Some doctors too reassuring about seizure risk

Howcast's video, "What Is Photosensitive Epilepsy (PSE)?"

The Howcast video, “What Is Photosensitive Epilepsy (PSE)?” is apparently designed to be upbeat and reassuring to families worried about video games.

You know how you’re not supposed to trust all the medical information on the Internet? Very true, and sometimes it’s actually the medical professionals who are placing material online that is oversimplified to the point of being misleading.

Trying to explain photosensitive epilepsy in a video of a minute and a half is pretty tough, and a Howcast clip that attempts to do that is just full of statements that make me very uncomfortable. It’s one of a series of videos on different aspects of epilepsy, but the presenters, despite their epilepsy expertise, aren’t necessarily experts in the specialty of photosensitivity. Photosensitive seizures are considered so out of the mainstream of epilepsy that few epilepsy specialists know a great deal about them.

The video in question, uploaded a year ago, features a pediatric epilepsy nurse and the Director of Pediatric Epilepsy at highly respected hospitals in New York City. My own qualifications for assessing the content of their video are found here.  I’m quite certain that I’ve read more of the research on photosensitive epilepsy and seizures triggered by video games than anyone on the planet who isn’t a photosensitive epilepsy specialist. There are very, very few photosensitivity experts in the US.

This video downplays the overall prevalence/likelihood of photosensitive seizures, and it doesn’t address photosensitivity in people with no other seizures. And it overstates the conclusiveness of EEG for identifying seizure activity. Epilepsy clinicians and advocacy groups tend to want to reassure young patients and their families that in the vast majority of cases, video games and other flash-filled leisure pursuits don’t pose a seizure risk. While it’s good to encourage patients to live lives that are as normal as possible, the oversimplified message promotes the view that photosensitive epilepsy is quite rare and that doctors can know for sure, based on EEG testing, whether an individual should worry about video games as a seizure risk.

If you want to watch the video, please come back here to read my responses to what’s in it! Here’s a transcript with my comments in blue.

————————————————————————————————————————————————————————————————————-Nurse: “You know, whenever anybody comes into the office, they always ask us first thing whether epilepsy can be triggered by strobe lights, and people often think back to when the first Pokemon movies came out and all those children in Japan seized during the movies. So photosensitive epilepsy is something people worry about all the time.”

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Two issues here:

1) Epilepsy is a condition that makes people vulnerable to seizures. It’s the seizures that are triggered; the epilepsy condition already exists. Why take issue with such a seemingly minor point? Being less than careful in how she worded things allowed a doctor in a WebMD video to incorrectly reassure viewers that video games cannot cause seizures!

2) The problem is much bigger than the population of epilepsy patients who come in to be evaluated by neurologists–people with no seizure history may develop photosensitive epilepsy (for example, the Navy pilot who can’t ever fly again after having a grand mal seizure while playing Oblivion: The Elder Scrolls IV). The general public, though–which presumably is the audience for this video–doesn’t worry enough about it. The epilepsy community should be doing more outreach to the general public to let them know they could be at risk.

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Doctor: “On all the video games there’s those warnings that say, you know, you shouldn’t play this game in case you have epilepsy. But only one specific type of epilepsy has photosensitivity to it, and that’s a generalized epilepsy, that’s when the whole brain turns on all at once–“

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This is what neurologists believed in the past.  But numerous studies in the last 20+ years show this is not the case. A 1994 paper that included a review of other studies concluded that about 30 percent of photosensitive seizures are partial seizures—which do not involve the whole brain. The doctor’s statement could lead viewers to think that only people with generalized (typically grand mal) seizures need to worry about photosensitivity.

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Nurse:…”lights up all at once, there’s a big burst of electricity through the whole brain. It’s one of the reflex epilepsies, so kids for the most part with epilepsy can play video games and can go under strobe lights unless they very specifically seize when they’re under strobe lights, and when we do the EEGs, we do the tests of their brain waves, we actually flash lights at them to see if it does create a seizure.”

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The intermittent photic stimulation procedure used during EEG measures the brain’s reaction to a strobe light. The effect of a strobe light on the brain is not equal to the effect of playing a fast-moving, flashing video game. Some people who don’t respond to the strobe light can have seizures in response to video games or other visual stimuli. Studies of video game seizures frequently include individuals who experience seizures from games but do not test positive for photosensitivity. Photosensitive epilepsy in the research literature describes epileptic discharges on EEG in response to a strobe light in a laboratory. Some studies discuss non-photosensitive video game seizures: people who have the seizures even though a strobe light doesn’t produce signs of epilepsy on an EEG.  

