Parents’ and Children’s Experiences of Participation in the Family Centered Program for Problematic Gaming and Excessive Screen Use in Child and Adolescent Population

Altogether, seven families, in some cases with several children and both parents, were included in the pilot-FAME program. Specifically, eleven children, nine boys and two girls (12–17 years) were included, however after dropping out of three boys, the final participating number of children in the program was eight: six boys (75%) and two girls (25%) (Table 1). Every participating child had at least one parent involved in the program, totaling eleven parents. Some parents had multiple children participating. Four parents dropped out of the program: three were parents of children who also dropped out, and one was a parent from a family where both parents participated; the other parent and their child remained in the program. The total number of participating parents in the pilot-FAME were six: one father (17%) and five mothers (83%) which finally constitutes five participating families in the program (Table 2). All children and parents included in the pilot-FAME, were asked to participate in the current study. As shown in Table 1 and 2, eight children, all completers of the pilot-FAME, agreed to participate, whereas eleven parents, thus both dropouts and completers, agreed to participate in the study.

The children and parents were invited to participate in this sub study at the last session of the pilot-FAME program. Dropouts were invited through a phone call. Participants received comprehensive information about the study through both written materials and verbal explanations. They were given the opportunity to ask questions about the interview process before providing informed consent to participate. If a child wanted to participate, the parents also needed to provide their written consent. Upon agreeing to participate in the interview, participants received an email confirming the scheduled interview time and location. The interviews were conducted in a semi-structured format, designed to maintain a balance between flexibility and structure. This approach facilitated in-depth exploration of individual participants’ perspectives while maintaining consistency across the interviews (22). The interview guide covered topics related to the participants' experiences with the pilot-FAME program. Key areas included participation frequency and barriers, program evaluation and feedback, the meaningfulness of the program, and additional reflections. The participants were given the freedom to withdraw from the study at any point.

The interviews, conducted by SW and ECK, who had no role in program delivery, took place via in-person meetings, telephone, or video calls. With participants' consent, interviews were recorded to ensure accuracy, facilitating transcription and analysis. The duration of the interviews was within the range of fifteen to thirty minutes, allowing sufficient time for participants to share their experiences. The interviews were conducted and transcribed in Swedish and later translated into English. The study adhered to the ethical standards set forth in the Declaration of Helsinki and received approval from the Swedish Ethical Review Authority on 08/11/2023 (EPN/DNr 2023-05533-01).

Reflexive Thematic Analysis (RTA) (23, 24), widely recognized for its robustness and adaptability in qualitative research, was employed to analyze the data. RTA enables researchers to identify, analyze and report patterns (themes) within the data, providing rich and detailed insights. Moreover, such an approach to data analysis combines systematic precision with the flexibility required to capture the complexity and depth of participants’ experiences and perspectives (25, 26). Based on the recommendations from Braun and Clarke (24) and other scholars (26) we conducted the analyses in the following steps: 1) we read and re-read the transcriptions which allowed us to familiarize with the data; 2) we systematically identified the initial codes and labelled data segments that appeared meaningful; 3) we organized the codes systematically into themes; 4) we reviewed, ensuring their alignment with the coded extracts and the entire dataset; 5) we defined and refined these themes further, ensuring they had clear definitions and names that encapsulated the essence of each theme; 6) we reported the findings, making sure to weave together the themes to construct a coherent and compelling narrative about the data. It should be noted that the analysis was at first conducted separately for the two groups, thus parent and child data independently. Upon observing that the codes and themes aligned across the groups, we proceeded to analyze the data collectively (see Supplementary file for codes and themes).

To minimize the risk of influence of individual researcher bias (26, 27), the analysis was conducted by a team of three researchers (SW, SK and MW), each with different perspectives and varying degrees of involvement. Moreover, as an integral part of the RTA, we have tried to maintain reflexivity throughout the analysis, examining how our own potential biases and assumptions, could have shaped the interpretation of the data. Through collaborative analysis and ongoing dialogue, we aimed to enhance the credibility and trustworthiness of the findings (28).

Two themes related to the second research question representing suggestions for improvement from the children and parents on the pilot-FAME program: Theme 1. Program delivery, including two sub-themes: Interaction with each other and Customization of program delivery and structure; and Theme 2. Content development, including two sub-themes: Refining program structure for enhanced learning, and Homework.

Overall, the interviewed children and parents expressed a generally positive attitude toward the program content and format. The program structure provided opportunities for discussion, which was appreciated especially by children. Likewise, the parents valued the group sessions for the peer support they offered, allowing them to help each other by sharing their own experiences. The interactive format not only facilitated group dialogue but also encouraged the participants to reflect on their own behavior, offering them new perspectives and deeper self-reflection. Such peer support in group settings has been shown to enhance the coping mechanisms of participants, providing emotional support and practical advice through shared experiences (30). Additionally, the interactive nature of these sessions can promote a sense of community and belonging, which is crucial for effective group therapy (31). However, the children expressed some initial difficulty in starting discussions, due to shyness and the group dynamics. Over time, as they became more comfortable with the group, these barriers diminished, allowing for more open and productive discussions. The findings from the data are in line with previous research in the field and support the assumption that group-based treatment can be helpful for adolescents (32). Although the literature is not clear on why the group format could be helpful (33), the findings of the current study can contribute to an increased understanding of what may constitute effective program components in group-based interventions for adolescents.

