). However, according to Derevensky and Gupta
from the International Centre of Youth Problem Gambling and High-Risk Behaviors in
Canada, the tools are suitable for children over the age of 12 and the criticism is hence
unjustified (53).
Further criticism put forward by Ladouceur is that DSM-IV-J has been used
erroneously in several studies. Instead of requiring four criteria out of nine to be fulfilled
in order to classify a person as a probable pathological gambler, in several cases four
affirmative answers out of a possible 12 have been used (52). According to Derevensky
and Gupta this erroneous classification has not, however, had an impact on the results,
according to new calculations based on the correct system (30, 53).
In a comparative study of SOGS-RA, DSM-IV-J and GA, the prevalence of problem
gambling varied depending on the tool. DSM-IV-J identified 3.4 per cent, SOGS-
RA 5.3 per cent and GA 6 per cent problem gamblers or pathological gamblers in the
same group of young people. The variation between the tools was greater for girls,
1 per cent (DSM-IV-J), 1.5 per cent (SOGS-RA) and 3.5 per cent (GA) (46). The fact
that girls reported fewer gambling problems than girls indicates that all these tools have
a problem with conceptual validity since none of them presume a gender difference.
Moreover, it is impossible to state which prevalence figure lies closest to the truth as
there is no external “golden standard”. In another study where SOGS-RA was compared
to MAGS-7, the tools did not really correspond in their classification of risk and
problem gamblers respectively. They did, on the other hand, correspond fairly well
when it came to problem free gamblers. Of the in total 269 individuals who according
to one or other of the tools were assessed as risk gamblers, only 39 of them were classified
by both tools, which gives a concordance for risk gamblers of 14.5 per cent. For
problem gamblers the concordance was 20.5 per cent while for problem free gamblers
the concordance was 82.2 per cent (48).
The self-assessment tools are based on young people reporting negative consequences
of gambling. One study asked young people to instead say whether they felt they had a
gambling problem or not, which 1 per cent said they did compared with 3–6 per cent
problem gamblers based on the self-reported negative consequences (54). This can
perhaps be explained by the fact that young people themselves do not always know
whether they have a gambling problem or not, partly because the problem is not wellknown
and partly because the consequences of the problem may seem more vague to
young people as compared to adults who for example are unable to pay their bills or

28
who neglect their work. Regardless of the reasons behind the differences between the
young people’s direct answers to the question of a gambling problem and what they
self-report via tools, the difference indicates that there are general validity problems
with measuring gambling problems using self-assessment tools. It is therefore important
to develop this field of research so that the precision of the estimates can be improved
and thus the probability that the right people are observed as having problems so that
they may get the help they need.
conclusions with regard to the tools
The tools that are used clinically and in research on the gambling problems/addictions
of young people have at most been available for the last twenty-odd years and can
therefore be said to still be at the development stage. There is as yet no agreement with
regard to what a gambling problem/addiction actually entails and thus what it is we
wish to measure. This means that it is not possible to say that a certain measured prevalence
of pathological gambling among young people via one tool is closer to the truth
than another prevalence measured with another tool. In addition to this shortcoming
there are question marks as regards further validity and reliability, where the results are
more often than not contradictory. Despite this the information you can gain from the
tools is important and it does not appear to be possible to replace them with direct
questions to the young people about whether they have a gambling problem/addiction.
The recommendation must be that these tools are used where validity and reliability
have been studied, but that the results are interpreted with care awaiting either studies
that will rectify the problems or entirely new tools where the precision and reliability
have been improved.
Summary
The most common tools for measuring the gambling problems of young people are the South Oaks
Gambling Screen (SOGS-RA), DSM-IV-MR-J, Gamblers Anonymous (GA) and the Massachusetts
Gambling Screen (MAGS), and Lie/Bet. These tools differentiate between those who do not gamble,
those who gamble without a problem, those who probably have a gambling problem and those who are
probably pathological gamblers, and sometimes also those who are presumed to be at risk of developing
a problem. There is at present no agreement as regards what characterises a gambling problem/
addiction and therefore what we wish to measure. This means that it is not possible to say whether a
certain measured prevalence of pathological gamblers among young people via one tool is closer to
the truth than another prevalence measured using another tool. In addition to this shortcoming there
are question marks as regards further validity and reliability, where the results are more often than not
contradictory. The recommendation must be that these tools are used where validity and reliability
have been studied, but that the results are interpreted with care awaiting either studies that will rectify
the problems or entirely new tools where the precision and reliability have been improved.

4.
pathological gambling
in young people

30
Introduction
In his book Det är som ett kärleksförhållande – spelmissbruk bland ungdomar (It Is Like a Love
Affair – Pathological Gambling in Young People), the writer Stig Helling describes how pathological
gambling develops in a young person and what it is that distinguishes pathological gambling from
social gambling (55). Helling interviewed 33 young people, 18 of whom were problem or pathological
gamblers. Several of these young people were winners for periods of time, or perceived themselves as
winners, but all were losers in the long term, both as gamblers as well as socially and psychologically.
The young pathological gamblers described how they went from gambling together with good
friends as a social activity to becoming withdrawn and gambling alone. Gambling alone enables you
to decide for yourself how long and for how much you are going to gamble and you are left in peace. One
young man described it as becoming “one” with the fruit machine: “it was almost like a love affair.”
Many of the pathological gamblers had trouble distinguishing between reality and “wishful thinking”
when they gambled. Despite them normally being rational and logical human beings, when
they gambled they may have thought in the following terms:
• It is not chance that determines the game but luck. There are lucky machines, lucky numbers,
lucky days and so one (magical thoughts).
• I can influence the outcome of the game thanks to my skill (or similar) (illusion of control).
• Dreaming about easy money, an easy life without worries.
Many of the gamblers gambled when they were in a difficult period in their lives, they gambled to forget
and to escape into “a protective cocoon”. In the long term it became a vicious circle; they gambled
because they felt down, they felt down because they gambled (and lost) and then they escaped even
more through their gambling.
For the pathological young gamblers, gambling was about trying to win money in desperation to
pay off gambling debts. When the debts instead kept on growing they gambled more and more and
many committed crimes in order to pay for their gambling. Some of them were already into crime,
while others started behaving criminally as a consequence of their gambling, and for them the thefts
and the fraud increased at the same pace as the gambling debts grew. They stole from their families,
embezzled money and some committed even more serious crimes, like burglaries or robberies. The
more time passed, the more serious the consequences on other areas of life, like school and work,
friends and spare time activities (55).
The prevalence of pathological gambling in young people
The studies on the prevalence of gambling problems/addiction in young people are the same as the
ones that were presented under the heading “How much do young people gamble?”, with a few exceptions
and additions. In these studies, the young people have usually been asked about both their
gambling habits and their addiction. This means that also here it is a matter of cross-sectional studies,
usually in the shape of a questionnaire, and in a very few cases telephone interviews. The studies
presented here have randomly selected the young people participating, which means that they are
sometime representative for an entire population, for example young people in Norway (the studies
have also been summarised in table form, see appendix 1).
international studies
Shaffer and Hall have compared a number of studies from the USA and Canada that have mapped out
the prevalence of pathological gambling in young people in different states during the 1980s and the
first half of the 1990s. In the studies included in the comparison, different tools were used, all of
which distinguished between young people who did not gamble or did not have a gambling problem,
those that had a gambling problem and those who seemed to be pathological gamblers. The review

included nine studies of in total 7 700 North American adolescents where the prevalence of problem
and pathological gambling and was estimated at between 9.9 and 14.2 per cent. The latter group, the
pathological gamblers, comprised 4.4 – 7.4 per cent of all young people (5). The corresponding
analyses of studies of both adults and young people have subsequently been carried out, where it is
possible to compare adults with young people. In 2001, there were 32 studies on young people and 66
on adults. In these studies, the average proportion of young pathological gamblers in the last year was
4.8 per cent and the figure for adults was 1.4 per cent. An average of 14.6 per cent of the young people
in these studies and 2.5 per cent of the adults had a gambling problem (56).
The prevalence of pathological gambling and problem gambling seems to be much the same in
Australia compared to North America. Two regional studies classify between 2–4 per cent of young
people as pathological gamblers and a further 11 per cent as problem gamblers (15, 16). One study
from New Zealand indicates that the prevalence of gambling problems in adolescents aged between
13 and 18, lies somewhere in the region of 11 to 21.6 per cent (depending on the tool used; DSM-IV-J,
SOGS-RA or 8 screen Y) (57).
Corresponding figures and patterns can be seen in various European countries, in for example the
UK and Spain, the proportion of young people with a gambling problem and addiction has been estimated
at approximately 6–7 per cent using DSM-IV-J and 14–17 per cent using SOGS-RA in
different regional studies (58–61). In the Nordic region, studies on young people have been carried
out in Iceland and Norway. Two major prevalence studies on pathological gambling have recently
been conducted in Iceland and in these studies the prevalence of pathological gambling among 13 to
18-year-olds is estimated at in the region of 2–3 per cent (depending on the tool; SOGS-RA or DSM-
IV-MR-J) with a further 3–4 per cent having a gambling problem (62, 63). In the two Norwegian
studies that have been published, the prevalence of a gambling problem/addiction among 12 to 18year-olds
has been estimated at 3–5 per cent (10, 12).
in sweden
Despite the fact that young Swedes play less than Swedish adults, a greater proportion of young people
report that they have a gambling problem. In the Swedish population study, 5.1 per cent of the young
people said that they had a gambling problem/addiction, compared to 2 per cent of the adults. Among
18–24-year-olds the proportion with a gambling problem/addiction was just over 3 per cent, a higher
figure for adults over the age of 24 (17). According to the Swedish population study it would seem that
the prevalence of problem gambling and pathological gambling in young Swedes is roughly the same
as in young people in other countries, bearing in mind, however, that the studies available have all
been conducted in the West. That the prevalence in the Swedish study is higher than in the Norwegian
studies, despite the fact that young people in Norway gamble more than their Swedish counterparts,
can perhaps be explained by the fact that different tools have been used. In Sweden, SOGS-R for
adults was used, while in the Norwegian studies a tool similar to DSM-IV-MR-J was used in one, and
an expanded version of Lie/Bet was used in the other (10, 12, 17). According to studies (see section on
screens) it would seem that SOGS-RA generally estimates the proportion of those with a problem as
higher compared to DSM-IV-MR-J, which may also apply to SOGS-R (46).
In Sweden a smaller study was conducted in 2003 at an upper secondary school in Östersund
(central Sweden). Only boys participated in this study, which was a questionnaire using SOGS-R (for
adults, same as in the Swedish population study). Of the 178 boys, who were 16 or 18, 15.7 were
classified as pathological gamblers, 6.7 per cent as problem gamblers and a further 25.8 per cent as
moderate problem gamblers (64). In other words, it appeared that almost 50 per cent of these boys had
some kind of gambling problem, a figure that is much higher than other studies. An explanation for
this might be the fact that only boys participated in the study, and that gambling problems and pathological
gambling is much more common among boys than girls. However, despite this the figure is
still startlingly high. What is also surprising is the fact that pathological gambling seems to be more
common among these adolescents than problem gambling, in most other studies the opposite is true.
A smaller study commissioned by the Swedish National Institute of Public Health was carried out
at the Maria Ungdom Clinic in Stockholm in 2004. The Maria Ungdom Clinic is a clinic for young
people with an addiction. 180 adolescents, on average 17 years old, who had sought help at the Clinic,
31