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Doctor: “So by doing the EEG and flashing the lights in the child’s eyes, and having the EEG run at the same time, we can conclusively tell families whether the children can play video games or not play video games, and that will make a child very happy, hopefully finding out that it’s perfectly safe to play the video games and that they don’t have photosensitive epilepsy.”

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EEG doesn’t conclusively rule out any type of seizure! It can confirm seizures but cannot rule them out since the technology does not detect all seizure activity. Some people who have seizures have normal EEGs. Oddly enough, in another video, What’s the Difference between Seizures and Epilepsy?” featuring the same clinicians in the same Howcast series, they contradict their statements in the first video, conceding that some seizures are too located too deep inside the brain to be detectable by EEG on the scalp.  

7/19/2014 update: See information on a study showing just 6.2 percent of patients with visually induced seizures tested positive for photosensitivity in the photic stimulation EEG procedure.

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Nurse: “As well as the teenagers and the young adults who will call or text and say, “Can I go–we’re going to a party and I know there’s going to be strobe lights. Is that OK?” So at least we have an answer for them after we’ve done the initial EEG.

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Photosensitive epilepsy is a genetic trait that is dormant until it becomes activated by a combination of factors. The most common time for the disorder to emerge is in adolescence. Thus a child who shows no signs of photosensitivity (again, based on testing with strobe lights, not video games) may later experience photosensitive seizures.

We need epilepsy clinicians and advocacy organizations to:

  • be more concerned about the many visual stimuli in our environment that can trigger seizures
  • think more broadly about who may be at risk–including members of the public who have no other seizures
  • convey their concern about hazardous visual stimuli to the public, the digital entertainment industry, and lawmakers
  • push for public policy changes that will rein in the stimuli and reduce the occurrence of visually triggered seizures.
  • question reliance on EEG and photic stimulation to diagnose vulnerability to visually induced seizures

It’s a big job. It’s a much bigger undertaking than I can even imagine, but it needs to be done.


“Problematic” gaming higher in autism, ADHD

Boy video Game autisticA study released today in the journal Pediatrics confirms what a lot of parents have already figured out: kids with autism spectrum disorders (ASD) and kids with ADHD spend much more time playing video games than typically developing peers and “may be at particularly high risk for significant problems related to video game play, including excessive and problematic video game use.”  Only boys participated in the study merely because both disorders are diagnosed more frequently in boys–there is no reason to expect the results would be any different if girls were included.

The study notes that in the general population, long-term. excessive video game use can have a variety of detrimental effects. “Although longitudinal research [collecting data on a group of subjects over an extended time] is needed to examine the outcomes of problematic video game use in these special populations…the current findings indicate a need for heightened awareness and assessment of problematic video game use in clinical care settings for children with ASD and ADHD.” Of course, many kids start playing video games before they are diagnosed with ASD or ADHD, so maybe the heightened awareness and assessment should extend to all kids?

Well, this is a first step, to compare, as this study did, behavioral characteristics and game usage of neurotypical kids against kids with ASD and ADHD. The problem with these studies is that all they can point to is associations between behaviors and game use in the three cohorts. No causality. There’s an association between attention problems and problematic video game use, which means the attention problems could already exist or could be the result of game use (or both, probably). The study calls for longitudinal studies (following the participants over a long period of time) “to examine the long-term effects of screen-based media use in children with ASD.”

Without waiting for the results of a longitudinal study, researchers could find out pretty quickly how the brain responds to video games in kids with ASD and ADHD and in neurotypical peers. Hook up all three groups to an EEG while they play, note the differences in the way their brains react. Track brain activity when they aren’t playing, and compare it to their activity in front of a game. This provides the opportunity to show causality. Despite the drawbacks of EEG, it’s the most practical tool for this type of study.

I’m willing to bet that the rate of seizures (especially the kind you can’t see) detected during playing is higher in the ASD and ADHD kids. The seizures and seizure-like abnormalities in brain waves have an immediate effect on cognitive function (including attention/focus)and behavior. Inability to focus is a very common post-seizure symptom, and it can last for a day or two after a seizure.  A child who plays video games often and who has this sort of neurological response to video games may therefore exhibit inability to pay attention and other behavioral difficulties all the time.

