“Problematic” gaming higher in autism, ADHD

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

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

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

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

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

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

Nintendo knew about, downplayed seizure risks: BBC report

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

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

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

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

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

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

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

Top First-Person Shooters Fail Safety Test

FPS screen captureA while back, I looked at some MMORPGs (massive, multi-player, online role-playing games) and found that they typically don’t pose a high risk of triggering photosensitive seizures. Their appeal lies in the social world of collaborative missions, the acquisition of skills and material goods, and immersion in a detailed narrative.

First-person shooter (FPS) games are a different story. They offer continuous combat with lots of vivid, brightly flickering sequences, a scenario that is much more likely to bring on visually induced seizures. Because players watch from the shooter’s up-close perspective, the flashes from explosions brightly illuminate much of the entire screen. When more of the field of vision is exposed to flashes, more neurons are activated for visual processing, raising the seizure risk. Lots of quick scene cuts are typical while the shooter races and maneuvers through territory at top speed. In addition, the rapid fire of high-caliber weapons causes shaking and vibrating of the scene that adds to players’ visual processing load.

I don’t offer an opinion about the content, value, message, or age- appropriateness of video games. My purpose  is to provide information on their potential to induce photosensitive seizures in people who may have this genetic vulnerability. But I will confess that I turned my attention to FPS games after the recent news that that Navy SEALS had shared classified information with the developer of  Medal of Honor: Warfighter. I was curious as to whether the game was also likely to provoke seizures. In fact Warfighter does fail the test for seizure safety, and it also received poor reviews and didn’t sell well. My testing showed that two blockbusters in this game genre, Halo 4 (with launch day sales of $220 million) and Call of Duty Black Ops 2 ($500 million during its first 24 hours), released last month, violate international guidelines for preventing photosensitive seizures.

Given their huge popularity and the high ranking of many FPS games on reviewers’ best-of-the-year lists, it seemed like an appropriate time to look at the seizure safety of FPS games as a category. I tested the 14 games on GameSpot’s list of the most popular FPS games (which includes all gaming platforms). To obtain representative scenes from each game, I downloaded official trailers and user-submitted video  from YouTube. Most were less than 5 minutes long. If the first clips I tested for a game didn’t fail the safety test, I tested several more clips for each game, since it was possible that failing sequences weren’t included in a particular clip. In all I tested several dozen video segments on the Harding Flash and Pattern Analyzer. As shown in the table below, the visuals in every game either exceeded the limits for photosensitive seizure safety or came close to the limits, a result that received a “Caution” grade from the analyzer software. Note that any game that didn’t actually fail cannot be deemed seizure-safe, since it could easily have unsafe sequences I didn’t locate.

PlanetSide 2, Far Cry 3, Halo 4, Warface, S.T.A.L.K.E.R:  Call of Pripyat, Call of Duty:  Black Ops Declassified, ZombiU, Call of Duty: Black Ops 2, Borderlands 2, Natural Selection 2, Metro 2033, Team Fortress 2, Borderlands, Call of Duty:  Black Ops

FPS games from GameSpot’s “best games by popularity” list

The Caution designation by the analyzer software recognizes that every individual’s vulnerability to seizures changes in response to internal factors (such as fatigue, illness, alcohol, menstrual cycle, stress) and environmental conditions (proximity to/size of screen, screen brightness, duration of play). The risk of seizures for any individual using the same game on different occasions varies depending on  these circumstances.

So caution when playing shooter games is certainly appropriate. Take breaks, don’t play when sleep-deprived, and don’t sit too close to the screen. A game that’s never triggered seizures before may trigger a seizure another time, even in people who’ve never had a seizure in their lives because photosensitivity is a latent trait until it is activated. Sometimes seizures are so subtle people may not realize they are happening, but even small seizures can affect mental and physical functioning for a day or two.

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.

MMORPGs don’t provoke many seizures

“Got to find my way out of this damned forest already…!”

What do these massive, multi-player, online role-playing games (MMORPGs) have in common?

Grim Dawn
Guild Wars 2
The Secret World
Civilization V
World of Warcraft

I tested all of them for photosensitive seizure safety.  Five out of these seven games tested within photosensitive seizure safety guidelines, meaning they’re unlikely to provoke visually induced seizures. Judging by what I found, this genre of video games is probably one of the safest, in contrast to, say, racing or shooter games. Those that failed contained just one failure apiece, based on what I looked at, anyway.

Lots of factors contribute to the risk of a game provoking seizures.Visual overload results from certain styles of directing (close-ups, quick cuts and zooms, overall pacing, image brightness), the artistic “look” (bold outlines, bright colors rather than a more “painterly” approach), and production (maximizing speed, violence, and explosions).  In general the MMORPGs show a wide-angle view of the action, which lessens the visual impact of each individual blow, shot,or  explosion that is shown with a screen flash. The scenes are built by designers who pride themselves on the careful crafting of the game’s elaborate and fantastical story lines, landscapes, creatures, and structures. The pace is slow enough for players to appreciate the scenery and plan strategies.

