Lawrence Kutner, PhD

There is no shortage of hyperbole when politicians of all stripes describe the 

. Republican presidential candidate Mitt Romney proclaimed, "Pornography and violence poison our music and movies and TV and video games. The 

, like the Columbine shooters before him, had drunk from this cesspool."

 Democratic presidential candidate Hillary Clinton spoke of the game, 

 which has so many demeaning messages about women, and so encourages violent imagination and activities, and it scares parents."

Some researchers have echoed similar sentiments, noting that 

 shooters Dylan Harris and Eric Klebold were avid computer gamers.

 Several television pundits quickly drew a link between the recent Virginia Tech shootings and video games, as well. (Ironically, Seung-Hui Cho's college roommates found it odd that he never joined them in playing video games.

 leading to similarly violent behavior among child and adolescent players make sense? A review of the research gives us insights into which patterns of video game play may serve as potential markers of more serious problems among children and adolescents, and which are normal or even possibly beneficial.

Additional research and case studies may shed some light on parents' concerns, such as whether video games are addictive or dangerous. Finally, we will offer recommendations on what parents can do to reduce potential risks and to maximize potential benefits of video game play.

The biggest fear of clinicians and the public alike-that violent video games turn ordinary children and adolescents into violent people in the real world-is not borne out by the data. Analyses of 

 and the Federal Bureau of Investigation National Center for the Analysis of Violent Crime

 do not support a link between violent games and real-world attacks. But what does research show about more subtle behaviors, such as bullying or changes in game players' perceptions of violence?

An August 2007 search of the OVID database for titles incorporating some variation on "video game" yielded 30 articles; a similar search of PsycINFO (limited to peer-reviewed journals) found 418 articles. Most reports focused on studies of the effects of violent video games on aggressive cognitions, emotions, and behavior.

This body of research, however, is of limited use to clinicians for a range of reasons.

 The most-cited studies are laboratory experiments on college students, generally involving brief exposures to a single violent game. Correlational studies typically involve small, nonrepresentative samples, and assess playing time rather than game content. The terminology is vague, and some researchers use "aggression" and "violence" interchangeably, implying that one inevitably leads to the other. Studies done in the 1980s and 1990s are outdated because of rapidly evolving content and technologies. Recent studies that involve child or adolescent exposure to violent game content represent a tiny fraction of this literature.

In the sections below, we review some findings relevant to clinicians, including our own surveys and focus groups with young adolescents. Unless otherwise specified, "video games" refers to console and handheld games as well as games played on computers.

In a 2005 national sample, the Kaiser Family Foundation surveyed 2032 children in grades 3 to 12 about their media use, including computers and video games.

 On average, children aged 8 to 18 years spent 49 minutes per day on video games (console or handheld) and 19 minutes on computer games. Boys aged 8 to 10 years were the heaviest users of video games; 73% played on a typical day for an average of an hour and a half.

To learn more, we surveyed 7th- and 8th-grade students at 2 middle schools in Pennsylvania and South Carolina. Virtually all eligible children attending school on that day participated.

 For most, electronic game play was a routine activity. Of 1254 children surveyed, only 6% had not played any electronic games in the 6 months before the survey. (These nonplayers were excluded from most analyses.) Gender differences were striking. Boys typically said they played video games 6 or 7 days per week; girls typically played 1 day per week.

To assess exposure to various types of game content, we asked children to list the games they had played "a lot in the past months." We found that 68% of boys and 29% of girls aged 12 to 14 years included at least one M-rated (for those aged 17 years and older, often because of violent or sexual content) game on this list of frequently played games.

We presented children and adolescents with a list of 17 possible reasons for playing video games. More than half cited creative reasons for play, such as "I like to learn new things" and "I like to create my own world."

"To relax" was chosen as a reason to play by the majority of boys and close to half of girls. "To get my anger out" was selected by 45% of boys and 29% of girls; 25% of boys and 11% of girls said that they played to "cope with anger." Violent video games might provide a safe outlet for aggressive and angry feelings.

