That lets me get to work assessing those games for seizure risk, so I can identify which popular titles in the next crop of releases are less likely to trigger seizures. (I suspect I’m one of very few on the planet who tunes in for this purpose to the annual “best-of” video game lists. I want to see if the development studios are doing more to cut down on image sequences that can set off seizures in people with photosensitive epilepsy.)
I tested the winners chosen by Hardcore Gamer in 9 game categories. Five of the winners—including the Best Game of Show winner, Deus Ex: Mankind Divided—contained seizure-provoking flashes and/or patterns.
Here are my results, using the Harding Flash and Pattern Analyzer to check for images likely to trigger seizures in individuals with photosensitive epilepsy. Please remember that there are no guarantees your results will match mine and that many factors affect a person’s susceptibility to visually induced seizures.
I run downloaded gameplay clips, cinematic clips, and promotional trailers for each game and submit the sequences to the Harding Flash and Pattern Analyzer. The FPA is widely used by producers and networks in the UK—including by the BBC—to ensure seizure safety of all material on broadcast TV.
The analyzer examines video sequences for very specific and measurable image qualities that researchers have found can trigger seizures:
- rapidly alternating light and dark images (flash/flicker)
- certain stripes and geometric patterns with high contrast
- large areas of very bright (“saturated”) red
- problem images take up more than one quarter of the total screen area
If the first clip I test of a game fails the safety test, I note that and move on to test the next game. If no safety violations are found, I typically test at least 4 or 5 additional clips of that game–sometimes more, if I have a hunch due to the game genre and/or overall look of the sequences that there might be unsafe “footage” that I haven’t yet found.
Games I’ve listed as safe could have seizure-provoking sequences that I was unable to locate. I don’t do this testing while actually playing these video games. Instead I work with video clips available online, some of which are official marketing and gameplay trailers; others are cutscenes and gameplay sessions posted by reviewers or fans. I avoid clips showing games that have been modified with other software.
Each person’s seizure threshold can be affected by a number of factors apart from the visual stimulus itself, including illness, hunger, stress, fatigue, alcohol, medications, length of play, and the player’s menstrual cycle, among others. So a game that seems OK may trigger a seizure in that same player under different conditions.
A big reason seizures induced by video games aren’t more widely known is the absence of new research findings about the problem. There continues to be a lot of misinformation out there, and meanwhile we get farther away in time from the studies showing there’s good reason to take the seizure risk very seriously. Without announcements of new results or a concerted education effort by advocacy organizations, it’s tough to keep this issue alive for the public. When today’s researchers of video games miss the opportunity to remind readers of the seizure studies, they perpetuate the public’s disregard for the seizure risk. Here’s why this happens:
- The research showing video games can trigger seizures is old news! Many studies on video games and photosensitive epilepsy have already been published, beginning in the early 1980s. The findings and methods have been refined over time, but the results have been fairly consistent. Since there wasn’t much controversy about the studies, the research community has largely moved on from what was already considered a niche subject. More recent studies by these same specialists in photosensitive epilepsy aren’t the type to be appreciated outside the scientific community: research methdologies, specific genes, and the place of reflex seizures in the spectrum of seizure disorders. Not very newsworthy for the general public.
- Most studies today on the effects video game use are about long-term influence on skills, behavior, and attitudes, and on their use in education and health-related applications. These studies are typically done by social scientists, who in general are not including medical issues in their analyses. Studies like this are looking at a different body of previous work–studies done by other social scientists–and the authors may not be familiar with the photosensitive epilepsy research.
- There’s a real backlash these days against studies warning about negative influences of video games. Video games are clearly here to stay; researchers and game developers are eager to demonstrate games’ potential for good. Unfortunately, people who write about video games’ beneficial effects and purposeful applications tend to treat with suspicion (or worse) any earlier studies showing problems attributed to games. Or the seizure issue is omitted altogether from summaries of previous findings.
