Granero, G., Fernández-Aranda, F., Demetrovics, Z., Ayala-Rojas, R. E., Gómez-Peña, M., Moragas, L., Jiménez-Murcia, S., (2021). Profile of Treatment-Seeking Gaming Disorder Patients: a Network Perspective. Journal of Gambling Studies.

https://link.springer.com/article/10.1007%2Fs10899-021-10079-2

This study explored the network structure of correlates of gaming disorder (sociodemographic, personality and other clinical measures) in treatment-seeking patients. The network analysis carried out in this study provided insight into the structure of the main contributing factors of gaming disorder. The central nodes in the network were global psychological distress, chronological age, and age of onset of gaming related problems.

Linkage analysis also identified psychopathological status and age as the variables with the most valuable information in the model. Identification of such variables can be useful for developing precise management plans to prevent and treat gaming disorder related problems.

Shaw, C.A., Hodgins, D.C., Williams, R.J. et al. (2021). Gambling in Canada During the COVID Lockdown: Prospective National Survey. Journal of Gambling Studies (2021).

https://link.springer.com/article/10.1007%2Fs10899-021-10073-8

This study aimed to investigate the extent to which the COVID pandemic lockdown influenced gambling and problem gambling in Canada. The re-surveying of AGRI National project’s online panel participants (n=3449) allowed for a quantitative comparison of gambling behaviours during the pandemic relative to six months prior. Findings showed that nearly one-third of gamblers ceased gambling completely during the lockdown. Whereas for those who continued, gambling decreased across nearly all engagements metrics including gambling frequency, time spent in gambling sessions, money spent, and the number of game types engaged in.

Over 17% of participants migrated from pre-pandemic land based gambling to online gambling during the lockdown. Further studies are required to assess if these changes herein remain stable or revert to pre-pandemic levels.

Bányai, F., Zsila, Á., Kökönyei, G., Griffiths, M. D., Demetrovics, Z., Király, O., (2021). The moderating role of coping mechanisms and being an e-sport player between psychiatric symptoms and gaming disorder: Online survey. JMIR Mental Health, 8(3):e21115  [https://mental.jmir.org/2021/3/e21115/PDF]

 

This study aimed to investigate the effect of coping strategies and type of videogame usage (i.e., professional/esport vs. recreational use) on the relationship between psychiatric symptoms (e.g., depression, anxiety) and videogame addiction. The results showed that there is a moderately strong relation between psychiatric symptoms and videogame addiction and that neither coping strategies, nor the type of videogame usage have a considerable effect on this relation.

Murray, A., Koronczai, B., Király, O., Griffiths, M. D., Mannion, A., Leader, G., Demetrovics, Z. (2021). Autism, Problematic Internet Use, and Gaming Disorder: A Systematic Review. Review Journal of Autism and Developmental Disorders, in press [https://link.springer.com/content/pdf/10.1007/s40489-021-00243-0.pdf]

 

This literature review investigated the relationship between autism and problematic internet use and videogame addiction. A systematic literature search was conducted, and 21 studies were identified examining this question. The majority of the studies found a weak or moderate relationship between internet addiction and autistic-like traits and a relationship with varying strength between internet addiction and clinically diagnosed Autism Spectrum Disorder. Additionally, individuals with Autism Spectrum Disorder were more likely to exhibit symptoms of videogame addiction, however there is a lack of studies investigating the relationship between autistic-like traits and videogame addiction.

Rafiemanesh, H., Farnam, R., Rahimi, J., Hamzehzadeh, M., Ghani, K., Jobehdar, M. M., Amin-Esmaeili, M., Shadloo, B., Demetrovics, Z., Király, O., Rahimi-Movaghar, A. (2021). Online Gaming and Internet Gaming Disorder in Iran: Patterns, Motivations, and Correlates. Current Psychology [https://link.springer.com/article/10.1007/s12144-021-02490-0]

 

The aim of this study was to assess patterns and motivations of online gaming, the symptomatology and prevalence of Gaming Disorder (GD) and its health implications, and the correlates of these phenomena in an Iranian population of online gamers. The study was carried out as part of a national survey collaboration with a cross-cultural study. The findings showed prevalence estimate of GD was 3.7% amongst the 791 participating gamers, and higher game time and GD was 9.4 times more prevalent amongst males. Additionally, time spent on gaming, younger age, using a PC rather than smartphones and “escape” and “fantasy” gaming motivations and psychiatric symptoms were associated with the GD as well. This study concludes that a small minority of Iranian online gamers may be at risk of pathological gaming and its associated harms, especially those of a young age who play long hours with “fantasy” related incentives.

