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Video games: When does play become pathology?
Nick, age 13, enjoys playing video games, but his parents think he may be “addicted.” His primary care doctor has referred Nick to you for evaluation.
Nick has played video games since age 7 and likes to share ideas with friends about to “beat” difficult games. Lately, though, he plays an online role-playing game, mostly alone, on the computer in his bedroom. Nick hasn’t seen his friends outside of school for 6 weeks.
Nick’s parents say he is growing short-tempered, and his grades have fallen for several months. He seems to worry a lot but becomes angry and storms out of the room when they try to talk with him about it.
Like Nick, 70% to 90% of American youths play video games, according to the American Medical Association (AMA).1 Most boys and girls find the games fun, entertaining, or relaxing (Table 1) and do not encounter difficulties as a result of their play.2 In some cases, however, they may:
- spend excessive time playing video games
- model inappropriate behavior from games
- over-invest in online relationships.
This article describes developmentally appropriate characteristics of play in general—and aspects of video game play in particular—to help you educate families about normative and excessive video game play.
Table 1
Top 10 reasons why children say they play video games
| Boys |
|
| Girls |
|
| * Response likely reflects the number of survey respondents living in a suburban/rural environment in which hunting is a popular leisure activity. |
| Source: Reference 1 |
An addiction?
Originally researchers believed video game play was not addictive and viewed excessive play as high engagement. More recently, efforts are being made to understand:
- how to classify excessive video game play that impairs psychosocial adjustment
- whether substance abuse models are appropriate for describing and treating pathologic video game play.
What is normative play?
Play is a motivating way for children to make sense of the world. By re-creating themes, relationships, places, or events in play children can control things that outside of play might be intimidating or overwhelming. Through play, children can explore situations in a setting that feels safe.4,5 Video games offer children play opportunities to explore roles and worlds that otherwise are unavailable to them.6
Video game play is one of the most popular leisure-time activities for middle-school students. Our group7 recently surveyed >1,200 students age 12 to 15 about their video game play and found:
- One-third of boys and two-thirds of girls played video games for ≤2 hours/week.
- One-third of boys and 11% of girls played video games 6 or 7 days each week.
- Boys played more than girls, with 45% of boys playing for ≥6 hours/week.
- 12.6% of boys played ≥15 hours/week.
- One-half listed ≥1 games rated M for mature (Table 2)7 among 5 games they played most frequently in the preceding 6 months.2
Pathologic behavior. Excessive video game playing can be viewed as pathologic if it involves an overwhelming need to play video games, with negative feelings and behaviors related to this need that lead to distress or functional impairment.9,10 Charlton et al
11 define pathologic video game play as incorporating high engagement plus core addiction characteristics such as interference with work or social life, failure to sleep, etc. In video game play, peripheral DSM addiction characteristics—such as high cognitive salience—may indicate high engagement. Characteristics of pathologic video game play, as identified by this group, are listed in Table 3.11
Table 2
ESRB video game ratings system and content descriptions*
| Rating | Content may be suitable for: | Examples |
|---|---|---|
| Early childhood | Age 3 and older; no material that parents would find inappropriate | Atari/others’ Dora the Explorer (series), Knowledge Adventure/Vivendi Universal’s Jump start (series) |
| Everyone | Age 6 and older; minimal cartoon, fantasy, or mild violence and/or infrequent use of mild language | Disney Interactive Studios/Buena Vista Games’ Hannah Montana (series), Taito Corporation’s Bubble Bobble |
| Everyone 10+ | Age 10 and older; more cartoon, fantasy, or mild violence, mild language and/or minimal suggestive themes | Electronic Arts’ Need for Speed: ProStreet, Ubisoft’s Rayman Raving Rabbids 2 |
| Teen | Age 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling, and/or infrequent use of strong language | Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar (MMO), Sony Online Entertainment’s EverQuest (series; MMO) |
| Mature | Age 17 and older; may contain intense violence, blood and gore, sexual content, and/or strong language | Microsoft Corporation’s Halo (series), Rockstar Games’ Grand Theft Auto (most games in the series) |
| Adults only | Age 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity | Vivendi Universal’s Leisure Suit Larry: Magna Cum Laude Uncut and Uncensored, Rockstar Games’ Grand Theft Auto: San Andreas |
| * On video game boxes, look for rating symbols on the front and content descriptions on the back. | ||
| ESRB: Entertainment Software Rating Board | ||
| MMO: massively-multiplayer online role-playing game | ||
| Source: Reference 7 | ||
Characteristics of ‘pathologic’ video game play
| Feeling agitated when not playing |
| Feeling “addicted” to play |
| Not being able to decrease time spent playing |
| Not sleeping because of video game play |
| Missing meals because of video game play |
| Being late because of video game play |
| Having arguments at home because of video game play |
| Letting video game play interfere with social relationships |
| Letting video game play interfere with schoolwork |
| Spending excessive amounts of money on video game play |
| Source: Reference 11 |
CASE CONTINUED: Going with the ‘flow’
Nick says he enjoys playing with people he’s met through a massively-multiplayer online role-playing game (MMORG, or also called MMO or MMP). The “guild” he has joined is a small community that collaborates to complete quests in the game. Nick describes his character—a healer—as a key figure who supports fellow players by replenishing their in-game health. Everyone in the guild thinks he’s important, and he likes to feel respected. Nick says this is quite different from how people treat him in “real” life. He says he often feels worthless and scared that his friends and family don’t think he’s good enough.
Video game play facilitates the experience of “flow”—a mental state of positive energy and effortless focus experienced while immersed in an activity over which one feels a sense of control. Video game play incorporates components of a flow experience (Table 4), including clear, focused goals that are attainable yet challenging and require a high level of concentration. Individuals who engage in artistic, athletic, or meditative activities often report experiencing flow.12
Flow can distort one’s sense of time, setting the stage for frustration on both sides when parents want their video game-playing child to engage in other activities. Their efforts to redirect their child’s attention—whether effective or not—disrupt the pleasurable feeling of flow.