Seizure research swept under the rug
People who grew up using computers and video games from an early age now comprise a sizeable segment of the research community. Many of them feel there has been a consistently negative bias in studies about video games and they are eager to show another perspective. Here’s an example. Prof. Mark Griffiths in the UK wrote a piece last year entitled, “Video Games Are Good for Your Brain – Here’s Why” that he begins this way:
“Whether playing video games has negative effects is something that has been debated for 30 years, in much the same way that rock and roll, television, and even the novel faced much the same criticisms in their time. Purported negative effects such as addiction, increased aggression, and various health consequences such as obesity and repetitive strain injuries tend to get far more media coverage than the positives.”
Prof. Griffiths had greater difficulty getting his own papers published when they showed positive positive influences of games than when they addressed difficulties such as video game addiction. The article points out positive outcomes using video games for social engagement, therapeutic applications, and education, and then concludes with this irresponsibly inaccurate statement:
“What’s…clear from the scientific literature is that the negative consequences of playing almost always involve people that are excessive video game players. There is little evidence of serious acute adverse effects on health from moderate play.” [However, there is extensive evidence of seizures–a pretty serious acute adverse effect–that can occur even with very brief exposure. — JS]
Social scientists pick and choose
Earlier this year a piece titled “Video games can be good for you, new research says” (no link because it’s behind a pay wall) appeared in the Chicago Tribune. The reporter opens the piece by putting video game research into historical context.
“Researchers have done thousands of studies on gaming since the 1980s, often with unmistakably negative results. Some associated video games with an increased risk of epileptic seizures, while others cautioned that the games could provoke dangerously elevated heart rates. Many studies also linked violent games to aggression and anti-social behavior.”
Then the article turns to a psychology professor whose new study forms the basis of the article. Prof. Christopher Ferguson has done dozens of studies on effects of video game use. Prof. Ferguson, who’s found that violent video games do not contribute to societal aggression, reasons that early research into any new technology is often flawed. Studies that aim to find negative effects get funded and promoted, while those with more benign findings are unpublished and forgotten, he explains.
“When a new generation of scholars more familiar with the technology comes along, different results often appear — and that’s what is happening with gaming. We’re just not seeing the kind of data emerge that would support the techno-panic that was common in earlier years.”
There is no further mention in the article of studies about the video game seizure problem–as if all the video game seizure research was part of the so-called “techno-panic.”
I contacted the Tribune reporter to point out that the seizure problem is for real and hasn’t gone away. He said he was aware of this fact and was interested in writing about it sometime. However, without a piece of news tied to it, such as results from a new study, other stories are obviously much more compelling for a newspaper to cover.
P.S. I’m on a mission, too
I’ve chosen to focus on the seizure risk from exposure to video games, and on the after-effects these seizures–even small ones–can have. If you’ve read other posts of mine, you’re aware I believe there is still some research on video game seizures that needs to be done and it’s on issues that could produce newsworthy results:
- the higher risk of visually induced seizures in specific populations, such as young people with autism. One small, unpublished study found 25 percent of young people over age 15 with autism spectrum disorders are photosensitive, but more study is needed.
- the real prevalence of photosensitive seizures, which researchers admit are probably underdiagnosed because they aren’t noticed or reported.
Momentum is growing to eliminate the barriers that make it difficult or impossible for people with disabilities to play video games. An assortment of game accessibility specialists and organizations are advocating with and educating game developers on how to adapt their offerings for gamers with physical, sensory, and/or cognitive impairments many types of disabilities. In addition some of these organizations work with individuals to resolve specific accessibility issues.
Q: How might this trend bring about progress on the seizure hazard that persists in many games?
A: Remains to be seen because game-induced seizures don’t typically receive a lot of advocacy attention amid so many other disabilities.
Some advocacy efforts focus on modifying the user interface to accommodate certain types of disabilities—such as mobility limitations that make a typical game controller too challenging. There are also two well-established game accessibility groups—both founded more than 10 years ago—that address all sorts of disabilities and could therefore actively promote the development of games that are unlikely to trigger seizures.
The leading advocacy players (as it were)
The Able Gamers Foundation is a non-profit, staffed by volunteers, that is supported by donations from individuals and some big names in the industry, including Sony, Harmonix, the Steam storefront, and others. Able Gamers advocates with and provides free consulting to game developers in order to open gaming up to individuals with disabilities. The organization published a set of game accessibility guidelines written by developers and by gamers with disabilities. The guidelines appear under the title Includification (I love that term). Accommodations for mobility impairments make up the largest category in the Includification booklet: remappable keys, compatibility with specialized input devices, and so on. Accommodations for hearing, vision, and cognitive disability are outlined as well. Able Gamers says that flash and flicker guidelines, not currently in the document, will be added in a revision scheduled for later this year.