This use of video games to manage emotions came up repeatedly in focus groups we conducted with 42 young adolescent boys. A typical comment was, "If I had a bad day at school, I'll play a violent video game, and it just relieves all my stress."

Children also play violent electronic games for predictable developmental reasons, such as rebellion, curiosity about the forbidden, and testing the limits of acceptable behavior in a safe environment.

 "You get to see something that hopefully will never happen to you," said one boy in our focus groups. "So you want to experience it a little bit without actually being there."

In both surveys and focus groups, boys described video game play as a social activity. Although most boys played games alone at times, most also routinely played with one or more friends. Just 18% of boys and 12% of girls surveyed said they always played alone.

Our survey results, combined with other research, hint at some markers of abnormal (though not necessarily unhealthy) game play patterns. It is uncommon for girls to be frequent, heavy players of video games, especially violent games. One third of girls in our survey played electronic games for less than an hour per week on average. By contrast, it was unusual for boys to rarely or never play video games; just 8% of boys played for less than an hour per week. (Since game play is often a social activity for boys, nonparticipation could be a marker of social difficulties. These boys were also more likely than others to report problems such as getting into fights or trouble with teachers.) Finally, boys and girls who exclusively play games alone are atypical.

In our survey of young adolescents, we found significant correlations between routine play of M-rated games and greater self-reported involvement in physical fights, with a stronger association for girls. It is likely that aggressive or hostile youths may be drawn to violent games. There is limited but suggestive evidence that persons with trait anger or aggression may be affected differently by violent games.

 In one study, players tended to be less angry after playing a violent game, but this was not true for subjects who scored high on trait anger and aggression.

 Thus, another possible marker of unhealthy video game use may be increased anger after a round of play.

It must be emphasized that correlational studies, including ours, cannot show whether video games cause particular behaviors. Far too frequently, this important distinction between correlation and causation is overlooked.

Case Vignette: Games and Attention/ Learning Disorders

Alex, a 13-year-old boy, spends 6 to 7 hours a day playing video games. He locks himself in his room, misses meals, and often stays up most of the night, which results in school tardiness. He learns "cheats" (tricks to find quick solutions to game-based problems) online, converses with players in chat rooms, and has accumulated a great deal of knowledge about the intricacies of the many, often violent, games he plays.

Although very bright, Alex has a nonverbal learning disability, social difficulties, poor athletic skills, and attention problems, and he was often made fun of at school. The primary source of his self-esteem, beyond academic achievement, is his video game prowess.

His parents have no understanding of the games, nor of the video games' central importance in his life. Other children in school often come to him for advice about games and strategies and ask to play with him. This has become his claim to fame in and out of school.

While his parents need to educate themselves about the games he is playing and to set limits on his game play, their initial response to curtail them has been modified over time, allowing for an important avenue in the socialization of their son.

Therapy for Alex and his parents involved their appreciation of the role and meaning of games in his life. His parents needed to understand that competence is a crucial component of positive self-esteem-something Alex needed tremendously in order to take on academic and social challenges. Video games provided a means for Alex to feel more confident in moving ahead in these areas. With a greater understanding of the role the games played in his life, his parents were much more tolerant of his game playing.

The therapist continues to work with Alex and his parents and teachers to find additional ways for him to build a stronger sense of himself, improve his self-worth, and learn new ways of connecting with peers. His increased sense of competence has translated into greater academic achievement and the development of friendships outside the realm of video games.

Little research has been done on how subgroups of children, including those with diagnosed mental illness or learning difficulties, may be differentially affected by video games-for better or worse.

 Our survey included Pediatric Symptom Checklist subscales

 on attention and internalizing symptoms. Boys whose responses put them over a threshold level for attention-deficit/ hyperactivity disorder (ADHD) symptoms were more likely than others to use games to cope with angry feelings.

Among girls with ADHD symptoms, twice as many (almost 1 in 4) played games to make new friends compared with girls who did not have ADHD. In moderation, these are probably healthy uses of video games. As in the case of Alex above, children with ADHD often are adept at playing video games and using computers. This can provide a highly valued source of self-esteem.