Table 4
Characteristics of flow experiences related to video games
| Characteristic | Effect associated with video game play |
|---|---|
| Clear goals | Discernible objectives are appropriate to player’s abilities |
| Highly focused concentration | Allows player to become absorbed within a limited field of attention |
| Lack of self-consciousness | Player’s actions seem effortless |
| Distorted sense of time | Player lacks accurate sense of how long he/she has been playing |
| Direct and immediate feedback | Success and failure are quickly evident, allowing player to change strategies |
| Appropriate level of challenge | Difficulty is balanced with player’s ability |
| Control | Player has sense of control and self-efficacy |
| Source: Reference 7 | |
Types of games and devices
Role-playing games (such as Square Enix’s Final Fantasy series) involve players’ assuming identities and managing role-specific tasks and resources to progress through the game (for instance, a ranger befriending animals and tracking enemies in the wilderness).
Turn-based and real-time strategy games (such as Take 2’s Civilization series) and some simulation games (such as Atari’s Roller-Coaster Tycoon series) require players to manage resources to achieve larger goals—such as building an empire and negotiating with world leaders or constructing and maintaining a successful amusement park.
Video game play can be a social experience, involving friends or family in the same room or long-distance players online. Game consoles—such as Xbox 360, Play-Station 3, or Nintendo Wii—facilitate playing together in the same room, although they also support online play.
Games played on computers tend to be more solitary, although some games—particularly MMORPGs—also support online play. MMORPGs can connect hundreds or thousands of individuals around the world playing online. Examples include Blizzard Entertainment’s World of Warcraft or Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar. Most MMOs are intended for older audiences, but some (such as Walt Disney Internet Group’s Toontown) are designed for children.13
Maladaptive play
Children’s video game play becomes maladaptive or dysfunctional if it prevents them from engaging in developmentally appropriate activities and relationships—either because of excessive time spent playing or the possible influences of developmentally inappropriate content.14
Associated factors. Boys may be at particular risk of video game overuse. Compared with girls, boys spend more time playing—even normatively—and are more likely to play M-rated games.2 Sensation-seeking, boredom, animosity, poor academic achievement, and high family conflict also have been linked to excessive video game play.15,16 The 20% of middle school students who have a computer, game console, or television in their bedrooms are twice as likely as others to play video games ≥15 hours/week and to play M-rated games.2
Children who have experienced negative life events—trauma, family conflict, or social rejection by peers—also may spend excessive time playing video games. Gaming can interfere with more adaptive ways of coping with adversity, such as seeking support from friends and family.17,18 The draw of online relationships can be strong, especially for children who have grown up with video games and the Internet. Girls may be at particular risk for maladaptive online relationship patterns.19
Research has yet to show whether excessive video game play causes or results from these associated phenomena. Because any relationship that exists is probably transactional, pay attention to ways in which video game play may cause or result from distress or functional impairment when evaluating a patient for excessive video game play.
Violence and sexual content
Evidence is inconclusive but suggests that video games with violent content may influence children’s perceptions of aggression and violence, which may increase their likelihood of behaving aggressively or violently.20-22 Middle-school students who frequently play ≥1 M-rated games are somewhat more likely to:
- engage in physical fights
- beat someone up
- vandalize property for fun
- receive poor grades
- be threatened or injured with a weapon.23
- Does playing video games with violent content cause aggressive and violent behavior?
- Or does a tendency toward aggressive or violent behavior lead to the playing of video games with violent content?
Video game play with violent content may be analogous to rough-and-tumble play in early adolescence. In this way, it may serve boys’ developmentally appropriate needs for establishing social hierarchy—especially because video games with violent content often involve competition.13 Predispositions toward aggressive or violent behavior—such as neurologic impairments that result in poor impulse control or conduct disorders—may be exacerbated by playing violent video games.24
- talk with children to learn how these stereotypes may be influencing concerns about body image
- compare the positive and negative aspects of how men and women are portrayed in video games with adults the children know who model desired attitudes and behavior
- encourage children to internalize healthy perceptions of their physical appearance through healthy eating and physical activity.
Recommended approach
Explore whether a child’s behavior could be characterized as normative or excessive, in terms of how much time he or she spends playing video games. This can help put parents’ concerns in context. Regardless of how much time the patient spends playing video games, pay attention to whether his or her thoughts, emotions, and behaviors seem pathologic.
Try to determine if the child is experiencing distress or functional impairment because of video game play or if excessive time spent playing video games is exacerbating symptoms of a comorbid mood, anxiety, or disruptive behavior disorder. Assess overall functioning, participation in activities, engagement in relationships, and how the child perceives his or her play. Investigate the family environment, peer relationships, and history of trauma.
If these interventions fail to address excessive or pathologic video game play, or if comorbid disorders and functional impairment are severe, medication or residential treatment may be needed to effectively control video game exposure.
Table 5
Advice to parents for monitoring children’s video game use
| Keep computer and game consoles in a community area in the home |
| Check age-based ratings and content descriptors of games before renting or buying |
| Talk to your kids’ friends’ parents about the video games they play in their households |
| Talk with your kids about Internet safety, particularly if they play MMOs |
| Play games with your kids—have them teach you how to play and show you what they like about particular games |
| Engage in frequent casual conversations with your kids about the games they play and what the experience is like for them |
| Consult a mental health professional if you’re concerned about changes in your child’s mood, school performance, social relationships, or eating or sleeping habits |
| MMOs: massively-multiplayer online games |
- Entertainment Software Rating Board. Search for video game titles or publishers by rating, platform, and content descriptor. www.esrb.org.
- Jones G. Killing monsters: why children need fantasy, super heroes, and make-believe violence. New York: Basic Books; 2003.
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. AMA takes action on video games (news release). Chicago, IL: American Medical Association; June 27, 2007. Available at: http://www.ama-assn.org/ama/pub/category/17770.html. Accessed October 30, 2007.
