Safe to play a game that passes the seizure test?

I've been using charts like this one to show results of testing for adherence to photosensitive epilepsy guidelines.

Until now I’ve posted charts in this format to show whether a game meets photosensitive epilepsy guidelines…

According to a Reddit post, a game that I’ve said “passed the seizure test” triggered a seizure. Recently the same game—Hearthstone—could have been implicated in a professional gamer’s seizure that happened during a live stream. What’s going on?

I write about games I’ve tested to alert readers to the games that don’t meet internationally recognized image safety guidelines. But I don’t want to create undeserved confidence that a game that passed the seizure test will be safe for anyone with photosensitive epilepsy.

Ian Hamilton, a user interface designer who specializes in and advocates for game accessibility, clarifies the role of testing this way:

“Passing the Harding test doesn’t mean that a game is safe. It means ‘reasonably safe’ because common triggers have been avoided. Something that gets a ‘pass’ can still absolutely cause seizures.”

I regularly write that your experience may differ, that I’m not trained in quality assurance, that I test excerpts of game play, and that health and lifestyle variables affect every individual’s vulnerability to seizures at any given time. Still, the meaning of my findings could be misleading without an understanding of the limitations of the seizure test itself:

  1. the pass/fail guidelines aren’t expected to prevent seizures in all individuals
  2. the test was designed for TV images, not video games

What the Pass/Fail guidelines mean

The guidelines originated in 1994, when the UK’s agency for regulating TV broadcasting (now known as Ofcom) inserted into its code of standards some technical guidelines to accommodate viewers with photosensitive epilepsy. These guidelines, based on studies of photosensitive epilepsy and consultation with Prof. Graham Harding and other photosensitive epilepsy experts, detail flash rates and spatial patterns that typically trigger seizures in people with photosensitive epilepsy. Specifications regarding saturated red images were added later, after the 1997 Pokémon incident in Japan.

Some compromises in the guidelines were made for the sake of practicality. Criteria for acceptable images (commonly referred to as the Harding test) were developed with the understanding that they would realistically protect most individuals with photosensitive epilepsy, but not all. For example, the guidelines permit images that flash at a rate of up to 3 times per second because flash at that frequency affects only 3 percent of photosensitive individuals. UK regulators decided that was “an acceptably small risk.”

I'm taking the word "safety" out of the chart since passing the test doesn't guarantee seizure safety

…but I’m updating all the charts by removing the word “safety” since passing the test doesn’t guarantee seizure safety.

The introduction to the guidelines states that their purpose is “reducing the risk of exposure to potentially harmful stimuli.” It also concedes that even when broadcasting images that comply with the guidelines,

“it is…impossible to eliminate the risk of television causing convulsions in viewers with photosensitive epilepsy.”

Applying TV guidelines to video games

There are no formal guidelines for reducing the seizure risk from video games. A 2005 consensus paper by experts on photosensitive seizures acknowledges that additional work would be required first on the existing guidelines for TV. In the meantime, it is reasonable to use the television guidelines since the impact of screen images on the visual system is the same.

The biggest challenge in applying TV specifications to video games is explained in the consensus paper:

“These principles are easier to apply in the case of fixed media (for example, a prerecorded TV show), which can be analyzed frame-by-frame. Interactive media, such as video games, may afford essentially limitless pathways through the game, depending on user actions. Therefore …in the case of video games, the consensus recommendations apply to typical pathways of play but cannot cover every eventuality of play.”**
Also,when players set their own viewing perspectives and preferences in newer video games, they may create unanticipated seizure risks.

Reducing risk going forward

In sum, a game that fails the Harding test is best avoided by those with photosensitive epilepsy. A game that passes is less likely to act as a trigger. Despite all the qualifiers, I believe there’s value in reminding people that seizures can happen to anybody, that certain video games can trigger them, and that you can lessen the risk by selecting games without lots of flash and patterns. Other strategies to lessen the risk of photosensitive seizures can be found here and here.

