A continuum of visual sensitivity

Even readings outside the red zone may indicate the need for caution.

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.


ADHD, video games, and seizures

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.


The problem with irresistible

According to a GameSpot review, Diablo III is “devilishly captivating and addictive.”

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.


Canaries, autism, and sensory overload

Like canaries testing air safety in a coal mine, people with autism are the first to be affected by hazards in our everyday environment.

“I believe that when the science is in, we will see that people with autism are ‘canaries in the coal mine,’ the most susceptible, who are affected first by problems that may eventually reach us all.”

–from The Autism Revolution by Martha Herbert, MD, PhD, with Karen Weintraub (Ballantine Books, 2012)

Martha Herbert reasons in her remarkable book that the rapidly increasing prevalence of autism indicates the disorder can’t possibly be due to genetics alone. She makes the case, based on findings in diverse fields of medical research and on her own clinical experience, that autism is not a genetic trait destined to be lifelong. Instead, she’s suggesting that the rise in autism is a consequence of the environment we live in, and that many autism symptoms can be reduced by making environmental changes. It’s compelling reading whether or not someone you love has autism, because, Herbert contends, many of the environmental influences that probably contribute to autism will likely affect all of us in time.

While the development of autism may begin with genetic vulnerability, she argues, the emergence of the disorder begins after a tipping point is reached following a multitude of modern-day environmental exposures. The cumulative effects of these environmental stresses influence the expression of genes associated with autism, leading to a cluster of brain and body dysfunctions typical of this spectrum disorder. Autism rates are sharply rising because the biological systems of growing numbers of young people are running out of the resilience required amid burgeoning environmental challenges.

Sensory overload as environmental stressor 

Dr. Herbert explores environmental influences including toxins, emotional stress, infection, diet, and sensory overload. She cites many cases where people with autism got a lot better when specific changes in these environmental factors were made, thereby reducing assorted stresses on the brain and body. Eliminating the right stressors, which may require considerable trial and error, can allow some children to become significantly higher-functioning, healthier individuals.

city-night-explosion-fireworkIn any individual, whether or not autism is present, identifying and avoiding environmental seizure triggers can produce big improvements in a range of physical, cognitive, and emotional difficulties associated with seizure activity. Dr. Herbert suggests that seizures, which are not uncommon in people with autism, can cause or exacerbate some problem behaviors in this population.

The only study done to date on autism and photosensitivity indicates children on the autism spectrum have much higher rates of photosensitive epilepsy. Given the high rate of other types of epilepsy in those with autism, this is not surprising. To be quite clear, I’m not suggesting that video games cause autism, nor does Dr. Herbert. But preventing seizures that exacerbate autism symptoms can be a major stepping-stone to wellness.

Dr. Herbert outlines many steps parents can take, beyond seizure reduction, to limit exposure to things that can magnify autism symptoms and may contribute to its emergence. While not every approach works for every child with autism, she provides a range of additional strategies such as eliminating gluten, dairy, and food additives, regulating sleep, getting rid of toxic household chemicals, and reducing sensory overload.

“Too much sensory stimulation, trouble being coordinated, not enough sleep, seizures, not being able to say what you want—all can contribute to frustration and stress. Looking for solutions at each of these levels can help reduce the stress and increase the time spent truly learning and enjoying life.”

“Gray zone” electrical activity

Dr. Herbert does not assume that a finding of “no seizures” on an EEG means that visual stimuli are not affecting the brain’s normal electrical firing. The consequences of brain waves that are “somewhere between ‘normal’ and ‘disease,'” she contends, could be “subtle but still important”–even if no actual seizures are triggered. In other words, even mildly abnormal rhythms in the brain, which can be provoked in some individuals by exposure to visual overstimulation, may result in impaired neurological functioning. Even if your child has not been experiencing actual seizures, Dr. Herbert says these abnormal rhythms due to excessive sensory stimulation from visual media may actually affect the brain’s ability to process information.

“…A lot of kids with autism might be having ‘gray zone’ electrical problems—too mild to meet the formal definition of seizures, but enough to interfere with their quality of life.”

These “gray zone electrical problems” are not limited to those with autism. Other populations likely to be in this gray zone include people with learning disorders, intellectual disability, or psychiatric conditions—the more vulnerable among us. In other words, it may not make sense to dismiss as irrelevant the EEG abnormalities that don’t clearly indicate seizures.

