How violent video games may violate children's health

Cover Article How violent video games may violate children's health By Elisa Hae-Jung Song, MD, and Jane E. Anderson, MD Evidence is mounting that playing violent video games contributes to aggressive behavior. Pediatricians can protect their patients by knowing the potential risks of these games and advising parents. Before 1950, books, comics, motion pictures, phonograph records, and radio programs, which included dramas and game shows, were the only media entertainment available to children. Since the offerings were relatively slim, it was rather easy for parents to control what their children listened to and watched. In the past 50 years, however, children's access to media has exploded, beginning with the introduction of television, which rapidly became a fixture in more than 98% of American homes. The emergence of video games, designed initially as large consoles and then modified for use on home television sets, dramatically changed children's media environment. This new form of entertainment raised concern because the negative effects of violent television on children's behavior had been extensively documented, and video games added an interactive component to the entertainment. The second most popular form of entertainment after television, video games have rapidly become the largest segment of the entertainment industry, taking in $6.3 to $8.8 billion in 1998, compared with $5.2 billion in Hollywood box office receipts.1 Video games, which now can be played at home on a computer or a television set, account for 30% of the toy market in America. With 181 million computer games sold in 1998, each home has, on average, two video games.2 The time is right to ask the inevitable question: "Are violent video games having a negative effect on children's health?" Although the answer to this question remains equivocal, data now exist to suggest that the answer may, indeed, be "Yes." Everybody plays Consider these statistics: About 90% of United States households with children have rented or own a video or computer game,3 49% of children have a video game player or computer on which to play the games in their own bedroom, and 46% of children would choose, in preference to any other form of media, to take a video game player or computer to a desert island.4 Clearly, many homes in America are affected by the explosion of video games. According to a 1993 survey of 357 seventh- and eighth-grade students, boys spent more time playing video games than girls. While 60% of girls clocked an average of two hours a week playing video games, 90% of boys played for more than four hours a week. Boys and girls also differed in where they liked to play: 50% of boys spent time in arcades, compared with 20% of girls. Only 2% of preferred games had educational themes, while about half had violent themes.5 A 1996 survey of 1,000 fourth- to eighth-grade students confirmed that boys spent more hours each week than girls playing video games, with game playing decreasing as grade level increased.6 Children of all ages preferred games with violent content; boys preferred human violence, girls, fantasy violence. A study of 227 college students showed that 97% of students played games.7 Again, girls spent less time than boys in this activity. The survey also investigated respondents' earlier use of games: Students reported that the time they spent playing games gradually decreased from the junior high years (five and one half hours a week) to college (about two hours a week). Figures on earlier use of games may not be reliable, however, because they were based on long-term recall. Parents are usually not aware of the nature of the video games their children are playing. In a 1999 study, most parents were not able to name their child's favorite game, or named an incorrect game. In 70% of these incorrect matches, the child described their favorite game as violent.8 Even when a parent watches her child playing a video game, she is unlikely to still be looking as her child attains higher levels with increased violent content. On average, according to another study, parents recognized only nine of the 49 most popular video games.9 In a study from British Columbia, only 22% of teens said that their parents had set rules for playing video games. This compares with 39% of teens who had rules for television viewing. The rules for video games, when they existed, related to when and for how long the child was allowed to play but did not usually address the content of the game. About 40% of teens had to finish their homework and chores before playing. Only 15% were subject to restrictions on the type of game they played.10 These findings are especially of concern because the graphic violence depicted by video games has increased greatly in recent years. According to the National Coalition on Television Violence, a nonprofit organization dedicated to reducing gratuitous violence on television, sales of games rated extremely violent (see "What the ratings mean" below) have jumped from 53% of all sales in 1985 to 82% in 1988.11 Analysis of a sample of the 33 Sega and Nintendo games that were most popular in 1995 showed that nearly 