Able Gamers does a lot of community outreach to gamers with special needs and tours the country demonstrating assistive technology devices that make game play possible for individuals who cannot use conventional controllers or other standard input/output technology. The group reviews games for accessibility features, and it provides online forums where disabled players can connect with each other. Able Gamers also provides grants to individuals who need customized assistive technology for gaming.
The Game Accessibility Special Interest Group of the International Game Designers Association, founded by a member of Stockholm University’s Department of Computer and Systems Sciences, is comprised of game developers and academic and industry experts in accessibility. The group presents at conferences, surveys developers, and organizes accessibility competitions for game design students. The goals of the SIG include advocacy, cross-industry cooperation, and creating a curriculum on accessible design that can be incorporated into existing post-secondary game design courses. The SIG is embarking on an ambitious multi-faceted agenda to move the accessibility agenda forward.
For developers seeking references on how to make games more accessible, the SIG recommends Able Gamers’ Includification and www.gameaccessibilityguidelines.com, a document that received an award from the Federal Communications Commission (FCC). The guidelines detail 100 accessibility features and include a remarkably clear outline of how to reduce the risk of flash- and pattern-induced seizures. The SIG also promotes a list of 14 accessibility features–such as easily readable closed captioning and colorblind-friendly design–that would have the most impact on gamers with disabilities. (Seizure risk reduction didn’t make the top 14 list.)
How photosensitive epilepsy is unlike other disabilities
I exchanged emails with London-based Ian Hamilton, an accessibility specialist and user experience (UX) designer active in the SIG. Hamilton was instrumental in organizing and producing gameaccessibilityguidelines.com. He respects the importance of seizure safeguards. “…even though epilepsy is relatively uncommon compared to things like colourblindness or dyslexia,” he wrote, “it’s one of the only accessibility issues that can result in physical harm, so it’s absolutely critical to get right.”
As he so rightly pointed out, the stakes (that include the potential for serious medical issues and life-long limitations) in the case of photosensitive epilepsy are quite apart from the frustrations of being unable to play because of, say, inadequate captioning. While photosensitive epilepsy absolutely belongs in any set of game accessibility guidelines, it differs in some other significant ways from the other conditions/disabilities that need accommodations:
- It is particularly important to proactively reduce the seizure risks to all consumers since many people aren’t aware they have the condition and are therefore at risk. They’ve either not yet been triggered or they aren’t aware of seizures they’ve already had. Nobody really knows how many people are affected by photosensitive epilepsy, but awareness is low, diagnostic methods are unreliable, and estimates of how common it is are very conservative.
- Advocates say many developers are responsive to specific requests for modifications that help those with a particular disability, because many accessibility issues stem from a lack of awareness by product designers of accessible design practices. Although it’s true that accessible design isn’t typically included in the game design curriculum, this argument doesn’t really hold up when it comes to seizure-inducing images. Game publishers have acknowledged for more than 20 years that their games could pose a risk to individuals with photosensitive epilepsy. The legal departments of game publishers should communicate with their own designers and developers about making games less likely to spark seizures. Many popular games continue to contain seizure-inducing images.
- Advocates encourage the involvement of individuals with disabilities in the design and testing of games for the benefit of all parties. For people with visually induced seizures, this isn’t feasible, nor is it necessary. Testing needs to be done without placing people at risk, using existing analysis applications that utilize research-based image specifications. For these consumers there is little chance of developing an ongoing collaborative relationship with the industry.
- Despite a 2005 consensus paper by the Photosensitivity Task Force of the Epilepsy Foundation of America identifying seizures from visual stimulation as a significant public health problem**, there has been no organized advocacy to reduce visual stimuli in our everyday environment that can trigger seizures. Advocacy efforts (in the USA, anyway) to improve the lives of people with photosensitive epilepsy appear to be practically non-existent. In contrast, the interests of people with vision, hearing, and movement impairments are represented by organizations that proactively take on quality-of-daily-life issues.