Might video games be helpful with other illnesses, such as depression? In our survey, children who endorsed internalizing symptoms, such as feeling sad, hopeless, and worthless were much more likely to select "to forget my problems" as a reason for playing video games. These children did not spend significantly more time with video games, but they were more likely to play alone. Unfortunately, we do not know enough to say whether using video games to manage emotions is healthy or unhealthy for depressed children in general, or any child in particular. It may be that temporary or intermittent immersion in a game is therapeutic, while playing games alone for hours most days after school makes matters worse. Talking with a child about where, when, why, and how he or she uses electronic games could provide some useful insights.

In our survey, more than three quarters of respondents said their parents "rarely" or "never" played video games with them. In focus groups, many parents expressed frustration about being too much in the dark about the games their children were playing. Many worried that their child spent too much time in game play to the detriment of homework, socializing, or sports.

For their part, boys liked the action, challenge, and excitement of their violent games. While 

was the most popular game series among the boys we surveyed, thesecond most-cited series was 

 For many, and perhaps most boys in middle school, violent and/or sports games are a key to initiating and structuring social interactions. As one boy in a focus group told us, "If I didn't play video games-it's like a topic of conversation-and so I don't know what I'd talk about, 'cause I talk about video games a lot."

Contrary to parental concerns, our focus groups-as well as a British study of college students

-suggest that realistic sports games may actually encourage interest and participation in real-world sports.

Case Vignette: Parent-Child Conflict Over Video Games

Peter is a popular 14-year-old boy who is a fine athlete and does well academically. However, according to his parents, he seems to care more about playing video games and buying the latest version of games and consoles than anything else. He is an avid reader of video game magazines, clearly preferring them to "good books." His parents worry that these activities will "rot his mind," much like comic books.

Peter and his parents are frequently embroiled in battles around video use. His parents have tried offering money and other rewards to redirect Peter's behavior. He contends that his schoolwork, social life, and sports are not compromised by his game playing.

His parents need to appreciate that there are no indicators pointing to interpersonal, moral, emotional, or cognitive developmental delays in Peter's situation, and they need to reconsider their personal values and the way they assess their child's growth and development. A short course of brief family therapy, laced with considerable psychoeducation and media literacy, can help resolve the parent-child conflict.

The public bandies about the term "addiction" freely, talking about being "addicted to e-Bay" or "addicted to food." Players of the online game series 

 half-jokingly refer to it as "Never Rest" and "EverCrack" because of its supposedly addictive qualities. The vignette below presents the case of an adolescent who plays video games up to 12 hours a day. Although many parents and some physicians would refer to this type of behavior as an addiction, is that really the case?

Case Vignette: Video Game Play as a Marker of a Psychiatric Disorder

Ben is a 15-year-old boy who has been hospitalized for depression and for cutting himself. He is failing in school, not because he is not smart, but because he cannot reduce the time he spends playing 

 He spends 10 to 12 hours a day playing the game-until somebody makes him get off the computer. His parents have put controls on the computer to limit its use, but he has figured out ways to bypass them. He pretends to go to sleep and gets up in the middle of the night to play.

In psychotherapy, Ben revealed that his use of games was "to distract himself" and "to feel happier and not be so upset about things." It became apparent that his game use was, in part, related to untreated depression. With a combination of medication management and individual psychotherapy, the depression improved, and so did his game use. However, the long-standing involvement with games had to be replaced by other hobbies and social activities, and this has become a focus of therapy and work in his daily life.

The AMA has recently considered whether Internet and video game addiction should be considered formal diagnoses and added to the next edition of 

 In its recent report, "Emotional and Behavioral Effects, Including Addictive Potential, of Video Games," the AMA refers to such behaviors as video game overuse.

 It concluded that more research is needed before making specific recommendations.