80% featured aggressiveness or violence; in 21% of the games, the aggression or violence was directed toward women. In nearly 50% of the games examined, violence or aggression was directed against other characters, and the violence generally was very graphic.12 Another survey found that violence was a theme in 40 of the 47 top-rated Nintendo video games.11 This means that, on a typical day, one of four boys in the United States plays an action or combat game like "Doom" or "Duke Nukem." The many faces of video violence Violence in video games can be categorized as fantasy violence or human violence. Each of these categories can be further divided into games where the player controls a character on screen who performs the violence (third-person shooters) or those where the player views the game as if he or she were the character performing the violence (first-person shooters). First-person violence allows the player to actually look along the barrel of the gun on the screen and feel as though he were pulling the trigger and killing someone. "Super Smash Brothers" is an example of a game that uses fantasy animated violence. The game is rated E (meaning it is for everyone). Descriptions of the game appearing on the package include "Duke it out as your favorite Nintendo characters," "It's a bumpin', bruisin', brawlin' bash!," and "Smash your opponent silly." This game was placed on the "Dirty Dozen" list by the Lion and Lamb Project (see the table below). Resources on media violence American Academy of Pediatrics Media Matters Campaign 847-981-7870 (contact Jennifer Stone) www.aap.org A program to help pediatricians understand and become familiar with research on how the media affect the health and well-being of children and adolescents. Provides a media history form for use during well-child visits. Center for Media Literacywww.medialit.org National, nonprofit organization whose mission is to bring media literacy education to every child, every school, and every home in North America Entertainment Software Rating Boardwww.esrb.org Independent board created to rate interactive entertainment software products Federal Communications Commissionwww.fcc.gov Establishes policies to govern interstate and international communications by television, radio, wire, satellite, and cable The Lion & Lamb Projectwww.lionlamb.org National grassroots initiative by parents for parents, providing information about the effects of violent entertainment, toys, and games on children's behavior Media Awareness Networkwww.media-awareness.ca Canadian-based organization whose mission is to promote and support media education Mediascopewww.mediascope.org National nonprofit research and policy organization working to promote issues of social relevance within the entertainment industry National Institute on Media and the Familywww.mediafamily.org National resource for research, education, and information about the impact of the media on children and families Recreational Software Advisory Councilwww.icra.org Independent council that rates interactive computer entertainment software Human violence is the main component of many video games. "Carmageddon" is rated M for mature audiences and is described on the package as "The racing game for the chemically imbalanced." The object of the game is to run over people or crash into other cars. "Waste contestants, pedestrians, and farmyard animals for points and credit," the game instructs players. Points are scored for artistic gore, based on how blood is smeared on the tires after each crash. A player who completes all levels may have killed as many as 33,000 people. The most popular third-person shooter game is "Mortal Kombat," which is rated M. The package states: "3D fatalities: Watch as brand new and classic fatalities take on a completely different meaning in three dimensions." In 1993, Sega sold a version of the game in which a warrior rips off his opponent's head and spine while spectators shout, "Finish him! Finish him!" Nintendo's version, also rated M, did not include that scene, but it was outsold three to two by Sega's product. Games that use first-person shooters are increasingly popular. "Doom" (rated M) is the best known because Eric Harris and Dylan Klebold, the Columbine killers, were avid players. The manufacturer introduces "Doom" this way: "A single Demon Entity escaped detection. Systematically it altered decaying, dead carnage back into grotesque living tissue. The Demons have returned stronger and more vicious than ever before. Your mission is clear, there are no options: Kill or be killed." "Doom" allows players to use more powerful and more gory weapons as the level of play progresses, so players can trade in shotguns for automatic weapons and then chain saws. Another M-rated game, "Quake," has the following descriptions on the package, "Nail them to the wall," "Incorporates the ferocity of the-single-player game with the supreme bloodlust of the two-player death match," and "Realistic explosions echo and reverberate, transporting the player to a hellish, dungeon-like environment." "Quake" sold more than 1.7 million copies the first year it was introduced. "Duke Nukem," rated M, advertises "32 levels of non-stop