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Background and aimsLimited research has investigated how individuals' problem gaming affects significant others. The present study investigated the extent to which partners and parents were personally affected by their partner or child's problematic gaming behavior and what steps, if any, were taken in relation to treatment and other help-seeking by the gamers and the respondents themselves.MethodsTwo targeted samples (parents, n = 104; partners, n = 264) in Australia were recruited and administered an online survey. The survey assessed gaming-related harm across multiple domains, including financial, relationship, emotional wellbeing, physical health and work/study. Treatment and help-seeking questions referred to seeking psychological assistance, self-help, and community support. Non-parametric tests compared groups on harm measures based on GD status.ResultsParents and partners of individuals rated in the ‘problem gaming’ range reported significantly greater harms compared to those in the at-risk and non-problem categories. The most frequently endorsed harms were in the relationship domain, including neglected household responsibilities, withdrawal from social events, and relationship conflict. Some parents consult with friends and family (15%) to resolve their child's gaming-related problems. Partners reported to seek outside support and assistance for themselves, including 30% who sought a psychologist. No partners reported having consulted a psychologist for their gaming partner.DiscussionProblem gaming affects significant others across multiple life areas, but few seek outside help or support, suggesting there may be significant unmet needs.ConclusionsFurther research should examine factors that influence acceptance and engagement with problem gaming help options. Harm indicators may be useful for evaluating targeted interventions and other measures to reduce problem gaming.

Background and aimsIt is well understood that engagement with some forms of gambling, like EGMs, is riskier than other forms. However, while reports of associations are common, few studies have attempted to evaluate and compare the relative risk of all available forms, and none have estimated the relative contribution of each form to the total burden of gambling problems (GP) in a population.MethodsUsing an aggregated dataset of national and state-based prevalence studies in Australia (N = 71,103), we estimated prevalence and unique effects of frequency of engagement on each form on GP. Two alternative numerical methods were then applied to infer the relative contribution of each form to the total amount of GP.ResultsEGMs are responsible for 51%–57% of gambling problems in Australia, and 90% of gambling problems are attributable to EGMs, casino, race, and sports betting. Casino table games and EGMs are equally risky at the individual level, but the former contribute far less to problems due to low participation. Bingo and lottery play show no statistically detectable risk for GP.Discussion and conclusionThe results illustrate which forms present the greatest population burden and illuminate the reasons why. EGMs have an outsized impact. EGM uniquely combines high risk conditional on play, with a high participation rate and a high frequency of play among participants. This is in contrast to risky but less commonly played casino games, and prevalent but non-risky forms like lotteries. We conclude that EGM regulation should be a primary focus of policy action in Australia. More innovative policy ideas relating to EGMs should be tested due to the disproportionate impact of this product type.

Background and aims Play-to-earn (P2E) gaming is a newly emerging form of gaming increasingly based on blockchain technology. In this paper, we examine the mechanics and business model of these games and their potential benefits and risks for players. Methods The paper draws upon and critically synthesises the developing published literature on predatory monetization in gaming as well as objective market data drawn from credible online sources. Results P2E gaming blurs the boundaries between gaming and trading and may not yield many of the benefits promoted to consumers or otherwise conveyed through marketing and social media messaging. Particular risks include the deflationary nature of reward currencies and the asymmetric reward structures that heavily favour early investors and exploit late adopters. Discussion and conclusions This paper highlights the need for greater consumer awareness of the mechanics and risks of these new gaming models. It will be important for business models to be more transparent and designed so as to encourage more equitable game outcomes, sustainable returns, a balance between intrinsic and extrinsic rewards, and protection for potentially vulnerable players.

Although child wellbeing is known to be negatively affected by gambling, relatively little is known about the specific harms experienced by children exposed to parental gambling problems. The current study aimed to better understand gambling harm directly attributed to regular parental gambling in key areas of child wellbeing: financial, psychological, interpersonal wellbeing and intergenerational transmission of problem gambling. Using data from a national survey of Australian adults exposed to parental gambling under the age of 18 (n = 211), the results show that parental gambling was related significant levels of financial harm, abuse, neglect as well as relational and psychological problems as a direct result of parental gambling. The likelihood of experiencing gambling harms was positively associated with parental problem gambling severity. Harmful impacts of parental gambling as a child were also associated with a range of psychological problems in adulthood including depression, anxiety, Post-Traumatic Stress Disorder and intimate partner violence victimisation. Parental problem gambling severity was negatively associated with own lifetime gambling problems, suggesting a specific pattern of intergenerational transmission of problem gambling in children of regular, or heavy, gamblers. This research highlights the need for more supports for families with children in which at least one parent gambles regularly.

