Is the American Academy of Pediatrics changing its recommendations to parents about children’s media use? Not really. Well, yes, in a way. But hard to say. It depends on what you think constitutes a recommendation.
As recently as 2013, the Academy’s official policy on media use discouraged any screen exposure for children under age 2 and recommended less than two hours of screen entertainment after that.
But in a piece in the October 2015 AAP News, after acknowledging that this advice already appears seriously out of step with today’s media environment, the Academy announced it intends to update its guidelines. No date for the update was provided.
Then, in the same article, the Academy proceeded to offer some advice for parents about children and media use, directing parents as follows:
“Play a video game with your kids. Your perspective influences how your children understand their media experience. For infants and toddlers, co-viewing is essential.” [emphasis added]
So, what is going on here? This is kind of murky. Despite some headlines to the contrary, the Academy of Pediatrics does not have a new policy on children’s media use. Instead, concerned about its reputation and trying to stay relevant, the Academy has published a dozen so-called “key messages” regarding media use “to inform and empower families.” Messages, not guidelines.
The key messages are mostly commonsense things like using media alongside your child, setting (unspecified) use limits, creating tech-free zones at home, etc. The messages are decidedly laid-back. Apart from the acknowledgment that “like any environment, media can have positive and negative effects,” the only potential negatives mentioned are sexting, posting self-harm images, and limited participation in other activities.
For the record, I strongly disagree with one of the messages: “The quality of content is more important than the platform or time spent with media.” No, no, no. This assertion runs counter to plenty of research on adverse neurological effects of screens. Platform matters: big screens, flashy images, and extended exposure all increase the risk of seizures and other manifestations of nervous system overload!
Predictably, this month’s key messages are being hailed in some quarters as validation of the safety of electronic media and repudiation of concerns about such safety. For example, in a Forbes piece with the misleading title “The American Academy of Pediatrics Just Changed Their Guidelines on Kids and Screen Time,” Jordan Shapiro writes, “It is about time…the AAP guidelines seemed like they were the result of familiar technophobic paranoia that always accompanies new technologies.” He cites his own words from a previous post:
“At this point, worrying about exposure to screens is like worrying about exposure to agriculture, indoor plumbing, the written word, or automobiles. For better or worse, the transition to screen based digital information technologies has already happened and now resistance is futile.”
It’s easy for Shapiro and others to be dismissive of any health concerns related to media, when the American Academy of Pediatrics’ “key messages” fail to include reminders that there still are health issues to be concerned about. Issuing these bland recommendations may do more harm than good by creating the impression for parents there’s nothing really serious to worry about.
Not So Fast…
The AAP’s key messages around media use resulted from an invitation-only symposium of researchers held in May. An article reporting on the proceedings of that symposium shows that—to their credit—the presenters in fact voiced concerns in a number of areas and called for more investigation of:
- Problematic/addictive media use that is often associated with mental health conditions such as depression and anxiety
- The relationship between media violence and aggressive/violent behavior
- The adverse effects of screen media on sleep
- The need for cultural diversity to be reflected in digital media
In addition, researchers:
- “urged the AAP to not shy away from unpopular recommendations and to formulate policy guided by the best available research”
- Noted that “one size doesn’t fit all with respect to digital interactions…the diversity of youth, families, and communities will influence resilience factors and vulnerabilities”
Unfortunately, few families are likely to know about these concerns, because very few will read the article summarizing the symposium’s presentations and recommendations. They’ll just hear the key messages and relax about it all.
One can hope that the next round of formal media use guidelines will thoughtfully incorporate these and other health issues related to digital media use by young people. The account of the proceedings suggests that the guidelines themselves will be more nuanced than the so-called key messages.
In particular I would like to see media guidelines for kids with mood disorders, ADHD, and autism spectrum disorders (ASD), whose brain physiology leaves them more vulnerable to adverse effects. Given government estimates that 13 to 20 percent of children ages 3 – 17 have a diagnosable mental health disorder, these children’s needs should figure prominently in any policy recommendations by the AAP.
“The mission of the American Academy of Pediatrics is to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.” — from AAP Facts
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.
Parents concerned about their kids playing shooter and adventure games that feature a lot of violence may feel more comfortable with the racing game genre. But these games aren’t necessarily harmless–because they contain lots of images with the potential to trigger seizures in those with photosensitive epilepsy.
Problem image sequences in racing games involve lights and patterns in a variety of scenes, such as:
- close-ups of rotating wheels/tires
- revolving scenery as seen by driver when cars do airborne flips
- collision impact shock, lighting change, and vibrations
- fast-moving patterns of quickly changing views of bridges, tunnels, and landscape features
I tested clips from 7 recommended racing games listed on a site that reviews video games, movies, music, and other media, and advises parents on their content. The potential of particular games (or any other media) to provoke seizures is absent in product reviews on this site and others.