carnage" so the player can "Bag some aliens with over a dozen hi-tech weapons." New video games with improved graphics and more realistic violence are constantly being developed. Video games also can be downloaded from the Internet and customized, adding a new dimension to the violence in keeping with individual preferences. Columbine killers Harris and Klebold customized "Doom" to graphically portray their neighborhood and school, allowing them to practice the shooting they would later enact in real life. Does exposure to violence harm children? What effect does exposure to this type of violence have on children? Studies of the effects of violent video games are limited, but investigations of the effects of violent television programming, which have been thoroughly evaluated during the past 50 years, offer insight. In more than 1,000 studies, researchers have used laboratory- based exposure, population-based observations, and longitudinal analysis, among other methods, to document that children exposed to violent programming are more likely to behave in an aggressive or violent manner and are more likely to become involved with the justice system than children who have not had such exposure. Defenders of violent video games use the same argument as defenders of violent television do, however. They claim that the catharsis these games offer allows players to release aggressive tendencies. To evaluate how violent video games affect children, one must consider the techniques these games rely on and what the literature shows about the games' impact. Unfortunately, most of the existing research was performed before 1993, the time after which violent content and realistic images began to increase greatly. Video games and principles of learning. Exposure to violent video games is of even more concern than exposure to violence on television because the games take advantage of many of the principles of learning-identification (or participant modeling), practice and repetition, and reward and reinforcement. Identification with the aggressor increases the likelihood that the participant will imitate behavior; in most violent video games, the player must identify with one violent character and perform violent acts through his eyes. The interactive nature of video games may also increase the likelihood that the participant will learn aggressive behavior. Adding to the increase in learning, the player of a video game is required to repeat behaviors. Last, video games reinforce violent choices with rewards of additional points, longer playing time, or special effects for certain acts of aggression or violence. A recent study shows that physiologic changes associated with learning take place while playing video games.13 It demonstrated that striatal dopamine release increases during video game playing and that the correlation between dopamine release and performance level was significant. Dopaminergic neurotransmission is probably related to learning, reinforcement behavior, attention, and sensorimotor integration. The profound effects of video games on learning were summed up by researchers J. B. Funk and D. D. Buchman, who wrote: "If, as many believe, violence is primarily a learned behavior, then the powerful combinations of demonstration, reward, and practice inherent in electronic game playing creates an ideal instructional environment.... the lessons being taught are that violence is fun, obligatory, easily justified, and essentially without negative consequences."6 The Columbine shooters are chilling examples of this principle. They were "Doom" fanatics who reconfigured a version of "Doom" to be in the "God mode" (the format in which the player becomes indestructible). The pair graphically reenacted the behavior they learned from the video gamethey said the planned shooting was "going to be like f - ing 'Doom,'" "Tick, tick, tick, tick ... Haa! That f - ing shotgun is straight out of 'Doom.'"14 The type of learning that takes place may be influenced by the type of violent video game that is being played. Video games played on computers rely on the "mouse" to do the shootings, and players therefore learn strategies and warfare tactics. Video games played in arcades are much more likely to use "joy sticks" or hand-operated devices that simulate pulling the trigger on the gun. Players of these games learn not only strategies but improve their hand-eye coordination and their aim. By joining "clans," online players can cooperate making battle plans and specialize in various aspects of warfare. The most disconcerting and convincing argument for the hypothesis that violent video games teach violent behavior comes from Lieutenant Colonel David Grossman, a psychologist and adjunct professor at Arkansas State University, who specialized as a "killologist" for the United States military. After more than 25 years researching the psychology of killing for the Army, Grossman is convinced that the willingness to kill another person does not come naturally but is a learned behavior. It requires desensitization by repeated exposure to violence and classical conditioning by associating aggressive acts with a pleasant experience. Willingness to kill also relies on