Tip of the hat to Ian, who suggested that I avoid the word “safe” when describing games that have passed the test. I also will be revising my prior posts to do some rewording.

Gamer’s seizure on live stream

Here’s a reminder that seizures can happen to anyone. A professional gamer known as Lothar had a seizure recently during his live feed while playing Hearthstone on Twitch. Lothar apparently has no history of seizures and the seizure may or may not have any connection to Hearthstone. In updates about his condition and hospital stay, Lothar didn’t mention photosensitive epilepsy nor has he said he’s been advised to limit his gameplay. 

For the record, Lothar is also a body builder—he’s obviously a guy who has enjoyed good health and takes good care of himself. Lothar has a large and caring following and has been receiving lots of well wishes as he recovers. Why do I mention this incident here? Viewing the incident (you can find it on YouTube) and seeing how it affected so many fans who care about him reinforced for me the seriousness of seizures and the importance of preventing those that are preventable.

** Graham Harding et al. (2005), Photic- and Pattern-induced Seizures: Expert Consensus of the Epilepsy Foundation of America Working Group. Epilepsia, 46: 1423–1425.


CNET endorses 7 video games that can trigger seizures

Uncharted: The Nathan Drake Collection is the only one of CNET's recommended games where I didn't find image sequences that can provoke seizures.

Uncharted: The Nathan Drake Collection is the only one of CNET’s recommended games that didn’t fail the seizure test.

Wouldn’t it feel terrible to give someone a present that could set off an epileptic seizure? If you consult the CNET guide to video games for 2015 holiday giving, you’ve got 8 games to choose from–of which 7 contain seizure-inducing images. In the 3+ years that I’ve been testing selected video games for seizure-provoking graphics, this is easily the most lopsided result I’ve found.

The following table shows the games recommended in CNET’s “The best video games to give this holiday season” feature, with results of testing them for image sequences capable of triggering seizures. Testing is done with an application designed for this specific purpose (more info on that is below in the testing methdology section).

Uncharted: The Nathan Drake Collection, Call of Duty: Black Ops 3, Fallout 4, Halo 5: Guardians, Just Cause 3, Super Mario Maker, Star Wars Battlefront, Rise of the Tomb Raider

CNET’s choices for best video games to give this holiday season

Interpreting the results

Passing the seizure guidelines test means that in the 1.5+ hours of gameplay and cutscenes I tested, all image sequences meet well-defined guidelines for reducing visually induced seizures. I am not set up to test every possible sequence (video game developers should be able to do this, though). To get a “fail” on my tests, all that’s needed is one violation of the guidelines, which could occur within the space of a second or two. Again, since I do not test every possible sequence, it’s very possible–and likely–that the game also has other problem images that I didn’t test.

Your results may be different. Each person’s seizure threshold can be affected by a number of factors apart from the visual stimulus itself: illness, hunger, stress, fatigue, alcohol, medications, length of play, and others. So a game played without incident may trigger a seizure in the same player under different conditions. Also, players can be exposed to new and different image sequences in subsequent games.

CNET selected conventional action/adventure titles for its gift-giving guide. These games typically have plenty of shooting, explosions, and rapid movements that produce flicker in the seizure-inducing range of more than 3 flashes per second. In contrast, recent video game recommendations from both the New York Times and Los Angeles Times, with less tech-focused audiences, added some unconventional titles to their top picks. It’s worth noting that the less traditional games were less likely to fail the seizure test.

Uncharted: The Nathan Drake Collection–the one game CNET chose that meets the seizure reduction guidelines–is an action/adventure game, too, with some shooting and the occasional explosion, but designed without flickering images or other visual overload.

 Call of Duty Black Ops 3 Fallout 4 Halo 5: Guardian Just Cause Super Mario Maker Star Wars Battlefront Rise of the Tomb Raider

Images in Uncharted: The Nathan Drake Collection show explosions yet stay within seizure prevention guidelines.