Under the heading “Ways to further accessibility in the games industry” Ian published a comprehensive list of steps required for making video games accessible to people with disabilities. In addition to game developers and disabled gamers, the stakeholders involved would include educators in game design, game publishers and distributors, platform manufacturers, government bodies, trade groups, development tool builders, and so on. Among the recommendations: “Include basic access requirements in publisher certification requirements, such as subtitles and avoidance of common epilepsy triggers (both of these examples are required at a publisher level by Ubisoft).” Ian notes in his preface to the list that bringing about this accessibility within the game industry amounts to “wide-scale cultural change.”
I applaud the work of the Games Accessibility SIG, the Able Gamers Foundation, and other groups addressing of accessibility. They are making strides on an important issue while faced with the task of convincing the industry that design changes for accessibility will pay off in improved overall game design and a larger customer base.
But in order to make possible the massive and broad-based cultural change that’s needed, I believe these talented and dedicated advocates need significantly greater resources, buy-in, and recognition. The industry needs to declare publicly that it is committing itself to making gaming more inclusive of people with disabilities. In the face of frequent challenges about the contents of video games and their influence on young people, the accessibility issue offers a win-win public relations opportunity for video games. The Entertainment Software Association is just the organization to proactively announce an industry-wide goal of providing people with disabilities easier access to video game entertainment and learning. The ESA should establish and contribute major resources to a game indistry consortium for promoting and achieving accessibility education, standards, learning, and collaboration, leading to a more inclusive—and larger—customer base.
** “The Photosensitivity Task Force of the Epilepsy Foundation of America believes that a seizure from visual stimulation represents a significant public health problem. No known method can eliminate all risk for a visually induced seizure in a highly susceptible person, but accumulation of knowledge about photosensitivity is now at a level sufficient to develop educational programs and procedures in the United States that substantially will reduce the risk for this type of seizure.”
— from Robert S. Fisher et al., “Photic- and Pattern-induced Seizures: A Review for the Epilepsy Foundation of America Working Group.” Epilepsia Volume 46, Issue 9 (September 2005), pages 1426–1441.
The Game Developers Choice Game of the Year Award was given yesterday to Middle-earth: Shadow of Mordor, a title containing scenes that can provoke epileptic seizures.
Many people vulnerable to visually induced seizures are unaware they have this genetic sensitivity, unless they’re aware of prior seizures triggered by visual stimuli. This means that before playing this game, consumers should carefully consider the typically ignored seizure warning in the packaging. The game’s visual sequences violate guidelines for preventing seizures provoked by flashing and/or other provocative visual stimuli.
Game Developers Choice Awards are voted on by an invitation-only group of leading game creators across the video game industry, and are presented at the annual Game Developers Conference, an event that attracts more than 20,000 attendees. Here are some excerpts from the conference website describing the Game Developers Choice Awards:
- the premier accolades for peer recognition in the digital games industry
- innovation and excellence in the art of making games
- recognize and celebrate the creativity, artistry and technical genius of the finest developers and games created in the last year
You get the idea. Consumer safety and inclusiveness, though, are apparently–no surprise–absent from the selection criteria.
Game of the Year Award
The winning game was chosen from a field of five nominees, only one of which–Hearthstone: Heroes of Warcraft (Blizzard)–tested as seizure-safe.***Please note that while my testing didn’t find unsafe sequences in Hearthstone, a Reddit poster had seizures triggered by the game. I’ve previously posted on the other three nominated games that tested as unsafe:
At this point I explain how I test games for seizure safety and explain that there are no guarantees your results will match mine.
I run downloaded gameplay clips, cinematic clips, and promotional trailers for each game and submitted the sequences to the Harding Flash and Pattern Analyzer. The FPA is widely used by producers and networks in the UK—including by the BBC—to ensure seizure safety of all material on broadcast TV. It examines video sequences for very specific and measurable image qualities that researchers have found can trigger seizures:
- rapidly alternating light and dark images (flash/flicker)
- certain stripes and geometric patterns with high contrast
- large areas of very bright (“saturated”) red
- problem images take up more than one quarter of the screen
If the first clip I test of a game fails the safety test, I note that and move on to test the next game. I typically test at least 4 or 5 additional clips of a game if no safety violations are found initially. If I have a high level of suspicion due to the game genre and/or overall look of the sequences that there might be unsafe “footage” that I haven’t yet found, I may test a lot more clips.