stimulus-response training so that the conditioned response (shooting a gun) becomes automatic with the right stimulus (alien or person in view). According to Grossman, the United States Army and Marines use the same techniques that violent video games depend on to train recruits to kill. The Army also turns to an actual video game"Doom"to train soldiers to kill. This game, as well as "Quake" and similar games, teaches players to "clear the room" by moving quickly from target to target; to aim for the head; and to avoid repeatedly shooting the same target, as novices do. Grossman goes so far as to call violent video games "murder simulators."15 People who have never fired a gun but have practiced shooting on video games are excellent marksmen when they fire a gun for the first time. A lawsuit filed against Michael Carneal, the 14-year-old Paducah, Ky. boy who killed three students, alleges that Carneal "clipped off nine shots in about a 20-second period. Eight of those shots were hits. Three were head and neck shots and were kills. That is way beyond the military standard for expert marksmanship. This was a kid who had never fired a pistol in his life, but because of his obsession with computer games had turned himself into an expert marksman."16 According to Grossman, "Michael Carneal ... fired eight shots ... at a bunch of milling, scrambling, screaming children.... Even more astounding was the kill ratio. Each kid was hit once. Three were killed; one was paralyzed for life. Never, to my knowledge, in the annals of law enforcement or military or even criminal history can we find an equivalent achievement.... It turned out that while the kid had never fired a pistol before ... he held the gun in two hands. He had a blank look on his face. He never moved his feet. He never fired too far to the right or the left or up or down. He simply fired one shot at everything that popped up on his screen."17 What studies show. In 1997, the Canadian Journal of Psychiatry published a meta-analysis of 13 studies on the relationship between video games and aggression.18 Among the reviewed studies were some performed in the laboratory, where children played video games and were then observed during free play. One of those studies showed that 7- and 8-year-old boys who played video games with violent content were more likely to exhibit interpersonal aggression during free play than boys who had not played such games. In another study in the meta-analysis, researchers observed 5- to 7-year-old children after they played video games with aggressive or nonaggressive content and found that children who played a karate game were more likely to imitate the behavior seen in the game and were more aggressive than children who played a jungle game. These studies have obvious limitations, including short duration of observation. The authors of the meta-analysis concluded, however, that "the majority of the studies show that children do become more aggressive after either playing or watching a violent video game."18 Studies conducted in the 1980s that relied on questionnaires to correlate time spent playing video games and aggressive behavior provide conflicting results. Some studies demonstrated that playing video games increases aggressive behavior; others did not. In a study published last year, investigators surveyed college students about exposure to video game violence and self-reported aggressive behavior and delinquency. College students played a violent or nonviolent video game and then engaged in a competitive game in which they could punish their opponent by delivering a blast of noise, the length of which they could determine. Those who played violent games delivered significantly longer blasts after losing than nonviolent game players did.29 In a separate study outside the laboratory by the same investigators, violent video game play was positively related to aggressive behavior and delinquency.7 A slightly earlier investigation found that third- and fourth-grade children who played a violent video game later provided more hostile interpretations of a story with an ambiguous ending (provocation story) than children who played a nonviolent game.19 Undergraduates who played a violent virtual reality game had more aggressive thoughts than students who simply observed the game.7 According to a 1992 survey of sixth through 12th graders, playing violent video games contributed to an increase in aggressive behavior. Investigators also found that the longer a child played video games, the more likely she was to be considered aggressive by her teacher. 