Many studies have been conducted to identify potentially useful behavioural markers of harmful behaviour using online gambling data sourced from operators. However, less is known about how such markers could be used to identify higher risk products. The study examined whether certain categories and subcategories of product are more strongly associated with behavioural markers of harm than others. Analyses were based on 6 months of data (N = 100,000 individual gamblers) drawn from the population of UK users of an online gambling website in 2022. Measures included individual-level expenditure data across multiple forms of gambling and a series of literature-informed behavioural markers of harm including declined deposits, easing/removing responsible gambling settings, within-session repeat deposits (or ‘top-ups’), bonus-seeking behaviour and gambling at unusual hours. Negative binomial models examined how well the number of active days playing different products predicted behavioural markers of harm. All markers apart from easing/removing responsible gambling settings appeared to covary with the number of active days engaging in specific product types, most notably slots, in-playing betting and some most forms of combination bets on sports. These findings highlight the potential value of using measurable markers to differentiate the risk and potential harm associated with different online products.

Stigma refers to the attribution of negative sentiments towards a particular entity, object or individual. Stigma can be public, perceived, or self-referential and can have negative consequences for individuals, including losses of self-esteem, self-efficacy, social isolation and a reluctance to seek help. Problem gambling is known to be a stigmatized activity, but less is known about what factors are associated with this perception and how it might vary in different countries. The current study examines the relationship between perceived stigma towards problem gamblers and gambling attitudes. perceptions of gambling regulations, gambling involvement, perceived accessibility to gambling, and exposure to people with gambling problems. The sample comprised 1787 university students aged 18–30 years from four countries: Australia, Canada, Croatia and Israel. The results indicated that greater perceived stigma was associated with more negative gambling attitudes, less engagement with gambling, and lower perceived social accessibility (the perception that others approve of the activity). Respondents from Croatia, the country with a newer gambling market, reported the most stigma towards problem gamblers as compared with Australia and Canada where gambling is longer established. The findings appear consistent with exposure–adaptation theory, in which tolerance towards people with problem gambling can develop over time in line with greater social acceptance or familiarity with the activity and its consequences. It is suggested that community campaigns and educational programs draw a distinction between attitudes towards gambling in general and those who are negatively affected by the activity.

Evidence suggests that harms may result from gambling participation as a result of a complex interaction between individual differences among consumers, environmental factors, and the characteristics of the gambling product. The latter of these factors, broadly referred to in this paper as product risk, has received increased policy attention in recent years. Product-focussed approaches to harm reduction, however, are under-developed relative to other forms of player protection and likely reflects the limitations of existing evidence and relative complexity of the topic. In this position paper, we define and explain the concept of product risk and consider what is currently known regarding the link between gambling products and harm. The paper describes the present barriers to develop effective product risk regulation and harm mitigation strategies. These include the competing interests of stakeholders, limited collaboration and information sharing, clear roles, responsibilities and leadership and a lack of integrated evidence-informed approaches. In response to these challenges, we propose adopting a framework comprised of a series of principles to progress this contested area of policy. The framework encourages better collaboration and communication between stakeholders; the accelerated production of valid and reliable evidence; a strategic alignment of stakeholder activity; and, more effective and efficient approaches to assessing and mitigating product risk.

