The pediatricians of this country, working with the American Academy of Pediatrics, are in a position to help reduce the continuing public health risk of video games and other media that can induce seizures. They should lobby the entertainment industry — something they already apparently do regarding other media matters — to produce games without seizure-inducing images.
As I’ve written previously, the AAP is rethinking its policy on media use by young children. Now it’s clear why: the American Academy of Pediatrics’ Council on Communications and Media published new data this month on media use by very young children. According to the study, there is “almost universal exposure to mobile devices, and most had their own device by age 4.”
The media landscape has changed significantly since the AAP drafted its 2011 policy statement discouraging media use in children under age 2. Mobile ownership has increased sharply–the authors note that tablets weren’t available yet when the 2011 recommendations were written.
As part of its updated policy statement on media use, the Academy will issue revised advocacy and research objectives. How about advocating for electronic entertainment that doesn’t provoke seizures?
AAP’s current advocacy priorities on kids and media
The AAP’s Council on Communications and Media policy statement on media use from November 2013 contains a variety of advocacy recommendations, including proposals that pediatricians and the AAP:
- Advocate for a federal report within the National Institutes of Health or the Institute of Medicine on the impact of media on children and adolescents
- Encourage the entertainment industry to “reassess the effects of their current programming”
- Establish an ongoing funding mechanism for new media research
- Challenge the entertainment industry to make movies without portrayals of smoking and without product placements
Proposed changes to above initiatives
Here’s how these points should be expanded to encompass the health risk to unknown numbers of children who experience seizures from flashing visuals:
- Advocate for a federal report within the National Institutes of Health or the Institute of Medicine on the impact of media on children and adolescents, including the neurological impact of flashing screens
- Encourage the entertainment industry to “reassess the effects of their current programming” – including the physiological effects of flashing and high-contrast patterns
- Establish an ongoing funding mechanism for new media research that includes studies on the vulnerability of young people with ADHD, autism spectrum disorders, and mood disorders
- Challenge the entertainment industry to make movies without portrayals of characters smoking and without product placements and to make video games without the flashing and pattern characteristics that can trigger seizures
Question for the AAP Council on Communications and Media
There are many angles and interests that must be considered in making your next policy statement. I have a lot to add to the conversation as far as reducing the risks to young people of screen-triggered seizures, many of which go undetected. Would you accept my assistance? I would be happy to help.
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
Many parents sense that media use affects their children in vague, unseen ways. They’re not imagining it. I have an excellent book to recommend if you’d like to understand more about the way children’s brains–and therefore all aspects of daily function–are stressed by video games. Three years ago I cited a piece by child and adolescent psychiatrist Victoria Dunckley about the effects on the nervous system of interactive screen time. Dr. Dunckley outlined a syndrome of dysregulated mood, attention, executive function, and arousal that develops in response to exposure to video games and other interactive, screen-based applications.
I’m delighted that last month she published a comprehensively researched, clearly and compassionately written book explaining how interactive screens affect children’s mood, thinking, and arousal, with a lot of practical guidance on how to restore their children. In Reset Your Child’s Brain: A Four-Week Plan to End Meltdowns, Raise Grades, and Boost Social Skills by Reversing the Effects of Electronic Screen-Time, Dr. Dunckley validates parents’ concerns, pulling together research from a range of scientific fields, and in clear language explains screen-time’s effects on the nervous system.
Dr. Dunckley suggests thinking about the stress on the brain from the stimulation of electronics use as not unlike caffeine, amphetamines, or cocaine. She makes a compelling case that the nervous system’s hyperarousal (fight-or-flight response) that kicks in while playing video games sets in motion an array of biological mechanisms that lead to significant functional impairments. She says that seizure activity, along with other tangible symptoms including migraines and tics, is at the extreme end of a continuum of nervous system dysfunction due to the brain’s hyperarousal. Irritability and general nervous system dysfunction are at the other end of the continuum. Other symptoms on that spectrum include mood swings, poor executive functioning, poor impulse control, anxiety, depression, body clock disruption, and immune system suppression.
Dr. Dunckley stresses that the impairments from screen-time are not limited to screen-addicted kids or those who play violent video games, and that playing “in moderation” can still affect a child’s nervous system. Exposure tolerance varies greatly, so some children can resume limited screen use without relapses in behavior and functioning. Those with ADHD or autism spectrum disorders have a greater likelihood of becoming dysregulated by screen exposure. In general, though, the more stimulating the sensory experience, from vivid colors, rapid movements and scene changes, and multi-modal sensory input, and the more frequently the child is exposed to it, the greater the accumulated strain on the nervous system. The greater that strain, the more difficult it becomes for children to control their emotions and behavior.
“Whatever the subject manner, the style or manner in which content is delivered has its own impact. Research indicates that movement, zooms, pans, cuts, and vividness…contribute to repeated fight-or-flight reactions. Screen size affects arousal levels as well, with larger screens producing higher levels of arousal.”
On to the good news: if given respite from overstimulation, the nervous system can restore itself. Dr. Dunckley has treated hundreds of patients whose mood, behavior, and cognitive abilities have been restored after an electronic “fast,” in which electronic screens are set aside for 3 to 4 weeks for an initial evaluation period. In many cases serious limits or total abstinence from screens is necessary to sustain the remarkable improvements in daily functioning that occur. The majority of the book is devoted to practical guidance for parents on how to undertake the daunting task of disentangling a young person from daily screen use.
This book is done extremely well. It begins with a thoughtful synthesis of non-industry-funded research from widely dispersed fields, connecting the dots to show what the body’s response is to environmental stressors. Dr. Dunckley shows considerable respect for parents’ conflicted feelings and their guilt about their own screen habits:
“Let’s face it. Hearing that video games, texting, and the iPad might need to be banned from your child’s life does not fill one with glorious joy. Rather, for many, it creates an immediate urge to find a way either to discredit the information or to work around it…the inconvenience of what I’m proposing can seem overwhelming…some folks feel as though their parenting skills are being judged, or that their efforts or level of exhaustion are underappreciated.”
Dr. Dunckley provides cases from her own practice that show how life-changing the difference can be when a child’s nervous system is given a respite from electronic screens. This is serious business:
“The goal of screen limits is not merely to get rid of bothersome symptoms but to optimize a child’s development over time. All children benefit from screen limits, which have a compounded effect on functioning later in life.”
She is spot on. As some of you know, I’ve been there. Eight years ago it was a bittersweet revelation to see my daughter’s potential reemerge after a long period of impairments and health problems brought on by video game seizures. She lost several years of optimal learning, social development, and health because of frequent seizures we were unaware of during her daily video game use. We didn’t realize just how severely she’d been affected until she swore off gaming and made dramatic gains.
For the record, I don’t hate video games. But I am very disturbed that they can be so damaging to kids’ everyday functioning and potential. Read this book! Share it with your friends, too.
Note: I’ve linked to the book’s Amazon.com page so you can see the very enthusiastic reviews posted there. I am not endorsing Amazon, nor do I have a financial stake in any purchase you may decide to make.
A 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.
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.
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?