Alcohol and heroin addiction clearly meet the criteria for addiction. Do video games? Unfortunately, the best answer we can give is that we do not know. Some "video-game addicts" may be struggling with a compulsion similar to an obsessive-compulsive disorder. Although their game playing may be interfering with their lives, the underlying mechanism may be different from that of someone addicted to a drug. Others may simply be more sensitive to the variable-ratio reinforcement schedule that is inherent in many games. Thus, video-game overuse may have more in common with compulsive gambling than with drug addiction.

Some supposedly addicted game players may be behaving normally-but not in the ways that the adults around them believe to be normal. For example, many young children and adolescents have difficulty with transitioning between activities, especially when the initial activity is pleasurable. Is this a sign of addiction? No. It is a reflection of normal brain development. But parents sometimes misinterpret this type of behavior as anything from spite to laziness.

Adults also may unconsciously apply different standards to different behaviors. If a child plays basketball or plays the piano for 4 hours a day, we may describe him as a dedicated athlete or musician. But if that child takes the same approach to playing video games, spending hours each day at the computer, and reveling in the details and strategies of play, we may worry about an addiction.

The danger in calling video game playing an addiction is that if it is not, we might miss an underlying problem such as depression. On the other hand, if we do not identify the behavior as a video game addiction when that is what is really going on, we may be distracted by other behavioral problems and miss the opportunity to treat the underlying cause.

What can clinicians tell parents about the use of video games? First, we all need greater knowledge about the form, content, and epidemiology of video game use, and media in general. Research is needed on whether all violence in games has the same impact; how developmental stages influence game use; whether game play may be a healthy form of sublimation; and how much playing is too much. Second, parents should become familiar with Entertainment Software Rating Board (ESRB) age symbols and "content descriptors" found on game boxes and advertisements. Parents also need to know that potentially important information, such as the context, target, and goals of the violence in their children's games, is not provided by the ESRB; they may need to ferret out more details to help their children make appropriate choices. The 

presents suggested guidelines that can be offered to parents to help them establish a plan for the use of video games at home.

It should be noted that for most well-adjusted adolescents-who are doing well in school, sports, other extracurricular activities, at home, and with peers-there can be minimal limits on video games. Parents need to consider what is best for the optimal development of their child, commensurate with their own set of values and ideals.

Mental health professionals need greater knowledge about the role and function of media in family life.

 The ubiquitous presence of multimedia content has elevated media literacy from a nice-to-have frill to an important basic skill for our children. Clinicians should routinely incorporate media use (and misuse) in their histories. What exposure is there to television, movies, the Internet, and video games at home? Are these media supervised or unsupervised? What access to media do children have at home and with friends?

Watching or playing for just 1 or 2 hours will probably not provide enough information to understand the content of a game. Checking game reviews and images on a commercial Web site (such as Gamespot.com) can help parents determine whether that game is a good match for their child. Ratings are not enough. For example, the difference between T (teen, for those aged 13 years and older) and M ratings may not be violence, but whether blood and bodies disappear-making violence look clean and consequence-free.

Parents may also visit nonprofit game sites such as Commonsense Media (www.commonsensemedia.org), which offer reviews and evaluations of games, including issues such as sexual content, violence, language, message, social behavior, commercialism, drug/ alcohol/tobacco use, and educational value. The Coalition for Quality Children's Media, a collaboration among the media industry, educators, and child advocacy organizations (www.kidsfirst. org) can help parents become more familiar with the video games their children are playing. GetNetWise (www. kids.getnetwise.org), a coalition of industry and advocacy groups, offers an online safety guide that provides advice tailored to children's ages and likely activities (including chat, e-mail instant messaging, and newsgroups). The site also reviews the technologies available to families to restrict access to Internet content.

Finally, parents can help by encouraging critical thinking, including talking to their children about alternative, nonviolent solutions to problems. They can also encourage skepticism; for example, by talking about the consequences of media story lines if they were to happen in real life.

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Articles

There is no shortage of hyperbole when politicians of all stripes describe the nature and effects of video games. Republican presidential candidate Mitt Romney proclaimed, "Pornography and violence poison our music and movies and TV and video games.

Lawrence Kutner, PhD

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Children and Video Games: How Much Do We Know?