32
were asked about their gambling habits and possible gambling problems. The results showed that 15
per cent of the boys and 5 per cent of the girls said they had a gambling problem or were pathological
gamblers, and according to a diagnostic interview, 14 per cent of the boys fulfilled at least two of the
criteria in DSM-IV for pathological gambling (i.e. fulfilled enough of the criteria for the diagnosis
gambling problem but not pathological gambling). However, it is not possible to compare these figures
with the other figures presented in this section since they only apply to young people who sought help
at an addiction clinic and not to young Swedes in general. They are, however, included in this review
since so few studies have been carried out in the field in Sweden (65).
Prevalence at different ages
A majority of the studies found that the older the adolescents, the more they gambled. The number of
young problem gamblers or young pathological gamblers increases with age. In most studies, only
adolescents over the age of 14 have participated, although in a few even younger adolescents, from the
age of 11, have participated. In one Spanish study even 8-year-olds participated. These studies indicate
that gambling problems occur at a young age, but are fairly uncommon before the age of 11.
Pathological gambling does not, however, occur before the age of 14 in these studies (60, 33, 35, 66).
As has already been described, in the section on young people and gambling, the gambling habits
of boys and girls differ. Girls start gambling later, they gamble less often, for less money and for shorter
periods of time compared to boys. Girls also tend to play games that are not regarded as risky, for
example lotteries, while boys prefer fast games like betting on sports or fruit machines. Bearing in
mind the fact that boys gamble a lot more than girls and choose games that are regarded as more risky,
it is hardly surprising that a greater proportion of boys are problem gamblers or pathological
gamblers. Two to five times more boys are problem or pathological gamblers compared to girls (3,
5–8, 10, 12, 14, 21, 22, 31, 33, 36, 67–72). This also applied in the above-mentioned study at the
Maria Ungdom Clinic in Stockholm, where three times as many boys compared to girls said that they
had some type of gambling problem (65).
The gambling habits of young pathological gamblers
gambling debut
A couple of studies have found a connection between an early debut and a gambling problem/addiction
later on in life. Among young people who have some type of gambling problem a larger proportion
started gambling when they were children compared to young people who gamble less (6, 14, 77).
risky games
Characteristic gambling habits of young problem/pathological gamblers is that the stakes are high,
they gamble often and for a long period of time. Moreover, it would seem that young pathological
gamblers prefer to play so-called risky games (76, 78). One British study has looked at the aspects, or
factors, in the games themselves that may contribute to people finding it easier to play them for a
longer period of time or for higher stakes than they had anticipated. According to Griffiths and Wood
(29) the factors are the following:
• Betting (and losing) a great deal of money.
• Rapid feedback (you lose/win quickly).
• The chance of winning is greater than for other games (the chance of winning is great).
• High winnings.
• The game includes functions that may make the gambler feel clever.

• The game often leads to results; you are often close to winning, without actually having won
anything.
• Certain visual effects and sound effects in the game.
• The game is easily accessible.
The Swedish sociologist Ove Svensson has written a thesis on young people and gambling which is
based partly on the Swedish population study and its follow-up and partly on a number of qualitative
interviews with young people. Ove Svensson writes that certain types of games more readily provide
a sense of “flow”, an experience that allows the gambler to disconnect from the outer world for a while
and go in and flow with the game. The types of games which allow this experience are fast and continuous
games that increase the participation of the gambler and prolong the continuity of the game.
According to Svensson, you get this feeling more easily if you play often, for a long time and
intensively (76). Types of games which include several of the above-mention factors, which are fast
and continuous and can thus be regarded as risky games are amongst others:
– Fruit machines: Give rapid feedback, high winnings, are designed in such a way that the gambler
readily believes that he or she can influence the game through skill.
– Most casino games: Give rapid feedback, the stakes are high as are often the winnings.
– Betting on sports: The gambler readily feels that he or she can influence the game through skill,
the games often lead to a result that is “close to winning” and the stakes can be high.
– Most games on the Internet: Internet gambling is easily accessible, the games have many attractive
visual and graphical effects, feedback is rapid (moreover, you can gamble on several websites at a
time) and they are open round-the-clock. You can also gamble on your own, undisturbed and high
on alcohol and drugs.
In a study on British adolescents playing on fruit machines, Griffiths has highlighted the fact that not
only are fruit machines in the UK technically designed in such a way that they enhance the gambler’s
belief in the importance of his/her own skill, but they have also been given names that lead to such
associations. Some are, for example, called Skill Cash, Fruit Skill and Real Money (79).
According to Svensson, young people generally prefer fast and continuous types of games.
Adolescent Swedes at the end of the 1990s preferred to gamble on the riskiest games and it was most
of all adolescent problem and pathological gamblers who did so. Compared to other young people,
they played more often on, for example, fruit machines, sport games, card games and instant lotteries
(17, 76). Norwegian studies also indicate that playing fruit machines is over-represented among
children with gambling problems, two out of three adolescents with gambling problems mostly play
on fruit machines (12).
Unrealistic understanding of the possibilities of the game
In yet another study, Moore and Ohtsuka (78) found that young problem/pathological gamblers had a
more irrational understanding of the game than other young people. Problem/Pathological gamblers
were more prone to an exaggerated belief in their own ability to control the outcome of the game, in
other words the illusion of control over the game. In addition, they believed that gambling was a good
way of getting money. Young problem or pathological gamblers overestimated their control over their
own gambling, in other words the ability to be able to stop in time, limit their gambling and the stakes,
more than young people without problems.
Computer and TV games
Computer and TV games are not geared towards winning money, only towards entertainment and
enjoyment. There are various types of games geared towards children and young people, for example
action games, puzzles, role plays, strategy games, games played on the Internet (online games), sports
games, quizzes and adventure games. All of these games are different in character; some of them are
similar to gambling games others are completely different. Too few studies are as yet available to be
able to say anything about computer or TV game addiction and whether there is a link between these
games and problem/pathological gambling. A handful of studies indicate that some children and
33

34
young people play computer and/or TV games in a way that is reminiscent of problem gambling, in
other words they play uncontrollably and impulsively without being able to limit their playing, sacrificing
other social activities to play and neglecting their schoolwork. In addition we can see that some
young people who have gambling problems also play more computer and/or TV games than other
young people, and that they also with this games have trouble limiting themselves (29, 80–82).
An experimental Canadian study of children aged between 9 and 14 compared both the behaviour
of children who played computer games frequently with children who played more rarely as well as
their understanding of games. Children who played computer games often and for long periods of
time also said that they gambled more than other children. Moreover, they said that their gambling
made them feel “more important” and apparently these children were more prone to taking risks when
they played Black Jack compared to children who did not play computer games as often. The link
between computer games and gambling in boys also applied to girls. One interesting find in this study
was the fact that girls who played a lot of computer games also gambled, more than both boys and girls
who did not play computer games at all (81).
gambling as a form of escapism and as a distraction
In a study from the International Centre for Youth Problem Gambling and High-Risk Behaviors,
young people who were problem or pathological gamblers said they gambled to escape their problems,
to reduce the effects of depression, to relax, to feel older or for social reason more often than
other young people. Young people who did not have a gambling problem played for pleasure, to make
money or for the excitement. Moreover, those who were problem
or pathological gamblers mentioned a
dissociating experience when they
gambled, in other words they lost all
sense of time and space, felt that they
were “outside themselves” or that they
were in a trance-like state. These feelings
occurred more seldom in those
who gambled without problems (6). This
description seems to correspond to what
the pathological gamblers in Ove
Svensson’s thesis described as a sense of
“flow”, in other words they flow with the
game, totally immersed in the game
and thus block off all other thoughts
for a moment (76).
Svensson continues that gambling
can become a way for young people to
handle pressure during their teenage
years, for example different problems,
conflicts or stress. Gambling can act as an
outlet and help young people cope with their
every day lives by giving them renewed strength.
On the other hand, if they gamble too much this can lead to a lack of a sense of context and meaning in
their lives, which in turn may contribute to making them feel worse and to problem or pathological
gambling.
This is also confirmed in a study carried out by the researchers at the International Centre for
Youth Problem Gambling and High-Risk Behaviors in Canada. In this study, young pathological
gamblers handle stress and unpleasant feelings in a different way compared to young people with a
gambling problem or who have no gambling problems at all. In this study, young people with a gambling
problem or without problems said that they actively tried to resolve problems or handle stressful
situations, both inner emotional stress and outer pressure. In other words, they confronted their problems
actively and were focused on finding a solution. The young pathological gamblers in the study,

however, tended to try to distract themselves in order to avoid feeling stress or the unpleasant feeling
that a problem or conflict in their lives gave rise to. Gambling for them filled a distracting function
(83). Finally, another study from the same research centre, found that boys and girls who were problem/
pathological gamblers differed in the way they handled stressful situations and unpleasant thoughts.
While boys tried to distract themselves from the perceived stress (for example by joking or activating
themselves), girls with gambling problems or who gambled a lot took drugs to dampen the unpleasant
feelings (85).
Other problems in young pathological gamblers
In the above-mentioned studies on pathological gambling, a number of questions were also put to the
young people as regards other health-related habits and possible problems, above all about mental
health, drug problems and criminal behaviour. Young people who gamble a lot, or who are
problem/pathological gamblers have one or several of these other problems compared to their peers.
Some of these associated problems have been examined in several studies and are clearly substantiated
while it is unclear whether others are associated with gambling. In the Rossow and Hansen study
on the gambling habits of young people for example, 75 per cent of the young problem or pathological
gamblers also had at least one other “additional problem” (12). In the study carried out at the Maria
Ungdom Clinic in Stockholm, boys with gambling problems were more prone to other psychosocial
problems compared to the other boys in the study. This difference was not found among the girls (65).
The results of the studies that have examined the problems that young problem/pathological gamblers
have are summarised below under the following headings:
• Mental ill health
– Depression, suicidal tendencies and feelings of anxiety
• Cognitive difficulties and behavioural problems
– Impulsivity, risk-taking behaviour, hyperactivity and attention disorders
– Learning difficulties
– Problems at school
• Crime
• Other addictions
• Differences between young pathological gamblers and young problem gamblers
mental ill health
Young people who have a gambling problem or who are pathological gamblers have reported poorer mental
health compared to other young people in studies. Many of these young people feel that they are alone
and have poor social support and few friends. They often seem to feel that they have a bad relationship
with their family, above all their parents. This is expressed as conflicts within the family, poor communication,
a poor family atmosphere or that they do not feel that their parents are supportive (12, 67, 84).
Depression, suicidal tendencies and feelings of anxiety
Young problem/pathological gamblers are more often depressed, think about taking their own lives or
have actually tried taking committing suicide more often than other young people, particularly girls.
Anxiety-related symptoms are also more common among these young people. The boys are more
worried about their lives than other boys and as regards girls they are more prone to anxiety disorders,
for example eating disorders (6, 12, 54, 84–86).
Boys who were problem/pathological gamblers in the study carried out at the Maria Ungdom
Clinic in Stockholm said that they had more social problems and feelings of anxiety compared to boys
with no gambling problems. This difference could not be found among the girls. It should be noted in
this context that nearly all the girls had more or less serious mental problems which might explain the
fact that the anticipated difference was not found (65).
35