Why it matters

Nobody wants to think about the risk of seizures that can be triggered by video games, figuring they’re extremely rare (they aren’t) and that the risk only applies to “people with epilepsy” (not so). Also, people assume that seizures are always of the grand mal type, with loss of consciousness, lots of involuntary movements, etc., so that they would be very obvious events (most seizures are not like this).

If you assume seizures are very obvious, then you also assume you’d hear a lot more about seizures that happen in front of computer screens and consoles. But many seizures are much more subtle, some so subtle that nobody realizes they’re happening. Even in these instances, though, the after-effects may mean impaired functioning for up to several days, or longer, affecting energy, concentration, memory, sleep, and mood. You can read here about how game-induced seizures we couldn’t see affected my daughter.

Vulnerability to seizures from bright flashes and rapid flicker, known as photosensitive epilepsy, is a genetic trait that’s latent in an unknown percentage of the population. This means that there are people with no idea they have this sensitivity to visual stimuli–until they are triggered and experience a noticeable seizure. So these people assume the seizure warnings accompanying video games don’t apply to them, or they just ignore them.

Testing tool and methodology

I run downloaded gameplay clips, cinematic clips, and promotional trailers for each game and submit the sequences to an application called the Harding Flash and Pattern Analyzer. (Graham Harding is one of the world’s leading experts on photosensitive epilepsy.) The FPA is widely used by producers and networks in the UK—including by the BBC—to reduce the risk of seizures from material on broadcast TV. I don’t know how many of the major game developers in this country use the FPA–they keep such information very much to themselves.

The analyzer examines video sequences for very specific and measurable image qualities that researchers have found can trigger seizures:

  • rapidly alternating light and dark images (flash/flicker)
  • certain stripes and geometric patterns with high contrast
  • large areas of very bright (“saturated”) red
  • problem images take up more than one quarter of the total screen area

If the first clip I test of a game fails the seizure guidelines test, I then move on to test the next game. If no guideline violations are found, I typically test at least 4 or 5 additional clips of that game–usually more, if I have a hunch due to the game genre and/or overall look of the sequences that there might be unsafe “footage” that I haven’t yet found. Most image sequences that fail the test do so because of strobe-like flicker.

Games that pass could have seizure-provoking sequences that I was unable to locate. I don’t do this testing while actually playing video games. Instead I work with video clips available online, some of which are official marketing and gameplay trailers; others are cutscenes and gameplay sessions posted by reviewers or fans. I avoid testing any clips of gameplay that were made using modifications to the original game software.

Other games I tested in 2015

This year I’ve tested also tested some other highly praised video games for their seizure risk (plus the games recommended by the New York Times and Los Angeles Times as noted above). Those results are here and here.


LA Times’ best video games of 2015: 4 can trigger seizures–and that’s progress

The mobile game Prune is about cultivating trees. The object is to prune branches in order to let the tree grow around obstacles.

In the game Prune, players help trees grow.

The Los Angeles Times’  list of 10 best video games of 2015 includes 4 with images that could provoke a seizure. While this isn’t great, it’s not as bad a ratio as I typically find. Usually the best of year/best of show lists contain a higher percentage of games with a real seizure risk, so this is actually better than I expected.

The Times reviewer, Todd Martens, noted that this year there was a broader selection of games and they offered a wide range of player experiences and perspectives. And a number of his favorites are refreshingly novel in their imagery.

Martens writes about his choices in an accompanying piece entitled “Games in 2015 were better when they stepped away from the guns.”

“For a medium that for much of the last decade has been overrun with machismo, 2015 in video games represented a year of powerful role reversals. It was time, finally, to put down the guns… At a time, culturally, when mass shootings are part of our daily conversation, the industry’s over-reliance on games with guns is not only no longer fun, it’s exhausting.