Király, O., Zhang, J., Demetrovics, Z., & Browne, D. T. (2021). Gambling Features and Monetization in Video Games Creates Challenges for Young People, Families, and Clinicians. Journal of the American Academy of Child & Adolescent Psychiatry, S089085672102044X.
[https://www.jaacap.org/article/S0890-8567(21)02044-X/fulltext]

 

This article highlights how “loot boxes” (in-game consumable virtual items, that can be purchased with real money or obtained in games as a reward) may act as a gateway to problem gambling and in turn, the impact this may have on children from a developmental perspective, disruptions within families and barriers faced by paediatric clinicians. This study includes key areas of research that need to be considered to be able to facilitate effective prevention methods.

Spritzer, D. T., Machado, W. D., Yates, M. B., Astolfi, W., Laskoski, P. B., Pessi, C. P., Laconi, S., Kaliszewska-Czeremska, K., Demetrovics, Z., Király, O., Passos, I. C., Hauck, S. (2021). Psychometric properties of the nine-item Problematic Internet Use Questionnaire in a Brazilian general population sample. Frontiers in Psychiatry, 12:660186 [https://www.frontiersin.org/articles/10.3389/fpsyt.2021.660186/full]

 

This study aimed to adapt and examine the psychometric properties of the Brazilian version of the Problematic Internet Use Questionnaire (PIUQ-SF-9) in the framework of a multicentric project carried out in 16 countries investigating the cross-cultural aspects of problematic internet and smartphone use. The PIUQ-SF-9 is the short form of the original 18-item PIUQ developed by Demetrovics et al., 2008. It is a nine-item comprehensive screening tool assessing three basic areas of problematic internet use: obsession (i.e., preoccupation and withdrawal symptoms); neglect (i.e., negligence of everyday activities and basic needs); and control disorder (i.e., trouble in controlling internet use). The sample consisted of Brazilian Internet users between the ages of 18 and 89. According to the results the Brazilian Portuguese version of the PIUQ-SF-9 proved to be a valid and reliable instrument to be used in future studies on problematic internet use in Brazil.

Horváth, Z., Király, O., Demetrovics, Z., Németh, Á., Várnai, D., & Urbán, R. (2021). Polysubstance Use Is Positively Associated with Gaming Disorder Symptom Severity: A Latent Class Analytical Study. European Addiction Research, 1-11. [https://pubmed.ncbi.nlm.nih.gov/34284387/]

 

The aim of the present study was to explore alcohol and illicit drug use classes among adolescents and how gaming disorder is associated with these. The final sample consisted of 2768 students (ninth and eleventh graders), with a mean age of 16.73 years. Four subgroups were identified: polysubstance users, high-risk alcohol users, moderate alcohol users, and infrequent substance users. Based on the results severe gaming disorder was associated with various drug use, which may be due to the intention to increase performance in the game. There may be common psychological mechanisms in the background (e.g., sensation-seeking tendencies), and shared neurobiological mechanisms may also explain the relationship. The level of alcohol consumption did not correlate with the severity of the symptoms of gaming disorder.

Kótyuk, E., Urbán, R., Hende, B., Richman, M., Magi, A., Király, O., Barta, C., Griffiths, M. D., Potenza, M. N., Badgaiyan, R. D., Blum, K., & Demetrovics, Z. (2022). Development and validation of the Reward Deficiency Syndrome Questionnaire (RDSQ-29). Journal of Psychopharmacology, 026988112110691. [IF: 4.153] [https://journals.sagepub.com/doi/10.1177/02698811211069102]

 

This present study developed and validated a 29-item reward deficiency syndrome questionnaire (RSDQ-29) containing four subscales to assess psychological and behavioural characteristics that may contribute to addictions generally. Reward deficiency syndrome (RDS) seems to have a crucial role in the development of addictive behaviours. While former studies described carefully the neurobiological and genetical background of the reward deficiency syndrome until now the psychological description of the phenomenon was not available. The currently developed scale fills this gap by providing a psychometrically sound instrument to assess RDS and its components.