36
cognitive difficulties and behavioural problems
Impulsivity, risk-taking behaviour, hyperactivity and attention disorders
Most studies indicate that young people who are problem/pathological gamblers are more prone to
impulsive behaviour and tend to take more risks than other young people (6, 30, 87). This applies
in particular to boys in their early teens, and for many of them the more impulsive and risky their
behaviour becomes, the more they gamble and the more serious does their gambling problem risk
becoming (see also the section on risk factors, impulsivity and risk-taking behaviour in boys) (88–92).
A couple of studies found that hyperactivity and attention disorders are more common among
young people who are problem/pathological gamblers than other young people. A Canadian study by
Hardoon et al in Ontario found that among the just over 2 300 pupils aged between 11 and 19, 57
per cent of whom were girls, those that were problem/pathological gamblers reported the clinical
symptoms of Attention Deficit Hyperactivity Disorder (ADHD) to a greater extent. In other words
they had problems with attention and concentration and were impulsive and restless. Nearly 50 per
cent of the adolescent pathological gamblers and a third of those with gambling problems risked
being diagnosed with ADHD, compared to 12–18 per cent of the adolescents without any type of
gambling problem. A slightly greater proportion of who were either problem gamblers or pathological
gamblers said that they had these problems (67). Questions about ADHD were also included in the
Icelandic prevalence study on adolescents aged between 13 and 15. The results indicated that 33 per
cent of the adolescent pathological gamblers and 16 per cent of those with a gambling problem were
judged as probably fulfilling the criteria for ADHD (62).
Learning difficulties
In the above-mentioned Ontario study, a greater proportion of the adolescent problem/pathological
gamblers said that they had been diagnosed with learning difficulties and they themselves felt that
they were slower than their peers. This applied above all to the girls. Nearly twice as many girls with
some type of gambling problem said that they had learning difficulties compared to boys who were
problem/pathological gamblers. Normally among adolescents without gambling problems it is more
common for boys to have learning difficulties than girls (93).
Problems at school
Some studies indicate that adolescent problem/pathological gamblers get lower grades at school.
They are also more likely to play truant and to have to retake a year or fall out of school altogether
compared to their peers who are not problem/pathological gamblers. Moreover they also say that they
break the rules, are told off and do not bother to do their homework more often (6, 58–60, 67, 68, 72,
77, 94). Yet further studies indicate that adolescents, above all boys, who are problem/pathological
gamblers, are more prone to playing truant, neglecting their schoolwork, stealing and being involved
in violent activities compared to other adolescents. This might indicate a link between problem/
pathological gambling and behavioural disorders (i.e. anti-social behavioural patterns among adolescents,
for example truancy, shoplifting, stealing, fights, vandalism and assault) (67, 95). A study
from the International Centre for Youth Problem Gambling and High-Risk Behaviors supports this
idea where 50 per cent of the adolescent problem/pathological gamblers also fulfilled the criteria for
behavioural disorders (67).
crime
According to several studies it is more common for young people who are problem/pathological
gamblers to be involved in various types of criminal activity. They report stealing money from their
parents or selling family belongings, but they may also commit more serious crimes like embezzlement,
robberies and burglaries (3, 6, 12, 21, 22, 68, 72, 77).

other addictions
According to most studies, young people who gamble often and with high stakes also consume more
alcohol than their peers who gamble less. The corresponding link also exists between being a problem/pathological
gambler and having other types of addiction problems with alcohol and drugs, a
connection that is particularly clear in boys (3, 12, 21, 32–34, 59, 60, 67–70, 72, 85, 87, 90, 95–99).
differences between young pathological gamblers
and young problem gamblers
In the above-mentioned longitudinal study by Winters and Stinchfield in Minnesota in the USA, 305
young people were followed from the age of 16 to the age of 24. The young people were not only
asked about their gambling habits, problem/pathological gambling but also about their mental health,
crime, schoolwork and their parents’ gambling history. It was clear that young pathological gamblers
and young problem gamblers respectively and those
without a problem differed in a number of ways. The
young people who were pathological gamblers suffered
from mental ill health, for example depression
and anxiety symptoms, more often than other young
people including those with a gambling problem.
These young people also tended to have parents who
were problem/pathological gamblers compared to the
other young people in the study. The young people
who had a gambling problem were, on the other hand,
more prone to criminal behaviour compared to both
young people without a gambling problem and those
who were pathological gamblers. Two of the groups,
problem gamblers and pathological gamblers, had
difficulties at school and the young people in these
groups had started gambling earlier than other young
people (74).
Pathological gambling – not a chronic state
Only very few studies have followed young people over a number of years to see how their problem or
pathological gambling has developed and whether the problems remain in adulthood or whether there
has been an improvement. However, according to the few studies that are available problem gambling
in young people does not appear to be a “chronic state”. Usually it is seems to be a temporary state
that abates with age.
An American study by Slutske, Jackson and Sher followed 468 university students over an elevenyear
period, from the age of 18–19 to 30. The proportion who were problem/pathological gamblers in
the group remained constant throughout the period, at 2–3 per cent. However, at each interview new
people, 1–2 per cent of all the students had developed a gambling problem/addiction while others had
improved. A person who had had gambling problems at one stage increased the risk of suffering from
such a problem later on in life. The risk was greatest 3 to 4 years after the initial gambling problem
had surfaced but with time the risk decreased, even if it was still higher than for those who had never
had a problem (73).
Winters and Stinchfield followed 305 young people in Minnesota, USA, from the age of 16 to the
age of 24 and asked them about possible problem/pathological gambling at three opportunities. They
found that most were totally problem free for the entire period (60 per cent). Second most common
was being a problem or pathological gambler at two but not all three of the screenings (34 per cent).
Only 4 per cent were problem or pathological gamblers for the entire period, at all three screenings.
Those who were pathological gamblers seemed to have a less temporary problem than those who had
37

38
only a gambling problem. If you were a pathological gambler at one screening, you were usually a problem
gambler at “at least” one more screening if not at both. This study also found that the proportion of
participants who were problem or pathological gamblers remained constant throughout the period (74).
In the Swedish population study by Rönnberg et al from 1999 (17), a follow-up study was carried
out two years later where 93 adolescents were sought out and asked again about their gambling habits
and any possible problems. In the follow-up they found two clear trends as regards the gambling
problems of the adolescents during the two-year period. One trend indicated that the number of
pathological gamblers remained constant, while the group problem gamblers had decreased in numbers.
Two-thirds of the adolescents (aged between 15 and 17 in the initial study) who had had a gambling
problem, no longer had a problem at the follow-up. The fewer the points they had scored on the
SOGS-R in the initial study, the greater the probability that the problems were no longer an issue. Half
of those who were pathological gamblers in the initial study had also improved. Even if they still had
gambling problems they reported fewer negative effects of the gambling according to SOGS-R.
However, for a smaller group of young people their problems had deteriorated in the follow-up. In the
follow-up study the problems had deteriorated for 50 per cent of the adolescents who in the initial
study were pathological gamblers and who had in other words scored at least 5 points on SOGS-R.
Some of them who had had a gambling problem initially were classified as pathological gamblers at
the follow-up stage (75).
Ove Svensson claims in his thesis that the gambling habits and problems of young people are
much more changeable than has previously been assumed in research – namely that the problems are
fairly constant in young people over time. This assumption originates from the idea that the gambling
problems of young people develop in the same way as adults, in other words that they remain for many
years. This assumption has remained because there has been a lack of data from longitudinal studies
that can give more definitive answers to how the gambling habits and problems of young people develop
and abate. According to Svensson the gambling problems of young people are more changeable
than those of adults because young people are more prone to risk-taking and are not used to limiting
their gambling (76).
Summary
It is fairly common for young people in the West to be problem or pathological gamblers despite the
fact that few of them gamble regularly. A meta-analysis of nine North American studies estimates the
prevalence of some form of gambling problem at between 10–14 per cent. These figures correspond
fully with studies from Australia and Europe. Only a population study has been carried out in Sweden,
this was at the end of the 1990s and there the proportion of young people who were problem or pathological
gamblers was estimated at 5 per cent, 2.5 times higher than for the adult population. Obviously
the consequences of gambling and/or the effects of these consequences differ between young people
and adults, since gambling problems are more prevalent among young people despite the fact that
they gamble less. Problem and pathological gambling are more prevalent among boys than girls, 2–5
per cent more boys compared to girls have gambling problems.
Young pathological or problem gamblers often have one or two other problems at the same time.
Some of these associated problems have been examined in many studies and have been clearly substantiated
while for others it is still rather unclear whether they are associated to gambling or not. The
problems that are associated to gambling in young people and have been studied most are mental ill
health, cognitive difficulties and behavioural problems, crime and alcohol and/or drug addiction.
Many of the studies have also found that young people with gambling problems differ from pathological
gamblers. It would appear that young pathological gamblers have more problems with their
mental health than those with a gambling problem. On the other hand, those with a gambling problem
seem more prone to criminal activity than those who are pathological gamblers. Gambling problems
in young people appears to be a relatively changeable problem, and for many the problem abates in
adulthood. For some, above all those with more serious problems or who are pathological gamblers,
the problems remain for many years, and in some cases they even deteriorate.

5.
risk factors of
pathological gambling
in young people

40
Introduction
Studying and determining the factors that increase the risk of gambling problems in young people is
a very important area of research. If we know the risk factors of problem/pathological gambling, it
will increase our chances of understanding the mechanisms behind the development of pathological
gambling. If we know what the mechanisms are, we can plan interventions, measures and not least
preventive action in order to avoid the risk factors in the first place, or at least to reduce their importance
for the development of pathological gambling.
The previous section described a number of problems that are associated with problem/pathological
gambling in adolescents. In everyday speech these associated problems are often rather carelessly
called risk factors of gambling problems since they exist in one and the same individual simultaneously.
We tend to conclude that they have generated each other or that the presence of one problem has been
the cause of the presence of the other. The presence of these problems in an adolescent does not,
however, necessarily increase the risk of him/her having a gambling problem/addiction, in other
words it is not certain that alcohol abuse for instance increases the risk of starting to gamble too
much. It may also be the case, in fact often is the case, that two associated factors, for example alcohol
abuse and a gambling problem are both determined by a third factor that increases the risk of both
these types of behaviour. An example of a third factor of this kind would be impulsivity. In this
example, it would mean that alcohol abuse and a gambling problem are not risk factors of each other,
even if they are associated, instead the risk factor is impulsivity. In order to understand which factors
increase the risk of developing problem/pathological gambling, you cannot just examine the types of
behaviour that are associated with these problems and whether these occur in an individual the moment
you start studying him/her. Instead, in order to establish risk factors and their impact on pathological
gambling for instance you need to study the circumstances and the behaviour of the individual over time
and see how these circumstances and this behaviour have an impact on what it is you wish to study.
A couple of fundamental pre-conditions must exist for a risk factor to be called a risk factor:
• A risk factor must emerge before the problem it is supposed to be a risk of. If alcohol abuse, for
instance, is to be called a risk factor of problem gambling it must have existed before the development
of the gambling problem.
• There must be a direct or indirect causal relationship between the risk factor and the problem it
increases the risk of. In other words, if the risk factor increases or decreases, the problem it is said
to be a risk factor of must also increase or decrease. This may occur directly or by the risk factor
affecting other factors, which in turn have an impact on the problem that is being studying. If alcohol
abuse is a risk factor of pathological gambling, the gambling must decrease if the consumption
of alcohol decreases.
It is difficult to study risk factors since the analyses rapidly become very complex. Moreover, you
need to study an individual over long periods of time and examine how the outcome is affected by
various consequences, events and factors either separately or together in order to know where the risk
factors lie and what they are. Studies of that kind are naturally both complex and expensive to conduct
which is why they are not very common.
Risk factors can in turn be divided into different types or classes. A classification system of risk
factors as defined by Sven Andréasson at the Swedish National Institute of Public Health in a report
on the prevention of alcohol abuse is used in this review (101). Risk factors are divided into individual
factors, social network factors and social factors in Andréasson’s report. The individual factors consist
of, for example, biological and psychological factors, including genetics, behavioural patterns and
personality. Social network factors include relationships and structures in the local social environment,
for example your family, upbringing, friends, school and spare time activities. Finally, social
factors include laws and regulations, attitudes and norms in society that may have an impact on the
gambling habits of adolescents.
Knowledge about risk factors from all the risk factor groups is still fairly limited in research on
pathological gambling in adolescents. No studies have been found on social factors, while there are a
couple of studies on the individual and social network factors. Some studies have also look into how