I’m still eager to have researchers take up the pilot study I proposed a few years ago that looks at the EEGs of ASD kids and neurotypical kids, both at rest and while playing video games. In the meantime, whether or not the studies are telling us something totally new, if they encourage parents to think more carefully about their children’s gaming habits and question possible links to behavior issues, that’s a good thing.


David Lynch music video: 70 safety violations

This warning is shown briefly before the video begins showing an onslaught of flashing images.

This warning is shown briefly before the video begins showing an onslaught of flashing images. This is just a screen shot, not the video itself.

David Lynch’s just-released music video for Nine Inch Nails’ “Came Back Haunted” provides more than 4 minutes of nearly constant seizure-provoking flashes and images. When analyzed for seizure safety, the video fails in 70 instances to adhere to international safety guidelines for flash, including the intermittent use of saturated red images.

Before the barrage of flashes begins, the official release on the Vevo music video website is accompanied by the following message: “WARNING: This video has been identified by Epilepsy Action to potentially trigger seizures for people with photosensitive epilepsy. Viewer discretion is advised.”

Two very big problems with this:

1. There’s a disturbing, no doubt intentional, consequence of highlighting the risk of seizures. Emphasizing that viewers are flirting with danger seems to be a marketing move. Unfortunately, this tactic does attract attention, but it trivializes the actual health risks.

2. Contrary to the claim that the UK Epilepsy Action organization determined that there was a photosensitive seizure risk in the video, Epilepsy Action’s website states that the organization was not consulted about the video. The organization is investigating and plans to continue reporting on it. A news item on the website quite correctly states, “It appears conscientious to show a warning before the video. However, many people with photosensitive epilepsy do not know they have it until something like this triggers their first seizure.” If filmmaker Lynch is conscientious, why not remove the seizure risk in the first place?

Trivializing seizures by using them for marketing

Here’s what happens when the seizure risk is used for marketing purposes. People who know nothing about epilepsy are charmed by the video’s association with seizures and use it to spice up their commentary:

“…before getting into the fact it comes with a STERN WARNING THAT IT HAS BEEN KNOWN TO CAUSE SEIZURES one must take into account it was directed by David Lynch, the man responsible for Twin PeaksEraserhead and Blue Velvet…. I know you’ll all click on the video below to see if I’m just being outlandish and overreactive (what I like to call Glenn-Beck-ish), but remember, you were warned. Also, if you’re rendered comatose (or worse), I call dibs on your watch.”

“Came Back Haunted” packs in a myriad of flashing, distorted clips interspersed with Renzor singing as the camera captures the footage in a near-epileptic state of jitter.”

I found one reasoned commentary. Instead of swallowing the seizures-as-marketing bait, Rachel at bangs.com, to her credit, sees through it:

“…who wants to just hang out and watch a dumb boring music video anyway? I want a bit of DANGER in my viewing experience!”

Safely see for yourself how seizure-inducing it is!

I recorded what happened when I tested “Came Back Haunted” with the program I use to test images for seizure safety, the Harding Flash and Pattern Analyzer. If you view the testing session, you can see what it looks like when a clip is chock full of violations of seizure safety guidelines. When viewing the clip below of the Harding Flash and Pattern Analyzer test session, seizures are very unlikely unless you stare at the upper left-hand corner of the screen at very, very close range. (Smaller images affect a smaller area of the brain’s visual cortex, making it harder to generate the requisite number of neurons misfiring to get a seizure going.)

In this clip the video itself runs at twice its normal speed in the upper left corner of the screen. The rest of the screen shows the analyzer’s findings, in a large line graph and a table that tracks the number of frames that fail the safety test. This is not a borderline case! 

Note: If you’re curious to see the offending video on YouTube in its official form, do keep in mind that since the flashing is downright nasty, the smaller you make the image on your screen, the less danger there is of triggering a seizure.

About Epilepsy Action’s role

Apart from the unauthorized and false statement that Epilepsy Action was consulted, there’s yet another problem with the claim. David Lynch is an American filmmaker, Nine Inch Nails is an American band, and the epilepsy warning refers to a British epilepsy advocacy organization that is vigilant and outspoken in monitoring photosensitive seizure triggers in popular media. Epilepsy Action has drawn the public’s attention to photosensitive seizure-provoking material in visuals broadcast on UK TV, in music videos (Kanye West) and in movies (Twilight: Breaking Dawn).