Of the 7 games, 4 contained seizure-provoking sequences, and the remaining 3 had sequences that approached the safety limits. The very fast-paced action and inevitable crashes provide many opportunities for visual overstimulation, although some of the games with equally exciting visuals did not actually fail the seizure safety test.
My results were arrived at using the Harding Flash and Pattern Analyzer, a tool for determining compliance of video images with guidelines for prevention of visually induced seizures. Your results may vary:
- settings on your monitor affecting brightness, contrast, and other visual effects can raise or reduce the demands on the visual cortex
- factors such as fatigue, illness, alcohol, etc. temporarily lower an individual’s seizure threshold
- players will encounter game scenes I didn’t analyze
- sitting farther away from the screen and taking frequent breaks can lessen the images’ visual impact
Here are the results from the Harding Flash and Pattern Analyzer:
Methodology: I ran multiple video clips through the analyzer, including official announcement trailers and gameplay clips uploaded by users. If the initial test for a game didn’t show safety violations, I continued testing up to an additional 6 – 8 clips for each game before moving on (or until a failure occurs, if that came first).
I’ve previously tested multi-player, role-playing games (MMORPGs) and first-person shooters. Overall, based on my samplings of these genres and racing games, MMORPGs are least likely to trigger seizures.
Playing video games during school used to be against the rules, but not anymore. In fact, more students play them in school now, and not necessarily because they’re bored. Popular video games are being brought by teachers into the classroom as teaching tools.
While parents can monitor which games their kids play at home, when an entire class is working on projects in Minecraft—as part of the history curriculum–parents may not know or have any say in the matter. If parents have concerns about the teacher’s choice of games, they’re typically thinking about age appropriateness of content or the amount of violence depicted. The likelihood of particular games triggering seizures is unlikely to be on anyone’s mind. Shouldn’t the games our kids are exposed to during school pass tests for seizure safety?
Some years ago I observed my daughter in math class using an educational application to practice “math facts.” She had nothing to do after she’d finished the in-class assignment, so she was sitting in front of a program that ran a flashy screen sequence to reward students for getting a certain number of answers correct. We had already requested that she not be exposed to computer screens during school. I began to wonder what other video games were being used in school and whether they might possibly provoke seizures.
Since then computer use in schools and elsewhere has grown tremendously. Teachers are increasingly incorporating more complex games into the curriculum to engage students and provide more creative, immersive, open-ended learning experiences. Using World of Warcraft, Minecraft, Civilization, and other games teachers are providing instruction in such diverse skills as problem-solving, collaboration, resource management, narrative style, and inference, and in subjects such as government, history, and language arts. This trend is expected to grow as more teachers enter the workforce who grew up playing these immersive games.
Which of these games are safe?
Recognizing the opportunity for a huge new market and a promising approach to raising student engagement and performance, video game companies and teachers are now collaborating on developing school-friendly versions of popular games. The education consultancy TeachThought recommends six video games as platforms teachers can use to enrich instruction in any content area at any grade level:
The Elder Scrolls IV: Skyrim
Civilization V – one minor safety violation in about a dozen gameplay clips and trailers.
Using the Harding Flash and Pattern Analyzer, I tested these six for compliance with internationally developed guidelines for image safety for individuals with photosensitive epilepsy. Only one game—Armadillo Run—had real potential to trigger seizures. Surprisingly, it’s also the only game in this group that has no fiery explosions, villains, or monsters that typically generate the problem flashes in video games. Instead it’s a puzzle game showing simulated action of shapes and patterns, with a clean and appealing illustration style. Without actually testing a game for seizure safety, you can’t make assumptions about what’s safe and what isn’t.
When I previously tested World of Warcraft and other MMORPGs, and again in more extensive recent tests, I didn’t find a seizure problem. Minecraft, however, contains images that can trigger seizures in individuals with photosensitive epilepsy.
With so many games to choose from, there’s no telling which will be incorporated into classroom instruction and homework. And teachers (as well as students, parents, and doctors) don’t know which games are seizure safe. (Most game companies probably don’t know, either.) When choosing video games as teaching tools, teachers are likely to be swayed by other factors: their level of familiarity with the game, recommendations of colleagues, the relevance of story lines to the curriculum, and the degree of age appropriateness for their students.
How to get people to pay attention to the image safety issue? More on that in my next post.
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:
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.”
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).