The idea of swapping weapons for actual stories should be celebrated in any medium, but in gaming, where guns, bullets and senseless bloody murder have long ruled the day, it felt downright revolutionary.”

So here’s another reason to celebrate the appearance of appealing games that don’t rely on guns: without the widespread shooting, mayhem, and destruction that have dominated in many top-selling games, there are fewer scenes with flicker and flash that can provoke seizures. (It is quite possible, though, to depict such scenes without creating large, rapid, and bright flashes on the screen.)

I tested clips from the Los Angeles Times Top Ten list using an application that detects image sequences that can trigger seizures in vulnerable individuals. If you’re still doing holiday shopping, you might want to consider these results when choosing gifts. Here’s what I got:

Best video games of 2015 chosen by the Los Angeles Times

Disclaimers

Please remember that there are no guarantees your results will match mine and that many variables affect a person’s susceptibility to visually induced seizures. Each person’s seizure threshold can be affected by a number of factors apart from the visual stimulus itself: illness, hunger, stress, fatigue, alcohol, medications, length of play, and others. So a game played without incident may trigger a seizure in the same player under different conditions. Also, players can be exposed to new and different image sequences in subsequent games.

Testing methodology

I run downloaded gameplay clips, cinematic clips, and promotional trailers for each game and submit the sequences to an application called the Harding Flash and Pattern Analyzer. The FPA is widely used by producers and networks in the UK—including by the BBC—to reduce the risk of seizures from material on broadcast TV. I don’t know how many of the major game developers in this country use the FPA–they keep such information very much to themselves.

The analyzer examines video sequences for very specific and measurable image qualities that researchers have found can trigger seizures:

  • rapidly alternating light and dark images (flash/flicker)
  • certain stripes and geometric patterns with high contrast
  • large areas of very bright (“saturated”) red
  • problem images take up more than one quarter of the total screen area

If the first clip I test of a game fails the seizure guidelines test, I then move on to test the next game. If no guidelines violations are found, I typically test at least 4 or 5 additional clips of that game–sometimes more, if I have a hunch due to the game genre and/or overall look of the sequences that there might be problem “footage” that I haven’t yet found.

Games receiving a PASS could have seizure-provoking sequences that I was unable to locate. I don’t do this testing while actually playing video games. Instead I work with video clips available online, some of which are official marketing and gameplay trailers; others are cutscenes and gameplay sessions posted by reviewers or fans. I avoid testing any clips of gameplay that were made using modifications to the original game software.

Other games tested in 2015

I’ve tested additional video games this year for their seizure risk. You can find results herehere, and here.

 


Seizure-inducing images found in 6 video games from NY Times 2015 holiday gift guide

boy opens presentWhen choosing a video game for someone on your holiday gift list (or for yourself), wouldn’t it be good to know whether the game contains images that could trigger a seizure? The seizures caused by certain video game visuals are a health risk that most people don’t stop to consider.

They’re also more common than people realize.

So at this time of year I like to provide some guidance on seizure likelihood in the games you might be thinking of buying. I test the games recommended in holiday gift guides, looking for the types of image sequences that can provoke seizures.

Today I’m reporting on the 10 video games suggested as gifts this year by the New York Times. Take a look at the introduction to the video games section of the guide.

“Buying someone a new video game can be a little like sending a family member on an unexpected foreign trip. It’s a nice gesture, and will surely be appreciated, but it’s awfully hard to know whether you’ve picked the right destination….Here are a few places to consider taking yourself, or your loved ones, on vacation this winter.”

— New York Times 2015 Holiday Gift Guide

There’s no hint in the prose above that the “right destination” could involve more than the entertainment value of the game. The narrative reads as though the worst possible consequence of your buying choice could be a less-than-totally-fun game experience. The “right destination” stakes actually are much higher for some people, since seizures are pretty serious business.