Williams, R. J., Shaw, C. A., Belanger, Y. D., Christensen, D. R., el-Guebaly, N., Hodgins, D. C., McGrath, D. S., & Stevens, R. M. G. (2022). Etiology of problem gambling in Canada. Psychology of Addictive Behaviors. Advance online publication. https://doi.org/10.1037/adb0000843

 

A large-scale national cohort study has been conducted to identify the current etiological risk factors for problem gambling in Canada. A cohort of 10,119 Canadian gamblers completed a comprehensive self-administered online questionnaire in 2018 and were reassessed in 2019. The strongest multivariate predictors of current and future problem gambling were “gambling-related” variables, such as current and past problem gambling, intensive gambling involvement, playing electronic gambling machines, gambling fallacies, socializing with other people having gambling-related problems, and family history of having gambling-related problems. Beyond gambling-related variables, greater impulsivity and lower household income were robustly predictive.

Király, O., Billieux, J., King, D. L., Urbán, R., Koncz, P., Polgár, E., & Demetrovics, Z. (2022). A comprehensive model to understand and assess the motivational background of video game use: The Gaming Motivation Inventory (GMI). Journal of Behavioral Addictions. https://doi.org/10.1556/2006.2022.00048

 

This study aimed to create a comprehensive motivation inventory applicable to any gaming genre and to evaluate its psychometric properties in a large sample of highly engaged video gamers. A sample of 14,740 video gamers were recruited via an online survey, and the findings showed that 26 gaming motives clustered into six higher-order dimensions (Mastery, Immersion/Escapism, Competition, Stimulation, Social, Habit/Boredom).  Gaming motives had moderate relationships with variables such as competitiveness, sociability, and positive and negative affect. Gaming disorder symptoms were directly predicted by depression symptoms and indirectly via immersion/escapism, habit/boredom, and competition motives. The authors conclude that the Gaming Motivation Inventory is a useful tool for gaining insights into factors underlying gaming behaviours.

Király, O., Browne, D., Demetrovics, Z. (2022). Developmental and Family Implications of State Controlled Videogame Play in China. JAMA Pediatrics, [IF: 16.193] https://doi.org/10.1001/jamapediatrics.2022.0322

Recently, China imposed laws limiting children younger than 18 to 1 hour of online gaming between 8 and 9 PM on Fridays, Saturdays, Sundays, and public holidays. There are potential benefits and risks associated with state control of children’s video game play. These regulations have been welcomed by some, but there is evidence that video game play can have several benefits, including helping players master skills and be part of a community. The rules may also stigmatize an activity that is harmless for most people. From a family systems perspective, the regulations may externalize the problem of parent-child conflict over video game play outside the family, meaning parents and children now work together to find new ways to spend time. Alternatively, they could form a coalition against the regulation. The regulations could strengthen family relationships, but they may also inhibit the independent negotiation of media use within parent-child dyads, which is an important opportunity for families to work through challenging issues.

Nower, L., & Glynn, J. (2022). Adopting an affordability approach to responsible gambling and harm reduction: considerations for implementation in a North American context. Gaming law review, glr2.2022.0020. Https://doi.org/10.1089/glr2.2022.0020

The proliferation of gambling opportunities worldwide has generated concern over how to protect individuals and families from harm caused by excessive spending. In response, researchers and operators have worked with big data to develop models that identify indicators of problem gambling. Such models are generally proprietary, non-transparent, and non-generalizable across games, jurisdictions, or player populations, rendering them impractical as regulatory tools. In the UK and elsewhere, regulations have shifted to a model of shared responsibility that targets ‘affordability,’ the amount individual players can afford to lose. This approach avoids the need for regulators and operators to be clinicians, attempting to identify disorder. We discuss approaches to operationalizing affordability guidelines in a North American context – to promote the objective identification of players who are spending beyond their means and reduce related harm.

