Some teens can dabble in it, enjoying it in small quantities and then walking away satiated. Their consumption may be with friends – an hour here or there – or alone in their rooms, but their grades never fall, they maintain strong friendships, are usually good-natured and friendly around the house, getting to school on time and never missing sports practices or other extracurricular activities. While it's an enjoyable addition to their lives, it's not something that's a make-or-break part of their lives.
Yet other individuals become consumed, returning over and over, literally unable to let go. Their personalities undergo a dramatic change. Grades plummet, attendance at school, sports and extracurricular activities, as well as chores, take a nosedive, while friendships and family relationships become frayed or dissolve. Some people reportedly suffer from mental health disorders. As a parent, just try taking it away from your child.
“It” is not alcohol, opioids or another toxic substance, but video games, which according to many experts and scientific researchers, can cause an actual addiction for a portion of the playing population while simultaneously negatively impacting the development of the brains of children and adolescents, including causing permanent brain damage in some users.
Over 150 million people in the United States play video games on a regular basis, which is considered approximately three hours a week. While numerous players are children and adolescents, the average American gamer is actually a 35-year-old, with 72 percent of gamers 18-years-old and older. More males than females are regular video game players, with females utilizing social media more frequently than males. While there are many parents concerned about video game and screen time use, Hannah Nichols of Medical News Today noted that a majority of parents – 71 percent – currently indicate that video games have a positive influence on their child's life. Some parents utilize educational video games as part of their child's instructional life. There are education advocates who assert that educational games can improve a child's ability to learn, especially in a child's early years.
Video game sales are robust, with sales continuing to increase year-to-year. In 2016, there were 24.5 billion video games sold – up from 23.2 billion in 2015 and 21.4 billion in 2014. The top-selling video games of 2016 were “Call of Duty: Infinite Warfare;” “Battlefield 1;” and “Grand Theft Auto V,” which fall into the first-person shooter or action-adventure genres. The two genres – first-person shooter accounted for 27.5 percent of sales in 2016, while action-adventure made up 22.5 percent of sales – are often accused of stirring aggression and causing violence and addiction.
A current bestselling game, Fortnite, was released in 2017, is an online video game available free, of the survival, action building and battle royale genres. As of March 2019, Epic Games, which developed Fortnite, reported they had 250 million users worldwide, earning $6.9 billion – largely by the game selling “V-Bucks,” an in-game currency, for $9.99 per 1,000, which can be spent on customization items that are used during play.
A major contention and concern about video gaming of researchers and scientists is that it can affect and permanently change areas of the brain, as well as cause a small percentage of players to become so obsessed or addicted to gaming that they cease to be functional in other areas of their lives. For children and adolescents, whose brains and behaviors are still forming, the negative impact to younger brains can result in destructive behavior, impacted development and decreased social activity, which can have long-lasting ramifications. The world's neuroscientists and psychiatrists, who have been conducting studies of the potential problems, acknowledge that video games will have a different effect on different players, but caution that there can be real health implications.
“Psychologists have issued warnings about how addictive Fortnite – and other video games – are,” said Melissa Henson, program director, Parents Television Council. “There is a real and observable phenomenon with Fortnite, which is considerably addictive, of kids acting violent when it's turned off and/or taken away. It's comparable to taking alcohol away from an alcoholic. They become dependent on it and react violently when it's taken from them.”
Henson said that cat scans show physiological changes in the brains of children that play a lot of violent video games, where the area of the brain that monitors impulse control and judgement shrinks. “The hippocampus, which handles 'fight or flight' – that part grows,” she said. “There is a substantial body of research that shows that violent video games are more dangerous than violent TV shows because in violent video games you are the avatar – you are the one holding the gun, doing the action. With violent TV shows and movies, you're a passive observer.”
On May 25, 2019, the World Health Organization (WHO) officially adopted “gaming disorder,” adding it to the 11th revision of the International Classification of Diseases (ICD-11) as a behavioral addiction, explaining it is “a pattern of gaming behavior ('digital gaming' or 'video gaming') characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences. Some experts compare it to gambling addiction.
“For gaming disorder to be diagnosed, the behavior pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months… people who partake in gaming should be alert to the amount of time they spend on gaming activities, particularly when it is to the exclusion of other daily activities,” the WHO said.