How to know the level of risk

  • There is no practical way for consumers to know in advance whether a given video game contains the types of flashing and pattern movements that can provoke seizures. Games are rated for mature content and violence but not for seizure risk. One obvious clue, sometimes provided by the game studios, is the presence of lots of quick flashes in the promotional trailer.
  • Visually provoked seizures can happen in individuals with no history of seizures.
  • There is no way to know whether an individual might be at risk for visually induced seizures. They may not have encountered the specific visual provocation that leads to a seizure. Or they may have had a seizure while playing, without realizing it.
  • Seizures can be hard to identify–many are very subtle and don’t involved falling down or lots of movement. Even subtle seizures, though, can be followed by significant impairments: difficulties with concentration and disruption of emotional control and sleep patterns.

Which games in the Times gift guide appear to be OK?

Using software that analyzes visual sequences for the types of rapidly flashing images and moving patterns that can produce seizures, I tested the 10 games recommended by the Times buying guideIncidentally, this software is intended for developers, not for folks like you and me–it allows them, should they opt to use it–to deliver a safer consumer product. This chart shows the results:

Minecraft: Story Mode, Splatoon, Sage Solitaire, Her Story, Until Dawn, Super Mario Maker, SOMA, Star Wars: Battlefront, Metal Gear Solid Plan: The Phantom Pain, The Witcher 3: Wild Hunt

Recommended games from the 2015 New York Times holiday gift guide

I’ll get to the details in just a bit of how I do the testing—there is no way I can test anywhere near all the scenes and story lines in a game. I’m not a one-person quality assurance department! Basically, after looking at and submitting multiple clips of a given game to an analysis tool designed for detecting seizure-inducing images, I eventually either find material that poses a seizure risk, or determine that further testing won’t uncover any.

Please remember that there are no guarantees your results will match mine and that many variables affect a person’s susceptibility to visually induced seizures.

Testing methodology 

I run downloaded gameplay clips, cinematic clips, and promotional trailers for each game and submit the sequences to an application called the Harding Flash and Pattern Analyzer. The FPA is widely used by producers and networks in the UK—including by the BBC—to reduce the risk of seizures from material on broadcast TV. I don’t know how many of the major game developers in this country use the FPA–they keep such information very much to themselves.

The analyzer examines video sequences for very specific and measurable image qualities that researchers have found can trigger seizures:

  • rapidly alternating light and dark images (flash/flicker)
  • certain stripes and geometric patterns with high contrast
  • large areas of very bright (“saturated”) red
  • problem images take up more than one quarter of the total screen area

If the first clip I test of a game fails the safety test, I note that and move on to test the next game. If no safety violations are found, I typically test at least 4 or 5 additional clips of that game–sometimes more, if I have a hunch due to the game genre and/or overall look of the sequences that there might be unsafe “footage” that I haven’t yet found.

Games I’ve listed as safe could have seizure-provoking sequences that I was unable to locate. I don’t do this testing while actually playing video games. Instead I work with video clips available online, some of which are official marketing and gameplay trailers; others are cutscenes and gameplay sessions posted by reviewers or fans. I avoid testing any clips of gameplay from modified game software.

Disclaimers

Each person’s seizure threshold can be affected by a number of factors apart from the visual stimulus itself, including illness, hunger, stress, fatigue, alcohol, medications, length of play, and the player’s menstrual cycle, among others. So a game that ordinarily seems OK may trigger a seizure in that same player under different conditions.

Other games tested in 2015

Holiday buying/year-end isn’t the only season for seizure guidelines compliance testing. I’ve tested additional titles this year. You can find results here and here. Also here.


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


Reclaiming a child’s brain from video games

Reset Your Child's Brain book coverMany 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.”

Victoria Dunckley, MD

Victoria Dunckley, MD

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.

 


Epilepsy Action Tweet protects Twitterverse

Epilepsy Action Twitter 2

Fantastic what Epilepsy Action accomplished the other day with one tweet! The UK-based epilepsy advocacy group addressed a Tweet to Twitter UK asking for removal of 2 video advertisements with quickly changing colors that had the appeared as flashing images. Within an hour Twitter UK responded graciously that it had deleted the offending ads.   