The American epilepsy advocacy community should be much more proactive and visible to the public, explaining the dangers of seizure-provoking media–including the fact that many people without “regular” epilepsy who have just photosensitive epilepsy are unaware they have the condition. If the epilepsy organizations are concerned about stigma–and they are–they need to advocate against seizure-provoking media and against demeaning portrayals of seizures that stem from photosensitivity. A whole generation of young people is forming opinions about seizures and epilepsy by reading the relentlessly insensitive stuff like David Lynch and Nine Inch Nails making “seizure-inducing magic together.”

Hat tip to John Ledford for making me aware of the video!


Signs it could have been a video game seizure

what Alice sees - colors cropped

My daughter Alice drew this image of what she typically saw while regaining full consciousness after a video game seizure

How can you tell you’ve had a seizure? That your child may have?

It can be easy to recognize a seizure in someone else–if the seizure involves classic convulsions. However, if you have convulsions and nobody is with you to witness the episode, when you regain awareness you probably won’t remember any part of the seizure. You might figure out that something like a seizure happened if you’d been sitting down before and don’t know how you ended up on the floor, or if you experience unexpected bruises or muscle soreness. But since the nature of most seizures is that you aren’t fully aware of your surroundings, you probably won’t know all that happened.

Non-convulsive seizures are tougher to detect in yourself or someone else, since some symptoms can be subtle and many could be attributed to other factors. Before, during and after a seizure people may experience strange sensations that are difficult to describe. Children in particular may have trouble realizing that what they’ve experienced is out of the ordinary and should be reported to a parent.

So a lot of seizures are never identified because they aren’t obvious. The most difficult seizures to identify are complex partial seizures, which elude detection but slow down your thinking, mess with your mood, and scramble your body rhythms for days afterward. And of course, some of the symptoms that follow the event itself, such as irritability, could be attributed to any number of factors.

While it would be good to know for sure if what you or your child experienced was a seizure, very often you can’t know.  I’ve put together a 13 Signs You Might Have Had a Seizure While Playing a Video Game list. Consider the possibility that a seizure occurred if you notice rapid onset of any of these symptoms:

seizure symptoms list

Regarding item #13, consider that sometimes you hear about people with such serious addictions to gaming that they play non-stop for many hours without a break. The common assumption is that if they wet or soiled themselves while playing, they were just too involved in the game to want to stop for a bathroom break. I think it’s much more likely that these incidents occur during the involuntary muscle movement and altered consciousness of a seizure and that the player isn’t aware of either the seizure or the mishap.

Why seizure warnings aren’t very helpful

Given the range of possible symptoms, it’s impossible for game publishers to write a meaningful seizure warning that alerts consumers to all possible symptoms. As an example, Microsoft’s photosensitive epilepsy warning—if you can find it in small print at the bottom of the  Xbox Games Stores screen–says that seizures “may have a variety of symptoms, including lightheadedness, altered vision, eye or face twitching, jerking or shaking of arms or legs, disorientation, confusion, or momentary loss of awareness.”

The link to the Microsoft Games seizure warning is not very easy to see. I've circled it for you.

I’ve circled the link to the Microsoft Games seizure warning — it’s pretty easy to miss

If you even read the warning, that’s a lot to absorb and to keep in mind while playing. Most people aren’t looking for reasons not to go ahead and play.  Nobody really wants to think photosensitive seizures could happen to them or their kids, so it isn’t until something doesn’t seem quite right that you might start trying to figure out an explanation.

What you should watch for are unusual feelings, sensations, or behavior that could indicate a seizure’s start, middle, or aftermath. Until you’ve knowingly experienced a seizure, you probably wouldn’t realize those can indicate a seizure. One clue might be if you notice the same set of symptoms happening  on multiple occasions during a particular game, or in other conditions of flashing light (fireworks or flickering fluorescent bulbs, for example).


Video gaming while driving: not a good idea!

This photo in the UK's Daily Record newspaper led to the identification of the driver.

After this photo was published in the UK’s Daily Record newspaper, the “reckless” driver who played a game while driving was identified and charged.

This week a motorist in Scotland was seen—and photographed—playing the video game Real Racing on his iPad while driving on a highway at 65 miles per hour.

In this country some states have laws that prohibit texting or phoning while driving. Most people realize that using any electronic device while driving is a distraction that impairs the driver’s judgment and attention, placing him/her plus any passengers, pedestrians, and nearby drivers at risk. It’s risky and unwise, and illegal in some places, but it’s a widespread practice nonetheless.