Király, O., Potenza, M. N., & Demetrovics, Z. (2022). Gaming disorder: Current research directions. Current Opinion in Behavioral Sciences, 47, 101204. https://doi.org/10.1016/j.cobeha.2022.101204

Gaming disorder (GD) is a condition that involves recurrent videogaming behaviour that leads to serious functional impairment in personal, social, family, occupational, and educational areas. GD is characterized by poor control, increasing priority given to gaming over other interests and activities, and continuation of gaming despite negative consequences. The World Health Organization (WHO) has recognized GD as an official diagnosis, and research into this disorder is growing, resulting in new research directions.research directions are proposed The present narrative review covers important recent studies of GD between 2019 and 2021, and addresses topics such as  conceptualization, assessment, and prevalence; comparison of DSM-5 and ICD-11 frameworks; clinical studies; neurobiological studies; gambling elements in video games; and impacts of the COVID-19 pandemic on gaming and GD. : (conceptualization, assessment, and prevalence, (2) comparison of GD frameworks proposed by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases 11th Revision, (3) clinical studies, (4) neurobiological studies, (5) gambling elements in video games, and (6) impacts of the COVID-19 pandemic on gaming and GD. The authors discuss the most important findings and propose future directions of research.

Mackey-Simpkin, S., Williams, R. J., Shaw, C. A., & Russell, G. E. H. (2022). Prevalence and predictors of illegal gambling in Canada. International Gambling Studies, 1–16. https://doi.org/10.1080/14459795.2022.2149833

 This study investigated the prevalence of illegal gambling in Canada in 2018. The researchers conducted a survey of 10,199 Canadian adults as part of a larger national study on gambling. They found that the prevalence of illegal gambling was very low, with only 0.05% of respondents reporting using illegal betting shops or bookies, 0.07% patronizing illegal casinos or card rooms, 0.09% participating in illegal animal contests, and 1.59% engaging in illegal online gambling. The study identified several factors that were associated with an increased likelihood of participating in illegal gambling, including the presence of gambling problems, male gender, younger age, and engagement in a larger number of gambling formats. Overall, the study found that legal forms of gambling may have largely displaced illegal forms, but illegal gambling does continue to exist among certain groups, particularly those who are heavily involved in gambling.

Akbari, M., Bahadori, M. H., Khanbabaei, S., Milan, B. B., Horvath, Z., Griffiths, M. D., & Demetrovics, Z. (2023). Psychological predictors of the co-occurrence of problematic gaming, gambling, and social media use among adolescents. Computers in Human Behavior, 140, 107589. https://doi.org/10.1016/j.chb.2022.107589

This study aimed to identify psychosocial predictors associated with different co-occurrence patterns  of problematic gambling, problematic social media use and problematic gaming among adolescents. The study surveyed 2390 Iranian adolescents between the ages of 13 and 18, and found that four different latent classes emerged: a non-problematic behavior group, a group with problematic gambling, a group with problematic social media use and gaming disorder, and a group with disordered gambling and problematic social media use. The study found that different psychological risk factors were associated with these different groups, and that specialized prevention and treatment programs may be needed for adolescents who experience co-occurring addictive behaviors.

Lucas, I., Granero, R., Fernández-Aranda, F., Solé-Morata, N., Demetrovics, Z., Baenas, I., Gómez-Peña, M., Moragas, L., Mora-Maltas, B., Lara-Huallipe, M. L., & Jiménez-Murcia, S. (2023). Gambling disorder duration and cognitive behavioural therapy outcome considering gambling preference and sex. Journal of Psychiatric Research, 158, 341–349. https://doi.org/10.1016/j.jpsychires.2022.12.031

This study aimed to evaluate the effect of illness duration on the treatment outcome of different profiles of gambling disorder (GD) patients according to their gambling preference and sex. 1699 patients diagnosed with GD were analysed, all of whom received cognitive-behavioural therapy. Results showed that patients who presented a preference for strategic forms of gambling and women had a higher risk of poor treatment outcomes since the first stages of the disorder. These results highlight the importance of early intervention in these specific patients to prevent the chronicity of the disorder.

Horváth, Z., Qirjako, G., Pavlova, D., Taut, D., Vaičiūnas, T., Melkumova, M., Várnai, D., Vieno, A., Demetrovics, Z., Urbán, R, Németh, Á., (2021). The information capacity of adolescent alcohol consumption indicators along a continuum of severity: A cross-national comparison of sixteen Central and Eastern European countries. Alcoholism: Clinical and Experimental Research, [Epub ahead of print]

https://onlinelibrary.wiley.com/doi/10.1111/acer.14679

This study aimed to examine information capacity and measurement invariance of different alcohol consumption indicators in adolescents from 16 countries of the former Soviet (Eastern) Bloc in Central and Eastern Europe (CEE). Data was collected as part of the 2013/2014 wave of the Health Behaviour in School-aged Children study. The analysis measured the presence or absence of alcohol consumption in the last 30 days, lifetime drunkenness, weekly drinking frequency, and binge drinking.