A major bonus–the exchange resulted in news stories in dozens of media outlets, including the Los Angeles Times, Yahoo TechFortune, and the BBC News, raising awareness of the problem and showing Twitter UK as a responsive corporation. 

Epilepsy Action followed up with gracious words, too:

Epilepsy Action Twitter 3

Using the same Twitter strategy, Epilepsy Action succeeded again yesterday in getting an unsafe ad removed by media giant Virgin Media. (See Twitter exchange further down.) For some time I have been admiring Epilepsy Action’s diligence regarding photosensitive epilepsy awareness and their outreach to organizations whose products/services place the public at unnecessary risk of seizures.

Why don’t we see this kind of advocacy in the US?

  • It’s not a priority of US epilepsy advocacy organizations to proactively protect the public from seizure-inducing images.
  • Unlike the UK, we have no regulations barring images that could trigger seizures. In the UK both online and broadcast advertising are bound by the following rule:

“Marketers must take particular care not to include in their marketing communications visual effects or techniques that are likely to adversely affect members of the public with photosensitive epilepsy.”

  • Broadcast TV in the UK is governed by a rule that, in addition to protecting against seizure-inducing content, frequently reminds the public of the risk of photosensitive seizures. No equivalent reminder exists here that raises awareness among the entire public of photosensitive epilepsy:

“Television broadcasters must take precautions to maintain a low level of risk to viewers who have photosensitive epilepsy. Where it is not reasonably practicable…and where broadcasters can demonstrate that the broadcasting of flashing lights and/or patterns is editorially justified, viewers should be given an adequate verbal and also, if appropriate, text warning at the start of the programme or programme item.”

  • Because the public is often reminded of the potential for images provoking seizures, and because the government has chosen to enact regulation of moving images, it’s not an out-of-the-ordinary event for people to notice and report problem images.

Could individuals use Twitter to ask video game companies to remove potentially harmful images?

It certainly seems like something we should try. On the other hand, there are some major differences between reporting seizure-triggering online ads and bringing seizure-triggering images in a video game to the developer’s attention. For starters:

  • Removing/altering problem sequences from a video game is much more technically complex than removing or fixing a seconds-long video ad from an online platform. Many popular video games are built over a period of years, using huge amounts of code, and allowing lots of variation in what images might appear onscreen, depending on how the game is played.
  • An individual asking for a modification from a corporation doesn’t carry nearly the same weight as an organization such as the Epilepsy Foundation.
  • Consumers’ communication about specific games typically occurs within members-only user forums that aren’t seen by the general public–thus no pressure from outside the user community.
  • These user forums can be quite hostile when the topic of seizures comes up. Here’s one quote from within the gaming community.

“…(also, if you have epilepsy (knowingly), and you try to play a videogame, you don’t deserve a seizure, you deserve to be hit by a truck, and if you discover epilepsy when playing a game, that just means you have a very very sucky medical condition, its not like the game GAVE you epilepsy, just the seizure associated with your condition, its not the games fault, blame the DNA, DAMN DNA!)”

So…I will try contacting some game companies on their official Twitter page to let them know their game has failed the Harding Flash and Pattern Analyzer in my tests. Has anyone reading this tried to contact a video game company to report that a game triggered a seizure? I will let you know how I do!!

[Update: February 8, 2016] So I forgot to post an update. I tried tweeting 8 times to various game companies about their game having seizure-provoking images. No response…and assume that’s enough evidence to prove my point that some advocacy organization with name recognition needs to take on the issue.


Best games of E3 2015: how many look risky?

RIBBONS-BLUE-1ST-PLACE-ROSETTESGames industry websites and journalists have announced their picks for the best new video games demonstrated at this month’s annual Electronic Entertainment Expo (E3).