Gaming while driving is beyond reckless. Think of it: what if, in addition to the game creating a dangerous distraction, the images trigger a seizure in the driver? Even a brief seizure of a few seconds, especially at 65 mph, could lead to tragedy.

I tested lots of “footage” of Real Racing on the flash and pattern analyzer that determines whether digital image sequences fall within safety guidelines for photosensitive epilepsy. Although this particular game tested within the safety limits for luminosity/flash rate/pattern movement, many other games don’t. Maybe this driver only drives while playing games that pass the seizure safety test…and plays the rest at home.

Scottish police have brought charges against the 20-year-old suspect. “Motoring groups and politicians have condemned his antics,” according to the Daily Record. Read more


Open letter to the BioShock creative team

BioShock Infinite logo largerCongratulations on last month’s successful launch of BioShock Infinite. The reviews are extraordinary. BioShock Infinite is said to set a new standard for what the video game experience can be. Players are moved and enthusiastic about many aspects of the game and speak effusively about their unprecedented degree of involvement with the story and characters. With all the creative energy, care, and respect for players that went into developing BioShock, though, the game–like so many others–exposes players to visuals that can cause seizures.

I examined several BioShock launch trailers and some other “footage” – a total of eight clips of a few minutes each – and assessed them using an application that identifies video sequences that can trigger seizures. Most of the material was fine, but three of the clips contained brief flashing sequences that don’t meet criteria for safe viewing. It doesn’t take more than a brief exposure to trigger seizures in those who are vulnerable.

This BioShock scene uses safe levels of flash

This BioShock scene uses safe levels of flash.

Contrary to what many gamers assume, eliminating seizure triggers doesn’t make a game boring to look at or play. Irrational Software created a visually stunning, highly engaging experience in which most of the scenes don’t pose a seizure risk. Reports of video game-induced seizures began surfacing in 1981 in newspapers and medical journals. A great deal is known about what types of images and sequences can provoke seizures.

Guidelines for seizure-free video sequences were developed in the UK more than 20 years ago. Since 1991 all television programming and commercials there are required to pass a seizure-safety test. Japan put in place a similar measure following the 1997 Pokémon broadcast that led to hundreds of seizures. In 2005 the International Telecommunication Union published recommended universal guidelines for reducing photosensitive seizures from televised material.

While all these efforts were made to reduce the risk to consumers of photosensitive seizures, video game publishers took their own action—providing printed seizure warnings. The warnings began appearing in the early ‘90s, after a few consumers filed personal injury lawsuits. Putting a seizure warning on video games has thus far provided legal cover for your industry, but offers little protection for customers.

Flash in this scene is safe, too.

Flash in this scene is safe, too.

The warnings all state that photosensitive seizures happen to “a very small percentage of people.” Seizures from flashing images are not rare, but people believe they are because that’s what the warnings say! The wording of these warnings is based on researchers’ estimates that were made decades ago, before today’s sophisticated graphics and before more recent studies that suggest that many photosensitive seizures could be going completely unnoticed. Many doctors continue to think these seizures are rare because that’s what they were taught.

If you haven’t heard many reports of seizures happening while playing BioShock, don’t assume the seizures aren’t occurring. They’re just not being identified. A person experiencing seizures is likely to lose awareness and not even realize what’s happening, or notice that a bit of time has passed that they can’t account for. Furthermore, most seizures don’t involve convulsions, and the only sign others might see could be as subtle as a short period of staring.

Whether or not a seizure is noticeable, it’s a serious event with real risks to health. It can impair health, thinking, and behavior for days afterward. Sometimes a seizure results in permanent disability.

This scene failed seizure safety guidelines.

But this screen capture from the Harding Flash and Pattern Analyzer shows that flash in the BioShock sequence shown at upper left failed seizure safety guidelines.

It’s not reasonable to expect parents to continually monitor their kids for possible signs of a seizure, particularly given that video games are played while people face a screen. So let’s turn to older teens and adults in the midst of a game, who might theoretically be more self-aware and responsible for their own well-being. Will they be vigilant for seizure symptoms such as odd sensations or altered consciousness?