Findings confirmed that adolescent alcohol consumption indicators are informative for different severity levels. In most countries, alcohol consumption in the last 30 days and lifetime drunkenness were indicative at lower severity levels, while binge drinking and weekly drinking frequency were informative at higher levels of alcohol use severity. Different indicators suggested the presence of diverging drinking cultures in the CEE countries.

Zsila, Á., Orosz, G., McCutcheon, L. E., & Demetrovics, Z. (2021). Individual differences in the association between celebrity worship and subjective well-being: The moderating role of gender and age. Frontiers in Psychology, 12, 1749. [https://www.frontiersin.org/articles/10.3389/fpsyg.2021.651067/full]

 

This study aimed to explore the association between celebrity worship and well-being based on major demographics using the largest sample size for this topic. By exploring individual differences in this association some specific subgroups of fans have been identified that may need particular attention in mental health care. The sample consisted of Hungarian adults aged 18 to 79 years. They were categorized into two groups based upon whether their gender matched with the gender of their favourite celebrity (opposite-gender celebrity worship / same-gender celebrity worship). Women with higher levels of celebrity admiration were more likely to report lower self-esteem than men. Younger individuals with higher levels of celebrity worship experienced more frequent daytime sleepiness compared to older individuals. Gender-based selection of a favourite celebrity had no specific role in the association between celebrity worship and subjective well-being. These results indicate that there is a generally weak but consistent tendency that the stronger the worship of celebrities, the poorer the mental well-being.

Urbán, R., Király, O. & Demetrovics, Zs. (2021). Who complies with coronavirus disease 2019 precautions and who does not? Current Opinion in Psychiatry (online ahead of print) [https://pubmed.ncbi.nlm.nih.gov/34001700/]

 

This study aims to examine on the determinants of adherence behaviours (e.g., the use of a face mask and protective gloves, personal hygienic behaviours, keeping physical distance and avoiding social gatherings), as the most important tools to prevent SARS/COVID-19 virus transmission. Based on previous studies, there are specific populations that are particularly vulnerable to COVID, such as people with behavioural and mental disorders and recently diagnosed substance users. These populations might be at bigger risk, compared to people with chronic conditions, so a high degree of adherence to preventive behaviours is required from patients, caregivers, and the wider social environment.

There are factors, which determine the adherence to preventive behaviours. These can be  for example gender (males less likely to behave as recommended) and  age (younger people tend to feel safer, and consequently less likely to avoid social gatherings). Developing ways of engaging men and young people in adopting preventive behaviours and emphasizing the severity of the illness is important. Further research is needed to understand the vulnerable populations’ determinants of adherence behaviour.

Gjoneska, B., Potenza, M. N., Jones, J., Corazza, O., Hall, N., Sales, C. M. D., Grünblatt, E., Martinotti, G., Burkauskas, J., Werling, A. M., Walitza, S., Zohar, J., Menchón, J. M., Király, O., Chamberlain, S. R., Fineberg, N. A., & Demetrovics, Z. (2022). Problematic use of the internet during the COVID-19 pandemic: Good practices and mental health recommendations. Comprehensive Psychiatry, 112, 152279
[https://www.sciencedirect.com/science/article/pii/S0010440X21000572]

 

The present narrative review summarizes information on problematic use of internet (PUI) in relation to online gaming, gambling and pornography viewing, during the COVID-19 pandemic. The authors conclude by outlining research priorities and provide guidance, using evidence-based therapeutic approaches and preventative interventions on PUI for mental health professionals, patients and the general public.