20 Correlational studies have also supported the relationship between violent video games and aggressive behavior. Interpol reported that, between 1977 and 1993, the assault rate in Australia and New Zealand increased almost 400%, tripled in Sweden, and doubled in Belgium, Denmark, England, France, and Scotland.16 Although these cultures differ in many ways, they have had a similar increase in violent video game exposure. Some studies show no relationship between video game playing and aggression or violence. A 1987 study of eighth-grade students found that game play did not affect subsequent aggressive behavior.21 In another investigation, frequent users of video games seemed to play more when they were tense and felt more relaxed after playing.22 Findings in two studies performed in 1985 and in 1987 in 6- to 11-year-old children were conflicting. In the first study, children had more assertive fantasies after playing violent video gamesa finding that the second study failed to confirm. Because these studies were conducted before the more violent and realistic video games were introduced, their results may not be applicable to today's environment.23 More research into the long-term effects of video game playing is needed, especially in light of the recent improvements in the graphic display of games and the increase in their violent content. Academic and educational concerns Like watching television, playing video games displaces other activities of childhood, such as reading, playing outside, exercising or participating in sports, working on hobbies such as music or art activities, doing homework, or simply talking with friends and family. One study of 234 fourth- through sixth-grade students evaluated ratings of academic performance and various behaviors. A small but significant negative relationship was seen between arcade game use and teachers' ratings of math ability and general academic ability in boys. No such relationship was found when games were played at home.24 Another study that examined only "new game" use found that children were more likely to avoid homework when a new game was introduced, but over time played less frequently and for a shorter time. Homework and chores were the activities most likely to be displaced by game playing, according to 21% of teens surveyed in a study from British Columbia. Teenagers who played video games more than seven hours a week were most likely to play games instead of participating in other activities; 37% of these heavy players said they played at the expense of homework and chores, and 18% said they gave up family activities.10 Research in this area is scanty, however, and results are often inconsistent. The Henry J. Kaiser Family Foundation, which has extensively studied children's use of all forms of media, found that children who earned lower academic grades spent about one hour more a day exposed to media than their counterparts with higher grades did. The study could not evaluate what caused the lower grades, and both groups of students spent about the same amount of time on video games.25 Video games also pose medical risks that stem from the equipment on which they are played or their content. For further discussion of this subject, see "A variety of medical concerns" below. What can pediatricians do? Pediatricians are in a unique position to influence what computer and video games families and children use, and how they use them. That they make the effort to exert this influence is important if only because playing video games, like watching television, displaces more important activities of childhood. In addition, children, as eager learners, may be especially vulnerable to the impact of violence in video games as they identify with aggressors and practice and repeat the violent actions, delighting in the reward and reinforcement offered by the games' multiple levels of play. Some data suggest that younger children are more at risk and that if children do not start playing video games until they reach adolescence, they are more likely to choose sport-oriented and strategic planning games (such as "Sim City") instead of first-person shooter games. Encouraging parents to delay the introduction of video games may be an effective tool for decreasing children's exposure to violent games. Pediatricians also can encourage parents to be actively involved in their children's choice of media entertainment. A useful tool is the accompanying parent guide for choosing video games (below). When a child has behavioral or academic problems, it is especially important to pay attention to how much time the child spends on interactive media. Parents should be aware that interventions to decrease television, video, and video game exposure have been shown to be effective. Third and fourth grade students in San Jose, Calif. who received a series of classroom lessons encouraging them to monitor and decrease their media use demonstrated less physical and verbal aggression when observed on the playground than students who didn't have the lessons.26 Pediatricians and parents who want to become advocates for wise video game choices in their community have several avenues. Recognizing that video game ratings are merely advisory, they can campaign local video stores, libraries, and arcades to require parental approval before a child can rent, buy, or play a video game with a T, M, or A rating. Another possibility is to conduct workshops and make presentations at schools and churches and in the community. Finally, consider contacting the manufacturers of violent video games and the Federal Communications Commission to urge them to limit violence in video games. Regardless of what intervention is chosen, the most important first step is to recognize that violent video games do indeed harm our children. References 1. Rich, Michael: Pediatricians Should Educate Parents, Youth about Media's Effects. AAP News September, 1999,16:92. 