Your results could vary. Games I’ve listed as safe could have seizure-provoking sequences that I was unable to locate. I don’t do this testing while actually playing these video games. Instead I work with video clips available online, some of which are official marketing and gameplay trailers; others are cutscenes and gameplay sessions posted by reviewers or fans. I avoid clips showing games that have been modified with other software.
In addition, the seizure threshold of individuals is affected by a number of factors including illness, hunger, stress, fatigue, length of play, and the player’s menstrual cycle, among others. So a game that seems OK may trigger a seizure under different conditions.
There are many reasons for low awareness of the seizures induced by video games, but today I want to focus on a big one: the lack of current research.
Without new research or a concerted outreach effort by advocacy organizations, it’s tough to keep the issue alive in the media. New research means new findings to announce. The press isn’t likely to cover a subject that’s producing no news.
It’s not as if conclusive studies don’t exist on seizures triggered by video games. Many clinical studies on video games as a cause of photosensitive seizures have been published, beginning in the early 1980s. The findings and methods have been refined over time, but the results have been fairly consistent and haven’t stirred up controversy. In fact, photosensitive epilepsy has always been considered a niche disorder and an out-of-the-way area of research. What’s left to prove?
Today’s studies involving video games are all about how games influence behavior and attitudes. Social scientists are investigating questions such as how much video games affect cognitive performance, memory, physical response time, behavior, and attitudes about violence. The results of ongoing studies like this—unlike the old news about seizures triggered by video games–frequently appear in the news media, keep the issues alive, and are topics of public debate.
The last time significant research findings were published and the advocacy community acted upon this public health problem was in 2005, when consensus papers on photosensitive seizures were published and the Epilepsy Foundation acted by issuing new guidelines for families on preventing them. Very little has occurred or has been published since then to keep the issue before the American public. (One exception: in 2008 the Epilepsy Foundation publicly responded to an Internet attack that placed seizure-inducing images on its website.)
Here’s an example of how things work in the news business.
Last month a pretty balanced piece titled “Video games can be good for you, studies say” appeared in the Chicago Tribune. The reporter, John Keilman, begins the piece by putting video game research into historical context.
Researchers have done thousands of studies on gaming since the 1980s, often with unmistakably negative results. Some associated video games with an increased risk of epileptic seizures, while others cautioned that the games could provoke dangerously elevated heart rates. Many studies also linked violent games to aggression and anti-social behavior.
Then the article turns to Christopher Ferguson, a psychology professor at Florida’s Stetson University who’s found positive contributions of video games:
Ferguson has done dozens of studies on the subject and has consistently found that violent video games do not contribute to societal aggression. One recent project actually concluded that some children who play violent games are less likely than others to act like bullies. [That’s pretty newsworthy!–JS] Ferguson said early research into any new technology is often flawed. Studies that aim to find negative effects get funded and promoted, while those with more benign findings are unpublished and forgotten, he said. When a new generation of scholars more familiar with the technology comes along, different results often appear — and that’s what is happening with gaming, he said. “We’re just not seeing the kind of data emerge that would support the techno-panic that was common in earlier years,” he said.
Although Keilman balanced Ferguson’s remarks with quotes from another researcher, who’s quite skeptical about recent positive findings, there is no further mention in the article of studies about the seizure problem. Readers can easily assume that—as with early studies linking violent games to violent behavior—all the research showing video games can trigger seizures stems from the “negative attitude by technophobes” in the early days of gaming. If one follows Prof. Ferguson’s line of thinking, one could expect that newer studies—if there are any–on seizures and games can be expected to reverse the earlier studies.
I contacted Keilman to point out that the seizure problem hasn’t gone away. He responded that he was aware of this and was interested in writing about it sometime. He also mentioned continuing research on the seizure issue. I think he’d be interested in writing about the subject if there was some new study that’s newsworthy, but there simply isn’t.