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…
What do a loaf of bread and an action video game have in common? Both are man-made and widely consumed, yet hugely underrecognized as potentially serious health hazards. There are a lot more parallels.
Sensitivity to gluten, the primary protein in wheat, and to the bright flash and rapidly moving patterns game of screens, are both considerably more pervasive than the medical community and the general public had realized. Awareness of gluten sensitivity has grown tremendously in the past decade, though, because a portion of the medical community broadened its understanding of a disorder once defined by very rigid diagnostic criteria.
Consider this comparison:
Progress on the gluten front
For decades the only type of gluten sensitivity recognized by doctors was celiac disease, a severe condition that often, but not always, manifests with gastrointestinal problems. The only diagnostic testing required an intestinal biopsy that–turns out–is easily falsely negative. After a negative biopsy, would be told that celiac disease had been ruled out, and that therefore it was OK to eat wheat and other grains containing gluten. In actuality many of these patients either had celiac–but a misleading biopsy that didn’t collect tissue samples from the affected area of the intestine–or they had a different form of gluten sensitivity that causes damage only to other body organs, rather than the intestine.
Because doctors were taught in medical school that celiac disease is very rare, occurring in only one in several thousand individuals, there seemed to be little reason to consider the diagnosis in patients, order a biopsy, or question a negative biopsy result. Some researchers suggest that ten percent or more of the American public has a sensitivity to gluten, in most cases with no obvious symptoms or symptoms that don’t suggest a food sensitivity. Even without obvious symptoms gluten intolerance can be a very serious disorder that affects daily functioning and quality of life.
Growing numbers of consumers without an official diagnosis of gluten sensitivity are being more proactive by experimenting on their own with a gluten-free diet as a healthier way to eat. Many notice a range of improvements in their well-being from this change. A rapidly expanding market of prepared gluten-free foods makes a gluten-free lifestyle less burdensome. An increasing number of restaurants offer gluten-free menus, and new gluten-free foods are a booming market for food retailers. Celiac and gluten-free support groups provide practical and moral support. In addition to peer-reviewed research, there are now a lot of books for consumers and online resources. Probably most consumers are learning about gluten sensitivity from these sources rather than their clinicians, and some are helping educate their doctors about it.
The photosensitive epilepsy front
Because doctors were taught in medical school that photosensitive epilepsy is very rare, occurring in only one in several thousand individuals, there has seemed to be little reason to consider the diagnosis in patients, order an EEG with photic stimulation, or question a negative or inconclusive EEG. There is no practical, reliable way to know how prevalent photosensitive epilepsy is in the general population. Even without obvious symptoms of a seizure, people who experience subtle seizures can experience impairments that affect daily functioning and quality of life.
Without an official diagnosis of photosensitivity, consumers can experiment with a screen-reduced or screen-free lifestyle–should they have an inkling that subtle seizure activity caused by screen exposure is affecting their health. However, at this time there are few products or supports to help them cut back on recreational screen time. A limited number of mental health providers offer therapy for Internet or video game addiction. Most focus on treating the addiction itself rather than on overcoming the physical and mental health consequences of exposure to potentially seizure-causing screens. Consumers are still essentially on their own to figure out the connection between video games and seizure activity, and there is little for them to read on the subject. Little research is being carried out in the US on photosensitivity and today’s electronic entertainment.
Perhaps there is reason to be encouraged by the progress in educating the public and clinicians about gluten-related health problems. In the face of similar obstacles to wider awareness and prevention, it should be possible for seizures induced by visually overstimulating electronic media to become better known, understood, and prevented. In the interim, a great deal of work lies ahead to empower consumers with the information they deserve about screen-induced seizures. Please help spread the word.
If a neurologist tells you that you don’t need to worry about seizures from electronic screen exposure, because you’re not photosensitive, what does that really mean?
It means that when you were tested for your response to a white strobe light, an EEG didn’t detect a particular abnormal electrical pattern in your brain. (I’ve noted some limitations of this procedure elsewhere.) Epileptology looks for yes or no, typically relying on EEG to rule out epilepsy. If yes, possibly medicate; if no, it’s not a case the clinician will pursue.
It does not indicate that bright flashing and/or patterns from electronic screens don’t adversely affect your brain function.
Researchers have gradually come to consensus on exactly what the EEG must look like to indicate photosensitive epilepsy (the photoparoxysmal response): certain spike/wave patterns that appear in both brain hemispheres. In arriving at these criteria, researchers excluded three other types of EEG abnormalities that in prior research “qualified” as a photoparoxysmal response. Epilepsy researchers aren’t certain what the significance of these other abnormalities is, but because the other patterns cannot conclusively be associated with epileptic seizures, there’s little interest in further research.