2. Graf W, Chatrian G, Glass ST, et al: Video game-related seizures: A report on 10 patients and a review of the literature. Pediatrics 1994;93:551 3. Video games and their effects, in Issue Briefs. Studio City, Calif., Mediascope Press, 1999 4. Roberts DF, Foehr UG, Rideout VJ, et al: Kids & media @ the new millennium. Kaiser Family Foundation Report November 1999, p 13 5. Funk J: Reevaluating the impact of video games. Clinical Pediatrics 1993;2:86 6. Funk J, Buchman DD: Video and computer games in the '90s: Children's time commitment and game preference. Children Today 1996;24(1):12 7. Anderson CA, Dill KE: Video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. J Pers Soc Psychol 2000;78:772 8. Funk J, Hagan J, Schimming J: Children and electronic games: A comparison of parents' and children's perceptions of children's habits and preferences in a United States sample. Psychol Rep 1999;85:883 9. Funk J, Flores G, Buchman D: Rating electronic games: Violence is in the eye of the beholder. Youth and Society 1999;282 10. Video game culture: Leisure and play preferences of B.C. teens, in Media Analysis Laboratory. Burnaby, British Columia, Simon Fraser University, 1998 11. National Coalition on Television Violence: Nintendo tainted by extreme violence. NCTV News. 1990;11(1-2):1 12. Dietz T: An examination of violence and gender role portrayals in video games: Implications for gender socialization and aggressive behavior. Sex Roles: A Journal of Research. 1998;38:425 13. Koepp M, Gunn R, Lawrence A, et al: Evidence for striatal dopamine release during a videogame. Nature 1998;393:266 14. Gibbs N, Roche T: The Columbine Tapes, in Time Magazine, December 20, 1999 15. Grossman D, DeGaetano G: Stop Teaching Our Kids To Kill. New York, Crown Publishers, 1999, p 110 16. Hanson G: The violent world of video games. Washington Times Insight on the News. June 28,1999, pp v15, n24 17. Grierson B: Head rush. Adbusters 1999;25:22 18. Emes CE: Is Mr. Pac Man eating our children? A review of the effect of video games on children. Can J Psychiatry 1997;42:409 19. Kirsh SJ: Seeing the world through Mortal Kombat-colored glasses: Violent video games and the development of a short-term hostile attribution bias. Childhood 1998;5:177 20. Fling S, Smith L, Rodrigues T, et al: Video games, aggression, and self-esteem: A survey. Social Behavior and Personality 1992;20:39 21. Winkel M: Personality factors, subject gender, and the effects of aggressive video games on aggression in adolescents. J Research Personality 1987;21:211 22. Kestenbaum GI, Weinstein L: Personality, psychopathology, and developmental issues in male adolescent video game use. J Amer Acad Child Adolesc Psychiatry 1986;24:329 23. Graybill D, Kirsch JR, Esselman ED: Effects of playing violent vs. nonviolent video games on the aggressive ideation of aggressive and nonaggressive children. Child Study Journal 1985;15:199 24. Lin S, Lepper MR: Correlates of children's usage of video games and computers. J of Applied Social Psychology 1987;17:72 25. Kids & media @ the new millennium: A comprehensive national analysis of children's media use. A Kaiser Family Foundation Report. Menlo Park, Calif., 1999, p 70 26. Robinson TN, Wilde ML, Navracruz LC, et al: Effects of reducing children's television and video game use on aggressive behavior. Arch Pediatr Adolesc Med 2001;155:17 DR. SONG is Clinical Instructor of Pediatrics, UCSF/Mount Zion Medical Center, San Francisco, Calif. DR. ANDERSON is Associate Clinical Professor of Pediatrics at the same institution. What the ratings mean The Entertainment Software Rating Board (ESRB) assigns ratings to games designed for use on personal computers and home video systems. Three random raters from a pool of raters decide on each rating. Of the more than 5,000 products rated by the ESRB, 3% have an "EC" (early childhood) rating, 71% a "K-A" (kids to adults) or "E" (everyone) rating, 19% a "T" (teen) rating, and 7% an "M" (mature) rating. Definitions of the ratings are as follows: Early Childhood Suitable for ages 3 years and older. Does not contain inappropriate material. Everyone Suitable for ages 6 years and older. May contain minimal violence, some comic mischief (such as slapstick comedy), or some crude language. Older games may carry the rating K-A (kids to adults). The E rating recently was introduced as a substitute for the K-A rating. Teen Suitable for ages 13 years and older. May contain violence, mild or strong language, or suggestive themes. Mature Suitable for ages 17 years and older. May contain more intense violence, language, or sexual themes. Adults only Suitable only for adults. May contain graphic sex or violence. Not intended to be rented or sold to anyone younger than 18 years. Rating pending Game has not yet been rated. On the back of the game package, the ESRB also puts a brief description of the video's content. For example, a video with an EC rating might be described as "edutainment," which means educational entertainment. Although makers of computer games may choose not to have their games rated, most now use the ESRB system. Some games also