different types of problem behaviour in adolescents, like for instance alcohol and drug abuse, crime
and pathological gambling, are linked, in other words whether they form part of one and the same problem
syndrome or whether they are separate phenomena with different risk factors. The results are
summarised under the following headings:
• Individual factors
– Impulsivity and risk-taking behaviour in boys
– Crime, alcohol and substance abuse and problem/pathological gambling
• Social network factors
– Parental influence
– Parents with alcohol and substance abuse problems
– Financial situation
– Spare time and friends
• Differences between girls and boys
Individual factors
impulsivity and risk-taking behaviour in boys
Vitaro et al in Montreal, Canada, have conducted a number of longitudinal studies on boys with a
gambling problem/addiction and the link with other factors like impulsive behaviour, crime and
substance/alcohol abuse. The boys together with their parents and teachers were asked about these
types of behaviour and answered a number of other questions at several interview sessions during the
1980s and 1990s. Several of the studies were initiated when the boys were only six years old, in other
words before they started gambling, while others were initiated when the participants were between
10 and 14. The types of behaviour studied in addition to gambling were:
• Impulsive behaviour: defined as thinking before you act, “jumping” from one thing to another and
ending up in trouble because you do not think twice.
• Meekness/anxiety: being worried and careful.
• Criminal behaviour: stealing and violence.
• Other types of abuse: according to standardised tools for measuring alcohol and drug abuse.
• Hyperactivity/attention disorder: inability to concentrate and easily distracted.
• Aggressiveness/anti-social behaviour: fighting, not sharing, being disobedient, lying and
destroying things.
The studies indicate that the greater the impulsive behaviour (according to self-reports, teachers and
parents) between the ages of 6 and 14, the higher the risk in teenage years of (88–92, 102):
• Starting to gamble early.
• Gambling with high stakes and often.
• Being a problem or pathological gambler at the age of 17. The link was such that the greater the
impulsivity, the more serious the gambling problem. The most impulsive teenagers were more
often to be found in the pathological gambler group rather than the problem gambler group at the
age of 17.
• Abusing alcohol or drugs at the age of 17.
• In addition, for the most impulsive 13-year-olds, the risk of developing an alcohol/substance
abuse, a gambling problem and committing crimes at the age of 17 simultaneously increased.
Being less meek and less careful at the age of ten to eleven also increased the risk of gambling later
on as a teenager (92). As regards the other types of behaviour, for example hyperactivity/attention
41

42
disorder and aggressive/anti-social behaviour, the researchers were not able to find that these increased
the risk of frequent gambling or gambling problems later on.
Three groups of boys were distinguished in these studies, boys whose gambling habit and degree of
impulsivity differed during their childhood. Gambling patterns and the degree of impulsivity were also
linked to the proportion of boys who developed a gambling problem at the age of 17 in each respective
group (102):
• One of these groups consisted of boys who scored low on impulsivity as children and who throughout
gambled very little or not at all. It was rare for the boys in this group to develop a gambling
problem later on.
• Another small group consisted of slightly more impulsive children who frequently gambled as
teenagers. These boys were more likely to become problem/pathological gamblers later on compared
to the first group.
• Finally, there was a group of boys who were the most impulsive six-year-olds, who started gambling
at an early age and who subsequently gambled a lot later on. More boys in this group became
pathological gamblers at the age of 18/19 compared to the first two groups
The results in these studies are reflected in several cross-sectional studies where adolescents who
report that they are problem or pathological gamblers are more prone to impulsive behavioural
patterns and to taking risks than other adolescents (6, 29, 62).
crime, abuse and problem/pathological gambling
It is unclear whether different types of problem behaviour, for instance crime and alcohol/substance
abuse, increase the risk of developing problem/pathological gambling. Similarly, it is unclear whether
problem/pathological gambling increases the risk of crime and other abuse. According to many studies
presented in the previous section, adolescents who gamble often and for high stakes consume more
alcohol compared to their peers who gamble less. There is also a similar link between problem/
pathological gambling and alcohol/substance abuse, a link that is particularly strong in boys (3, 12,
21, 32–34, 59, 60, 67–70, 72, 85, 87, 90, 95–99). Different types of criminal behaviour are also more
common among adolescents who are problem or pathological gamblers as compared to other adolescents.
They steal money from their parents or sell family belongings, or they may even commit more
serious crimes like embezzlement, robberies, burglaries or crimes of violence (3, 6, 12, 21, 22, 68, 72,
77). This link is also found in the study conducted at the Maria Ungdom Clinic in Stockholm (65).
There is, in other words, a correlation between gambling, abuse and crime, and several researchers
have examined whether the risk factors of these different types of behavioural problems are the same,
and if this is the case whether these types of behaviour are parts of or sides to one and the same “problem
syndrome”. The various behavioural problems would in this “problem syndrome” be expressions
of the same underlying syndrome and the same risk factors would apply for all the types of
behaviour. In the problem syndrome model there are a number of basic risk factors and mechanisms
that increase the risk of a certain outcome, for example a gambling or alcohol addiction. Therefore, in
this model the different outcomes are linked but they do not control each other. A change in the joint
risk factors affects all the types of behaviour they have an impact on. However, a decrease in the consumption
of alcohol caused by taking Anta bus, for example, does not affect the gambling problem
since both these types of behaviour are governed by risk factors that are probably not affected by the
fact that the individual is taking Anta bus
According to Vitaro, whose studies were presented above, impulsive and risk-taking behaviour at
an early age is a risk factor of gambling, alcohol/substance abuse and crime, and these behavioural
problems are therefore part and parcel of the same “problem syndrome” (90–92).
Barnes et al have conducted two longitudinal studies in Buffalo in the USA in which they examined
whether gambling, alcohol or substance abuse or crime might have common risk factors and whether
they were part of the same problem syndrome. One of these studies followed in total 699 boys and
girls under a seven-year period during the 1990s, from the age of 13 to 15 to the age of 18 to 22. The
young people were interviewed six times, sometimes with a parent and sometimes with a friend.

Corresponding interview sessions were conducted between 1992–1997 in a parallel study of 625 men
who were initially aged between 16 and 19 and who were known to the authorities because of their
criminal behaviour. As regards gambling, these men were asked about gambling frequency but not
about any gambling problems. The risk factors studied were parental control, impulsivity, criminal
friends and socio-demographic background.
The results indicated that both gambling and the consumption of alcohol were common in all the
adolescents and that there was a link between all the behavioural problems – gambling, alcohol and
drug abuse, and crime. The link between gambling, alcohol/substance abuse and crime was not
strong, however, particularly among girls/women. Among the girls/women there was only a weak link
between gambling and alcohol and drug consumption, while there was a strong link among the
boys/men. As regards risk factors, gambling was distinguishable from the other behavioural problems
in the study. However, the risk of the other behavioural problems increased when there was poor
parental control and if the participants had criminal friends. The boys/men in the crime study gambled
less if their parents had had clearer control over them and if they drank less than the other boys/men.
There was only a link between alcohol abuse and frequent gambling among the girls/women if they
were regarded as impulsive and if there was poor parental control. Moreover, the risk of gambling at a
later age among girls/women increased if they had criminal friends at a young age, but this did not
apply to the boys/men. In this study, there was no link between impulsivity, criminal friends and
frequent gambling among the boys/men. The conclusion of this study was that gambling is not part of
an overall problem syndrome and that the risk factors of gambling, abuse and crime are not the same
(35, 103–105). The fact that no link was found in this study between impulsivity and gambling among
boys, when one was found in Vitaro’s studies, might be explained by the fact that gambling frequency
was studied and not problem or pathological gambling.
Finally, Willoughby et al in Canada have studied how various behavioural problems, alcohol/
substance abuse, crime, aggressive behaviour and gambling problems (no difference was made
between problem and pathological gambling) are related to each other. This was not a longitudinal
study, instead the researchers took a cross-sectional study and tried to find a statistic model for how
these types of behaviour might be related to each other. According to the model, all these behavioural
problems together form a syndrome, which in turn consists of three factors. Problem/pathological
gambling and crime (from less serious crimes like shoplifting to more serious ones using weapons)
represent one of these factors. Problem/pathological gambling is weakly associated to the other behavioural
problems in this study (106).
Social network factors
parental influence
Several studies indicate that the gambling habits of parents have an impact on the gambling habits of
their children. As mentioned previously, children are often introduced to gambling by their parents,
and it is often the parents who provide the children and adolescents with, for example, lottery tickets.
Adolescents with gambling parents gamble more and from an earlier age and more often have problems
with their gambling compared to adolescents with non-gambling parents (3, 4, 9, 21, 24, 31,
68, 70, 102, 107, 108). Moreover, adolescents who are problem/pathological gamblers are more prone
to saying that their parents have also previously had the same problems compared to their peers who
do not have gambling problems (3, 9, 14, 21, 24, 29, 58, 59, 67). In the longitudinal study carried out
by Winters and Stinchfield in Minnesota in the USA, it was, as already mentioned, primarily adolescents
with parents who were problem/pathological gamblers who were themselves pathological
gamblers, rather than the adolescents who “only” had a gambling problem (77).
In a Canadian study where both adolescents and their parents were allowed to report their
gambling habits and any gambling problems, the researchers found that it was more common for
adolescents who gambled a lot to have parents who either gambled a lot or who had problems with
their gambling compared to other adolescents. When the researchers changed the association around
and studied the parents, they found that the problem/pathological gambling of the adolescents was
43