Furthermore, most participating children and parents responded positively regarding the session themes, considering them well selected and relevant. The session themes introduced new knowledge about emotions, communication and conflict management. This newfound understanding led to an increased self-reflection prompting the children to contemplate what is truly important in their lives. The manual's themes combined CBT-based strategies with systemic family interventions. By combining these two approaches, it is likely that participants received a combination of intra- and interpersonal strategies that were perceived as helpful by both children and their parents (16).

There was some criticism toward the program, particularly by the parents. Specifically, some parents felt that their situations were either less severe or more severe than the program’s focus. This raised concerns about the accuracy and appropriateness of the program for all participants. In line with other intervention research (34), our findings highlight the importance of clearly defining the groups based on age, the severity of the PG or ESU, and previous treatment attempts to ensure that the program meets the diverse needs of the participants. In addition, it appears that some of the participants experienced that their expectations were not fully met, which poses challenges in terms of feasibility of the program. Specifically, some parents felt marginalized within the program’s scope experiencing disparities in the levels of psychoeducational support received in their previous contact with social services or health care. A subset of parents expressed dissatisfaction with inadequate learning opportunities, finding the program repetitive and desiring more specific knowledge, particularly clearer guidelines on screen use. These observations underscore a misalignment between parental expectations and the program’s goals. Similar findings appeared in a study with parents of children who had undergone individual treatment for PG (19) where parents expected concrete and practical advice regarding their child's PG. If such an expectation was not met by the clinician, parental dissatisfaction arose. The results from the current study, together with results from previous studies, can help to illuminate and further understand the expectations that parents carry with them when they contact the healthcare system for support for their child.

Addressing the second research question, the interviewed children and parents participating in the pilot-FAME shared numerous ideas for improvement of the program. They expressed a desire for more discussions, more peer support, learning opportunities and time for reflection. As suggested by the participants, extending the program’s duration would allow for more discussions and sharing experiences. Indeed, a longer program could help to sustain the participants motivation for change and reduce the risk of reverting to old habits once the program concludes. Moreover, it is also possible that a longer duration of the program would give the families more time to apply and internalize the new methods introduced by the program. In response to the desire for longer treatment, it can be noted that longer treatment programs have been evaluated for this patient group. These are primarily based on CBT models with varying intervention focus (35). The evaluated models are often quite extensive (8–15 sessions) (36, 37) and therefore risk becoming too exclusive to be offered widely. A question for future studies is whether it is possible to offer a shorter but still helpful intervention that also meets the expectations of parents and children.

Lastly, the children suggested incorporating brevity, regular breaks and a recap at the end of each session. This was suggested because the children sometimes had difficulty focusing, primarily due to the leaders talking for extended periods of time and only having one break during the entire ninety-minute sessions. To address this, the program could include more active discussions among the participants as well as incorporate more breaks in order to help the children maintain focus in the intervention (38). A recap at the end of each session could also be beneficial, ensuring that children who may have missed a part of a session still can keep up.

There are some noteworthy limitations to this study. First, we invited both program dropouts as well as participants who completed the program to gain valuable insights. This decision was made to gain a broader range of lived perspectives about the program. However, while we managed to interview the parents who did not complete the program, no child dropouts participated in the interviews which may have bearing on the depth of our understanding and the further development of the program. On the other hand, the interviews with parent dropouts may have influenced the results, as these parents tended to offer more criticism (60% of negative answers) and less positive feedback (34% of positive answers) compared to those who completed the program.

Furthermore, there was a predominance of boys and their mothers participating in the study. This gender imbalance could potentially influence the results, as different genders may have varied overall needs and priorities affecting their satisfaction with the program. Additionally, the gender composition in the program could impact the group dynamics, potentially making it more challenging or easier for individuals of the minority gender to participate in discussions. Next, most families primarily expressed gaming-related problems, leading to a treatment focus on that issue and potentially biasing the evaluation towards gaming-related concerns.

As in many self-report and interview studies, there is a risk of response bias, as participants’ answers might reflect what they believed was expected rather than their true opinions. To mitigate this, we created a comfortable setting and emphasized the importance of honest feedback for program improvement. Finally, while our design provides in-depth insight from the participants’ perspective on the FAME program, our findings may not be generalizable to other programs with the same target group. Despite the above-mentioned limitations, the findings can be used to advance the development of preventive efforts relating to families experiencing challenges relating to their child PG and ESU.

The results demonstrate that the program format successfully facilitated participant discussion and peer support, which was valued by both parents and children. Additionally, the families achieved personal and familial improvements during the program, even though some of the participants noted inadequate learning opportunities with unclear recommendations about screen use which tempered their enthusiasm for the program. Participants suggested extending the program slightly to accommodate new learning opportunities and possibilities to engage in discussions. Overall, these implications suggest that future iterations of the program should maintain successful elements while addressing areas for improvement to better meet the needs and expectations of participants.

For child and youth clinics, as well as other services providing care for families with children, these results emphasize the necessity of incorporating family dynamics into treatment and preventive program plans and tailoring interventions to address the diverse needs of both parents and children. By integrating these findings, professionals can develop more comprehensive and effective strategies to support healthy screen habits and improve family relationships, ultimately contributing to better developmental outcomes for children and adolescents.