Adolescents and loot boxes: a systematic review of behavioral mechanisms and problematic outcomes.

This systematic review synthesizes empirical evidence on the associations between loot box engagement and adolescents' behavioral or psychological outcomes. Following the PRISMA guidelines, 26 empirical studies published between 2017 and 2025 were identified through comprehensive searches in PsycINFO, ERIC, Medline, Web of Science, Scopus, Ovid, PubMed, and ScienceDirect. Guided by the Stimulus-Organism-Response (S-O-R) model, the review categorizes findings into three domains: (1) external stimuli associated with exposure to loot boxes, (2) cognitive and habitual factors that mediate individual responses, and (3) behavioral outcomes related to problematic engagement. External stimuli interact with cognitive biases and habitual tendencies to shape adolescents' engagement patterns. Four hypothetical pathways are proposed: (1) The Gaming-Loot Box-Gambling Convergence Pathway; (2) The Multifactorial Pathway Influencing Loot Box Engagement; (3) The Moderating Pathway of Perceived Normative Pressure; and (4) The Feedback Loop Between Problematic Use and Cognitive-Behavioral Factors. The findings offer implications for prevention and youth protection in digital gaming contexts.