44
only linked to the problem/pathological gambling of the fathers. It appeared that the problem/pathological
gambling of the mothers did not form a link to the children’s ditto. Moreover, it was also
apparent that the parents’ involvement in their children’s actions had an impact on the children’s
gambling habits. The children whose parents did not have an insight into or control over what they did
in their spare time gambled more often than those with better parental control (109). The way in which
parents teach their children how to handle money and their own finances also has an impact on the
children’s gambling habits according to a further study. If parents teach their children to stick to a
budget and to save money, the children are less likely to gamble in the future (110).
parents with problems with alcohol/substance abuse
It is also more common for adolescents with a gambling problem/addiction to have a parent who
abuses alcohol or drugs (67). As previously mentioned (see prevalence of pathological gambling), a
questionnaire has been carried out in Sweden on
gambling problems at an upper secondary
school in Östersund. In this study, boys were
also asked about their parents’ alcohol/
substance abuse. The boys who reported a
probable gambling addiction tended to
have a parent who abused alcohol or drugs
as compared to the boys who were not pathological
gamblers (64).
financial situation
An Australian study examined the
socio-economic status of families and
the link with gambling habits, and
found that in marginalised families
family members gambled more, this
also applied to the adolescents. This
means that adolescents from the native
population were over-represented among
young problem gamblers in Australia (32).
Also Swedish and Norwegian studies have
found this link. It would seem that adolescents
in families with less money to spend
gamble more than other adolescents. It is also more
common for adolescents with an immigrant background to gamble often and
with high stakes, and problem and pathological gambling is also more prevalent compared
with adolescents who do not have an immigrant background (12, 17).
When it comes to the disposable income of the adolescents themselves, the opposite seems to hold
true. The more money they have to spend, the more they gamble. A Norwegian study found a link
between how many hours adolescents worked extra along side their studies and how much they
gambled – the more hours they worked, the more they gambled (9, 12, 21, 23, 108, 111).
spare time and friends
In a study by Moore and Ohtsuka in Australia, the researchers found that adolescents who had a lot of
spare time and above all unstructured spare time gambled more than others (15). Many studies indicate
that adolescents often choose to gamble together with their friends as a social activity. American and
Canadian studies also indicate that adolescents who are problem/pathological gamblers also often
have friends with the same problems (6, 9, 14, 67, 91, 94, 70). In his thesis, Ove Svensson describes
the family as the gambling debut arena, and that friends only take over the importance of the parents

later in life. Adolescents happily gamble together with their friends as a spare time activity and as a
way of experimenting with limits and risk-taking, where the adolescents’ lack of experience in limiting
and controlling their behaviour may contribute to a rapidly developing problem (76).
Differences between girls and boys
Two to five times as many boys are problem or pathological gamblers compared to girls. This can partly
be explained by the fact that boys gamble more than girls and that they tend to choose risky games,
which in turn increases the risk of problem/pathological gambling. A further possible explanation
might be the fact that the screening tools have not been adapted to measure girls’ attitudes to gambling,
gambling patterns and consequences of gambling, and have therefore not been able to highlight
any gambling problems. Some of the studies presented here have not studied girls’ gambling problems
at all, for example the Vitaro studies on impulsivity and risk-taking behaviour or the Swedish
study from Östersund.
The studies that include girls indicate, however, that there are differences between the
problem/pathological gambling of girls and boys. Barnes’ studies from Buffalo in the USA indicated
that there are differences in the links between different behavioural problems in
girls/women and boys/men, and also in the risk factors behind the development of
these problems. For boys/men there was a link between consuming too much
alcohol or alcohol abuse and gambling too much. This was a link that
was only found in girls who were impulsive and
where parental control was poor. This
study also indicated that having
criminal friends increased the
risk for girls developing a
gambling problem later
on, but not boys.
Summary
The links between various behavioural problems like crime, alcohol/substance abuse and problem/
pathological gambling are still unclear and there is not enough research on the subject. Also there are
not enough longitudinal studies examining which factors at an early age have an impact on later gambling
habits and any gambling problems. Risk factors of the development of problem/pathological
gambling are among others to as a child and as a teenager behave impulsively (for boys), to have
friends who gamble, to have friends who are problem/pathological gamblers, to have parents who
introduce them to gambling and parents who gamble a lot, above all if they do so together with their
children. Further risk factors are having parents who are problem/pathological gamblers and having
money to spend. The risk of developing a gambling problem seems to be greater for boys. On the other
hand, there are very few if any studies on gambling problems among girls.
45

6.
prevention

48
Introduction
By prevention the author means preventive measures, for example measures aimed at preventing illness
(universal or primary prevention), reducing the risk of an illness escalating or recurring (selective or
secondary prevention) or rehabilitation or treatment of illness (indicated or tertiary prevention). In an
ideal world there would be measures for all these levels that had been evaluated as well as prevention
programmes for adolescent pathological gamblers. Research on the prevention of pathological gambling
among adolescents is, however, still extremely limited. Only two studies on primary prevention
measures were found in the literature search along with a study on treatment. Only four boys were included
in this single study on treatment and there was no control group. Hence, the study does not allow for
any conclusions to be drawn with regard to treating adolescent pathological gamblers (112).
Instead, current knowledge on the prevention of pathological gambling in young people has to be
retrieved from research on a subject close to the one at hand, for example the treatment of adult pathological
gamblers and the prevention of other addictions in young people. In addition, some authors have
described a number of possible treatment models based on their own practical experience of treating
adolescents together with theoretical knowledge. However, these models have not been tested for their
effectiveness in accordance with current scientific methods. Knowledge the author gained during study
visits to two treatment clinics in Montreal, Canada, is also presented in this section.
Evaluated primary preventive (universal) measures
A couple of preventive measures aimed at enhancing knowledge about gambling and its risks has
been carried out among lower secondary and upper secondary adolescents in the Province of Quebec
in Canada. One of these studies is an experimental study by Ferland, Ladouceur and Vitaro. It tested
the impact of an information video on common misconceptions about gambling, which aimed at
enhancing knowledge about gambling and its risks. The study compared the impact of the information
video with a practical informative lesson on gambling, with a combination of video and lesson
and finally with a control group that were not subject to any intervention measures at all. The results
showed that the knowledge about gambling of the pupils in the three intervention groups was enhanced
and they were better able to identify
typical misconceptions about gambling
than those who had not been subject to
an intervention measure at all. The best
results were achieved in the group with
the combined intervention measure,
i.e. both video and lesson. However,
there was no follow-up and hence
we do not know whether the results
remained over time, nor do we know
whether there was an impact on the
gambling behaviour, in other words the
gambling habits and any gambling problems
of the adolescents (113).
In another rather more extensive
prevention intervention, again carried
out by Ladouceur and Gaboury in
Canada, the focus was on cognitive
distortions to do with games and gambling.
134 pupils of different ages in
Quebec City were given information on
gambling, gambling problems and the
gaming market. They were also taught

strategies to control their gambling. Immediately after the intervention, the pupils who had participated
in the intervention measure had better knowledge about gambling and better strategies to control their
gambling. At a follow-up six months later they had forgotten the strategies while the knowledge about
the risks of gambling remained. The gambling behaviour was not affected by the intervention (114).
Treating adult pathological gamblers
In a review of studies on the treatment of adult pathological gamblers from 2003, eleven studies were
found in which the participants had been randomly selected for treatment or to be included in a control
group. The treatment methods were based on behavioural therapy, cognitive behavioural therapy
(with or without motivating sessions), cognitive therapy, pharmacological treatment and self-help
based treatment. The authors of the review observed that many of the studies had shortcomings as
regards method. Participants were too few to be able to observe any effects or the baseline data was
too poor to be able to observe whether any changes had taken place in the comparison between before
and after the start of treatment. In addition, not many had carried out manual-based treatment, or had
checked the integrity of the treatment, in other words what treatment had actually been given.
Despite these shortcomings the authors concluded that the method that had the best treatment
effect of all the treatment methods presented was cognitive behavioural therapy, sometimes combined
with motivating interview sessions. It is, however, unclear whether this conclusion has to do with the
fact that the studies that were based on cognitive behavioural therapy treatment used the best methodology,
or whether it was the treatment itself that gave the better effect. The length of the treatment did
not seem to be related to treatment results, nor were there any differences between treatment in the
form of sessions with a therapist or via a self-help manual (115).
Practical experience of treating young pathological gamblers
treatment at the international centre for youth problem gambling
and high-risk behaviors in montreal, canada
Jeffrey Derevensky and Rina Gupta at the International Centre for Youth Problem Gambling and
High-Risk Behaviors have treated adolescent pathological gamblers since the beginning of the 1990s.
Their treatment model consists of interventions that focus on psychological, physiological, developmental
psychological, cognitive and behavioural aspects. The reason for this broad focus is the fact
that they believe that all these aspects interact to create the prevailing situation of problem gambling.
The treatment aims at increasing the protective factors which are weak, for example social skills, the
ability to communicate and problem-solving.
Psychiatric problems are treated at the same time as the protective factors are reinforced.
Experience from the centre indicates that adolescents who apply for care nearly always have other
problems at the same time, for instance depression, anxiety disorders, attention disorders, psychosocial
problems, including other addictions and crime. The gambling behaviour is regarded as a strategy for
coping with the other emotional and psychiatric problems, for example stress and unpleasant
feelings, or as a form of escapism from depression and anxiety. The treatment lasts up to several
months, depending on the individual problems of the adolescent.
The adolescents have not usually sought help for their gambling problems themselves which
might be due to a lack of motivation, or to the fact that they did not know where to go for treatment or
did not even know that there was such a thing as a gambling problem. In order to get adolescents with
gambling problems to come for treatment, the centre has tried to raise awareness among the general
public and professionals but also primarily among adolescents and their parents with regard to problem
gambling. This has been done by providing information at schools and in other contexts where
adolescents, parents and other adults who work with adolescents can be found. The information focuses
on the fact that it is possible to become a problem gambler, how to recognise it in yourself and in
49

50
others and where to turn to for help. If adolescents and adults do not have this knowledge you can
hardly expect adolescents to seek help or that the adults in their lives ensure that they go for treatment.
Preventing relapses and follow-up work is included in the treatment model. In the centre’s experience,
if adolescents have a relapse after treatment has been completed it often means that other concurrent
problems have not been treated (116, 117).
treatment at the dollard cormier centre in montreal, canada
Dollard Cormier is a clinic for adolescents with addiction problems and pathological gambling has
been included in recent years as one of several addictions that are treated at the centre. In its treatment
of adolescent pathological gambling, the centre uses a cognitive behavioural therapy model that focuses
a lot on the cognitive aspects of gambling, for example thought traps, thoughts on gambling, as
well as identifying risk situations in gambling. The treatment of other concurrent problems is included
as is parental training and family therapy sessions. This is because the centre believes that only
focusing on the gambling behaviour itself as has been done with adults, is not sufficient when it comes
to helping adolescents in an effective way. The course of treatment starts with an assessment of the
mental health of the adolescent and any other problems, the gambling problem and how motivated the
adolescent is to change his/her gambling behaviour. An individual treatment plan is then drawn up
based on this assessment and it is designed as a contract that the adolescents sign. The plan can be
changed, for example as the motivation to change or the goal of the treatment changes during the
course of the treatment (118).
Theoretical prevention models
model based on the stages of change theory
Di Clemente, Story and Murray have developed a prevention model for gambling problems in adolescents
which is based on an earlier general model for behavioural change by Di Clemente and
Prochaska. In the article at hand, Di Clemente, Story and Murray have applied the Stages of Change
model on the prevention of gambling problems among adolescents. There is no actual interest or
motivation to gamble before a young person has actually gambled for the first time.
According to Di Clemente et al, American adolescents usually leave that phase between the age of
10 and 13, which is when they first think about trying gambling out. Prevention measures may have an
enormous impact during this phase since it is possible to prevent the adolescents from starting to
gamble. It is important to identify factors that make adolescents contemplate gambling and to concentrate
measures aimed at adolescents who are in this phase on conveying information and knowledge
about the risks of gambling, since positive attitudes to gambling may make a person contemplate
trying it out. For those who still decided to gamble and who subsequently develop regular gambling
habits there is a risk that these habits will develop into risky gambling habits which may in the long
run lead to negative consequences. In this phase, gambling is a habit that does not require a great deal
of planning or thought since it has become a routine. This is why information and knowledge-based
prevention measures have little or no effect in this phase. Prevention measures should instead focus
on reducing the damage caused by gambling, by enhancing skills to control your gambling.
Finally, for those who have already develop a pattern of problem gambling, measures should be specifically
aimed at stopping the gambling. Treatment should be based on the individual adolescent’s
“gambling career” and where he/she is in the process, for example how long he/she has gambled and
what the motivation has been. Di Clemente et al claim that adolescents with gambling problems often
move between the phases – they stop gambling only to start again, then stop and so on. Hence, measures
aimed at adolescents with gambling problems should include elements aimed at finding motivation to
not start gambling again, or for those who are active gamblers, to break the pattern. The treatment centre
should also focus on other behavioural problems that may exist along side the gambling, for example
alcohol/substance abuse, psychosocial problems, mental illness and criminal behaviour (119).