Yet others are not as convinced, noting that despite the noted WHO classification, “It's not a set-in-stone diagnosis. It's controversial – and I'm a video game scholar. I'm very interested in the discussion,” said Sam Srauy, assistant professor, Department of Communications and Journalism, Oakland University. “We're still in the early days of video game research.”
Srauy goes as far as to ask – what is a video game?
“Since the 1970's, when video games first emerged, the definition of video games has changed dramatically,” he said, noting the 1970's was the era of Pong and Pac-Man. “Today, they're like a movie from Marvel that's interactive. Fortnite (played online against other players online) is very interactive. We also have games that are violent to others that lets you choose your own adventure. They look very different because tech barriers to the nitty gritty have been lowered, leaving us with no clear definition of what is a video game. It might be like obscenity – I may call it an obscenity, but you may not. The question is technical, so the tenet of what video game you can be addicted to – are you addicted to the playing? The button mashing? The dopamine in your brain being released? The violence?”
“Violence and aggression is subjective – it's emotionally-loaded terminology,” asserted Chris Ferguson, psychology professor at Stetson University. He said conflating video game usage with “something as toxic as the effect of smoking to lung cancer is a pretty extreme conclusion. Part of the problem is it can include so many video games – from PacMan to Grand Theft Auto – just like literature can range from the Bible to Shakespeare. PacMan gobbles up everything, but most people don't worry about the PacMans. If you're talking about bullying and aggression, video games don't contribute to that. It's not a risk factor. The correlation between screen time and suicide could be the same as eating bananas and suicide – everything can be nuanced if you look hard enough.”
Ferguson said it was a mistake for the WHO to label gaming disorder an addiction for a couple of reasons.
“The focus is on the game itself. The WHO has singled out gaming devices. Why is it concerned about video game overuse but not shopping overuse or exercise overuse?” he asked. “It's not that there aren't people who don't overuse video games – but is this a health disorder? It's one percent (of users). The WHO has seemingly responded to a technological panic. It's because old people don't like video games, and it's a political decision – especially from some Asian countries.”
Video games are extremely popular in Asia, from S. Korea to Singapore to China, with esports – a form of competition among using video games – finding its largest market in China. According to Bloomberg, in 2017 China was described as the “Games Industry Capital of the World.” Plagiarism by Chinese developers has been a worldwide problem for over a decade.
In April 2019, China announced it would ban video games that had blood, gore and gambling in any form.
Barry Fishman, professor of information and education at University of Michigan, takes it a step further, calling it a “moral panic” – where fear spreads among a group of people that some evil threatens the well-being of society.
“There is a long history of moral panics,” Fishman said, “where a new medium spurs a panic among the populace,” describing previous “moral panics” against the pulp novel, comic books, forms of kids' TV, movies, rap music and music lyrics.
“The theme is always 'kids are doing something terrible and it will tear kids apart,'” Fishman stated. “It's almost always about kids doing something parents don't understand and don't like – and it almost always turns out to be nothing.”
Except the lure and attachment of video games may not be nothing. That is something even professor Fishman acknowledges.
“I think there is something to be said about how modern technology gets us engaged and keeps us engaged,” he said. “I think the real threat is social media, and the way we are all interacting with social media. I agree with the World Health Organization that there is an issue with too much time playing with video games – and the probability of addiction – not because it's something inherently bad in video games, like the hidden ingredients in cigarettes – but because video games are designed with harm. Video game designers are very overt that they want you to keep playing.
“Doing too much of anything is bad. You could be addicted to video games, social media, cell phones,” Fishman said. “The tricky thing is – what do we mean by addicted?”
As for changes in the brain, such as in the hippocampus, Fishman said, “All experiences change the brain. That's how we grow. But what we don't know is what those changes mean for behavior. Brain-based learning (educational games) was all snake oil – what we do about it is all more nuanced and not supported by science.”
Fishman, who teaches a course called “Games for Learning,” about video games and learning, said most games designed for education are not designed well – which Henson of the Parents Television Council acknowledges.
