Playing video games is a preferred leisure activity for many children and adolescents. Most spend less time playing video games than watching television,1 but the story-directing, interactive, repetitive nature of game-playing may amplify the potential impact.2'4 Conventional wisdom about the impact of playing video games has ranged from the near-hysteria of the early 1980s to the relative complacence of the late 1980s. The latter response followed an Atarisponsored conference where preliminary research seemed to suggest that playing video games had no significant negative impact.5 The video games of the 1990s are even more popular, more graphic, and more violent than earlier games (compare "Pong" to "Mortal Kombat"). Interest in the significance of gameplaying has grown, but research remains preliminary. As many popular video games are now also available for computer, "video games" will be used as a generic label as we examine current controversies.
VIDEO GAMES AND HEALTH
Video Game-Related Seizures (VGRS)
Video game-related seizures (VGRS) were first described in the early 1980s. Also known as video game epilepsy, this real, although probably uncommon, disorder recently has attracted increased professional and public attention.6 Video game-related seizures are described as a form of photosensitive epilepsy triggered by particular repetitive light or pattern stimuli during game play or observation in susceptible individuals. Symptoms may include generalized tonic-clonic seizures, visual changes, altered consciousness, confusion, and headache.6 Some manufacturers now include prominent epilepsy warnings in system instructions and game literature (Figure). Compared with the prevalence of play, the number of VGRS case reports remains relatively small, and most cases resolve when game-playing is eliminated. Anticonvulsant medication, in particular valproic acid, has been reported to be effective in refractory cases or for individuals who are unwilling to abstain from play.6
Figure. Epilepsy warning that appears on some video games. Reprinted with permission of Nintendo of America Inc.
General Physiologic Responses
Physiologic responses to sustained video game play have been examined both from the standpoint of possible harm and possible benefit. However, limited research is inconclusive. In one study of young adult males, significant increases in mean systolic blood pressure and mean heart rate were noted after playing video games.7 The authors speculated that this reaction could represent a risk for individuals with occult disease. More recent work associated video game play with increased energy expenditure in adolescents and young adults.8 Although not sufficient to improve cardiorespiratory fitness, the authors suggested that playing video games may not make as large a contribution to obesity as involvement with other sedentary media. In a novel approach to modifying the tedium of exercise, one equipment manufacturer even offers what is claimed to be a full body "joystick."
Case reports describing various video game injuries involving the upper extremities can be found beginning in the early 1980s. Such injuries have been attributed to the repetitive movements required to control game action. Although highly involved players seem to accept the temporary limitations caused by the fairly common "numb thumb," game manufacturers continue to work on improving system ergonomics. Case reports suggest that musculoskeletal injuries respond well to abstinence.9
Proponents frequently cite improvement in eyehand coordination as a defining benefit of playing video games. Research, however, is surprisingly inconclusive.10'11 According to studies, there is no causal relationship between video game experience and a generalized improvement in eye-hand coordination.3,10,11 However, those with better spatial skills are more likely to play video games.1011 Some propose that typical improvement in game-playing performance occurs secondary to increased knowledge of game characteristics, not improvement in eye-hand coordination.3 Therefore, generalization to other activities would not be expected. Although it is possible that reaction time for similar activities decreases with playing experience,12 at the present time, it is inaccurate to claim general improvement in eye-hand coordination as an established benefit of playing video games.
VIDEO GAMES AND ADJUSTMENT
Although the first wave of video game popularity prompted serious concern about psychological impact, significant emotional disturbance was identified only in case reports.13 However, increased behavioral problems, lower self-esteem, and feeling "addicted" to game-playing have been reported by subgroups of players.3
Video Game Violence
Consistent with general trends in the media, violence is a prominent theme in the most popular video games of the 1990s.1'3·4 Theoretically, playing violent video games could adversely influence behavior as follows: In addition to demonstrating specific, often maladaptive, problem -solving and coping skills, video games require the player to actively participate in the development and maintenance of the basic game scenario. Players are rewarded for consistently choosing the built-in strategy, which in violent games is typically merciless, brutal competition. Playing violent games may increase the likelihood of subsequent aggressive behavior through disinhibition of aggressive responses, identification with game characters, and by gradually diminishing empathy toward victims of violence. Playing games involving repeated violence directed against human figures may have more lasting impact than destroying cartoon characters or inanimate objects. Many games allow players to magically return a character to life after annihilation (called a "Continue"). For younger children, erasing the link between violence and its consequences may be especially important, particularly as games become increasingly realistic.