Just last month in a New York Times interview your creative director Ken Levine said, “We work really hard to wear down the audience’s ability to even process. If players are immersed enough, they stop treating it as a piece of artifice and just start experiencing it.” Do you see the problem here? In this ideal game experience, how can players be expected to “immediately stop playing and consult a doctor” as the warning advises, if they develop symptoms consistent with a seizure?

With BioShock Infinite now brought to market, people are asking what your company will do next. You could easily raise the bar further for the industry by publicly committing to developing seizure-safe games. I live in the Boston area and would welcome the chance to begin a conversation about this at your headquarters in Quincy.


Lawsuits filed after games caused seizures

courtroomNo  consumer has won a product liability/personal injury case against a game manufacturer whose video game triggered seizures. Cases were either dismissed, settled, or won by the game company.

Despite their limited usefulness to consumers,  seizure warning notices do seem to provide legal protection to game publishers. And juries have a hard time awarding damages to plaintiffs with a pre-existing condition, even if plaintiffs didn’t know of their photosensitive epilepsy prior to the seizure(s) triggered by a video game.

In one case Nintendo actually conceded that its game had in fact triggered seizures, but that didn’t get in the way of the company winning the case. A judge later overturned the jury’s verdict because Nintendo had withheld critical information in contempt of court.

The cases date back to 1991, but the apparent total number of cases–ten–is pretty small.  One has to wonder what percentage of the seizures triggered by exposure to video games are ever identified as visually induced seizures.

One of the few consumers to reach a settlement is John Ledford of Alabama, whose settlement agreement bars John from discussing his own case. John has found another way to raise awareness of video game seizures. He has researched other cases and reached out to epilepsy organizations around the globe to raise their awareness of the continuing seizure hazard from video game images. John’s Facebook page contains most of the history I’ve assembled here:

Year Filed State Plaintiff(s) Game(s)/Platform/Defendant  Outcome 
1991 MI 15-year old Laura Moceri had grand mal seizure while playing. Kid Icarus (Nintendo) Lost
1993 IL Chicago boy suffered occasional seizures during many hours of game play. Nintendo Dismissed
1995 AL John Ledford had his first ever grand mal seizure while playing game at an arcade. The seizure damaged his optic nerve and caused blindness in one eye. King of the Monsters II (SNK Corp.) Settled
1998 LA 13 year-old Joey Roccaforte had clusters of violent seizures Mega Man X (Super Nintendo) Jury ruled for Nintendo; judge later vacated the decision because Nintendo withheld critical information before and during trial.
2001 LA Esther Walker, mother of 30-year old Benjamin Walker, who died from hitting his head on a table and sustaining internal injuries during a game-induced seizure. Nintendo 64 Lost
2001 LA 11 year-old Michael Martin, son of  Eric Martin, mayor of St. Martinsville, LA. Seizures that began happening during games began occurring also during sleep. Super Mario Kart (Nintendo 64) Settled personal injury claim; lost case advocating better warnings.
2001 LA 6 year –old Kynan Hebert, son of Lynette Benoit Nintendo Dismissed
2002 FL 16 year-old Dominic Zummo Star Wars Episode I: Jedi Power Battles (LucasArts Entertainment, SONY) Unknown
2007 NY While watching his brother play a game, 4 year-old boy had a seizure causing permanent injury. Spyro: Enter the Dragonfly (Vivendi, SONY Playstation 2) Last available information: attorney for plaintiff was seeking other plaintiffs for class action suit
2011 CA Navy F-18 pilot John Ryan McLaughlin injured in a grand mal seizure that causes permanent loss of flight status Oblivion: The Elder Scrolls IV (Bethesda Software), Sony Playstation 3. Still pending; no other information available.

What constitutes product liability?

In 1997 the criteria for product manufacturer’s liability for a product that has caused harm were revised by the American Law Institute, an independent body of legal experts that drafts and publishes restatements of common law in order to clarify and simplify it. Its work is used as a resource by state lawmakers, judges, and lawyers. Every state has its own laws concerning burden of proof, the awarding of damages, and the like.

The 1997 restatement of product liability law states, “a product is defective when, at the time of sale or distribution, it contains a manufacturing defect, is defective in design or is defective because of inadequate instructions or warnings.” These conditions are then defined separately:

  • A product “contains a manufacturing defect when the product departs from its intended design even though all possible care was exercised in the preparation and marketing of the product.” 
  • A product “contains a design defect when the foreseeable risks of harm posed by the product could have been reduced or avoided by the adoption of a reasonable alternative design by the seller or other distributor, or a predecessor in the commercial chain of distribution, and the omission of the reasonable alternative design renders the product not reasonably safe.” 
  • A product “is defective because of inadequate instructions or warnings when the foreseeable risks of harm posed by the product could have been reduced or avoided by the provision of reasonable instructions or warnings by the seller or other distributor, or a predecessor in the commercial chain of distribution and the omission of the instructions or warnings renders the product not reasonably safe.”