Urbán, R., Paksi, B., Miklósi, Á., Saunders, J. B., Demetrovics, Z., (2021). Non-adherence to preventive behaviours during the COVID-19 epidemic: findings from a community study. BMC Public Health, 21:1462 [IF: 3.295] [https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11506-0]

 

This cross-sectional study had two aims: 1) to determine patterns of adherence and non-adherence to preventative behaviours recommended by public health authorities to slow down the transmission of SARS-CoV-2 and 2) to understand the roles that distal factors may have (i.e., age, gender, health beliefs and socioeconomic status) in implementing preventative behaviours among the general population. This study identified 15 preventative behaviours (including wearing facemasks, using hand sanitiser, maintaining social distancing etc.). Results showed 18% of participants identified as non-adherent. More specifically, men throughout the age ranges and generally younger people were less likely to adhere to preventative measures.

Moretta, T., Buodo, G., Demetrovics, Z., Potenza, M. N., (2022). Tracing 20 years of research on problematic use of the internet and social media: Theoretical models, assessment tools, and an agenda for future work. Comprehensive Psychiatry 112, 152286.
[https://www.sciencedirect.com/science/article/pii/S0010440X2100064X]

 

This overview highlights the current conceptualization and assessments of problematic use of the internet (PUI) and problematic use of social media. In doing so, the authors critically discuss the multiple existing theoretical models, whose differences partially reflect varying definitions and classifications of PUI (e.g., as an addiction or as an impulse control disorder; as an addiction to the internet or as an addiction on the internet). These differences do not allow for standardised assessment procedures, thereby limiting comparability across studies. The authors conclude by addressing the current controversies and make suggestions for two main areas and goals for future research direction.

Ágoston, C., Urbán, R., Nagy, B., Csaba, B., Kőváry, Z., Kovács, K., Varga, A., Dúll, A., Mónus, F., Shaw, C. A., Demetrovics, Z. (2022). The psychological consequences of the ecological crisis: Three new questionnaires to assess eco-anxiety, eco-guilt, and ecological grief. Climate Risk Managament. 37:100441   https://doi.org/10.1016/j.crm.2022.100441

The human contribution to global warming is causing increased concern regarding the future catastrophic consequences. Climate change affects physical and mental health in several ways, including direct effects such as trauma from natural disasters and indirect effects such as reduced social well-being due to destruction of the physical environment, reactions such as eco-anxiety, eco-guilt and ecological grief are becoming increasingly common. The aim of this study was to develop questionnaires to assess these psychological consequences, and to examine their relationship with pro-environmental behaviour. The developed questionnaires proved to be suitable to assess of a wide range of negative emotional states related to climate change and the ecological crisis. The results showed that pro-environmental behaviours were positively associated with eco-guilt, ecological grief and the two factors of eco-anxiety.

Fineberg, N. A., Menchón, J. M., Hall, N., Dell’Osso, B., Brand, M., Potenza, M. N., Chamberlain, S. R., Cirnigliaro, G., Lochner, C., Billieux, J., Demetrovics, Z., Rumpf, H. J., Müller, A., Castro-Calvo, J., Hollander, E., Burkauskas, J., Grünblatt, E., Walitza, S., Corazza, O., … Zohar, J. (2022). Advances in problematic usage of the internet research – A narrative review by experts from the European network for problematic usage of the internet. Comprehensive Psychiatry, 118, 152346. https://doi.org/10.1016/j.comppsych.2022.152346

This narrative review examines the scientific progress made in the understanding of problematic internet use (PUI) and the critical knowledge gaps remaining to be filled. Advances have been made in achieving consensus on the clinical definition of various forms of problematic internet use  and refining assessment instruments, but important gaps remain, including a better understanding of the course and evolution of problematic internet use -related problems, reliable methods for early identification of individuals at risk, and effective preventative and therapeutic interventions. The authors conclude with recommendations for achievable research goals.

Lukavská, K., Hrabec, O., Lukavský, J., Demetrovics, Z., & Király, O. (2022). The associations of adolescent problematic internet use with parenting: A meta-analysis. Addictive Behaviors, 135, 107423. https://doi.org/10.1016/j.addbeh.2022.107423

This meta-analysis examined the associations between adolescent problematic internet use (PIU) and general and media-specific parenting. The study found weak negative associations between PIU and general parenting, including warmth, control, and authoritative parenting, but no significant associations between PIU and media-specific parenting, such as active and restrictive mediation. The study suggests that media parenting has only weak association with PIU, and that restrictions should be used cautiously especially in the case of older adolescents, for whom they may even be counter-effective. . Further research on parenting and specific PIU activities is needed.