2. Olson CK, Kutner LA, Warner DE, et al. Factors correlated with violent video game use by adolescent boys and girls. J Adolesc Health 2007;41(1):77-83.
3. Statement of the American Psychiatric Association on “video game addiction” (news release). Arlington, VA: American Psychiatric Association; June 21, 2007. Available at: http://psych.org/news_room/press_releases/07-47videogameaddiction_2_.pdf. Accessed October 30, 2007.
4. Ritvo S. Play and illusion. In: Solnit A, Cohen D, Neubauer P, eds. Many meanings of play: a psychoanalytic perspective. New Haven, CT: Yale University Press; 1993:234-51.
5. Scarlett WG, Naudeau S, Salonius-Pasternak DE, Ponte I. Children’s play. Thousand Oaks, CA: Sage Publications; 2004.
6. Gelfond HS, Salonius-Pasternak DE. The play’s the thing: a clinical-developmental perspective on video games. Child Adolesc Psychiatr Clin N Am 2005;14:491-508.
7. Entertainment Software Rating Board. About the ESRB. Available at: http://www.esrb.org/ratings/faq.jsp. Accessed October 30, 2007.
8. Roberts DF, Foehr UG, Rideout V. Generation M: Media in the lives of 8-18 year-olds. Menlo Park, CA: Kaiser Family Foundation; 2005.
9. Fisher S. Identifying video game addiction in children and adolescents. Addictive Behaviors 1994;19(5):545-53.
10. Salguero RA, Moran RM. Measuring problem video game playing in adolescents. Addiction 2002;97(12):1601-6.
11. Charlton JP, Danforth IDW. Distinguishing addiction and high engagement in the context of online game playing. Comput Human Behav 2007;23:1531-48.
12. Csikszentmihalyi M. Beyond boredom and anxiety. San Francisco: Jossey-Bass; 1975.
13. Warner DE, Raiter M. Social context in massively-multiplayer online games (MMOGs): ethical questions in shared space. International Review of Information Ethics 2006;4:46-51.
14. Stern SE. Addiction to technologies: a social psychological perspective of Internet addiction. Cyberpsychol Behav 1999;2(5):419-24.
15. Chui S, Lee J, Huang D. Video game addiction in children and teenagers in Taiwan. Cyberpsychol Behav 2004;7(5):571-81.
16. Feng Y, Yan X, Guo X, et al. Behavior problem and family environment of children with video game dependence. Chinese Mental Health Journal 2003;17(6):367-8.
17. Yang Z. Research on the correlation between life events and video game addiction in junior middle school students. Chinese Journal of Clinical Psychology 2005;13(2):192-3.
18. Keepers GA. Pathological preoccupation with video games. J Am Acad Child Adolesc Psychiatry 1990;29(1):49-50.
19. Leung L. Net-generation attributes and seductive properties of the Internet as predictors of online activities and Internet addiction. Cyberpsychol Behav 2004;7(3):343-8.
20. Funk JB, Baldacci HB, Pasold T, Baumgardner J. Violence exposure in real-life, video games, television, movies, and the Internet: is there desensitization? J Adolesc 2004;27:23-39.
21. Anderson CA, Bushman BJ. Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: a meta-analytic review of the scientific literature. Psychol Sci 2001;12(5):353-9.
22. Gentile DA, Lynch PJ, Linder JR, et al. The effects of violent video game habits on adolescent hostility, aggressive behaviors, and school performance. J Adolesc 2004;27:5-22.
23. Olson CK, Kutner LA, Baer L, et al. M-rated video games and aggression. J Am Acad Child Adolesc Psychiatry. In press.
24. Salonius-Pasternak DE, Gelfond HS. The next level of research on electronic play: potential benefits and contextual influences for children and adolescents. Human Technology: An Interdisciplinary Journal on Humans in ICT Environments 2005;1(1):5-22.
25. Cassell J, Jenkins H. From Barbie to Mortal Kombat: gender and computer games. Cambridge, MA: MIT Press; 1998.
Nick, age 13, enjoys playing video games, but his parents think he may be “addicted.” His primary care doctor has referred Nick to you for evaluation.
Nick has played video games since age 7 and likes to share ideas with friends about to “beat” difficult games. Lately, though, he plays an online role-playing game, mostly alone, on the computer in his bedroom. Nick hasn’t seen his friends outside of school for 6 weeks.
Nick’s parents say he is growing short-tempered, and his grades have fallen for several months. He seems to worry a lot but becomes angry and storms out of the room when they try to talk with him about it.
Like Nick, 70% to 90% of American youths play video games, according to the American Medical Association (AMA).1 Most boys and girls find the games fun, entertaining, or relaxing (Table 1) and do not encounter difficulties as a result of their play.2 In some cases, however, they may:
- spend excessive time playing video games
- model inappropriate behavior from games
- over-invest in online relationships.
This article describes developmentally appropriate characteristics of play in general—and aspects of video game play in particular—to help you educate families about normative and excessive video game play.
Table 1
Top 10 reasons why children say they play video games
| Boys |
|
| Girls |
|
| * Response likely reflects the number of survey respondents living in a suburban/rural environment in which hunting is a popular leisure activity. |
| Source: Reference 1 |
An addiction?
Originally researchers believed video game play was not addictive and viewed excessive play as high engagement. More recently, efforts are being made to understand:
- how to classify excessive video game play that impairs psychosocial adjustment
- whether substance abuse models are appropriate for describing and treating pathologic video game play.
What is normative play?
Play is a motivating way for children to make sense of the world. By re-creating themes, relationships, places, or events in play children can control things that outside of play might be intimidating or overwhelming. Through play, children can explore situations in a setting that feels safe.4,5 Video games offer children play opportunities to explore roles and worlds that otherwise are unavailable to them.6
Video game play is one of the most popular leisure-time activities for middle-school students. Our group7 recently surveyed >1,200 students age 12 to 15 about their video game play and found:
- One-third of boys and two-thirds of girls played video games for ≤2 hours/week.