Reducing overload

If your child is on the autism spectrum, you probably already know to reduce your child’s sensory overload. One way to do that is to limit screen time and avoid overstimulating content. Try eliminating video games for a few days and see if your child begins to feel better and struggle less with learning, attention, emotions, and behavior. (Your child may be initially quite resistant to this experiment, which will temporarily make things more stressful. To get a fair reading on the effect, you need a few days free of any withdrawal symptoms.) During this video-game-free time all visually overstimulating media should be avoided, including fast-paced cartoons, movies, and music videos.

Those whose children aren’t on the autism spectrum should also take note. By applying the canary-in-the-coal-mine model, we may yet learn that visual overstimulation can profoundly affect the functioning and health of many people, including those without autism. When the visual system of anyone with hidden photosensitivity is no longer overloaded by daily video games, lives can be transformed.

Could anyone in your family be affected? It’s something to think about.

 


Toddlers with iPads

Darren Murtha Design’s Shape Builder was one of five iPad apps recommended to parents in a New York Times column.

A piece last week in the Wall Street Journal questioned whether there might be effects on brain development when really young kids play with iPads and similar devices. The answer is simply:  nobody knows. The article points out that

…In many ways, the average toddler using an iPad is a guinea pig. While the iPad went on sale two years ago, rigorous, scientific studies of how such a device affects the development of young children typically take three to five years.” 

and it quotes a couple of experts:

“‘There is ‘little research on the impact of technology like this on kids,’ says Dimitri Christakis, director of the Center for Child Health, Behavior and Development at Seattle Children’s Hospital….”

 “’Unfortunately a lot of the real-life experimentation is going to be done by parents who now have young kids,’ says Glenda Revelle, associate professor of human development and family sciences at the University of Arkansas.”

The article was written by Ben Worthen, a father who was concerned about the trance-like state he and his wife observed in their 4-year-old son playing with an iPad. Worthen notes that it soon became a battle every night when his son was asked to turn off the iPad.

“’It gives him a dopamine squirt,’” says Michael Rich, director of the Center on Media and Child Health at Children’s Hospital in Boston, referring to the brain chemical often associated with pleasure. Many apps for kids are designed to stimulate dopamine releases—hence encouraging a child to keep playing—by offering rewards or exciting visuals at unpredictable times.”

Some people say that after all the dopamine rewards from video games, it’s not as easy to pay attention to activities that don’t deliver regular bursts of dopamine. And while many parents are pleased with the way educational apps appear to help with early learning, they also speak of their kids’ immersion for hours at a time. When I think of toddlers, it’s hard to come up with any other activities that hold their attention for that length of time. Maybe the toddler brain isn’t designed to focus for so long on one thing at a time when they’re exploring the world around them?

A few small studies have shown gains in vocabulary in young kids who used educational apps. Some researchers think the iPad may not have the same neurological effects as video games and TV, which the American Academy of Pediatrics has cautioned can be harmful in very young children, whose brain development is at a critical stage in their first few years. But the technology is so new, there aren’t any such studies yet.

We don’t really know what effect major doses of screen time has on older kids, either, or on adults. Kids growing up today with so much fast-paced visual technology from such an early age may display differences in brain development in ways we haven’t uncovered yet. The issue is much broader and more complex than whether or not these young brains are experiencing seizures brought on by video action. There could well be subtle changes in brain function that wouldn’t register as seizures but that affect processing nonetheless. More on that in my next post.

In the meantime I encourage you to check out the article that started off the discussion, with accompanying video and audio reports.


Kanye West loves strobe lights

The Harding Flash and Pattern Analyzer shows flash levels in “Lost in the World” fail seizure safety guidelines by a wide margin. At upper left is a screen grab from the new video.

“Kanye West loves strobe lights,” cooed the Huffington Post the other day, reporting the release of the performer’s most recent flash-filled music video. “…the Chicago rapper…seemingly earns an epilepsy warning with every new project. His new video for the not-so-new song ‘Lost in the World’ certainly doesn’t deviate from the pattern.”

Apparently he loves strobe lights so much that–despite being informed, two music video releases ago–that his flashing visuals provoke seizures in some viewers, he is determined to use these effects anyway. Wow, you have to really respect a man who refuses to let the health of the viewing public get in the way of his artistic freedom. The Huff Post article continues in the same admiring tone: “…the rapper is known for his emphasis on quality videos (his half-hour ‘Runaway’ short film was perhaps the biggest statement of the rapper’s visual aesthetic).”