So these other EEG abnormalities from photic stimulation don’t count, in current neurology practice, and nobody would even tell you about them if they were found in your EEG. You’d be told the EEG was normal, period. But what if these other abnormalities were a sign that neurological function is in fact disturbed by visual stimuli, but not to the point of a seizure?
Let’s say you had one of the three other EEG abnormalities (which you wouldn’t know about, because the EEG was deemed normal). Maybe these indicate that you’re vulnerable to symptoms of a visual-overload-not-to-the-point-of-seizures syndrome. Neurologists have been examining the overlap between epilepsy, photosensitive epilepsy, and migraines. More about this in a future post, but actually there are many overlapping symptoms and correct diagnosis can be difficult. So if video game exposure or photic stimulation produces headaches and visual disturbances, and an inconclusive EEG, it may be that the visual overload is triggering migraines. Or perhaps the exposure is triggering another form of hyperexcitability in the brain’s visual cortex, which has been termed visual stress. While research has been done on this, it’s not part of a conventional neurology practice.
What about patients with more subtle or mood-related symptoms of a visual-overload-not-to-the-point-of-seizures problem? Who is treating these patients? Could be psychiatrists and psychologists, who view altered behavior and cognitive function through the lens of their respective training. Because there’s such a dearth of research of the gray areas of brain dysfunction following exposure to electronic screens, mental health providers have no basis for treating these patients for anything but mental health disorders. It’s clear that more research is needed and that more effects on the brain will be uncovered. One intriguing paper explores the contribution of fluorescent lighting to agoraphobia. The SpongeBob study published last year showed diminished executive function in children who viewed the cartoon.
In her Psychology Today blog, psychiatrist Victoria Dunckley recently posted a compelling piece about the effects on her patients of electronic screen time. She recommends creating a diagnostic category called Electronic Screen Syndrome to identify a dysregulation of mood, attention, or arousal level due to overstimulation of the nervous system by electronic screen media. She has seen dramatic improvements in hundreds of patients’ mood, behavior, and cognition after they go on an “electronic fast.” (Some have underlying psychiatric diagnoses, some don’t.) Maybe these patients were having very subtle seizures from electronic screens. Maybe the effects on the nervous system weren’t quite what epileptology defines as seizures. Either way, many kids exposed to electronic screens are experiencing diminished quality of life (as are their families) for a problem that medicine has not yet acknowledged.
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.
In a Taiwan Internet cafe last weekend, an 18-year-old identified only as Chuang died shortly after playing 40 uninterrupted hours of Diablo III. The exact cause of his death is still being investigated.
What would cause someone to lose touch with his surroundings so completely that a tragedy like this could happen? Whatever is found about the specific cause of death, the loss of this young man’s life is a reminder of the enormous power of some games to draw players in and keep some of them beyond spellbound.
To learn a bit about Diablo III, I read a review on GameSpot that was written shortly after the game’s release in May. In what is now a haunting foreshadowing, reviewer Carolyn Petit alludes a number of times to very positive game attributes that make players want to stay in the game. Staying in can turn dangerous when players lose all ability to connect with their judgment, their own bodies, and the world around them.
The problem with “irresistible” is that some people in fact absolutely cannot resist. Here are excerpts from the review:
- “The constant stream of gold and treasure you earn is irresistible. Blizzard has the recipe for crafting a habit-forming loot-driven action RPG down to a science, and in Diablo III, the results of that recipe are more exciting and more addictive than they’ve ever been.”
- “The rate at which you acquire new skills is part of what makes Diablo III so hard to pull yourself away from.”
- “It’s about employing those skills to slaughter the monsters you encounter as you travel the world, and collecting the loot the fiends drop. This is where Diablo III’s habit-forming pleasures lie.”
- “Loot is doled out at a pace that makes your victories fulfilling and makes fighting the next group of foes lurking in the shadows ahead nigh irresistible.”
- “The cycle of combat and loot and more combat is addictive, but without peril, it would eventually become unfulfilling. Thankfully, the hosts of hell become increasingly dangerous over time.”
- “You may ultimately be victorious at vanquishing the forces of hell, but if their true mission is to give you a compelling reason to sacrifice sleep as you keep clicking your mouse into the wee hours of the night, then they have won a decisive victory.”
I wonder if, since learning about what happened to Chuang, Ms. Petit has had any thoughts about what she wrote in her Diablo III review. Would she write it any differently now? In future reviews of other games would she write about their addictive qualities in the same way? Somehow, describing games with words like irresistible, habit-forming, hard to pull away from, and addictive doesn’t sound quite so positive anymore.