Background and aimsPrevious studies have reported that stronger avatar identification and negative self-concept are associated with gaming disorder (GD). This study aimed to examine the value and significance of avatars based on firsthand accounts from regular and problematic gamers, and to identify any potential links between avatar-related experiences and excessive gaming.MethodsAn online survey of 993 adult gamers yielded 3,972 text responses. Qualitative analysis of 59,059 words extracted 10 categories of avatar-related perspectives.ResultsSome problem and non-problem gamers employed sentimental language (e.g., ‘dear friend’, ‘like a child’, ‘part of my soul’) to refer to their avatar. However, most participants perceived avatars as a means of achieving in-game goals and enabling greater interactivity (e.g., socializing). When asked to reflect on hypothetically losing their avatar, participants generally anticipated feeling temporary frustration or annoyance due to lost time and effort invested into the avatar. Although some participants reported that their avatar ‘mattered’, avatars were often considered as superficial (‘just pixels’) and peripheral to the primary reinforcement of achieving in-game rewards and objectives. Some broader psychological and identity issues such as gender dysphoria, rather than ‘addiction’, were cited as motivating persistent avatar-related interactions and attachment.Discussion and conclusionsParticipants reported diverse views on the psychological value and function of avatars, but the relationship between avatars and problematic gaming or GD was largely unclear or inconsistent, and refuted by some participants. Future research with clinical samples may lead to a better understanding of player-avatar processes, including whether avatar-stimuli facilitate the development of maladaptive gaming habits, particularly among psychologically vulnerable players. Future investigations should be mindful of ‘overpathologizing’ avatar-related phenomena and recognize their important role in socializing, storytelling, and creative expression among gamers.

Countries with public policies that support gambling through gambling legislation foster an environment in which gambling is socially accepted, tacitly encouraged and actively promoted. Although gambling worldwide has features in common, countries differ in terms of the nature of their gambling markets. The current study examined the role of perceived gambling accessibility in gambling behaviors and problem gambling in four different countries: Australia, Canada, Croatia and Israel. A convenience sample comprised 1787 university students aged 18–30. Gambling behaviors and problems were found to be more prevalent and gambling was perceived to be more accessible in liberalized markets (e.g. Australia, Canada, and Croatia) as compared to Israel which is relatively more conservative and has more restrictive regulations. Social accessibility was perceived to be higher in those who gambled and associated with higher risk gambling, especially for women. The study highlights the potentially important role of social normalization of gambling and how supply variations can influence perceptions as well as impact gambling behavior.

The specific nature of harm and functional impairment in the context of gaming disorder (GD) has received limited attention. In this study, we present one of the first concerted attempts to measure the types and degree of harm experienced by people displaying signs of problem gaming. Attempts were made to assess the extent to which types of harm were attributable to gaming as opposed to other factors. The study also investigated potential behavioural indicators of harmful involvement, including exposure to loot boxes. A sample of 471 regular gamers (M = 380, F = 73), recruited through the online platform Prolific, completed a survey where problem gaming was identified using Petry et al.'s (2014) checklist. Individuals who met the cut-off for gaming disorder scored higher than the non-problem group on most dimensions of harm, with physical and psychological types being the most common issues. Loot box expenditure was low (M = $25 in 3 months, for the 10.8% of respondents who played loot boxes) but significantly positively associated with the degree of gaming-related financial harm. This study shows that problem gaming is most strongly associated with physical or psychological harm and that financial harms may manifest in gaming activities that facilitate continuous spending options.

Conspiracy Theories (CT) are complex belief systems that view the world as being manipulated by multiple actors collaborating in the pursuit of malevolent goals. Although culture, education and sociological factors have been implicated in their development, psychological factors are recognized as important. Certain individual differences, including schizotypy and cognitive processing style, have been shown to make some individuals susceptible to CTs. However, the finding that schizotypy often co-occurs with autism spectrum disorder raises a question as to the relative and potentially confounding role of autistic traits in increasing vulnerability to CT beliefs.A total of 508 adults were recruited from an international online panel. The study included measures of conspiracy beliefs, schizotypy and autistic traits as well as measures of information searching and cognitive style.The results confirmed that both autistic and schizotypy traits were positively associated with CT beliefs, but that schizotypy traits were the strongest predictor. Exploratory analyses of cognitive style measures indicated potential avenues for further investigation in relation in differences in cognitive processes that might underlie the development of CTs for in people with autistic traits as opposed to schizotypal traits.The study was based on a self-report methodology and did not utilise a clinical sample.Both schizotypal and autistic traits are reliable predictors of conspiracy beliefs, but schizotypy appears to be the stronger predictor and that autistic traits are not a strong confounding factor in this relationship. However, autistic traits may pose an additional risk factor for CT beliefs.