Revised Video Game Category Descriptions*
Research in this area is extremely preliminary; however, several studies have found that playing or observing violent video games in a laboratory situation increases subsequent aggressive behavior in younger children on a short-term basis.14 This effect has not emerged in all similar studies, and longer term impact has not been determined.14 To examine the importance of a preference for violent games, we have developed and refined a system of categories based on the perceptions of children and adolescents (Table)1,15 (Buchman DD, Funk JB. Unpublished data. January 1993). We have begun to identify complex negative relationships among gender, game preference, time spent playing, and self-concept, including self-esteem. We anticipate that the significance of game-playing will vary across developmental levels, with the playing habits of younger children being more important.
Given this potential for influence, should access to violent video games be monitored or restricted? The fate of the government-mandated rating system for video games remains uncertain. The rationale for a video game rating system parallels the motion picture rating system: most parents are unable to preview every movie or every video game currently on the market. Following public outcry over some particularly graphic, violent games, Sega independently established a three-part rating system, with games either recommended for all authences, for "mature" authences (over age 13), or for adults only. More recently, Sega and Nintendo, through the Interactive Digital Software Rating Board, have developed proposed standards for a four-part rating system. However, permitting groups of manufacturers to regulate products may encourage unequal standards and limit opportunities for meaningful comparisons. Some believe that highlighting mature content may increase the appeal of extreme games. Balancing these issues, it appears most likely that an informational video game rating system, administered by an autonomous body and mandated for all games, should be able to provide the guidance most parents would appreciate while avoiding the "censorship" forecast by some opponents.
EDUCATIONAL IMPACT OF VIDEO GAMES
Educational applications of video games are quite exciting. Both regular and special education students have benefited from the introduction of ordinary and specialized video games as instructional aids and to encourage positive behavior. For home use, parents will find some educational games available on dedicated game systems, but the majority are still located in the computer game section. Taking advantage of the larger storage capacity of CD-ROM, "Edutainment" games such as 3-D Dinosaur are combining state of the art graphics and high-quality sound to create exciting knowledge and adventure games. The preschool levels of games in The Learning Company's educational series skillfully merge instruction with visual and auditory reinforcement. Although many children respond to the fantasy violence approach of games like "Math Blaster," the adventure/story format of the "Carmen San Diego" series is also popular. The Sanctuary Woods series of mystery adventure games, some of which have been developed specifically for girls, promote problem-solving and decision-making within an "interactive comic book" format. This company has joined with Addison- Wesley publishers to develop math and science multimedia software based on real-world scenarios. If these intellectually challenging games succeed without primary emphasis on violent content, perhaps others in the industry will respond with similar products.
The question as to whether typical recreational game-playing has negative impact on school performance remains unresolved. In studies based on selfreport, students are likely to deny that playing video games lowers school performance.3,15 In at least one study, male elementary students who reported playing in arcades were more likely to have teachers independently identify them as being lower in perceived ability in mathematics and general scholastic competence.16 Associations between academic performance and game-playing are likely to be based on complex sets of characteristics including age and gender of player, typical time spent playing, and possibly choice of game. Currently, it seems reasonable to propose that academic performance is minimally influenced for players who usually play only a few hours a week. Controlled studies are needed to determine if there are subgroups that may be more vulnerable to negative impact.
In addition to the positive educational uses noted above, video games have enhanced the success of medical treatment programs including rehabilitation of burn victims17 and chemotherapy.18 Super Nintendo games that teach health education and self-care for individuals with chronic conditions including acquired immunodeficiency syndrome (AIDS) and diabetes are being developed by Raya Systems (for information, call (415) 949-3933).