In the absence of new research, or a Pokémon-type episode, it’s hard for journalists to write about a topic that just isn’t news.
Later this year parents will be able to monitor a child’s seizure activity by using wearable technology in the form of a sleek, stylish watch with sensors underneath. The $199 Embrace watch, which will debut in October, could eventually offer a way for parents to learn whether the video games their child is playing are triggering seizures.
The Embrace won’t be able to do a thorough job of that yet—primarily because the device is currently most accurate for detecting tonic-clonic (grand mal, convulsive) seizures. Many seizures aren’t that type; they’re complex or absence, so the device would need to reliably pick up all seizure types. In addition, the Embrace hasn’t been tested specifically for picking up seizures triggered by visual stimuli. In its initial release, though, Embrace will be able to alert parents to tonic-clonic seizures while their child is asleep or in another room.
Most seizure detection devices (except EEG) rely on motion sensors that transmit an alert to a caregiver about a convulsive seizure. The Embrace wristband works primarily by detecting subtle changes in the flow of electrical charges on the skin. These changes in skin conductance are reliable indicators of changes in deep-seated areas of the brain associated with seizures, the hippocampus and amygdala. In times of cognitive, physical, or emotional arousal—and during seizures, these parts of the brain are activated. In some instances, changes on the skin can even be detected prior to the onset of a seizure.
As I’ve noted elsewhere, although EEG is the gold standard used by doctors to diagnose seizures, it’s limited in what it can pick up from structures deep inside brain. EEG uses scalp electrodes to detect electrical signals that first must penetrate the outer brain layers (cortex) and the skull. Because electrodes are affixed to the other side of these layers of tissue and bone, not all seizure signals can be detected at the surface.
The Embrace sensor technology was initially developed by the MIT Media Lab to help people on the autism spectrum to identify and communicate their stress level. The MIT team subsequently discovered that the sensors could detect not only stress/arousal levels but also seizures, including some seizures not picked up on an EEG. A start-up was formed, Empatica, to bring the wearables to market with the help of Indiegogo crowdfunding. I’m intrigued by the company’s roots in technology to aid people with autism; the autism community is probably at highest risk for photosensitive epilepsy and would therefore significantly benefit by being able to identify visually triggered seizure activity.
If your child is fatigued and kind of “out of it” at the end of a gaming session, imagine being able to find out whether hidden seizures are occurring during certain games. Wouldn’t it be great to be able to correlate seizure activity with specific video games? I’d love to see this application of the Embrace watch come about.
A video about Embrace is available on Empatica’s Indiegogo page.
When the Duke and Duchess of Cambridge arrived at their New York hotel this week, it was big news. Did you catch the squeals of delight from the crowd and the flicker of so many cameras flashing? The arrival scene was featured on a number of American news programs.
How it was seen in the UK
This same New York arrival scene was shown in the UK as well—but with an important difference.
Rapid-fire flash photography from the swarm of media creates a strobe-like effect on the image, which is known to trigger seizures in some people. In the US this material is broadcast despite the seizure risk.
But for more than 20 years, TV programs and commercials flashing at frequencies that can provoke seizures have been barred from broadcast in the UK. An exception to the regulation is made for breaking news coverage, where potentially seizure-inducing material is allowed to air if accompanied by a warning. These regulations were put in place after a noodle commercial triggered seizures in several British viewers.
Out of curiosity I tested a video clip of that New York sidewalk scene to see if the flash freqency falls into the category of a seizure hazard. I used an application called the Harding Flash and Pattern Analyzer (below) that assesses video sequences for seizure safety. The clip did in fact exceed flash safety limits for people vulnerable to visually induced seizures. Folks in the UK at least got an on-screen warning, which perhaps gives susceptible viewers a chance to avert their eyes.
What happens when American TV programs are shown in the UK?
TV programs and music videos imported to Great Britain from the US (and other countries) need to be tested first, then modified to comply with the British seizure safety mandate. An engineer in a London post-production studio who does this compliance work shared with me that a popular US crime series had nearly 150 violations of seizure safety guidelines in a single episode. Where is the consumer lobby for seizure-safe TV programming in this country? Anybody?