programmes focused on risk and protective factors on all levels
According to the researchers at the International Centre for Youth Problem Gambling and High-Risk
Behaviors, it should be possible to incorporate pathological gambling in existing prevention programmes
for addiction and risk behaviour. Prevention programmes that have had a positive impact
have been programmes that have been aimed at reducing the effect of risk factors by increasing the
influence of protective factors (84, 120, 121). Programmes that are only aimed at informing or scaring
by pointing at risks of gambling do not give the desired effects, according to experience gained from
alcohol and drug prevention work (122). However, there is currently no research on the protective
factors for pathological gambling, in other words the factors that reduce the risk of developing a gambling
addiction. According to the researchers at the International Centre for Youth Problem Gambling
and High-Risk Behaviors, the protective factors for pathological gambling are presumably more
or less the same as those for other types of risk behaviour including alcohol or substance abuse/
addiction. These are (84):
• A good problem-solving ability; the ability to have abstract thoughts and to generate solutions to
cognitive and social problems.
• Good social skills; flexibility, communication skills, thoughtfulness and “pro-social” behaviour.
• Strong autonomy; a faith in your own ability and ability to control.
• A sense of meaning and of the future, progress orientation, motivation and optimism.
Thus it is conceivable that prevention measures that strengthen these factors in adolescents might
slowdown the development of both problem gambling and other types of high-risk behaviour. There
is currently, however, no evidence in studies that these protective factors also apply to pathological
gambling.
Moreover, the prevention measures should be aimed at several levels at the same time: individual,
family, friends, school and spare time, the norms and service of society, legislation and restrictions. In
practice, this entails measures at all prevention levels, primary, secondary and tertiary. In primary
interventions you focus on delaying the gambling debut of children and try to reduce the accessibility
of gambling on a general level by informing adults and influencing the norms and attitudes of society
to ensure less tolerance of child gambling.
In secondary intervention measures the focus is on children and adolescents who are regarded to
be in a risk group as concerns the development of a gambling problem. High-risk adolescents are
characterised by the fact that they fulfil one or several gambling problem criteria, without, however,
showing any signs of having developed an addiction. The secondary prevention measures should be
carried out by professionals, for example social workers, who are responsible for both discovering the
increased risk and subsequently more advanced prevention work that may include shorter courses of
treatment.
Tertiary prevention means that society allocates resources for the care and treatment of the individuals
who have been identified as having the problem at hand. In the gambling context this might
mean that adolescents who are pathological gamblers would have access to advanced courses of
treatment for themselves, and their families would have access to support and counselling (123).
Summary
There is only very limited research on the prevention of pathological gambling in adolescents. The
only primary prevention measures that have been evaluated focused on increasing knowledge about
gambling and the risks entailed for young people. The measure was successful in its aim but it is not
known whether the knowledge gained remained over time as this has not been studied. Nor is there a
treatment model that has been systematically evaluated for adolescents with a gambling
problem/addiction. Based on the research reviewed and the models that have been presented after
study visits certain conclusions with regard to treatment can be drawn.
51

52
• For adults who are pathological gamblers, cognitive behavioural therapy, sometimes combined with
motivating sessions, is better than no treatment at all.
• Young people, parents and other adults must be informed about the fact that young people can have
gambling problems, how to recognise these problems and where the adolescents can turn to for
treatment.
• Motivation enhancing elements should be included that are based on the adolescent’s own desire to
change.
• Adolescents with gambling problems often have other problems at the same time that also need to be
treated. Treatment for depression, anxiety disorders and other behavioural problems, like for instance
criminal behaviour and alcohol/substance abuse should be given in parallel.
Prevention measures that have been evaluated in other addiction areas, and that have proved to have a
good impact, are aimed at reducing the effect of risk factors while trying to increase the influence of
protective factors. At present, however, there is no research on protective factors for gambling.
Finally, prevention measures for pathological gamblers should be aimed at several levels simultaneously:
the primary, secondary and tertiary prevention levels. In other words delaying children’s
gambling debut and reducing accessibility, focusing on groups of children and adolescents who are
judged as running a greater risk for developing a gambling problem, and care and treatment for the
individuals who have been identified as sufferers.

appendix
and references

54
Appendix
Table 1. A list of the proportion of adolescents who have gambled or who have some type of gambling problem.
Proportion who
have gambled once
in their life/in the
last year in %
90.5/
76.5
– 2.0/
1.3
82.4/ 3,46/
1.76
/78.5
/99 /5.7
75/
/5.6
– 4.92/
2.23
– 8.2/
5.6
27.5/ 5.3/
2.6
– 4.7/
1.6
– 11.5/
5.4
–
/6.8
Proportion of
Problem gamblers/
Pathological
gamblers in %
4.2/
0.9
Screening tool Site of study Age
Number of
participants
in study (N)
Author, year
SOGS-R Sweden 15–17 (17) Rönnberg, et al.,
1999
SOGS-R Sweden 18–24 (17) Rönnberg, et al.,
1999
Questionnaire with 10
questions based on the
DSM-IV criteria
Norway 12–18
N = 3 237
3,2/ Lie & bet + ”chase” Norway 13–19
N = 12 000
/70.4 /4.4 % DSM,
3.3 % VGB
Problem/risk gamblers:
/65
11.2 % DSNM-IV-RJ
20.8 % SOGS-RA
21.2 % 8 screen Y
87.7/ 11.5/
2.4
76/
65
87/
77
96,1/
90.2
/80.2
/98
5.6/
1.7
4.8/
2.6
16.7/
10.3
3.3/
4.7
– 7.5/
5.8
3.8–8.2/
/70.3
2.2–6.4
/38–63 (girls)
/70–86 (boys)
Only fruit machines,
DSM-IV-J,
DSM-IV-MR-J England
and Wales
DSM-IV-J.
Only fruit machines
UK 11–16
N = 430
Spain,
La Coruna
SOGS-RA Spain,
Galicien
SOGS Spain,
Teneriffa
DSM-IV-J.
Only fruit machines
Spain,
Gijón
SOGS-RA Spain,
Huelva
12–15
N = 9 774
11–16
N = 1 200
14–21
N = 2 790
GA Rumania 14–19
N = 500
DSM-IV-J
VGS
DSM-IV-MRJ
SOGS-RA
8 screen Y
(New Zealand instrument)
SOGS,
modified version
Australien,
Australian
Capital Territory
(10) Johansson &
Götestam, 2003
(12) Rossow &
Hansen, 2003
(14) Fisher, 1993
(21) Fisher, 1999
(58) Becoña &
Gestal, 1996
(59) Becoña, et al.,
2001
16–17 (124) Castro
Rodriguez, 1999
11–16
(61) Villa, et al., 1997
N = 2 185
8–17
(60) Arbinaga, 2000
N = 130
(125) Lupu, et al.,
2002
11–19 (16) Delfabbro, Lahn,
Gaborsky, 2005
New Zealand 13–18 (57) Sullivan, 2005
Australia,
Melbourne city
DSM-III Canada,
Quebec city
SOGS
(French version)
Canada,
Quebec city
SOGS-RA Canada,
Ontario
DSM-IV-J Canada,
Montreal
– Parts of SOGS-RA Canada,
Alberta
0.4–0.7/ (girls)
2–3/ (boys)
86/ 10.1/
5.8
– 14.8–21/
2.3–3.9
SOGS-RA Canada,
Ontario
SOGS-RA Canada,
West coast
Part of Minnesota
Student Survey: gambling
frequency, gambling
problem (2 questions)
USA,
Minnesota
SOGS-RA USA,
Louisiana
Telephone interviews, at 3
opportuities during an 8-year
period SOGS-RA and SOGS
USA,
Minnesota
15–18 (15) Moore &
Otshuka, 2000
14–?
N = 1 612
12–18
N = 3 426
14–19
N = 965
12–17
N = 817
12–15
N = 745
14–20
N= 2 371
Average age 15
N = 13 549
14–20
N = ca 75 000
Ca 12–20
N = 11 736
Average age
16–24 N = 305
(94) Ladouceur and
Mireault, 1988
(72) Ladouceur et al,
1999
(4) Govoni, et al.,
1996
(6) Gupta &
Derevensky, 1998
(66) Adebayo, 1998
(71) Adlaf &
Ialomiteanu, 2000
(8) Poulin, 2000
(36) Stinchfield,
2001
(68) Westphal, et al.,
2000
(77) Winters, et al.,
2002

References
1. APA. Diagnostic and statistical manual of mental disorders. DSM-IV-TR. 4. uppl. Washington
(DC): American Psychiatric Association; 2000.
2. WHO. International statistical classification of diseases and related health problems [electronic
resource]. ICD-10. 2. uppl. Genève: World Health Organization; 2005.
3. Winters K, Stinchfield R, Fulkerson J. Patterns and characteristics of adolescent gambling.
J Gambl Stud 1993;9(4):371–86.
4. Govoni R, Rupcich N, Frisch G. Gambling behavior of adolescent gamblers. J Gambl Stud
1996;12(3):305–17.
5. Shaffer HJ, Hall MN. Estimating the prevalence of adolescent gambling disorders. A quantitative
synthesis and guide toward standard gambling nomenclature. J Gambl Stud, Special Issue:
Prevalence studies of problem and pathological gambling 1996;12(2):193–214.
6. Gupta R, Derevensky J. Adolescent gambling behavior. A prevalence study and examination of
the correlates associated with problem gambling. J Gambl Stud 1998;14(4):319–45.
7. Jacobs DF. Juvenile gambling in North America. An analysis of long term trends and future prospects.
J Gambl Stud 2000;16(2–3):119–52.
8. Poulin C. Problem gambling among adolescent students in the atlantic provinces of Canada.
J Gambl Stud 2000;16(1):53–78.
9. Wiebe JM, Cox BJ, Mehmel BG. The South Oaks Gambling Screen Revised for Adolescents SOGS-
RA. Further psychometric findings from a community sample. J Gambl Stud 2000;16(2–3):275–88.
10. Johansson A, Götestam KG. Gambling and problematic gambling with money among
Norwegian youth 12–18 years. Nord J Psychiatry 2003;57(4):317–21.
11. National Opinion Research Center, University of Chicago. Gambling Impact and Behavior
Study. Chicago: National Opinion Research Center, University of Chicago; 1999.
12. Rossow I, Hansen M. Underholdning med bismak. Ungdom og pengespill. NOVA rapport
1/2003. Oslo: Norsk institutt for forskning om oppvekst, velferd og aldring; 2003.
13. McGowan V, Droessler J, Nixon G, Grimshaw M. Recent research in the socio-cultural domain
of gaming and gambling. An annotated bibliography and critical overview. Alberta: Edmonton
(AB): Alberta Gaming Research Institute; 2000.
14. Fisher S. Gambling and pathological gambling in adolescents. J Gambl Stud 1993;9(3):277–88.
15. Moore S, Ohtsuka K. The structure of young people’s leisure and their gambling behaviour.
Behaviour Change, Special Issue: Adolescent Health 2000;17(3):167–77.
16. Delfabbro P, Lahn J, Grabosky P. Adolescent gambling in the ACT. Canberra, ACT: Australian
National University, Centre for Gambling Research; 2005.
17. Rönnberg S, Volberg RA, Abbott MW, Moore WL, Andrén A, Munck I, et al. Gambling and
problem gambling in Sweden. Report No. 2 of the National Institute of Public Health Series on
Gambling. Stockholm: National Institute of Public Health Sweden; 1999.
18. Hvitfeldt T, Rask L. Skolelevers drogvanor 2005. Rapport nr 90. (The drug habits of schoolchildren
2005. Report no 90) Stockholm: Centralförbundet för Alkohol- och Narkotikaupplysning;
2005. Swedish Council for Information on Alcohol and Other Drugs; 2005.
19. Hvitfeldt T, Rask L, Andersson B, Hibell B. Skolelevers drogvanor 2004. Rapport nr 84. (The
drug habits of schoolchildren 2004. Report no 84) Stockholm: Centralförbundet för Alkoholoch
Narkotikaupplysning; 2004. Swedish Council for Information on Alcohol and Other Drugs;
2004.
20. Rask L. Drogvanor i gymnasiets år 2 2004. Rapport nr 87. (Drug habits in second-year uppersecondary
school 2004, Report no 87) Stockholm: Centralförbundet för Alkohol- och Narkotikaupplysning;
2005. Swedish Council for Information on Alcohol and Other Drugs; 2005.
21. Fisher S. A prevalence study of gambling and problem gambling in British adolescents. Add
Research 1999;7(6):509–38.
22. Huxley J, Carroll D. A survey of fruit machine gambling in adolescents. J Gambl Stud
1992;8(2):167–79.
55