- One-third of boys and 11% of girls played video games 6 or 7 days each week.
- Boys played more than girls, with 45% of boys playing for ≥6 hours/week.
- 12.6% of boys played ≥15 hours/week.
- One-half listed ≥1 games rated M for mature (Table 2)7 among 5 games they played most frequently in the preceding 6 months.2
Pathologic behavior. Excessive video game playing can be viewed as pathologic if it involves an overwhelming need to play video games, with negative feelings and behaviors related to this need that lead to distress or functional impairment.9,10 Charlton et al
11 define pathologic video game play as incorporating high engagement plus core addiction characteristics such as interference with work or social life, failure to sleep, etc. In video game play, peripheral DSM addiction characteristics—such as high cognitive salience—may indicate high engagement. Characteristics of pathologic video game play, as identified by this group, are listed in Table 3.11
Table 2
ESRB video game ratings system and content descriptions*
| Rating | Content may be suitable for: | Examples |
|---|---|---|
| Early childhood | Age 3 and older; no material that parents would find inappropriate | Atari/others’ Dora the Explorer (series), Knowledge Adventure/Vivendi Universal’s Jump start (series) |
| Everyone | Age 6 and older; minimal cartoon, fantasy, or mild violence and/or infrequent use of mild language | Disney Interactive Studios/Buena Vista Games’ Hannah Montana (series), Taito Corporation’s Bubble Bobble |
| Everyone 10+ | Age 10 and older; more cartoon, fantasy, or mild violence, mild language and/or minimal suggestive themes | Electronic Arts’ Need for Speed: ProStreet, Ubisoft’s Rayman Raving Rabbids 2 |
| Teen | Age 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling, and/or infrequent use of strong language | Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar (MMO), Sony Online Entertainment’s EverQuest (series; MMO) |
| Mature | Age 17 and older; may contain intense violence, blood and gore, sexual content, and/or strong language | Microsoft Corporation’s Halo (series), Rockstar Games’ Grand Theft Auto (most games in the series) |
| Adults only | Age 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity | Vivendi Universal’s Leisure Suit Larry: Magna Cum Laude Uncut and Uncensored, Rockstar Games’ Grand Theft Auto: San Andreas |
| * On video game boxes, look for rating symbols on the front and content descriptions on the back. | ||
| ESRB: Entertainment Software Rating Board | ||
| MMO: massively-multiplayer online role-playing game | ||
| Source: Reference 7 | ||
Characteristics of ‘pathologic’ video game play
| Feeling agitated when not playing |
| Feeling “addicted” to play |
| Not being able to decrease time spent playing |
| Not sleeping because of video game play |
| Missing meals because of video game play |
| Being late because of video game play |
| Having arguments at home because of video game play |
| Letting video game play interfere with social relationships |
| Letting video game play interfere with schoolwork |
| Spending excessive amounts of money on video game play |
| Source: Reference 11 |
CASE CONTINUED: Going with the ‘flow’
Nick says he enjoys playing with people he’s met through a massively-multiplayer online role-playing game (MMORG, or also called MMO or MMP). The “guild” he has joined is a small community that collaborates to complete quests in the game. Nick describes his character—a healer—as a key figure who supports fellow players by replenishing their in-game health. Everyone in the guild thinks he’s important, and he likes to feel respected. Nick says this is quite different from how people treat him in “real” life. He says he often feels worthless and scared that his friends and family don’t think he’s good enough.
Video game play facilitates the experience of “flow”—a mental state of positive energy and effortless focus experienced while immersed in an activity over which one feels a sense of control. Video game play incorporates components of a flow experience (Table 4), including clear, focused goals that are attainable yet challenging and require a high level of concentration. Individuals who engage in artistic, athletic, or meditative activities often report experiencing flow.12
Flow can distort one’s sense of time, setting the stage for frustration on both sides when parents want their video game-playing child to engage in other activities. Their efforts to redirect their child’s attention—whether effective or not—disrupt the pleasurable feeling of flow.
Table 4
Characteristics of flow experiences related to video games
| Characteristic | Effect associated with video game play |
|---|---|
| Clear goals | Discernible objectives are appropriate to player’s abilities |
| Highly focused concentration | Allows player to become absorbed within a limited field of attention |
| Lack of self-consciousness | Player’s actions seem effortless |
| Distorted sense of time | Player lacks accurate sense of how long he/she has been playing |
| Direct and immediate feedback | Success and failure are quickly evident, allowing player to change strategies |
| Appropriate level of challenge | Difficulty is balanced with player’s ability |
| Control | Player has sense of control and self-efficacy |
| Source: Reference 7 | |
Types of games and devices
Role-playing games (such as Square Enix’s Final Fantasy series) involve players’ assuming identities and managing role-specific tasks and resources to progress through the game (for instance, a ranger befriending animals and tracking enemies in the wilderness).
Turn-based and real-time strategy games (such as Take 2’s Civilization series) and some simulation games (such as Atari’s Roller-Coaster Tycoon series) require players to manage resources to achieve larger goals—such as building an empire and negotiating with world leaders or constructing and maintaining a successful amusement park.
Video game play can be a social experience, involving friends or family in the same room or long-distance players online. Game consoles—such as Xbox 360, Play-Station 3, or Nintendo Wii—facilitate playing together in the same room, although they also support online play.