Some game companies are apparently working to make games that do not provoke seizures, but only Ubisoft has made a public commitment. As far as I can tell, most are merely reworking their warnings.


DVDs for genius babies may flunk safety test

Whether or not DVDs marketed to stimulate educational development in babies and toddlers provide a headstart on learning, their visual content may be provoking seizures in viewers. When I tested a number of the Baby Einstein and Brainy Baby DVDs, I found some sequences of patterns and flickering that could easily provoke seizures in someone with photosensitive epilepsy.

Baby Bach DVD cover

Who would even consider the seizure risk from DVDs for babies? Not the producers, apparently.

The Harding Flash and Pattern Analyzer found no violations of seizure safety guidelines in most of the DVDs I tested, and those containing violations were not full of seizure-provoking sequences. For anyone vulnerable to visually induced seizures, though, the offending sequences are very clearly quite unsafe to watch. Even brief sequences of a few seconds of flickering images can trigger seizures in some people, even if they have no history of seizures. A soothing DVD for babies isn’t where you’d expect to be bombarded by images that in some people cannot be viewed without triggering a seizure.

The spinning pinwheel in Baby Beethoven.

The spinning pinwheel in Baby Beethoven

Flicker doesn’t always look like a light pulsing on and off. The pattern and flicker sequences in these DVDs that failed to meet criteria for seizure safety included screen-filling images of a swirling black and white spiral, a rotating pinwheel, interlocking gears in motion, and “snow” in motion that looks like a TV signal problem. The rotating pinwheel has small gaps between the colors so that when the pinwheel spins, in effect the colors and white areas create a flicker.

To be clear, photosensitivity has never been found in children under age 2, and it typically doesn’t emerge until age 6 or 7. The brains of babies may not have developed to the point where viewing these images might actually provoke a seizure. But who’s to say these images might can’t create some form of neurological stress in very young children? Then, of course, there is a seizure risk to any photosensitive parents, siblings, caregivers, and others who might be watching alongside the baby.

This spiral swirls for 5 seconds during Brainy Baby Left Brain

This rotating spiral fills the entire screen for 5 seconds during Brainy Baby Left Brain in a sequence that could trigger seizures. Even a small still image is hard to look at!

In addition, researchers have raised the possibility that one factor influencing the emergence of photosensitive epilepsy in an individual is that person’s cumulative exposures to visual stimuli. The theory is that each time the brain processes these intense visual experiences, its capacity to absorb more of them is reduced a little. Add all of those incidents up, and the brain eventually uses up its lifetime ability to normally absorb any more of these experiences. From that point onward, vivid patterns and flashing lights and images can provoke seizures.

Note that home videos are not subject to photosensitive seizure regulation in any country. The UK and Japan enforce seizure safety standards on broadcast TV, and the UK also provides at least a warning for movie theater audiences. New standards going through the approval process at the International Organization for Standardization (ISO) will eventually cover all image presentations, including interactive images.

In Baby van Gogh these spin for 12 seconds, a risk for anyone with pattern sensitivity

In Baby van Gogh these gears spin for 12 seconds, a risk for anyone with pattern sensitivity

With thanks to Michael Rich, MD, MPH, Director of the Center on Media and Child Health at Children’s Hospital Boston for first bringing to my attention the spiral image above.


Nintendo knew about, downplayed seizure risks: BBC report

Nintendo's Mega Man X was among the four games tested by the BBC that did not meet the flashing and pattern safety guidelines used by British TV.

Nintendo’s Mega Man X was one of the four games tested by the BBC for this investigative report that did not meet  British TV seizure safety guidelines.

A BBC report on Nintendo revealed that the company knew more than 20 years ago which of its games were most likely to cause seizures–and downplayed the seizure risk to customers. A former Nintendo customer relations employee interviewed for the story said that many customers called to  complain about experiencing seizures. Because he wanted to advise customers concerned about the seizure risk, he asked the company’s R & D group for a list of the games most likely to cause seizures. 