56
23. Ide S, Lea SE. Gambling in young adolescents. J Gambl Behav 1988;4(2):110–8.
24. Griffiths M. Scratchcard gambling among adolescent males. J Gambl Stud 2000;16(1):79–91.
25. Griffiths M. The observational study of adolescent gambling in UK amusement arcades. J Com
& Appl Soc Psychol 1991;1(4):309–20.
26. Wood R, Griffiths M. Adolescent perceptions of the National Lottery and scratchcards. A qualitative
study using group interviews. J Adolesc 2002;25(6):655–68.
27. Skinner H, Biscope S, Murray M, Korn D. Dares to addiction. Youth definitions and perspectives
on gambling. Can J Public Health 2004;95(4):264–7.
28. Tremblay GC, Huffman L, Drabman RS. The effects of modeling and experience on young
children’s persistence at a gambling game. J Gambl Stud 1998;14(2):193–210.
29. Griffiths M, Wood R. Risk factors in adolescence. The case of gambling, videogame playing, and
the internet. J Gambl Stud 2000;16(2–3):199–225.
30. Derevensky JL, Gupta R, Della Cioppa G. A developmental perspective of gambling behavior in
children and adolescents. J Gambl Stud 1996;12(1):49–66.
31. Wood R, Griffiths M. The acquisition, development and maintenance of lottery and scratchcard
gambling in adolescence. J Adolesc 1998;21(3):265–73.
32. Schissel B. Betting against youth. The effects of socioeconomic marginality on gambling among
young people. Youth & Society 2001;32(4):473–91.
33. Stinchfield R. Gambling and correlates of gambling among Minnesota public school students.
J Gambl Stud 2000;16(2–3):153–73.
34. Kassinove JI, Doyle KA, Milburn NG. Gambling and alcohol use in adolescence. J Soc Beh &
Personality 2000;15(1):51–66.
35. Barnes GM, Welte JW, Hoffman JH, Dintcheff BA. Gambling and alcohol use among youth.
Influences of demographic, socialization, and individual factors. Addict Behav 1999;24(6):749–67.
36. Stinchfield R. A comparison of gambling by Minnesota public school students in 1992, 1995,
and 1998. J Gambl Stud 2001;17(4):273–96.
37. Kaminer Y, Burleson JA, Jadamec A. Gambling behavior in adolescent substance abuse. Subst
Abus 2002;23(3):191–8.
38. Fisher S. Developing the DSM-IV-criteria to identify adolescent problem gambling in non-clinical
populations. J Gambl Stud 2000;16(2–3):253–73.
39. Winters KC, Stinchfield RD, Fulkerson J. Toward the development of an adolescent gambling
problem severity scale. J Gambl Stud 1993;9(1):63–84.
40. Winters KC, Stinchfield RD, Kim LG. Monitoring adolescent gambling in Minnesota. J Gambl
Stud 1995;11(2):165–83.
41. Shaffer HJ, LaBrie R, Scanlan KM, Cummings TN. Pathological gambling among adolescents.
Massachusetts Gambling Screen (MAGS). J Gambl Stud 1994;10(4):339–62.
42. Johnson EE, Hamer RM, Nora RM. The Lie/Bet Questionnaire for Screening Pathological
Gamblers. A follow-up study. Psych Reports 1998;83:1219–24.
43. Johnson EE, Hamer RM, Nora RM, Tan B, Eisenstein N, Engelhart C. The Lie/Bet
Questionnaire for Screening Pathological Gamblers. Psych Reports 1997;80:83–8.
44. Ben-Tovim DI , Esterman A, Tolchard B, Battersby M, Flinders Technologies Pty Lt. The
Victorian Gambling Screen Project Report. Melbourne: Gambling Research Panel; 2001.
45: Poulin C. An assessment of the validity and reliability of the SOGS-RA. J Gambl Stud Spring
2002;18(1):67–93.
46. Derevensky JL, Gupta R. Prevalence estimates of adolescent gambling. A comparison of the
SOGS-RA, DSM-IV-J, and the GA 20 questions. J Gambl Stud 2000;16(2–3):227–51.
47. Götestam KG, Johansson A, Wenzel HG, Simonsen IE. Validation of the lie/bet screen for pathological
gambling on two normal population data sets. Psychol Rep 2004;95:1009–13.
48. Langhinrichsen-Rohling J, Rohling ML, Rohde P, Seeley JR. The SOGS-RA vs. the MAGS-7.
Prevalence estimates and classification congruence. J Gambl Stud. 2004 Fall;20(3):259–81.
49: Fleiss JL. Measuring nominal scale agreement among many raters. Psychol Bull 1971;76:378–382.
50. Ladouceur R, Bouchard C, Rhéaume N, Jacques C, Ferland F, Leblond J, et al. Is the SOGS an
accurate measure of pathological gambling among children, adolescents and adults? J Gambl
Stud 2000;16(1):1–24.

51. Pelletier A, Ladouceur R, Fortin J, Mélanie. Assessment of high school students’ understanding
of DSM-IV-MR-J items. J Adolesc 2004;19(2):224–32.
52. Jacques C, Ladouceur R. DSM-IV-J criteria. A scoring error that may be modifying the estimates
of pathological gambling among youths. J Gambl Stud 2003;19(4):427–31.
53. Derevensky JL, Gupta R, Winters K. Prevalence rates of youth gambling problems. Are the
current rates inflated? J Gambl Stud. 2003 Winter;19(4):405–25.
54. Hardoon KK, Derevensky JL. Child and adolescent gambling behavior. Current knowledge.
Clin Child Psych Psychiat 2002;7(2):263–81.
55. Helling S. Det är som ett kärleksförhållande. Spelmissbruk bland ungdomar. Rapport nr 72. (It's
like a love affair. Pathological gambling in young people. Report no 72.) Stockholm: Centralförbundet
för Alkohol- och Narkotikaupplysning; 2003. Swedish Council for Information on
Alcohol and Other Drugs.
56. Shaffer HJ, Hall MN. Updating and refining prevalence estimates of disordered gambling
behaviour in the United States and Canada. Can-J-Public-Health 2001;92(3):168–72.
57. Sullivan S. A hidden curriculum. Gambling and problem gambling among high school students
in Auckland. Health Promot J Austr 2005;16(3):201–6.
58. Becoña E, Gestal C. El juego patológico en niños del 2 ciclo de E. G. B. (Pathological gambling
among 2nd-graders at “EGB”). Psicothema 1996;8(1):13–23.
59. Becoña I, Elisardo, Míguez V, María del Carmen, Vázquez G, Fernando L. El juego problema en
los estudiantes de Enseñanza Secundaria (Gambling problems among upper-secondary school
students). Psicothema 2001;13(4):551–6.
60. Arbinaga F. Estudio descriptivo sobre el juego patológico en estudiantes (8–17 años):
Características sociodemográficas, consumo de drogas y depresión (Descriptive study of pathological
gambling among schoolchildren, 8–17 years). Sociodemographic data, drug use and
depression). Adicciones 2000;12(4):493–505.
61. Villa A, Becoña E, Vázquez FL. Juego patológico con máquinas tragaperras en una muestra de
escolares de Gijón. (Pathological gambling on fruit machines among school pupils in Gijón).
Adicciones 1997;9(2):195–208.
62. Olason DT. Prevalence and potential risk factors of problem gambling among 13–15 year old
adolescents in Iceland. Konferenspresentation. 6th European Conference on Gambling Studies
and Policy Issues. Malmö; 2005.
63. Olason DT, Sigurdardottir KJ, Smari J. Prevalence estimates of gambling participation and
problem gambling among 16 to 18 year old students in Iceland. A comparison of the SOGS-RA
and DSM-IV-MR-J. Online publication. J Gambl Stud 2005 Dec;22:1–17.
64. Gerdner A, Svensson K. Predictors of gambling problems among male adolescents. Int J Soc
Welfare 2003;12(3):182–92.
65. Tengström A. Ung och oberoende. Erfarenheter från Maria Ungdom. Konferenspresentation.
Nordiskt seminarium om spel- och spelberoendeforskning. Helsingfors; 2005. (Young and independent.
Experiences from Maria Ungdom. Conference presentation. Nordic seminar on gambling
and gambling addiction research.) Helsinki; 2005.
66. Adebayo B. Gambling behavior of students in grades seven and eight in Alberta, Canada. J Sch
Health 1998;68(1):7–11.
67. Hardoon K, Gupta R, Derevensky J. Psychosocial variables associated with adolescent gambling.
Psych Addict Behaviors 2004;18(2):170–9.
68. Westphal JR, Rush JA, Stevens L, Johnson LJ. Gambling behavior of Louisiana students in
grades 6 through 12. Psychiatr Serv 2000;51(1):96–9.
69. Peacock RB, Day PA, Peacock TD. Adolescent gambling on a Great Lakes Indian Reservation.
J Hum Beh Soc Env 1999;2(1–2):5–17.
70. Langhinrichsen-Rohling J, Rohde P, Seeley JR, Rohling ML. Individual, family, and peer correlates
of adolescent gambling. J Gambl Stud 2004;20(1):23–46.
71. Adlaf EM, Ialomiteanu A. Prevalence of problem gambling in adolescents. Findings from the
1999 Ontario student drug use survey. Can J Psychiatry 2000;45(8):752–5.
72. Ladouceur R, Boudreault N, Jacques C, Vitaro F. Pathological gambling and related problems
among adolescents. J Child & Adol Subst Abuse 1999;8(4):55–68.
57