Games played on computers tend to be more solitary, although some games—particularly MMORPGs—also support online play. MMORPGs can connect hundreds or thousands of individuals around the world playing online. Examples include Blizzard Entertainment’s World of Warcraft or Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar. Most MMOs are intended for older audiences, but some (such as Walt Disney Internet Group’s Toontown) are designed for children.13
Maladaptive play
Children’s video game play becomes maladaptive or dysfunctional if it prevents them from engaging in developmentally appropriate activities and relationships—either because of excessive time spent playing or the possible influences of developmentally inappropriate content.14
Associated factors. Boys may be at particular risk of video game overuse. Compared with girls, boys spend more time playing—even normatively—and are more likely to play M-rated games.2 Sensation-seeking, boredom, animosity, poor academic achievement, and high family conflict also have been linked to excessive video game play.15,16 The 20% of middle school students who have a computer, game console, or television in their bedrooms are twice as likely as others to play video games ≥15 hours/week and to play M-rated games.2
Children who have experienced negative life events—trauma, family conflict, or social rejection by peers—also may spend excessive time playing video games. Gaming can interfere with more adaptive ways of coping with adversity, such as seeking support from friends and family.17,18 The draw of online relationships can be strong, especially for children who have grown up with video games and the Internet. Girls may be at particular risk for maladaptive online relationship patterns.19
Research has yet to show whether excessive video game play causes or results from these associated phenomena. Because any relationship that exists is probably transactional, pay attention to ways in which video game play may cause or result from distress or functional impairment when evaluating a patient for excessive video game play.
Violence and sexual content
Evidence is inconclusive but suggests that video games with violent content may influence children’s perceptions of aggression and violence, which may increase their likelihood of behaving aggressively or violently.20-22 Middle-school students who frequently play ≥1 M-rated games are somewhat more likely to:
- engage in physical fights
- beat someone up
- vandalize property for fun
- receive poor grades
- be threatened or injured with a weapon.23
- Does playing video games with violent content cause aggressive and violent behavior?
- Or does a tendency toward aggressive or violent behavior lead to the playing of video games with violent content?
Video game play with violent content may be analogous to rough-and-tumble play in early adolescence. In this way, it may serve boys’ developmentally appropriate needs for establishing social hierarchy—especially because video games with violent content often involve competition.13 Predispositions toward aggressive or violent behavior—such as neurologic impairments that result in poor impulse control or conduct disorders—may be exacerbated by playing violent video games.24
- talk with children to learn how these stereotypes may be influencing concerns about body image
- compare the positive and negative aspects of how men and women are portrayed in video games with adults the children know who model desired attitudes and behavior
- encourage children to internalize healthy perceptions of their physical appearance through healthy eating and physical activity.
Recommended approach
Explore whether a child’s behavior could be characterized as normative or excessive, in terms of how much time he or she spends playing video games. This can help put parents’ concerns in context. Regardless of how much time the patient spends playing video games, pay attention to whether his or her thoughts, emotions, and behaviors seem pathologic.
Try to determine if the child is experiencing distress or functional impairment because of video game play or if excessive time spent playing video games is exacerbating symptoms of a comorbid mood, anxiety, or disruptive behavior disorder. Assess overall functioning, participation in activities, engagement in relationships, and how the child perceives his or her play. Investigate the family environment, peer relationships, and history of trauma.
If these interventions fail to address excessive or pathologic video game play, or if comorbid disorders and functional impairment are severe, medication or residential treatment may be needed to effectively control video game exposure.
Table 5
Advice to parents for monitoring children’s video game use
| Keep computer and game consoles in a community area in the home |
| Check age-based ratings and content descriptors of games before renting or buying |
| Talk to your kids’ friends’ parents about the video games they play in their households |
| Talk with your kids about Internet safety, particularly if they play MMOs |
| Play games with your kids—have them teach you how to play and show you what they like about particular games |
| Engage in frequent casual conversations with your kids about the games they play and what the experience is like for them |
| Consult a mental health professional if you’re concerned about changes in your child’s mood, school performance, social relationships, or eating or sleeping habits |
| MMOs: massively-multiplayer online games |
- Entertainment Software Rating Board. Search for video game titles or publishers by rating, platform, and content descriptor. www.esrb.org.
- Jones G. Killing monsters: why children need fantasy, super heroes, and make-believe violence. New York: Basic Books; 2003.
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Nick, age 13, enjoys playing video games, but his parents think he may be “addicted.” His primary care doctor has referred Nick to you for evaluation.
Nick has played video games since age 7 and likes to share ideas with friends about to “beat” difficult games. Lately, though, he plays an online role-playing game, mostly alone, on the computer in his bedroom. Nick hasn’t seen his friends outside of school for 6 weeks.
Nick’s parents say he is growing short-tempered, and his grades have fallen for several months. He seems to worry a lot but becomes angry and storms out of the room when they try to talk with him about it.
Like Nick, 70% to 90% of American youths play video games, according to the American Medical Association (AMA).1 Most boys and girls find the games fun, entertaining, or relaxing (Table 1) and do not encounter difficulties as a result of their play.2 In some cases, however, they may:
- spend excessive time playing video games
- model inappropriate behavior from games
- over-invest in online relationships.
This article describes developmentally appropriate characteristics of play in general—and aspects of video game play in particular—to help you educate families about normative and excessive video game play.
Table 1
Top 10 reasons why children say they play video games
| Boys |
|
| Girls |
|
| * Response likely reflects the number of survey respondents living in a suburban/rural environment in which hunting is a popular leisure activity. |
| Source: Reference 1 |
An addiction?
Originally researchers believed video game play was not addictive and viewed excessive play as high engagement. More recently, efforts are being made to understand:
- how to classify excessive video game play that impairs psychosocial adjustment
- whether substance abuse models are appropriate for describing and treating pathologic video game play.
What is normative play?
Play is a motivating way for children to make sense of the world. By re-creating themes, relationships, places, or events in play children can control things that outside of play might be intimidating or overwhelming. Through play, children can explore situations in a setting that feels safe.4,5 Video games offer children play opportunities to explore roles and worlds that otherwise are unavailable to them.6
Video game play is one of the most popular leisure-time activities for middle-school students. Our group7 recently surveyed >1,200 students age 12 to 15 about their video game play and found:
- One-third of boys and two-thirds of girls played video games for ≤2 hours/week.
- One-third of boys and 11% of girls played video games 6 or 7 days each week.
- Boys played more than girls, with 45% of boys playing for ≥6 hours/week.