carry a rating by the Recreational Software Advisory Council (RSAC). This system assigns a score on a scale of 0 to 4 in the categories of violence, sex, nudity, and language. The RSAC also has an "ALL" rating for material that is suitable for all audiences but may contain violence considered harmless, such as innocent kissing or inoffensive slang. To earn an ALL rating, the game must not include nudity or profanity. In addition, all new coin-operated video games include a label with a "parental advisory disclosure message." A green label indicates the game is suitable for all ages, while yellow and red labels are a signal that the video may include animated or lifelike violence, sexual content, or bad language. Adapted from www.aap.org/family/ratingsgame.htm A variety of medical concerns Medical risks from playing video games may stem from the equipment used or the way the visuals are programmed, as well as the game content. Unexplained symptoms. Japanese pediatricians have reported an increase in "unexplained symptoms" in children who had played computer games for two to five hours a day for one to four years. Nineteen patients (17 boys and two girls) were referred because of persistent complaints lasting from two weeks to 18 months. These complaints included headache, abdominal pain, fatigue, nausea, anorexia, weight loss, chest pain, low-grade fever, and sweating. Common findings on physical examination included "exhausted facial appearance with black rings under eyes" and stiffness of the trapezius muscle contralateral to the dominant hand. In five of 19 patients, the scapula was displaced upwards. All symptoms disappeared completely after just one week of not playing video games, leading the authors to attribute the unexplained symptoms to eye and hand overwork.1 Induction of epilepsy. In patients with photosensitive epilepsy, who demonstrate sensitivity to intermittent light stimulation on electroencephalography, video game play may induce a generalized or partial complex seizure. About 10% of patients between 7 and 19 years of age with newly diagnosed epilepsy have photosensitivity, and in 3% of newly diagnosed patients seizure activity is first noted while the patient is playing a video game. In one study of 35 patients who had seizures while playing or watching video games, refraining from play was successful treatment in 73%.2 The pattern on the television monitor produced by the parallel lines that form the image determines the "flicker frequency," which, in turn, determines whether the video game can provoke seizure activity. Using monitors with a scanning frequency of 50 Hz and 100 Hz, investigators evaluated 30 photosensitive patients as they watched television or played video games to determine how important flicker frequency was to inducement of seizure activity. Seventeen patients had seizures while playing video games.3 A larger study from France evaluated additional factors that might contribute to video game-induced seizures. Investigators evaluated 115 patients between the ages of 7 and 30 years in five different laboratories. Patients, including those with and without photosensitive epilepsy, were exposed to sequences of images taken from 20 commercially available Sega and Nintendo games, played at varying distances from the screen on either 50 Hz or 100 Hz screens. Distance from the screen influenced the occurrence of seizures, with 1 meter being more protective than 0.5 meters. Between 19% and 24% of photosensitive patients were "pattern sensitive" and were more likely to have a seizure if they viewed a slowly moving pattern or bright static image than a rapidly moving object. This study also confirmed that 100 Hz screens were more protective than 50 Hz screens (most television sets in the United States have a 100 Hz screen).4 In the French study, seizures were not induced by video games in any of the patients who had been diagnosed as nonphotosensitive. Other studies, however, have reported seizures in nonphotosensitive patients while they were playing video games. Interestingly, one study demonstrated that EEGs of children with and without seizures showed task-related EEG modulation changes normally noted during mental effort.5 Metabolic and cardiovascular changes can occur in children playing video games, as noted in one report on 32 children who were studied while playing a popular video game. Investigators found an increase in systolic and diastolic blood pressures, as well as oxygen consumption, similar in intensity to what is seen in mild exercise, such as walking two miles an hour. The authors determined that playing video games does not provide adequate cardiorespiratory stress to enhance physical fitness.6 Other observers have noted changes in breathing patterns while children are playing video gamesa decrease in the breathing rate during times of intense concentration and an increase during heightened emotional response. One study at the University of Oklahoma reported that the adrenaline level increased during video game play, and researchers postulated that this may contribute to later heart disease. Exposure to magnetic fields. Some observers are concerned that the use of television sets to play video