Psychosocial problems arising from excessive gaming are a public health issue across the developed world. In its most serious form, problematic gaming is recognized as gaming disorder (GD) in the ICD-11. Research has tended to focus on the value of outpatient treatment for GD, but less attention has been paid to broader prevention strategies to address less serious but nevertheless harmful gaming behaviors. Another gap in this literature has been the lack of involvement of the gaming community as stakeholders to identify feasible prevention approaches. This study investigated: (1) regular and problematic gamers’ level of support for different prevention strategies within primary, secondary, and tertiary approaches; and, (2) whether self-efficacy is associated with greater support for prevention strategies, as predicted by the Health Belief Model. A total of 992 participants completed an online survey that evaluated support for problem gaming prevention strategies and included measures of self-efficacy, gaming involvement, and GD symptoms, psychological distress, and mental health help-seeking behaviors. Participants reported stronger support for primary prevention strategies, including education, screening, and warning labels, than for other prevention approaches. Overall, 61% of participants expressed support for primary prevention as compared to secondary (39%) and tertiary (36%) approaches. There was stronger support for outpatient care (48%) than inpatient services (25%). In-game shutdown features received the lowest support (65% disapproval). Contrary to the Health Belief Model, self-efficacy was not associated with prevention support. Younger, female, and less frequent gamers were more likely to support primary and secondary prevention strategies. These findings suggest that gamers may be more favorable toward prevention measures aligned with informed decision-making, autonomy, and self-directed actions. Gamers may be strongly opposed to modifications to the structure of gaming activities (e.g., shutdown features). Future research should evaluate the efficacy and cost-effectiveness of problem gaming prevention measures in different populations and regions.

A common assumption in many public frameworks is that the harms and behavioural risk factors associated with gambling disorder lie on a continuum. At one end is lower risk or recreational gambling, and at the other, problem or disordered gambling. Movements along this continuum are associated with gradual increases or decreases in the level of behaviour and associated harm. This perspective is often advanced in opposition to more clinical or categorical frameworks that view problem gambling as a distinct clinical category from the other groups. In this paper, we investigate these competing perspectives with reference to 15 years of Australian prevalence studies. We examine the relationship between PGSI severity classifications and the endorsement of the principal criteria of the DSM-5 (e.g. tolerance, chasing, impaired control). The results showed that while elements of behavioural dependence increase across the PGSI categories (low to moderate to problem), problem gamblers have disproportionately greater endorsement. The PGSI severity and behavioural dependence relationship corresponds more strongly to a J-curve than a linear or r-curve and therefore lends greater support of a more categorical conceptualisation of the disorder.

Volatility refers to the variability of bet outcomes in gambling and has been recognized as a potentially important influence on behavior. The research literature has developed competing ideas for ...

This article suggests that the type of Internet-enabled device should not be prioritised when conceptualizing diagnostic categories of addictive online behaviours. The diagnostic distinction between “predominantly mobile” and “predominantly non-mobile” forms of Internet use disorders (IUD) is not empirically based, may not be clinically useful and may lead to “diagnostic inflation.” Problems with the concepts of smartphone use disorder and IUD on which the proposed distinction is largely based call for their re-examination. Future proposals for the taxonomy of addictive behaviours may not need to be based on online/offline and mobile/non-mobile dichotomies.

Pre-commitment and limit-setting schemes have been widely discussed as potentially useful responsible gambling tools to minimize the financial harm associated with excessive gambling. Such systems ...

Most public surveys indicate that people generally hold negative attitudes toward gambling which is considered harmful, too prevalent and not sufficiently regulated by the authorities. Despite this...

In recent years, there has been an increase in advocacy and social media activism in the field of gambling studies. Much of the focus of this activity has been directed toward concern about the lac...

Similarities between video-games and gambling have led to the proposition that video-gaming could act as a ‘gateway’ activity for gambling. In this paper, we review the major lines of evidence adva...

Participation in electronic gaming machine (EGM) gambling has declined sharply in Australia over the last two decades. At the same time, there has been a gradual slowing and decline in revenue from this form of gambling. In this paper, we use data drawn from a series of population surveys in a single jurisdiction (South Australia) to gain insights into these changes. In particular, we examine whether changes in EGM participation have been reflected similarly in different demographic groups. The results indicate that there have been declines in every age group, in both men and women, and at different levels of household income. However, the decline has been greater in some groups than others, including for women, for middle aged groups (46–64 years), and for those living in the metropolitan area. The paper discusses some of the socio-demographic explanations for these changes. In particular, we highlight the role of population ageing and its potential implications for the long-term future for this form of gambling. EGM gamblers are now older and are not necessarily being replaced by a new generation of younger gamblers, which has implications for the industry and the State government finances as well as gambling-treatment services. At the same time, the evidence we present here does not, however, indicate a strong trend towards a concentration of EGM gambling in more vulnerable groups (e.g. disproportionately in lower income groups or the unemployed).