That lets me get to work assessing those games for seizure risk, so I can identify which popular titles in the next crop of releases are less likely to trigger seizures. (I suspect I’m one of very few on the planet who tunes in for this purpose to the annual “best-of” video game lists. I want to see if the development studios are doing more to cut down on image sequences that can set off seizures in people with photosensitive epilepsy.)

I tested the winners chosen by Hardcore Gamer in 9 game categories. Five of the winners—including the Best Game of Show winner, Deus Ex: Mankind Divided—contained seizure-provoking flashes and/or patterns.

Here are my results, using the Harding Flash and Pattern Analyzer to check for images likely to trigger seizures in individuals with photosensitive epilepsy. Please remember that there are no guarantees your results will match mine and that many factors affect a person’s susceptibility to visually induced seizures. Also, the seizure safety guidelines are designed to protect most (97 percent) but not all people with photosensitive epilepsy.

 Cuphead NHL 16 Unravel Horizon: Zero Dawn No Man's Sky Street Fighter V Battleborn Need for Speed Deus Ex: Mankind DividedTesting methodology 

I run downloaded gameplay clips, cinematic clips, and promotional trailers for each game and submit the sequences to the Harding Flash and Pattern Analyzer. The FPA is widely used by producers and networks in the UK—including by the BBC—to reduce the seizure risk of all material on broadcast TV.

The analyzer examines video sequences for very specific and measurable image qualities that researchers have found can trigger seizures:

  • rapidly alternating light and dark images (flash/flicker)
  • certain stripes and geometric patterns with high contrast
  • large areas of very bright (“saturated”) red
  • problem images take up more than one quarter of the total screen area

If the first clip I test of a game fails the guidelines compliance test, I note that and move on to test the next game. If no violations are found, I typically test at least 4 or 5 additional clips of that game–sometimes more, if I have a hunch due to the game genre and/or overall look of the sequences that there might be unsafe “footage” that I haven’t yet found.

The image analyzer found Deus Ex: Mankind Divided contained images that can provoke seizures.

The image analyzer found Deus Ex: Mankind Divided contained images flashing at a rate that can provoke seizures.

Disclaimers

Games with a PASS result could have seizure-provoking sequences that I was unable to locate. I don’t do this testing while actually playing these video games. Instead I work with video clips available online, some of which are official marketing and gameplay trailers; others are cutscenes and gameplay sessions posted by reviewers or fans. I avoid clips showing games that have been modified with other software.

Each person’s seizure threshold can be affected by a number of factors apart from the visual stimulus itself, including illness, hunger, stress, fatigue, alcohol, medications, length of play, and the player’s menstrual cycle, among others. So a game that seems OK may trigger a seizure in that same player under different conditions.


Researchers on a mission ignore seizure studies

Cherry-Picking-400x300A big reason seizures induced by video games aren’t more widely known is the absence of new research findings about the problem. There continues to be a lot of misinformation out there, and meanwhile we get farther away in time from the studies showing there’s good reason to take the seizure risk very seriously. Without announcements of new results or a concerted education effort by advocacy organizations, it’s tough to keep this issue alive for the public. When today’s researchers of video games miss the opportunity to remind readers of the seizure studies, they perpetuate the public’s disregard for the seizure risk. Here’s why this happens:

  1. The research showing video games can trigger seizures is old news! Many studies on video games and photosensitive epilepsy have already been published, beginning in the early 1980s. The findings and methods have been refined over time, but the results have been fairly consistent. Since there wasn’t much controversy about the studies, the research community has largely moved on from what was already considered a niche subject. More recent studies by these same specialists in photosensitive epilepsy aren’t the type to be appreciated outside the scientific community: research methdologies, specific genes, and the place of reflex seizures in the spectrum of seizure disorders. Not very newsworthy for the general public.
  2. Most studies today on the effects video game use are about long-term influence on skills, behavior, and attitudes, and on their use in education and health-related applications. These studies are typically done by social scientists, who in general are not including medical issues in their analyses. Studies like this are looking at a different body of previous work–studies done by other social scientists–and the authors may not be familiar with the photosensitive epilepsy research.
  3. There’s a real backlash these days against studies warning about negative influences of video games. Video games are clearly here to stay; researchers and game developers are eager to demonstrate games’ potential for good. Unfortunately, people who write about video games’ beneficial effects and purposeful applications tend to treat with suspicion (or worse) any earlier studies showing problems attributed to games. Or the seizure issue is omitted altogether from summaries of previous findings.

Seizure research swept under the rug

axe grindingPeople who grew up using computers and video games from an early age now comprise a sizeable segment of the research community. Many of them feel there has been a consistently negative bias in studies about video games and they are eager to show another perspective. Here’s an example. Prof. Mark Griffiths in the UK wrote a piece last year entitled, “Video Games Are Good for Your Brain – Here’s Why” that he begins this way:

“Whether playing video games has negative effects is something that has been debated for 30 years, in much the same way that rock and roll, television, and even the novel faced much the same criticisms in their time. Purported negative effects such as addiction, increased aggression, and various health consequences such as obesity and repetitive strain injuries tend to get far more media coverage than the positives.”

Prof. Griffiths had greater difficulty getting his own papers published when they showed positive positive influences of games than when they addressed difficulties such as video game addiction. The article points out positive outcomes using video games for social engagement, therapeutic applications, and education, and then concludes with this irresponsibly inaccurate statement:

What’s…clear from the scientific literature is that the negative consequences of playing almost always involve people that are excessive video game players. There is little evidence of serious acute adverse effects on health from moderate play.” [However, there is extensive evidence of seizures–a pretty serious acute adverse effect–that can occur even with very brief exposure. — JS]

Social scientists pick and choose

Earlier this year a piece titled “Video games can be good for you, new research says” (no link because it’s behind a pay wall) appeared in the Chicago Tribune. The reporter opens the piece by putting video game research into historical context.

“Researchers have done thousands of studies on gaming since the 1980s, often with unmistakably negative results. Some associated video games with an increased risk of epileptic seizures, while others cautioned that the games could provoke dangerously elevated heart rates. Many studies also linked violent games to aggression and anti-social behavior.”

to tell the truthThen the article turns to a psychology professor whose new study forms the basis of the article. Prof. Christopher Ferguson has done dozens of studies on effects of video game use. Prof. Ferguson, who’s found that violent video games do not contribute to societal aggression, reasons that early research into any new technology is often flawed. Studies that aim to find negative effects get funded and promoted, while those with more benign findings are unpublished and forgotten, he explains.

“When a new generation of scholars more familiar with the technology comes along, different results often appear — and that’s what is happening with gaming. We’re just not seeing the kind of data emerge that would support the techno-panic that was common in earlier years.”  

There is no further mention in the article of studies about the video game seizure problem–as if all the video game seizure research was part of the so-called “techno-panic.”

I contacted the Tribune reporter to point out that the seizure problem is for real and hasn’t gone away. He said he was aware of this fact and was interested in writing about it sometime. However, without a piece of news tied to it, such as results from a new study, other stories are obviously much more compelling for a newspaper to cover.

P.S. I’m on a mission, too 

I’ve chosen to focus on the seizure risk from exposure to video games, and on the after-effects these seizures–even small ones–can have. If you’ve read other posts of mine, you’re aware I believe there is still some research on video game seizures that needs to be done and it’s on issues that could produce newsworthy results:

  • the higher risk of visually induced seizures in specific populations, such as young people with autism. One small, unpublished study found 25 percent of young people over age 15 with autism spectrum disorders are photosensitive, but more study is needed.
  • the real prevalence of photosensitive seizures, which researchers admit are probably underdiagnosed because they aren’t noticed or reported.