Two trends define the future of video games: increasing access and realism. Most dedicated system games are quickly available for video store rental. The evolution of the information superhighway will further increase the availability of computer-format games, some with multiplayer options. However, there may be unanticipated encounters; news reports have already described pedophiles using cyberspace to entrap adolescents. To help children avoid such superhighway potholes, some commercial networks are developing parental control options.
Virtual reality (VR) technology is the ultimate in game realism, integrating the player into the game scenario through first-person visual perspective, digitized stereo sound effects, and various "peripherals." These include headgear, seats, and the recently introduced "virtual vest." If increasing the sensation of actual control and participation increases the impact of game-playing, then identifying the parameters through which playing violent games could influence vulnerable individuals becomes a paramount research goal.
Although playing video games may be a benign activity for most children, the game-playing habits of some individuals may be a marker for potential or existing adjustment problems. In our research, adolescent girls who played several hours a week and préadolescent boys who played a high proportion of violent games had lower scores in certain aspects of self-concept (Funk JB and Buchman DD. Unpublished data. February 1992 and January 1993). The most important recommendation, therefore, is for parents to be knowledgeable about children's game-playing habits. Both time commitment and game content are important. In addition to reading game literature, discussing content, and observing children play, parents should try out the game. With younger children, game discussions should include conversation about differences between video game violence and real violence as well as clarifying expectations for out of home play. The most graphic games are still found in arcades. It is important for parents whose children play in arcades to be familiar with game content, which will change periodically. If younger children play in arcades, this should be well supervised. Parents should limit the time children spend playing video games and clarify that game-playing is a privilege, not a right. Excessive time can be modified by reserving game-playing until after chores or homework are accomplished. Finally, opportunities to play challenging and entertaining prosocial games should be made available to players of all ages.
1. Funk JF. Reevaluating the impact of video games. Clin Pedían. 1993;32:86-90.
2. Chambers JH, Ascione FR. The effects of video game playing on children's donating and helping. J Genetic Psychol. 1987;148:499-505.
3. Funk JF. Video games. Adolescent Medicine: State of die Art Reviews. 1993;4:589-598.
4. Provenro EE Video Kids: Making Sense of Nintendo. Cambridge, Mass: Harvard University Press; 1991.
5. Video Games and Human Development: A Research Agenda for die '80s. Cambridge, Mass: Monroe C. Gutman Library; 1983.
6. Graf WD, Chatrian G-E, Glass ST, Knauss TA. Video game-related seizures: a report on 10 patients and a review of the literature. Pediatrics. 1994;93:551-556.
7. Gwinup G, Haws T, Elias A. Cardiovascular changes in video game players: cause for concern? rbstgrod Med. 1983;74:245-248.
8. Segal KR, Dieu WH. Physiologic responses to playing a video game. Am ] Dis Child. 1991;145:1034-1036.
9. BrasingtonR. Nintendinitis. N Engl J Med. 1990;322:1473-1474.
10. Gagnon D. Videogames and spatial skills. Educational Communication and Technology. 1985;33:263-275.
11. Griffith JL, Voloschin P, Gibb GD. Bailey JR. Differences in eye-hand coordination of video game users and non-users. Percept Mot Skills. 1983;57:155-158.
12. Orosy-FieldsC, Allan W. Psychology of computer use. Percept Mot Skills. 1989;69:243247.
13. Keepers G. Pathological preoccupation with video games. } Am Acad Child Adolesc Psychiatry. 1990.-29:49-50.
14. Griffiths M. Amusement machine playing in childhood and adolescence. ) Adolesc. 1991;14:53-73.
15. Harris MB, Williams R. Video games and school performance. Education. 1985:105:306309.
16. Lin S, Lepper MR. Correlates of children's usage of videogames and computers. Jounral of Applied Social Psychology. 1987;17:72-93.
17. Adriaenssens EE, Eggermont E, Pyck K, Boeckx W and Gilles B. The video invasion of rehabilitation. Bums. 1988;14:417-419.
18. Kolko DJ, Rickard-Figuem JL. Effects of video games on the adverse corollaries of chemotherapy in pediatric oncology patients: a single-case analysis. ) Consult CIm Psychol. 1985;53:223-228.
Revised Video Game Category Descriptions*