Testing Methodology

To get an unbiased sample of MMORPGs to examine, I turned to the GameSpy newsletter. Its current issue contains reviews of seven highly anticipated video games to be released or updated this year. I decided to test those. To determine whether these games could provoke seizures, I downloaded official marketing teasers and trailers plus gameplay clips from the Web and submitted them for analysis to the Harding Flash and Pattern Analyzer.  I have no financial interest in any of the companies involved in developing, producing, testing, or marketing any video games.

Admittedly, I’m not using rigorous sampling techniques. I don’t have a staff of reviewers or statisticians to ensure total methodological correctness in this investigation. So here’s what I did. If the FPA found no problem segments in the first trailer I looked at for a particular game, I tested another trailer or clip for that same game. My thinking was that if one trailer/clip contains no seizure-inducing segments, that doesn’t mean another clip would fare the same. In the case of World of Warcraft, though, I looked at four or five trailers that all passed the FPA. At that point it seemed reasonable to judge that the game is probably not teeming with undiscovered flashing material.

On the other hand, if I came across any material that failed the safety test, I didn’t feel the need to look for additional samples of that game just to show it has safe sequences, too. If a developer/publisher demonstrates unsafe video sequences in a trailer used for marketing, that suggests there may well be more unsafe material. Assuming the trailers posted online are reasonably representative of the game content, this exercise in looking at trailers can provide some idea of how risky the games might be, photosensitive seizure-wise.

Here are the results. And the disclaimers. The results are based on only the visual sequences I downloaded to be analyzed by the FPA software. Your results may vary! Certainly other excerpts, levels, expansions, versions, etc. of any given game may produce different results, as may extreme levels of photosensitivity. And any game using anime style–whether it calls itself an MMORPG or not–is very unlikely to be safe. With all the disclaimers, what is the value here? It’s exactly this:  if you have any concerns about the possibility of video games triggering seizures, it does seem that for the most part this type of game presents a lower risk than fast-action close-up shooting and racing. I’ll look at these other genres in upcoming posts.


Grim Dawn

Guild 2

TERA – some segments stayed just inside the safe zone, and its Frogster (European publisher) logo-in-motion didn’t pass

Passed, but limited “footage” was available for testing


World of Warcraft

Problems found

Civilization V – 1 brief sequence noted in 3 trailers/gameplay clips

The Secret World — 1 sequence noted in 3 trailers/gameplay clips

Click on each screen for a better look at images (upper left) within video segments that could trigger photosensitive seizures. Degree of compliance with seizure safety guidelines is shown in the line graph, where anything beneath the horizontal line falls within the guidelines.

Flicker in this scene caused the one seizure safety failure I encountered in looking at three downloaded clips/trailers of Civilization V.

This flame-filled sequence in TERA stayed awfully close to the pass/fail line. People with a greater degree of sensitivity to flash might be at risk.

A rapidly changing arrangement of newspapers in The Secret World caused excessive flash.

Extra video game usage worsens existing attention problems in impulsive kids

A new study is the first to show that kids with attention deficits play more video games, which worsens the attention problems they were born with. Unfortunately, they are especially strongly drawn to the stimulation of games that end up pulling them into a downward spiral of more screen time and then even greater disruption of neurological function. Previous studies have shown that screen time increases attention problems, but this is the first that shows that those who start with attention problems are more likely to be exposed to screen time that compounds their neurological vulnerability.

“Children with greater impulsiveness and attention problems spend more time playing video games, which in turn increases subsequent attention problems and impulsiveness.”

— From Douglas A. Gentile et al.’s “Video Game Playing, Attention Problems, and Impulsiveness:  Evidence of Bidirectional Causality” in Psychology of Popular Media Culture, January 2012 (Vol. 1 No. 1.)

ADHD develops in children not merely as a consequence of genetic make-up. Environment can be an influence on its expression and severity, too. The study authors note that not enough research has been done on environmental factors that influence attention and impulse control.

“For the past 30 years, most of the research on attention problems has focused on biological and genetic factors rather than on environmental factors. This allowed for rapid advances in drug therapies, but has also caused many researchers and members of the general public to assume that impulsivity and attention problems were not modifiable by experience. This is unfortunate, as it means we have only focused on part of the solution. Furthermore, many problems with genetic bases are clearly enhanced by environmental triggers. By understanding some of the environmental influences, we can develop more effective solutions for children and parents. More research is clearly needed on the environmental factors, especially factors that are easily modified by parents, such as screen time.”

This study mentions four possible explanations for the association of electronic media and greater attention problems, an association that has been shown in other studies.