- 12.6% of boys played ≥15 hours/week.
- One-half listed ≥1 games rated M for mature (Table 2)7 among 5 games they played most frequently in the preceding 6 months.2
Pathologic behavior. Excessive video game playing can be viewed as pathologic if it involves an overwhelming need to play video games, with negative feelings and behaviors related to this need that lead to distress or functional impairment.9,10 Charlton et al
11 define pathologic video game play as incorporating high engagement plus core addiction characteristics such as interference with work or social life, failure to sleep, etc. In video game play, peripheral DSM addiction characteristics—such as high cognitive salience—may indicate high engagement. Characteristics of pathologic video game play, as identified by this group, are listed in Table 3.11
Table 2
ESRB video game ratings system and content descriptions*
| Rating | Content may be suitable for: | Examples |
|---|---|---|
| Early childhood | Age 3 and older; no material that parents would find inappropriate | Atari/others’ Dora the Explorer (series), Knowledge Adventure/Vivendi Universal’s Jump start (series) |
| Everyone | Age 6 and older; minimal cartoon, fantasy, or mild violence and/or infrequent use of mild language | Disney Interactive Studios/Buena Vista Games’ Hannah Montana (series), Taito Corporation’s Bubble Bobble |
| Everyone 10+ | Age 10 and older; more cartoon, fantasy, or mild violence, mild language and/or minimal suggestive themes | Electronic Arts’ Need for Speed: ProStreet, Ubisoft’s Rayman Raving Rabbids 2 |
| Teen | Age 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling, and/or infrequent use of strong language | Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar (MMO), Sony Online Entertainment’s EverQuest (series; MMO) |
| Mature | Age 17 and older; may contain intense violence, blood and gore, sexual content, and/or strong language | Microsoft Corporation’s Halo (series), Rockstar Games’ Grand Theft Auto (most games in the series) |
| Adults only | Age 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity | Vivendi Universal’s Leisure Suit Larry: Magna Cum Laude Uncut and Uncensored, Rockstar Games’ Grand Theft Auto: San Andreas |
| * On video game boxes, look for rating symbols on the front and content descriptions on the back. | ||
| ESRB: Entertainment Software Rating Board | ||
| MMO: massively-multiplayer online role-playing game | ||
| Source: Reference 7 | ||
Characteristics of ‘pathologic’ video game play
| Feeling agitated when not playing |
| Feeling “addicted” to play |
| Not being able to decrease time spent playing |
| Not sleeping because of video game play |
| Missing meals because of video game play |
| Being late because of video game play |
| Having arguments at home because of video game play |
| Letting video game play interfere with social relationships |
| Letting video game play interfere with schoolwork |
| Spending excessive amounts of money on video game play |
| Source: Reference 11 |
CASE CONTINUED: Going with the ‘flow’
Nick says he enjoys playing with people he’s met through a massively-multiplayer online role-playing game (MMORG, or also called MMO or MMP). The “guild” he has joined is a small community that collaborates to complete quests in the game. Nick describes his character—a healer—as a key figure who supports fellow players by replenishing their in-game health. Everyone in the guild thinks he’s important, and he likes to feel respected. Nick says this is quite different from how people treat him in “real” life. He says he often feels worthless and scared that his friends and family don’t think he’s good enough.
Video game play facilitates the experience of “flow”—a mental state of positive energy and effortless focus experienced while immersed in an activity over which one feels a sense of control. Video game play incorporates components of a flow experience (Table 4), including clear, focused goals that are attainable yet challenging and require a high level of concentration. Individuals who engage in artistic, athletic, or meditative activities often report experiencing flow.12
Flow can distort one’s sense of time, setting the stage for frustration on both sides when parents want their video game-playing child to engage in other activities. Their efforts to redirect their child’s attention—whether effective or not—disrupt the pleasurable feeling of flow.
Table 4
Characteristics of flow experiences related to video games
| Characteristic | Effect associated with video game play |
|---|---|
| Clear goals | Discernible objectives are appropriate to player’s abilities |
| Highly focused concentration | Allows player to become absorbed within a limited field of attention |
| Lack of self-consciousness | Player’s actions seem effortless |
| Distorted sense of time | Player lacks accurate sense of how long he/she has been playing |
| Direct and immediate feedback | Success and failure are quickly evident, allowing player to change strategies |
| Appropriate level of challenge | Difficulty is balanced with player’s ability |
| Control | Player has sense of control and self-efficacy |
| Source: Reference 7 | |
Types of games and devices
Role-playing games (such as Square Enix’s Final Fantasy series) involve players’ assuming identities and managing role-specific tasks and resources to progress through the game (for instance, a ranger befriending animals and tracking enemies in the wilderness).
Turn-based and real-time strategy games (such as Take 2’s Civilization series) and some simulation games (such as Atari’s Roller-Coaster Tycoon series) require players to manage resources to achieve larger goals—such as building an empire and negotiating with world leaders or constructing and maintaining a successful amusement park.
Video game play can be a social experience, involving friends or family in the same room or long-distance players online. Game consoles—such as Xbox 360, Play-Station 3, or Nintendo Wii—facilitate playing together in the same room, although they also support online play.
Games played on computers tend to be more solitary, although some games—particularly MMORPGs—also support online play. MMORPGs can connect hundreds or thousands of individuals around the world playing online. Examples include Blizzard Entertainment’s World of Warcraft or Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar. Most MMOs are intended for older audiences, but some (such as Walt Disney Internet Group’s Toontown) are designed for children.13
Maladaptive play
Children’s video game play becomes maladaptive or dysfunctional if it prevents them from engaging in developmentally appropriate activities and relationships—either because of excessive time spent playing or the possible influences of developmentally inappropriate content.14
Associated factors. Boys may be at particular risk of video game overuse. Compared with girls, boys spend more time playing—even normatively—and are more likely to play M-rated games.2 Sensation-seeking, boredom, animosity, poor academic achievement, and high family conflict also have been linked to excessive video game play.15,16 The 20% of middle school students who have a computer, game console, or television in their bedrooms are twice as likely as others to play video games ≥15 hours/week and to play M-rated games.2
Children who have experienced negative life events—trauma, family conflict, or social rejection by peers—also may spend excessive time playing video games. Gaming can interfere with more adaptive ways of coping with adversity, such as seeking support from friends and family.17,18 The draw of online relationships can be strong, especially for children who have grown up with video games and the Internet. Girls may be at particular risk for maladaptive online relationship patterns.19
Research has yet to show whether excessive video game play causes or results from these associated phenomena. Because any relationship that exists is probably transactional, pay attention to ways in which video game play may cause or result from distress or functional impairment when evaluating a patient for excessive video game play.