Many governments around the world have adopted a public health (PH) approach as a framework to minimise, reduce or prevent gambling-related harm. In principle, this appears very sensible given the success of PH approaches in other areas of society: in disease control, nutrition, physical exercise and reductions in smoking. In this paper, we examine the challenges that are faced in applying PH principles to gambling. We argue that gambling is a difficult activity to address because of the highly skewed distribution of severity that makes PH interventions seem less relevant for the majority and difficult to apply to the complex minority. In our view, gambling harm can really only be reduced by changing the behaviour of individuals, and this objective is very much informed by the principles and practices of ‘individual-focused disciplines’ including psychology, social work and the medical sciences. Greater evidence and evaluation are needed to demonstrate how the ‘whole of population’ approaches advocated by PH are superior than ecological, individual-focused or responsible gambling approaches to reduce gambling-related harm.

An important consequence of adoption of public health approaches in the field of gambling studies has been the increasing emphasis afforded to gambling harm. Reducing or eliminating harm has now become the overt stated mission of many government foundations and funding bodies. A by-product of these developments has been the gradual reduction of references to terms capturing the nature of the primary disorder (problem or pathological gambling or gambling disorder) in preference for what are considered to be more neutral or less ‘stigmatising’ terms (e.g. ‘people with gambling harm’). In this paper, we argue that this conflation of gambling harm with the disorder is misguided. Not only does it fail to acknowledge the validity of the disorder but it is also unjustified by evidence and may have unintended negative consequences for both people affected by gambling and the field more generally. In particular, we focus on the clinical and legal advantages of adherence to an individual-centred, pathology model of gambling disorder.

Aim Critics of gaming disorder (GD; i.e., Internet gaming disorder in the DSM-5; Gaming disorder in the ICD-11) have expressed concerns about the potential risks of misclassification (e.g., false positives). An important consideration of relevance to this discussion is the extent to which commonly used screening instruments contain appropriate, sensible, and relevant items. The aim of this review was to evaluate the face validity of items within current tools for GD. Methods A systematic review of databases identified 29 instruments. An item bank (n = 417 items) was independently evaluated by three professional raters (i.e., a senior academic in clinical psychology, a senior psychometrician, and an academic/clinical psychologist) according to guidelines for defining and measuring addiction and gaming disorder. Findings Evaluation of the item bank identified issues related to: scope (i.e., “scope creep” or items of questionable relevance); language (i.e., confusing language, unusual wording or syntax); and overpathologizing (i.e., pathologizing typical and/or beneficial aspects or consequences of gaming). A total of 71 items across 23 tools had at least one face validity issue. Conclusions Most items (83%) demonstrated satisfactory face validity and were consistent with either the DSM-5 or ICD-11 GD classification. However, many tests contain at least one item that may pathologize normal gaming behaviors. Such items refer to basic changes in mood when gaming, a desire to play or continue playing games, and experiencing immersion when gaming. This analysis highlights the challenges of screening for problematic behaviors that are thought to arise within the context of normal recreational activities.

A recent innovation contributing to the massive growth and profitability of the gaming industry has been the development of in-game monetisation. In-game purchasing features (e.g. ‘loot boxes’, ‘skins’, and other microtransactions) have also generated debate in some jurisdictions as to whether some activities constitute a form of gambling. This brief review presents some academic perspectives and recent studies that have examined the validity of this claim. Evidence has focused on the nature of micro-transaction purchase behaviour, its similarity with gambling, parallel involvement in gambling, and its association with problematic gaming. Early evidence suggests that higher levels of involvement in monetised gaming activities may be associated with symptoms of problematic gaming or gambling.

Although most people gamble safely, national prevalence rates indicate that approximately 0.2 to 1% of the Australian population experience problems with gambling. An issue that has not been extensively researched in Australia is whether the nature of gambling, and the associated harms is consistently observed across the nation. In particular, are there are differences between metropolitan and rural areas in people’s experiences with gambling and the associated impacts? A qualitative study involving interviews with 10 help-seekers affected by problem gambling examined the nature of gambling in rural and remote areas and the potential barriers and challenges associated with help-seeking. Particular issues relevant to rural gamblers that set them apart from metropolitan gamblers were: limitations in leisure choices in rural areas; the problem of social familiarity in relation to anonymous help-seeking; and the dearth of specialized services. This study highlights the need to consider the role of rural-specific barriers, motivating and protective factors in developing service delivery models and specialized interventions for problem gambling in rural and remote communities.