“Educators are trying to figure out how to recreate incentives, like video games do, like in math, to incentivize them, because the first time they try they give up in apps and in math games,” she said. “Game developers have figured it out that if they don't get it right, it's okay and they can keep trying again and again – it's part of what makes them so addictive. So educators are directing (educational game developers) to app and math games.”
“Well-designed video games are tools for learning,” Fishman noted. “They're very powerful and gets you engaged in complicated games. It gets you to take on increasing challenges; it keeps you engaged and supports you as you increase in levels as you get better, until you ultimately succeed. If there was a game you couldn't get better at, you would stop playing. The thing that makes a well-designed video game is what makes a great educational game – there's a sense of self-autonomy, where you have a choice and it makes a difference; a sense of relatedness and belonging, the feeling of being part of something larger and still seen as an individual; and support for competence. Video games teach us a lot. Educational games aren't good – they're just better than a worksheet.
“Take Fortnite – you keep playing against other people, you're part of a large community, so they're not loners. It's similar to a sports fan community.”
Dr. Douglas Gentile, child psychologist at Iowa State University, said, “When we talk about 'addiction' we're talking about doing something so much where it interrupts other important things in our lives. It's an addiction when it causes such disruption to the rest of your life. There is a fine line and a difference from a passion. With a passion, you don't lose your job or your marriage. People manage their passions.”
Gentile said when he first began studying the topic in the 1990s, he was determined to disprove the theory of addiction. “And I learned I was wrong.”
While not a majority of users, “I did learn there are a certain small percentage of users who will have multiple disruptions to their lives, a percentage that has changes depending upon the sample size and statistics,” he said, pointing out that it is generally “between one and 10 percent of gamers. Most disorders, such as anxiety, depression, ADHD, learning disabilities, in any given population are between one and 10 percent, so that's very consistent. It's a small percentage. It's not zero – but it's also not 50 percent of the population. We're not talking about something like obesity, where it's 35 to 45 percent of the population.”
“The good news is most people can play video games – that's still 90 percent – without any disruption to their lives,” Gentile said.
But, he pointed out, “Even if we take the lowest number – the one percent of U.S. kids – there's about 40 million children between eight and 18, according to the 2010 U.S. census. Ninety percent of those play video games. If we take one percent – that's hundreds of thousands of kids who are doing serious damage to school function, their psychological and emotional function, their family function – where they feel anxious and depressed, they use games as a coping mechanism, are getting into fights with their parents, some of which are violent, they're doing badly in school, they drop other activities to game. It's not just that they like games – they need to play.
“The line is really clear – it's about dysfunction,” Gentile stated. “If your kid is playing games but keeping his grades up, playing with friends, continuing other obligations, doing his chores, staying in band, going to soccer practices – then go ahead and game. Then it's part of their entertainment. Because it's not about the game – it's about the gamer. That makes it about the substance.”
Regis Carozza, an attorney at Honigman and an educator, became interested in the topic of screen exposure and problems with brain development as a high school teacher at The Roeper School over the last decade, and began researching and speaking on the neuroscience and neuropsychology on the impact of screens on brain development.
“Dopamine is a neurohormone which is produced in specific areas of the brain. It's responsible for wanting and desiring things. It's not about pleasure,” Carozza explained.
Dopamine is essential for brain function, he said, which is why Parkinson's patients have such issues with not having enough dopamine.
“The problem that arises with screens, including video games, is that it triggers dopamine releases,” he said, pointing out that video games utilize “persuasive design” in order to stimulate production when a gamer is exposed to it, encouraging them to continue playing and playing and playing.
“Dopamine surges (for gamers) are similar to those who are pathological gamblers and drug addicts,” Carozza asserted. “It's the same neurological reaction. The technology is designed to maximize those dopamine surges to increase their use. This excessive dopamine – it's so constant and pounding on them from the new media – it's not an hour a day, it's constant surges of dopamine to kids' brains. They're awash in it. It suppresses the neuroactivity in their prefrontal cortex, which is supposed to be developing at this time.
“My concern with all of this screen time and video games is it interferes with the normal development of the brain. They're supposed to be looking at other kids in the eye, they're supposed to be learning to talk to each other, learning to engage – and instead they're in front of screens,” Carozza said. “Evolution wastes nothing. Biology is brutally efficient. It wouldn't waste the development of the prefrontal cortex if it wasn't critically important.”