Developers came up with a list of more than 30 games. Before the list was released to customers, he said, the company’s lawyers pared down the list to 12 – 15 titles. As customer complaints about seizures grew, Nintendo stopped releasing any seizure information about specific games. The Nintendo executive interviewed asserted that the company began making its games safer and started including seizure warnings with game instructions as soon as the problem came to their attention—in 1991.

The story, featured on the BBC’s Outrageous Fortune program in 2004, also includes an interview with photosensitive epilepsy expert Prof. Graham Harding. Using his own flash and pattern analyzer Prof. Harding shows the results of testing some Nintendo games for seizure safety.

To view the ten-minute segment about video game seizures in the report on Nintendo, first go to www.youtube.com/watch?v=0aFhW56c2Vg and fast forward to about 5:15 into the clip. The seizure segment continues at the beginning of this clip.

The documentary was never aired in the US, and I’d long since given up searching for it online. But I recently came upon it thanks to John Ledford, who has been tracking seizure lawsuits filed against the game industry. John became blind in one eye as a result of his first grand mal seizure—which occurred while he was playing a video game in 1994.


Today the sound, tomorrow the picture?

too loud2Have you noticed that watching TV is less annoying lately? Commercials are now required to be no louder than the programming surrounding them. On December 13 an FCC regulation went into effect that was designed for just that. The CALM Act, approved by Congress in 2010, directed the Federal Communications Commission to make it possible to watch TV without constantly turning down the volume of advertisements.

Since the introduction of television in the 1950s, many consumers have complained to the FCC  about the loudness of commercials. What prevented the FCC from doing anything in response was that the issue was technically complicated. Multiple factors can contribute to the perceived loudness of a broadcast, including the strength of the electrical signal, the degree to which the sound signal is compressed. In addition, there was no standard method for content creators and broadcasters to measure broadcast volume.  

In 2006, the International Telecommunication Union–the same UN-affiliated standards body that has published specifications for protecting TV viewers from photosensitive seizures–proposed a new technique for measuring broadcast volume that allows uniform evaluation across national boundaries. In addition, the ITU proposed a numerical “target loudness” using the new loudness gauge. Thanks to the ITU, it became possible to define, comply with, and enforce limits on loudness.

Four years later the United States Congress passed the CALM Act with little debate, by unanimous vote in the Senate and by a voice vote in the House. California Congresswoman Anna Eshoo, who introduced the bill, said it was by far the most popular bill she’d ever sponsored. She said the bill “gives consumers peace of mind, because it puts them in control of the sound in their homes.” She was quoted saying, “If I’d saved 50 million children from some malady, people would not have the interest that they have in this.” By that time the UK, France, Norway, Italy, Japan, Brazil, Israel, Germany, Austria, Switzerland, Poland, and the Netherlands were already limiting the loudness of commercials or had begun action on the issue. 

These days even the video game industry is paying attention to some kind of audio standards, if only for consistency across products. According to an July 2012 interview in Designing Sound, Sony Computer Entertainment Europe is looking at smoothing out the volume among their own game titles.

Unfortunately, in this country making TV safer to watch for the visually sensitive–or making video games safer to play–isn’t on the legislative agenda. Consumers and policy makers aren’t aware of the need. The technical groundwork is already in place for regulations to prevent screen-induced photosensitive seizures, thanks to ITU specifications (and similar versions developed by the UK and Japan), and to similar guidelines adopted by the World Wide Web Consortium for web-based content.

Here’s where things stand at the moment in making US electronic screens safe for those with photosensitive epilepsy: Photosensitive epilepsy protection standards now apply to all federal agency websites. The Photosensitive Epilepsy Analysis Tool (PEAT) downloadable from the PACE Center at the University of Wisconsin at Madison makes available to website designers and software developers a free tool that tests screen content for compliance with seizure safety guidelines. The tool is not intended for entertainment industry developers, however; these companies need to buy commercially available assessment tools.

I’ve written previously about some of the complexities of bringing new screen safety standards to the American telecommunications industry. I”m going to learn more about the legislative process in coming months. My State Representative filed a bill last week to create a commission to study the issue of video game safety for minors at home and in school here in Massachusetts. It will take considerable time to even bring the bill to a public hearing, but as I’ve recently learned, all bills filed in the Massachusetts legislature receive a public hearing at some point in the two-year session. The two years just began this month. Stay tuned.


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