The 2014 E3 (Electronic Entertainment Expo) just wrapped up in Los Angeles with all the major game publishers previewing their upcoming releases. The big companies publishing these games have mammoth budgets and should be able to fund some quality control that supports the interest of public health. Apparently that line item is still not getting the focus it deserves.
Last week PCMag.com listed the 10 most anticipated games to be announced at E3. How many of them might trigger seizures in people with photosensitive epilepsy?
So far, 4 of them tested positive for seizure-inducing sequences–meaning they failed the Harding automated seizure safety test. This isn’t a final result because not all have enough “footage” available online for me to test adequately. Some may ultimately seem safe.
These tested as unsafe:
Super Smash Bros. (Nintendo)
Call of Duty: Advanced Warfare (Activision)
Tom Clancy’s The Division (Ubisoft)
In other words, the patterns, flashes, and/or red intensity of onscreen images produce the exact type of visual stimulation–that’s been carefully defined by researchers–that places viewers at risk of photosensitive seizures. People with a genetic predisposition for these seizures are vulnerable, whether or not they have ever experienced a seizure before, and whether they even know they have this genetic trait.
Nintendo’s Mario games have been triggering seizures for more than 20 years. Reports began surfacing in 1992 about seizures from Super Mario. As a result, a study on video game seizures published in 1999 used Super Mario World to test subjects known to be photosensitive. And a lawsuit was filed in 2001 by parents of a boy who had a seizure while playing Super Mario Kart.
But what about new games such as Destiny? A whole new game provides the perfect opportunity to create an entirely novel visual experience. Why not architect the whole thing keeping in mind the seizure hazard that persists in many games?
In sum, some of the video game industry’s biggest players are continuing to ignore safety guidelines, placing the public at unnecessary risk. I don’t know where the myth originated that games produced nowadays don’t produce seizures.
Congratulations 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.
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.
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.
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.
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:
|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.”
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.
Have 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.
I read an article this week about video games designed to treat ADHD. The concept sounds appealing: use some time already spent on recreational video games to instead play therapeutic video games, and make ADHD treatment enjoyable enough that kids will stick with it. Another plus that developers point out is that treatment provided via games would not cause the side effects of ADHD medications. Games designed to improve some aspect of physical or mental health or performance are a fast-growing growing sector, and there’s even a scholarly research journal that launched this year, Games for Health Journal.
Video games are not without side effects, though, including seizures. ADHD, video games, and seizure vulnerability haven’t been studied together, but by piecing together some studies dealing with two of the three factors, the interconnectedness between them can be considered. So here is some information on ADHD and video games, and separately, information on ADHD and seizures. Put them together and think about about video games and ADHD being a risk factor for game-induced seizures. Developers of games to treat ADHD need to be conscious that the same neurological abnormalities that cause attention problems may also make people with ADHD more vulnerable to seizures from a video game.
ADHD and video games
Evidence is accumulating that exposure to typical (non-educational, non-therapeutic) video games is associated with later attention problems. It’s a highly charged subject, because scientists can never account for all possibilities and variables in a single study, and people tend to feel very strongly one way or the other about video games. A lot more study is needed because so little has been done that follows the same children over time. Based on findings including the following, the American Academy of Pediatrics issued cautions parents about video game use.
“…[A]mount of time spent playing video games is associated with greater attention problems…[B]oth television viewing and video game playing were uniquely associated with attention problems…[T]he total time spent with screen media (both television and video games) was positively related to attention problems.
…Exposure to screen media was associated with later attention problems even when earlier attention problems and gender were statistically controlled. This provides stronger evidence…that screen media may influence attention problems; controlling for earlier attention problems…rules out the possibility that the association between screen media use and attention problems is merely the result of children with attention problems being especially attracted to screen media.
…[T]elevision viewing and video game playing were associated with attention problems in both middle childhood and late adolescent/early adult samples…These similar associations across age groups raise an important possibility about the persistence of television or video game exposure effects on attention problems. Whatever the ages at which watching television or playing video games may increase attention problems, the consequences may be quite long lasting or cumulative.”
–Edward Swing et al., “Television and Video Game Exposure and the Development of Attention Problems” in Pediatrics, August 2010
ADHD and seizures
While findings from one study were announced regarding the high rate of photosensitive epilepsy in autism, no studies have been published on photosensitive epilepsy in people with ADHD. What studies do show, however, is that in people with ADHD seizures of all types occur at a much higher rate than in the general population. The findings suggest that environmental influences, including video games, could place people with ADHD at higher risk for photosensitive seizures.