Although digital media use confers many personal and social benefits, it is recognized that unrestricted and habitual use can have major negative health consequences, particularly for young people. Problematic gaming in its most serious form, for example, is recognized as an addictive disorder by the World Health Organization. In recent years, there have been calls from researchers and clinicians to also recognize problematic use of a range of online activities (e.g., social media, online shopping, pornography) in mental disorder classification systems, including the DSM-5 and ICD-11. There are continuing debates on the nature and prevalence of these potential conditions in the general population and in special populations (e.g., adolescents, individuals with preexisting disorders). At the same time, some jurisdictions have introduced various public health measures to attempt to respond to these problems. One of the larger areas of literature on interventions has been the study of treatments for gaming disorder, notably cognitive-behavioral therapies. In East Asia in particular, there have been broad prevention measures introduced to address less serious but nevertheless harmful digital technology use. This chapter will review and discuss the literature on interventions for digital technology-based problems, recognizing that the optimal approach to these problems may often entail the coordinated efforts of different areas of influence ranging from families and peers, schools, health providers, government bodies, and the industries that provide online content.

Gambling behaviour is likely to be strongly influenced by operant learning principles. Most forms of gambling, and most notably slot machine play, follow a random ratio (RR) schedule of reinforcement that should lead to rapid and extinction-resistant behaviour. In this paper we highlight the caveats that need to be applied when generalising animal models of learning to human behaviour. Studies need to be cognisant of the role of verbal rules and cognitive appraisals of contingency; the ability for participants to self-modify important elements of reward schedules; potential differences between concurrent and longitudinal schedule preferences; and, the role of important human motivations in financial decision-making. In particular, we believe that operant approaches to gambling may need to incorporate a greater focus on FOMO (or the fear of missing out) as a motivational construct that may explain some of the observed patterns of behaviour, including riskier behaviours, on slot games. The implications of these observations for future research and harm minimisation are discussed.

Video games as a consumer product have changed significantly with the advent of in-game purchasing systems (e.g., microtransactions, ‘loot boxes’). This review examines consumer protections related to in-game purchasing by anticipating some of the potential design strategies that might contribute to higher risk consumer behavior. Attention was directed towards the analysis of patents for potential in-game purchasing systems, with 13 identified on Google Patents. The design features were analysed in relation to the consumer rights and guarantees described in the terms of use agreements of the patent assignees. The analysis revealed that some in-game purchasing systems could be characterized as unfair or exploitative. These systems describe tactics that capitalize on informational advantages (e.g., behavioral tracking) and data manipulation (e.g., price manipulation) to optimize offers to incentivize continuous spending, while offering limited or no guarantees or protections (e.g., refund entitlement), with the potential to exploit vulnerable players (e.g., adolescents, problematic gamers). These findings are critically discussed in relation to behavioral economics, addiction psychology, and the clinical conceptualization of gaming disorder. Appropriate policy and consumer protection measures, psychologically informed interventions, and ethical game design guidelines are needed in order to protect the interests and wellbeing of consumers. This work received financial support from a Discovery Early Career Researcher Award (DECRA) funded by the Australian Research Council (Project ID: DE170101198).

Background. There is currently considerable public policy and regulatory interest in the nature and prevalence of underage gambling. Research in this area has purported to show that adolescents are at elevated risk of problem gambling and that early exposure to gambling or gambling-like activities could be a potential precursor to future harm. Method. In this commentary, we provide a critical appraisal of these arguments with reference to major studies in the field of gambling studies. It is argued that adolescent gambling research is a contentious area. Some questions remain concerning the validity of adolescent problem gambling measures, the strength of the association between adolescent and adult gambling and the impact of simulated gambling activities. Results. The paper summarises the conceptual and methodological issues that should be considered and addressed in future studies to strengthen the validity of research in this area. Conclusion. The paper encourages the greater use of harm-based measures, longitudinal and individual-level transition analyses and questions that capture the influence of activities rather than just their temporal sequencing.