  • Children accustomed to the greater excitement level of playing video games may have more trouble focusing on much less stimulating tasks, such as school work or chores.
  • Time spent with video games displaces time that might have been spent developing greater impulse control.
  • Kids with poorer self-control may find it harder to resist the pull of exciting screen time.
  • As-yet unidentified factors that may be hidden within the data already assessed

I’ve got a fifth explanation: Could it be that kids with attention problems are more likely to have visually induced seizures from video games? And that the seizures, which leave behind cognitive impairments, create additional deficits in attention? Individuals with ADHD develop epilepsy at a rate that is 2.5 higher than the general population. About 20 percent of individuals with epilepsy have ADHD, whereas about 4 – 8 percent of the general population do. This higher prevalence in both directions suggests some common neurological weaknesses and/or processes.

Nobody has ever studied the sensitivity of kids with ADHD to seizures from video games. Just as kids on the autism spectrum deserve a study on their vulnerability to video game seizures, so do kids with ADHD. Some real data would allow parents of these kids to be more vigilant about video game exposure and to be watching more carefully for possible after-effects of gaming.

Gentile and colleagues noted that one predictor of increased attention problems, in addition to the total amount of screen time, was video game violence. They speculate that this might support the theory of screen time displacing time that could be spent learning impulse control. Because these are psychology (not medical) researchers, and because they want to get away from the biological model, they don’t raise the issue of neurological overload and/or seizures as a possible cause of declining attention capacity. But thinking about it in terms of the neurological impact on a kid with ADHD is certainly consistent with the influence of screen violence on attention. Violent games are apt to involve higher levels of visual stimulation, with the flashes of explosions, crashes, and assorted dismemberment scenarios.

What do you think?

Are games the trigger or the cause of seizures? Does it matter which?

Photo by Ron Marshall. Some rights reserved. http://www.flickr.com/photos/ronmarshall/

Online forums open to all comers have a way of passing along bad information. For example, in response to a question about whether video games can cause tremors and muscle spasms that could be seizures, the following was recently posted:

“Computer games don’t cause seizures; they simply contain triggers that people with the condition photosensitive epilepsy (seizures that occur more frequently in reaction to certain patterns of light flashes) who already have epilepsy which [sic] causes them to have seizures. You cannot “get” seizures from playing video games…”

The responder is so intent on deflecting liability for seizures away from video games that a meaningless exercise in semantics is being played about whether the games cause seizures. C’mon. The question was whether the gamer could be having seizures due to video games. The answer is a definite yes. This was not a question along the lines of “Do cigarettes cause cancer?” Distinguishing between seizure triggers and their intrinsic causes fails to answer the question properly.

This poster’s response may have been influenced by a 30-second video about video game seizures, made by an internal medicine specialist who’s made clips about a variety of medical issues. Answering the question of whether playing video games can cause seizures, the doctor, Lisa Bernstein, MD, uses this same approach of making an unnecessary distinction between trigger and cause, saying:

“Video games cannot cause seizures. What we do know, however, is that people who are particularly prone to seizures, who have something called photosensitive epilepsy, have their seizures brought on by flickering or flashing lights often found in video games. So only these particular patients are at risk for having seizures with video game. Everyone else should be fairly safe playing them.”

Let’s examine Dr. Bernstein’s statements. We already know there’s a problem with the first sentence. But there are other problems as well:

  • Suggesting that nobody except those with photosensitive epilepsy needs to worry about video game seizures encourages a false sense of security. It presumes that anyone who is photosensitive already is aware he/she has the condition. Photosensitive seizures commonly occur in people who have never had a seizure before. These people are unlikely to have been tested for photosensitivity and are therefore completely unaware they’ve inherited this condition. When hundreds of Japanese children had seizures in 1997 during a Pokemon cartoon broadcast, only one fourth had ever had a seizure previously.
  • The prevalence of photosensitivity peaks in adolescence. Thus someone who’s played games for years as a child, while the inherited photosensitivity trait is still hidden, has no expectation that the condition is present and merely dormant. The trait is apparently activated by hormonal changes in adolescence.  From that point on it will declare itself only in the presence of certain visual triggers, and sometimes, only under certain circumstances such as sleep deprivation or alcohol consumption. A history of no visually induced seizures is no guarantee of a future free of them.
  • Her answer suggests that photosensitive seizures happen only to people who are “particularly prone to seizures.” A person whose seizures are triggered exclusively by specific visual stimuli is not necessarily particularly prone to seizures. For comparison, consider nonphotosensitive individuals with epilepsy who may have many seizures every day with no known trigger.

In August I emailed my concerns about the clip to Dr. Bernstein and VideoMD.com, the site that hosts health-related videos uploaded directly by Dr. Bernstein and other physicians. Although I didn’t hear back directly, I can no longer find this clip at www.videomd.com. However, the video has been picked up by other sites and lives on.