58
73. Slutske WS, Jackson KM, Sher KJ. The natural history of problem gambling from age 18 to 29.
J Abn Psych 2003;112(2):263–74.
74. Winters KC, Stinchfield RD, Botzet A, Slutske WS. Pathways of youth gambling problem
severity. Psych Addict Behav 2005;19(1):104–7.
75. Jonsson J, Andrén A, Nilsson T, Svensson O, Munck I, Kindstedt A, et al. Spelberoende i Sverige
– vad kännetecknar personer med spelproblem? Rapport om andra fasen av den svenska
nationella studien av spel och spelberoende. Rapport nr 2003:22. (Pathological gambling in
Sweden – what characterises people with gambling problems? Report on the 2nd phase of the
Swedish national study of gambling and gambling addiction. Report no 2003:22.) Stockholm:
Swedish National Institute of Public Health; 2003.
76. Svensson O. Ungdomars spel om pengar. Spelmarknaden, situationen och karriären. Doktorsavhandling.
(Gambling for money among young people. The gambling market, the situation and
their careers. PhD thesis.) Lund: Lunds University; 2005.
77. Winters KC, Stinchfield RD, Botzet A, Anderson N. A prospective study of youth gambling
behaviors. Psych Addict Beh 2002;16(1):3–9.
78. Moore SM, Ohtsuka K. Beliefs about control over gambling among young people, and their relation
to problem gambling. Psych Addict Beh 1999;13(4):339–47.
79. Griffiths M. Adolescent gambling. London & New York: Routledge; 1995.
80. Johansson A, Götestam KG. Problems with computer games without monetary reward.
Similarity to pathological gambling. Psych Reports 2004;95(2):641–50.
81. Gupta R, Derevensky JL. The relationship between gambling and video-game playing behavior
in children and adolescents. J Gambl Stud 1996;12(4):375–94.
82. Wood R, Gupta R, Derevensky JL, Griffiths M. Video game playing and gambling in adolescents.
Common risk factors. J Child & Adol Subst Abuse 2004;14(1):77–100.
83. Gupta R, Derevensky JL, Marget N. Coping strategies employed by adolescents with gambling
problems. Ch Adol Ment Health 2004;9(3):115–20.
84. Dickson LM, Derevensky JL, Gupta R. The prevention of gambling problems in youth. A conceptual
framework. J Gambl Stud 2002;18(2):97–159.
85. Lynch WJ, Maciejewski PK, Potenza MN. Psychiatric correlates of gambling in adolescents and
young adults grouped by age at gambling onset. Arch Gen Psychiatry 2004;61(11):1116–22.
86. Dubé D, Freeston MH, Ladouceur R. Potential and probable pathological gamblers. Where do
the differences lie? J Gambl Stud 1996;12(4):419–30.
87. Nower L, Derevensky JL, Gupta R. Taking risks. The relationship of impulsivity, sensation
seeking, stress-coping, and substance use in youth gamblers. Psych Addic Beh 2004 Mar;
18(1):49–55.
88. Vitaro F, Arseneault L, Tremblay RE. Impulsivity predicts problem gambling in low SES adolescent
males. Addiction 1999;94(4):565–75.
89. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male
adolescents. Am J Psychiatry 1997;154(12):1769–70.
90. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during
adolescence. Mutual influences and common risk factors. J Gambl Stud 2001;17(3):171–90.
91. Vitaro F, Ferland F, Jacques C, Ladouceur R. Gambling, substance use, and impulsivity during
adolescence. Psych Addict Behaviors 1998;12(3):185–94.
92. Vitaro F, Ladouceur R, Bujold A. Predictive and concurrent correlates of gambling in early
adolescent boys. J Early Adol 1996;16(2):211–28.
93. Hardoon K, Derevensky JL, Gupta R. An examination of the influence of familial, emotional,
conduct, and cognitive problems, and hyperactivity upon youth risk-taking and adolescent gambling
problems. Montreal: Report to the Ontario Problem Gambling Research Centre; 2002.
94. Ladouceur R, Mireault C. Gambling behaviors among high school students in the Quebec area.
J Gambl Beh 1988;4(1):3–12.
95. Winters KC, Anderson N. Gambling involvement and drug use among adolescents. J Gambl
Stud 2000;16(2–3):175–98.
96. Petry NM, Tawfik Z. Comparison of problem-gambling and non-problem-gambling youths
seeking treatment for marijuana abuse. J Am Acad Child Adol Psychiatry 2001;40(11):1324–31.

97. Griffiths M. An exploratory study of gambling cross addictions. J Gambl Stud 1994;10(4):371–84.
98. Griffiths M, Sutherland I. Adolescent gambling and drug use. J Com & Appl Soc Psych
1998;8:423–7.
99. Arbinaga IF. Conductas de juego con apuestas y uso de drogas en una muestra de estudiantes
adolescentes de la ciudad de Huelva. (Gambling behaviour and drug use among a group of
young students in the town of Huelva.) Anál Modific Conducta 1996;22(85):577–601.
100. Griffiths M. Addiction to fruit machines. A preliminary study among young males. J Gambl Stud
1990;6(2):113–26.
101. Andréasson S. Att förebygga alkoholskador. Stödinsatser för riskgrupper. Rapport nr 2003:03.
(Preventing alcohol damage. Support for high-risk groups. Report no 2003:03.) Stockholm:
Swedish National Institute of Public Health; 2003.
102. Vitaro F, Wanner B, Ladouceur R, Brendgen M, Tremblay RE. Trajectories of gambling during
adolescence. J Gambl Stud 2004;20(1):47–69.
103. Barnes GM, Welte JW, Hoffman JH, Dintcheff BA. Effects of alcohol misuse on gambling
patterns in youth. J Stud Alcohol 2002;63(6):767–75.
104. Welte JW, Barnes GM, Hoffman JH. Gambling, substance use, and other problem behaviors
among youth. A test of general deviance models. J Crim Justice 2004;32(4):297–306.
105. Barnes GM, Welte JW, Hoffman JH, Dintcheff BA. Shared predictors of youthful gambling,
substance use, and delinquency. Psych Addict Behav 2005 Jun;19(2):165–74.
106. Willoughby T, Chalmers H, Busseri MA. Where is the syndrome? Examining co-occurrence
among multiple problem behaviors in adolescence. J Cons & Clin Psych 2004;72(6):1022–37.
107. Felsher JR, Derevensky JL, Gupta R. Parental influences and social modelling of youth lottery
participation. J Com & Appl Soc Psych 2003;13(5):361–77.
108. Pugh P, Webley P. Adolescent participation in the U.K. National Lottery games. J Adolesc
2000;23(1):1–11.
109. Vachon J, Vitaro F, Wanner B, Tremblay RE. Adolescent gambling. Relationships with parent
gambling and parenting practices. Psych Addict Behav 2004;18(4):398–401.
110. Delfabbro P, Thrupp L. The social determinants of youth gambling in South Australian adolescents.
J Adolesc 2003;26(3):313–30.
111. Fisher S. Adolescent fruit machine dependency and delinquency. Questions on a question of
methodology. J Gambl Stud, Special Issue: Fruit machine gambling 1995;11(3):303–10.
112. Ladouceur R, Boisvert J-M, Dumont J. Cognitive-behavioral treatment for adolescent pathological
gamblers. Behav Modif 1994;18(2):230–42.
113. Ferland F, Ladouceur R, Vitaro F. Prevention of problem gambling. Modifying misconceptions
and increasing knowledge. J Gambl Stud 2002;18(1):19–29.
114. Gaboury A, Ladouceur R. Evaluation of a prevention program for pathological gambling among
adolescents. J Prim Prev 1993;14(1):21–8.
115. Toneatto T, Ladoucuer R. Treatment of pathological gambling. A critical review of the literature.
Psych Addict Behav 2003 Dec;17(4):284–92.
116. Gupta R, Derevensky JL. Adolescents with gambling problems. From research to treatment.
J Gambl Stud 2000;16(2–3):315–42.
117. Private discussion with Rina Gupta and Jeffrey Derevensky at the International Centre for Youth
Problem Gambling and High-Risk Behaviors. Montreal; 2005.
118. Private discussion with Geneviéve Siebes and Christian Carpenter at the Centre Dollard-
Cormier, Montreal; 2005.
119. DiClemente CC, Story M, Murray K. On a roll. The process of initiation and cessation of
problem gambling among adolescents. J Gambl Stud 2000;16(2–3):289–313.
120. Dickson L, Derevensky JL, Gupta R. Youth gambling problems. A harm reduction prevention
model. Addic Res & Theory, Special Issue: Clinical harm reduction 2004;12(4):305–16.
121. Dickson L, Derevensky JL, Gupta R. Harm reduction for the prevention of youth gambling problems.
Lessons learned from adolescent high-risk behavior prevention programs. J Adol
2004;19(2):233–63.
59

60
122. Evans R. Some theoretical models and constructs generic to substance abuse prevention programs
for adolescents. Possible relevance and limitations for problem gambling. J Gambl Stud
2003;19(3):287–302.
123. Messerlian C, Derevensky JL, Gupta R. Youth gambling problems. A public health perspective.
H Prom Intern 2005;20(1):69–79.
124. Castro J. Estudio de la proporción de jugadores patológicos en un grupo de menores, mediante el
South Oaks Gambling Screen. El problema de los falsos positivos (Study of the prevalence of
pathological gamblingin a group of minors using the South Oaks Gambling Screen. The problem
of false positives.) Electronic journal. Psic com Rev Elec Psic 1999;3(1).
125. Lupu V, Onaca E, Lupu D. The prevalence of pathological gambling in Romanian teenagers. Min
Med 2002;93(5):413–8.

The Swedish National Institute of Public Health (SNIPH) was commissioned by the Swedish
Government in 2001 to draw up a proposal for an action plan to combat pathological
gambling in Sweden. This review, the aim of which is to systematise the scientific
literature on the subject of young people who gamble for money, constitutes a basis
for the development of the measures relating to young people in the action plan.
The literature reviewed is made up of scientific articles published in international journals,
a small number of unpublished reports and a few presentations made at conferences.
Furthermore, knowledge acquired from study visits to research centres and treatment
clinics for adolescent gambling addicts is also included. Research on preventive measures
and the treatment of pathological gambling among young people is still rather limited,
but important elements include:
• Information to young people and parents about gambling and pathological gambling
is necessary.
• It is common for young pathological gamblers to have other problems as well,
including substance abuse, depression, etc. These must be treated in parallel with
their pathological gambling.
• Elements of treatment that enhance young people's motivation are important if the
treatment is to be successful.
The report has been compiled by public health planner Frida Fröberg at the Swedish
National Institute of Public Health. The scientific supervisor was Dr. Anders Tengström
at the Research Centre for the Psychosocial Health of Young People, and the Maria
Ungdom Clinic and Karolinska Institutet (FORUM). Anders Tengström also co-authored
the sections on the quality of assessment tools and the risk factors of pathological
gambling in young people.
swedish national
institute of public health
Swedish National
Institute of Public Health
Distribution
SE-120 88 Stockholm
Fax +46 8 566 135 05
E-mail fhi@strd.se
Internet www.fhi.se
Report R 2006:20
ISSN 1651-8624
ISBN 91-7257-471-2