There is increasing evidence and acceptance of some underlying brain dysfunction shared by epilepsy and ADHD, and people with one disorder have more than the usual risk of having the other condition as well.
As one study puts it,
“It is likely that there is a common neurobiological predisposition for both a lower seizure threshold and ADHD behaviors that may involve both genetic and environmental factors… We found a 2.7 fold greater incidence of epilepsy among children with ADHD than in controls.”
– Shanlee Davis et al., “Epilepsy in Children With ADHD: A Population-Based Study” in Pediatric Neurology, May 2010
Another study found that children with the predominantly inattentive type of ADHD have a risk of developing seizures that’s 3.7 times the normal odds. The odds for children with the combined type of ADHD, which includes inattention and hyperactivity, are 3.3 times the normal rate.
“ADHD precedes the development of epilepsy, and ADHD or its determinants must be considered risk factors for epilepsy.”
–Dale Hesdorffer, et al., “ADHD as a Risk Factor for Incident Unprovoked Seizures and Epilepsy in Children” in Archives of General Psychiatry, July 2004***
This was specific to the inattentive type of ADHD, which is presumably the intended market for video games for helping with focus, memory, screening out distractions, etc.
ADHD + video games = higher likelihood of seizures
I don’t know if games-for-health developers, particularly people working on ADHD treatment games, are more concerned about the seizure hazard than developers of games for pure entertainment. Presumably a therapeutic application’s on-screen action would not be full of strobe effects. Without seeing the games, though, it’s hard to know for sure about the kinds of screens and effects that are used to congratulate users on their score, signal the end of the game, etc.
Let’s hope these games don’t do harm in their efforts to do good.
***Note that “incident unprovoked” in the study title refers to means a seizure that is not provoked by a medical situation unrelated to epilepsy: a head injury, fever, intoxication, and so on. A photosensitive seizure triggered by flash is not considered provoked, because that is the nature of reflex epilepsies, that they are triggered by a sensory experience. The terminology is more than just confusing. Because the words trigger and provoke are close to synonymous, the use of “unprovoked” in defining seizures typical of epilepsy seems to to exclude reflex seizures. The terminology both reflects and contributes to the relegation of reflex seizures to the sidelines of clinical training and research funding and and perpetuates the perception that they are rare.
Earlier this month in Los Angeles the annual E3 (Electronic Entertainment Expo) trade show for computer and video games was held, providing an opportunity for game companies to showcase products that will be released in the coming year.
On the basis of demos, official marketing trailers, interviews with developers, and, no doubt, heavy lobbying behind the scenes, reviewers and game publications then choose their favorites in various game genres/categories (shooter, puzzle, strategy, action, etc.) for the major hardware platforms. Widely read IGN.com, the website of IGN (which describes itself as “a leading online media & services company obsessed with gaming, entertainment and everything guys enjoy”) also selected what it considered the best trailers at the show.
A compelling trailer shows the latest/greatest/neatest special effects, story lines, and characters, packaging them in a way to draw in viewers and help create that all-important “buzz” of anticipation. Parents and others can have a look at the content, age appropriateness, and perhaps get a sense whether seizure-provoking visuals are likely to be present. So, which trailers got top billing by IGN, and how much risk do the trailers themselves pose for people with photosensitivity?
None of the 4 games named in the best trailer category were clearly seizure-safe—they all included visual sequences that could provoke seizures in some people. Three of the four didn’t actually fail the seizure safety test, but they contained sequences that flirted with the guidelines for photosensitive seizure safety, meaning that very sensitive individuals under the right circumstances could experience a seizure. When tested for seizure safety, the three runners-up were given neither a Pass or Fail—they received a Caution rating by the Harding Flash & Pattern Analyzer.
Best trailer of show? The guys at IGN chose Tomb Raider, which during its three minutes exceeded seizure safety guidelines for flashing a couple of times and came close to failing in others. In addition, the moving title at the end that explodes in a screen of solid red was close to going over the guidelines not only for bright flash but also for the amount of bright red on screen. When the game is released next March, it will most likely affect photosensitive players. Trailers aside, Tomb Raider was also selected as best overall game in show…