Pediatricians should push for fewer seizures!

pediatricianThe 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.


Pediatricians backpedalling on kids’ media use?

backpedal

How much is the American Academy of Pediatrics retreating from its guidelines on media use in children? We’ll find out when the guidelines are in fact changed.

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.

Key Messages

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.

Looking Ahead

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


“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.


Lawsuits filed after games caused seizures

courtroomNo  consumer has won a product liability/personal injury case against a game manufacturer whose video game triggered seizures. Cases were either dismissed, settled, or won by the game company.

Despite their limited usefulness to consumers,  seizure warning notices do seem to provide legal protection to game publishers. And juries have a hard time awarding damages to plaintiffs with a pre-existing condition, even if plaintiffs didn’t know of their photosensitive epilepsy prior to the seizure(s) triggered by a video game.

In one case Nintendo actually conceded that its game had in fact triggered seizures, but that didn’t get in the way of the company winning the case. A judge later overturned the jury’s verdict because Nintendo had withheld critical information in contempt of court.

The cases date back to 1991, but the apparent total number of cases–ten–is pretty small.  One has to wonder what percentage of the seizures triggered by exposure to video games are ever identified as visually induced seizures.

One of the few consumers to reach a settlement is John Ledford of Alabama, whose settlement agreement bars John from discussing his own case. John has found another way to raise awareness of video game seizures. He has researched other cases and reached out to epilepsy organizations around the globe to raise their awareness of the continuing seizure hazard from video game images. John’s Facebook page contains most of the history I’ve assembled here:

Year Filed State Plaintiff(s) Game(s)/Platform/Defendant  Outcome 
1991 MI 15-year old Laura Moceri had grand mal seizure while playing. Kid Icarus (Nintendo) Lost
1993 IL Chicago boy suffered occasional seizures during many hours of game play. Nintendo Dismissed
1995 AL John Ledford had his first ever grand mal seizure while playing game at an arcade. The seizure damaged his optic nerve and caused blindness in one eye. King of the Monsters II (SNK Corp.) Settled
1998 LA 13 year-old Joey Roccaforte had clusters of violent seizures Mega Man X (Super Nintendo) Jury ruled for Nintendo; judge later vacated the decision because Nintendo withheld critical information before and during trial.
2001 LA Esther Walker, mother of 30-year old Benjamin Walker, who died from hitting his head on a table and sustaining internal injuries during a game-induced seizure. Nintendo 64 Lost
2001 LA 11 year-old Michael Martin, son of  Eric Martin, mayor of St. Martinsville, LA. Seizures that began happening during games began occurring also during sleep. Super Mario Kart (Nintendo 64) Settled personal injury claim; lost case advocating better warnings.
2001 LA 6 year –old Kynan Hebert, son of Lynette Benoit Nintendo Dismissed
2002 FL 16 year-old Dominic Zummo Star Wars Episode I: Jedi Power Battles (LucasArts Entertainment, SONY) Unknown
2007 NY While watching his brother play a game, 4 year-old boy had a seizure causing permanent injury. Spyro: Enter the Dragonfly (Vivendi, SONY Playstation 2) Last available information: attorney for plaintiff was seeking other plaintiffs for class action suit
2011 CA Navy F-18 pilot John Ryan McLaughlin injured in a grand mal seizure that causes permanent loss of flight status Oblivion: The Elder Scrolls IV (Bethesda Software), Sony Playstation 3. Still pending; no other information available.

What constitutes product liability?

In 1997 the criteria for product manufacturer’s liability for a product that has caused harm were revised by the American Law Institute, an independent body of legal experts that drafts and publishes restatements of common law in order to clarify and simplify it. Its work is used as a resource by state lawmakers, judges, and lawyers. Every state has its own laws concerning burden of proof, the awarding of damages, and the like.

The 1997 restatement of product liability law states, “a product is defective when, at the time of sale or distribution, it contains a manufacturing defect, is defective in design or is defective because of inadequate instructions or warnings.” These conditions are then defined separately:

  • A product “contains a manufacturing defect when the product departs from its intended design even though all possible care was exercised in the preparation and marketing of the product.” 
  • A product “contains a design defect when the foreseeable risks of harm posed by the product could have been reduced or avoided by the adoption of a reasonable alternative design by the seller or other distributor, or a predecessor in the commercial chain of distribution, and the omission of the reasonable alternative design renders the product not reasonably safe.” 
  • A product “is defective because of inadequate instructions or warnings when the foreseeable risks of harm posed by the product could have been reduced or avoided by the provision of reasonable instructions or warnings by the seller or other distributor, or a predecessor in the commercial chain of distribution and the omission of the instructions or warnings renders the product not reasonably safe.”

Some game companies are apparently working to make games that do not provoke seizures, but only Ubisoft has made a public commitment. As far as I can tell, most are merely reworking their warnings.


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.


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.


Pediatricians miss a big opportunity

Last month the American Academy of Pediatrics Council on Communications and Media issued a policy statement entitled “Media Use by Children Younger Than 2 Years.” The document reaffirms the AAP position of discouraging media use in children under age two, a position first articulated by the organization in 1999. The council based its recommendation on three factors, including the potential adverse health and developmental effects of media use.

Authors of the policy statement missed a big opportunity to mention to the public that visually induced seizures from electronic media are a possible health consequence worthy of concern. Instead, the AAP considered and listed the usual physiological and neurobehavioral outcomes that are typically measured in studies regarding media exposure:  behavior, attention, obesity, learning, mood, language development, and sleep. With the exception of obesity, all of these aspects of health and development can be indicators of seizure activity.

Why not even a mention of seizures, a well documented health risk?  Probably because visually induced seizures are considered so rare by the medical establishment that the vast majority of studies on media effects on children don’t even raise the issue. Interestingly, the policy statement didn’t mention the risk of media addiction, either. Too controversial perhaps—incredibly, there is still plenty of academic posturing about whether excessive time spent playing video games constitutes addiction.

In August 2004 the Epilepsy Foundation of America convened a task force on photosensitivity to review the considerable research on visually induced seizures and to make recommendations about prevention. In a paper published the following year in Epilepsia, the group concluded its findings by stating, “a seizure from visual stimulation represents a significant public health problem. No known method can eliminate all risk for a visually induced seizure in a highly susceptible person, but accumulation of knowledge about photosensitivity is now at a level sufficient to develop educational programs and procedures in the United States that substantially will reduce the risk for this type of seizure.”  

Who was supposed to take responsibility for this message and follow up? The nation’s pediatricians haven’t even received the message yet.

In its paper the task force laid out some of the methodological complexities and obstacles to ascertaining how common photosensitive seizures really are:  studies are generally done on selected populations that don’t represent an average cross-section, researchers have had varying definitions of what qualifies as an indicator of photosensitivity on an EEG, the inability of EEG to pick up all seizures, variation in specific stimuli that individuals respond to, the greater intensity of today’s computer graphics, and so on. As I’ve mentioned previously—and the Epilepsy Foundation photosensitivity task force states this—the conventional photosensitivity prevalence numbers are clearly an underestimation. Until researchers find ways to more accurately account for the number of those who are at risk, and recognize those whose symptoms are less easily noticed, doctors in the US aren’t going to take the problem seriously, and little progress will be made to protect the unsuspecting public against visual media-induced seizures.