games exposes children to magnetic fields produced by the equipment. The research on this subject is controversial, however. Two studies reported an increased risk of childhood leukemia associated with the length of time children watched television programs or played video games on television sets. Another investigation came to a different conclusion after researchers first measured the static, extremely low frequency (ELF), and very low frequency (VLF) magnetic fields produced by 72 television sets watched by children and 34 television sets used for video game playing and then evaluated their data in relation to time spent watching TV and playing video games.7 The authors concluded that, for most frequency ranges, children who played video games got little more exposure to magnetic fields than did children who watched television but did not play the games. They did caution that more research is needed, especially with regard to VLF magnetic fields. REFERENCES 1. Tazawa Y, Soukalo AV, Okada K, et al: Excessive playing of home computer games by children presenting as unexplained symptoms. J Pediatrics 1997;130:1010 2. Graf W, Chatrian G, Glass S, et al: Video game-related seizures: A report on 10 patients and a review of the literature. Pediatrics 1994;93:551 3. Ricci S, Vigevano F, Manfredi M, et al: Epilepsy provoked by television and video games: Safety of 100-Hz screens. Neurology 1998;50:790 4. Badinand-Hubert N, Bureau M, Hirsch E, et al: Epilepsies and video games: Results of a multicentric study. Electroencephalography and Clinical Neurophysiology 1998;107:422 5. Pellouchoud E, Smith ME, McEvoy L, et al: Mental effort-related EEG modulation during video-game play: Comparison between juvenile subjects with epilepsy and normal control subjects. Epilepsia 1999;40:38 6. Siegal K, Dietz WH: Physiological responses to playing a video game. Am J Dis Child 1991;145:1034 7. Kaune VV, Miller MC, Linet MS, et al: Children's exposure to magnetic fields produced by US television sets used for viewing programs and playing video games. Biomagnetics 2000;21:214 GUIDE FOR PARENTS Video games and your child's health Many studies show that children are affected by the video games they play. Most of the time, these effects are negative. Playing violent or otherwise inappropriate video games can lead to an increase in aggressive behavior and fears as well as a decline in academic performance. You can avoid these consequences by controlling what video games your child plays and how much time he or she spends playing them. Make the right choice. Assume a game has violent or sexual themes if the pictures or descriptions on the game's box feature these themes. Check your impressions by looking for the game's rating. Games that are most suitable for children are those rated "E" (everyone) as well as "EC" (early childhood) and "T" (teen), depending on the child's age. Show your child the ratings system so he will learn how to make wise decisions. Encourage him not to be influenced by advertisements he sees for particular games. For more information about the ratings, call 800-881-ESRB or visit www.esrb.org . Rent a game and play it with your child before buying it. In many games, the violence increases towards the end of the game or at higher levels of play, so make sure you stay with your child to observe until the end of the game. This also will give you an opportunity to talk to him about your values and whether the game you are previewing supports them. Look for games that need two or more players to encourage group activity, and try to select games that are mentally stimulating. Limit your child's exposure to video game magazines just as carefully as you do to the games themselves. These magazines offer many screen captures of the games and often portray violence and sexually suggestive images. Limit the time your child spends playing video games. Playing video games may keep your child from pursuing more worthwhile activities, such as participating in family or school events, doing homework, being with friends, or engaging in sports or other physically active pursuits. Encourage your child to spend time on these activities and try to delay introducing him to video games, preferably until he is a teenager. Remind your child that playing video games is a privilege, not a right. Set limits on game-playing time total "screen" time, including Internet use, should be no more than two hours a day. Set a good example by minimizing your own "screen" time. Also limit how much money your child can spend on games. Insist that homework and chores come before playing video games. And do not allow your child to have a video game console or computer in his bedroom. Practice damage control. Consider decreasing how much time your child spends playing video games or otherwise spends in front of a display screen if his performance in school is not as good as it used to be. Aggressive behavior, such as hitting or pushing other children, and frequent nightmares may also be signs that your child is being exposed to screen violence or having too much "screen" time. Jane Anderson, Elisa Song. How violent video games may violate children's health. Contemporary Pediatrics 2001;5:102.