Violence and sexual content
Evidence is inconclusive but suggests that video games with violent content may influence children’s perceptions of aggression and violence, which may increase their likelihood of behaving aggressively or violently.20-22 Middle-school students who frequently play ≥1 M-rated games are somewhat more likely to:
- engage in physical fights
- beat someone up
- vandalize property for fun
- receive poor grades
- be threatened or injured with a weapon.23
- Does playing video games with violent content cause aggressive and violent behavior?
- Or does a tendency toward aggressive or violent behavior lead to the playing of video games with violent content?
Video game play with violent content may be analogous to rough-and-tumble play in early adolescence. In this way, it may serve boys’ developmentally appropriate needs for establishing social hierarchy—especially because video games with violent content often involve competition.13 Predispositions toward aggressive or violent behavior—such as neurologic impairments that result in poor impulse control or conduct disorders—may be exacerbated by playing violent video games.24
- talk with children to learn how these stereotypes may be influencing concerns about body image
- compare the positive and negative aspects of how men and women are portrayed in video games with adults the children know who model desired attitudes and behavior
- encourage children to internalize healthy perceptions of their physical appearance through healthy eating and physical activity.
Recommended approach
Explore whether a child’s behavior could be characterized as normative or excessive, in terms of how much time he or she spends playing video games. This can help put parents’ concerns in context. Regardless of how much time the patient spends playing video games, pay attention to whether his or her thoughts, emotions, and behaviors seem pathologic.
Try to determine if the child is experiencing distress or functional impairment because of video game play or if excessive time spent playing video games is exacerbating symptoms of a comorbid mood, anxiety, or disruptive behavior disorder. Assess overall functioning, participation in activities, engagement in relationships, and how the child perceives his or her play. Investigate the family environment, peer relationships, and history of trauma.
If these interventions fail to address excessive or pathologic video game play, or if comorbid disorders and functional impairment are severe, medication or residential treatment may be needed to effectively control video game exposure.
Table 5
Advice to parents for monitoring children’s video game use
| Keep computer and game consoles in a community area in the home |
| Check age-based ratings and content descriptors of games before renting or buying |
| Talk to your kids’ friends’ parents about the video games they play in their households |
| Talk with your kids about Internet safety, particularly if they play MMOs |
| Play games with your kids—have them teach you how to play and show you what they like about particular games |
| Engage in frequent casual conversations with your kids about the games they play and what the experience is like for them |
| Consult a mental health professional if you’re concerned about changes in your child’s mood, school performance, social relationships, or eating or sleeping habits |
| MMOs: massively-multiplayer online games |
- Entertainment Software Rating Board. Search for video game titles or publishers by rating, platform, and content descriptor. www.esrb.org.
- Jones G. Killing monsters: why children need fantasy, super heroes, and make-believe violence. New York: Basic Books; 2003.
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. AMA takes action on video games (news release). Chicago, IL: American Medical Association; June 27, 2007. Available at: http://www.ama-assn.org/ama/pub/category/17770.html. Accessed October 30, 2007.
2. Olson CK, Kutner LA, Warner DE, et al. Factors correlated with violent video game use by adolescent boys and girls. J Adolesc Health 2007;41(1):77-83.
3. Statement of the American Psychiatric Association on “video game addiction” (news release). Arlington, VA: American Psychiatric Association; June 21, 2007. Available at: http://psych.org/news_room/press_releases/07-47videogameaddiction_2_.pdf. Accessed October 30, 2007.
4. Ritvo S. Play and illusion. In: Solnit A, Cohen D, Neubauer P, eds. Many meanings of play: a psychoanalytic perspective. New Haven, CT: Yale University Press; 1993:234-51.
5. Scarlett WG, Naudeau S, Salonius-Pasternak DE, Ponte I. Children’s play. Thousand Oaks, CA: Sage Publications; 2004.
6. Gelfond HS, Salonius-Pasternak DE. The play’s the thing: a clinical-developmental perspective on video games. Child Adolesc Psychiatr Clin N Am 2005;14:491-508.
7. Entertainment Software Rating Board. About the ESRB. Available at: http://www.esrb.org/ratings/faq.jsp. Accessed October 30, 2007.
8. Roberts DF, Foehr UG, Rideout V. Generation M: Media in the lives of 8-18 year-olds. Menlo Park, CA: Kaiser Family Foundation; 2005.
9. Fisher S. Identifying video game addiction in children and adolescents. Addictive Behaviors 1994;19(5):545-53.
10. Salguero RA, Moran RM. Measuring problem video game playing in adolescents. Addiction 2002;97(12):1601-6.
11. Charlton JP, Danforth IDW. Distinguishing addiction and high engagement in the context of online game playing. Comput Human Behav 2007;23:1531-48.
12. Csikszentmihalyi M. Beyond boredom and anxiety. San Francisco: Jossey-Bass; 1975.
13. Warner DE, Raiter M. Social context in massively-multiplayer online games (MMOGs): ethical questions in shared space. International Review of Information Ethics 2006;4:46-51.
14. Stern SE. Addiction to technologies: a social psychological perspective of Internet addiction. Cyberpsychol Behav 1999;2(5):419-24.