The rapper’s acknowledgement of a potential seizure problem has followed a strange path. In February 2011, accounts of seizures triggered by West’s “All of the Lights” video spurred UK-based Epilepsy Action to request that the video be removed from YouTube. In response, the video was temporarily removed and a warning was placed at the beginning:

This video has been identified by Epilepsy Action to potentially trigger seizures for people with photosensitive epilepsy. Viewer discretion is advised.

A year later the “N—-s in Paris” video was released with this same warning, although Epilepsy Action was never contacted about it.

And now there’s a warning at the beginning of the “Lost in the World” video that doesn’t even explain why the warning is important for viewers. All it says is:

Warning:  Strobe effects are used in this video.

I expect Epilepsy Action will probably make a statement regarding the risks of viewing this latest release, and perhaps take issue with the less-than-explicit warning that was provided. How about some advocacy in the US? It’s time to confront the very preventable public health problem created by strobe effects in entertainment media.


Teaching about photosensitive and “regular” epilepsy together: 1+1=3

Click image for 4/12/2012 editorial at epilepsy.com on including photosensitivity in epilepsy awareness campaigns.

The American epilepsy community makes information available on photosensitive seizures but in general doesn’t go out of its way to advocate for protecting consumers from visual media that can provoke seizures. Our epilepsy community doesn’t want to want to call too much attention to the risk of seizures from brightly flashing, visually overstimulating products and experiences. The priorities for public education and advocacy don’t include teaching the public about why video games contain those warnings.

But everybody wins–the “mainstream” epilepsy population, those with exclusively photosensitive seizures, and members of the public with a need to know–when epilepsy public education campaigns raise awareness of both types of epilepsy, in the context of the other.

Epilepsy doesn’t deserve its stigma and the notion that it’s an affliction exclusively of the seriously disabled. Raising awareness of epilepsy as a spectrum of seizure disorders that includes visually triggered seizures in otherwise healthy individuals could help engage the public and change misperceptions. And, much-needed photosensitivity education and advocacy can be most effectively delivered by established, well respected epilepsy organizations, as part of an overall public education program.

Here’s how I envision this:

  • Part of photosensitivity education is making people aware they could already be having visually induced seizures they have never identified. People who learn about subtle, undetected seizures experienced with or without a visual trigger can seek medical assessment and treatment. People with undetected photosensitive seizures might come to understand the source of  their unexplained symptoms during or shortly after being exposed to video games, TV, music videos, and other visual media.
  • Those with no history of seizures and no idea they might be photosensitive would realize they should be mindful of unusual sensations and actions while exposed to lots of flash and pattern motion. Parents would be more vigilant about observing their children who are engaged in screen-based activities, and about asking them about possible symptoms of subtle seizures.
  • Doctors would routinely inquire about patients’ exposure to visual media and about any unusual aftereffects, and they would recognize from patient histories when suspicion of photosensitivity is warranted.
  • People who learn they have photosensitive epilepsy would know how to protect themselves and their families from triggering stimuli–through avoidance, the use of dark glasses, and limiting problem images to a small portion of the viewing field.
  • The isolation and stigma endured by those with “regular” epilepsy will ease when people learn that seizures are a common disorder. The general public will understand that seizures are experienced by a broad spectrum of individuals, some who have other disabilities as well, and many who don’t. Some have seizures provoked by visual triggers, and others have seizures due to other, often unknown, triggers.
  • On the strength of the advocacy of  well-established epilepsy organizations, public health policy makers will become aware of the need for greater consumer protections, such as those in the UK, that require or encourage games, TV, online content, and movies to meet international guidelines for seizure-safe visual media. None of this is even under discussion in the US.

I’ve considered things from both the typical epilepsy and the exclusively-photosensitive-seizures perspectives. After discovering my daughter’s photosensitivity, we saw dramatic gains in her health and functioning after she gave up video games, her main visual trigger. But her wellness didn’t last and she went on to develop “regular” epilepsy. Daily life today is affected by unpredictable seizures and by the need to always be vigilant for visual triggers in the environment. I believe people with mainstream epilepsy–and the general public–have a tendency to assume that reflex seizures are simple to prevent and therefore the disorder is less burdensome than spontaneous seizures.

I wrote an editorial proposing that photosensitivity play a central role in a new type of awareness campaign about epilepsy. You can read “A Different Public Education Campaign” in this week’s epilepsy.com Spotlight newsletter, where I’m addressing the mainstream epilepsy community, and making the case for bringing photosensitivity under the epilepsy awareness umbrella, as it were.