Evidence-Based Reviews

Video games: When does play become pathology?

Current Psychiatry. 2007 December;6(12):27-38

References

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.

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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

Suggested mechanisms include desensitization toward violence over time²⁰ and adopting social learning cues from video games and applying them to life.²¹ This raises the question of cause and effect:

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?

State or trait aggression may influence children to choose a video game with aggressive or violent themes.²² Alternately, children anxious about conflict may seek out violent games to obtain a sense of conflict resolution when real-life efforts are ineffective or impossible.

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

Clinical Point

Cognitive-behavioral methods may help children recognize the negative consequences of excessive video game play

Sexual stereotypes. As children develop into adolescence, they often become concerned about their physical appearance. Video game depictions of men and women frequently emphasize idealized body types, which may exacerbate disturbed body image tendencies in children. Children also may learn negative sexual stereotypes from video game play.²⁵ To counter these influences, recommend that parents:

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.