15. Chui S, Lee J, Huang D. Video game addiction in children and teenagers in Taiwan. Cyberpsychol Behav 2004;7(5):571-81.
16. Feng Y, Yan X, Guo X, et al. Behavior problem and family environment of children with video game dependence. Chinese Mental Health Journal 2003;17(6):367-8.
17. Yang Z. Research on the correlation between life events and video game addiction in junior middle school students. Chinese Journal of Clinical Psychology 2005;13(2):192-3.
18. Keepers GA. Pathological preoccupation with video games. J Am Acad Child Adolesc Psychiatry 1990;29(1):49-50.
19. Leung L. Net-generation attributes and seductive properties of the Internet as predictors of online activities and Internet addiction. Cyberpsychol Behav 2004;7(3):343-8.
20. Funk JB, Baldacci HB, Pasold T, Baumgardner J. Violence exposure in real-life, video games, television, movies, and the Internet: is there desensitization? J Adolesc 2004;27:23-39.
21. Anderson CA, Bushman BJ. Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: a meta-analytic review of the scientific literature. Psychol Sci 2001;12(5):353-9.
22. Gentile DA, Lynch PJ, Linder JR, et al. The effects of violent video game habits on adolescent hostility, aggressive behaviors, and school performance. J Adolesc 2004;27:5-22.
23. Olson CK, Kutner LA, Baer L, et al. M-rated video games and aggression. J Am Acad Child Adolesc Psychiatry. In press.
24. Salonius-Pasternak DE, Gelfond HS. The next level of research on electronic play: potential benefits and contextual influences for children and adolescents. Human Technology: An Interdisciplinary Journal on Humans in ICT Environments 2005;1(1):5-22.
25. Cassell J, Jenkins H. From Barbie to Mortal Kombat: gender and computer games. Cambridge, MA: MIT Press; 1998.
1. AMA takes action on video games (news release). Chicago, IL: American Medical Association; June 27, 2007. Available at: http://www.ama-assn.org/ama/pub/category/17770.html. Accessed October 30, 2007.
2. Olson CK, Kutner LA, Warner DE, et al. Factors correlated with violent video game use by adolescent boys and girls. J Adolesc Health 2007;41(1):77-83.
3. Statement of the American Psychiatric Association on “video game addiction” (news release). Arlington, VA: American Psychiatric Association; June 21, 2007. Available at: http://psych.org/news_room/press_releases/07-47videogameaddiction_2_.pdf. Accessed October 30, 2007.
4. Ritvo S. Play and illusion. In: Solnit A, Cohen D, Neubauer P, eds. Many meanings of play: a psychoanalytic perspective. New Haven, CT: Yale University Press; 1993:234-51.
5. Scarlett WG, Naudeau S, Salonius-Pasternak DE, Ponte I. Children’s play. Thousand Oaks, CA: Sage Publications; 2004.
6. Gelfond HS, Salonius-Pasternak DE. The play’s the thing: a clinical-developmental perspective on video games. Child Adolesc Psychiatr Clin N Am 2005;14:491-508.
7. Entertainment Software Rating Board. About the ESRB. Available at: http://www.esrb.org/ratings/faq.jsp. Accessed October 30, 2007.
8. Roberts DF, Foehr UG, Rideout V. Generation M: Media in the lives of 8-18 year-olds. Menlo Park, CA: Kaiser Family Foundation; 2005.
9. Fisher S. Identifying video game addiction in children and adolescents. Addictive Behaviors 1994;19(5):545-53.
10. Salguero RA, Moran RM. Measuring problem video game playing in adolescents. Addiction 2002;97(12):1601-6.
11. Charlton JP, Danforth IDW. Distinguishing addiction and high engagement in the context of online game playing. Comput Human Behav 2007;23:1531-48.
12. Csikszentmihalyi M. Beyond boredom and anxiety. San Francisco: Jossey-Bass; 1975.
13. Warner DE, Raiter M. Social context in massively-multiplayer online games (MMOGs): ethical questions in shared space. International Review of Information Ethics 2006;4:46-51.
14. Stern SE. Addiction to technologies: a social psychological perspective of Internet addiction. Cyberpsychol Behav 1999;2(5):419-24.
15. Chui S, Lee J, Huang D. Video game addiction in children and teenagers in Taiwan. Cyberpsychol Behav 2004;7(5):571-81.
16. Feng Y, Yan X, Guo X, et al. Behavior problem and family environment of children with video game dependence. Chinese Mental Health Journal 2003;17(6):367-8.
17. Yang Z. Research on the correlation between life events and video game addiction in junior middle school students. Chinese Journal of Clinical Psychology 2005;13(2):192-3.
18. Keepers GA. Pathological preoccupation with video games. J Am Acad Child Adolesc Psychiatry 1990;29(1):49-50.
19. Leung L. Net-generation attributes and seductive properties of the Internet as predictors of online activities and Internet addiction. Cyberpsychol Behav 2004;7(3):343-8.
20. Funk JB, Baldacci HB, Pasold T, Baumgardner J. Violence exposure in real-life, video games, television, movies, and the Internet: is there desensitization? J Adolesc 2004;27:23-39.
21. Anderson CA, Bushman BJ. Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: a meta-analytic review of the scientific literature. Psychol Sci 2001;12(5):353-9.
22. Gentile DA, Lynch PJ, Linder JR, et al. The effects of violent video game habits on adolescent hostility, aggressive behaviors, and school performance. J Adolesc 2004;27:5-22.
23. Olson CK, Kutner LA, Baer L, et al. M-rated video games and aggression. J Am Acad Child Adolesc Psychiatry. In press.
24. Salonius-Pasternak DE, Gelfond HS. The next level of research on electronic play: potential benefits and contextual influences for children and adolescents. Human Technology: An Interdisciplinary Journal on Humans in ICT Environments 2005;1(1):5-22.
25. Cassell J, Jenkins H. From Barbie to Mortal Kombat: gender and computer games. Cambridge, MA: MIT Press; 1998.