Video game manufacturers understand this pathology because neuroscientists and psychologists are on development teams of large video game makers.
Marc Potenza, MD, professor of Psychiatry, Neuroscience and Child Study at Yale University School of Medicine and director, Yale Center of Excellence in Gambling Research, said brain imaging shows similarities in neurocognitive examinations between gambling and video game behaviors and other dysfunctional internet behavior, such as excessive pornographic viewing.
“We have found a number of different things in studies of gambling,” Potenza said. “Gambling disorder shares a number of attributes with gaming disorder and other addictive disorders in certain areas of the brain that have been seen to be affected, such as the ventromedial prefrontal cortex.”
The ventromedial prefrontal cortex is located in the frontal lobe of the brain, and is implicated in the processing of risk and fear, as it is a critical part of the regulation of the amygdala activity in humans. It is involved in the process of memory, decision making, self-control and in the cognitive evaluation of morality. The amygdala plays a significant role in instigating and monitoring emotional reactions associated with anger and violence.
Craig Anderson, editor of the journal Aggressive Behavior and distinguished professor of psychology, Iowa State University, said in the short term regarding use of violent video games, “The effects are generally the same for children, adolescents and young adults, although some researchers have found slightly stronger effects for children. The effects occur through changes in aggressive thoughts, aggressive feelings, and physiological arousal. In the short term, exposure to violent media can increase the accessibility to aggressive thoughts and increase aggressive feelings. Consuming violent media can also increase physiological arousal. Together, these three factors make a person more likely to behave aggressively, especially in a potentially aggressive situation.”
He said that when a person is exposed to violent media over the long term, it can lead to long-term changes in their brain and mindset.
“They become more desensitized – that is, they become less emotionally and physically reactive to scenes of violence and thoughts about behaving violently,” Anderson stated. “Both television viewing and video gameplay have been linked to attention problems, specifically difficulties in maintaining attention focus, like playing attention to a lecture… (it) has also been linked to impulsivity and impairments in self-control, cognitive control and executive functioning, all of which likely contribute to attention problems.”
In a letter written to the American Psychological Society (APA), 50 of the nation's prominent psychologists on August 8, 2018, said they were writing to “call attention to the unethical practice of psychologists using hidden manipulation techniques to hook children on social media and video games. These techniques – employed without children’s or their parents’ knowledge or consent – increase kids’ overuse of digital devices, resulting in risks to their health and well-being… In this letter, we describe how psychologists and other user experience researchers working for the consumer tech industry utilize persuasive technology (also called persuasive design or behavior design) to increase children's use of social media and video games, how this fosters children's overuse of screens, and how research demonstrates a connection between children's screen overuse and two problems afflicting this generation of kids: mental health struggles and poor academic performance.
“The typical U.S. teen now spends six hours, 40 minutes a day using screens for entertainment,” the letter continued, noting that less advantaged children and teens spend even more time behind screens – up to eight hours, 26 minutes a day for low income black teens. The letter urged the APA to call on psychologists and the tech industry to disclose its use of psychological persuasion techniques, and to take a strong advocacy position to educate parents, schools and child advocates about the use of psychological persuasion in social media and video games, as well as to inform the public of the potential harm of children’s overuse of screens.
Research continues on the effect of gaming on human brains – particularly younger brains. The National Institutes of Health launched a 10-year study on the effects of children who are heavy gamers and heavy social media users, closing the study in 2018. The aim of the study was to examine online social interactions along with patterns of video gaming behaviors and game addiction symptoms in order to better understand disorders related to excessive video game play using a sample of 9,733 adolescents based on heavy use of games, social networking and instant messaging, and game addiction symptoms.
In reporting their results, the researchers said they identified two types of heavy gaming classes. One group had a higher rate of online social interaction.
“Most adolescents estimated to be in heavy gaming classes had more depressive symptoms than normative classes. Male non-social gamers had more social anxiety. Female social gamers had less social anxiety and loneliness, but lower self-esteem. Friendship quality attenuated depression in some male social gamers, but strengthened associations with loneliness in some male non-social gamers,” the researchers stated.
“Consistent with our second study hypothesis, we found differences in well-being across gaming subgroups, such that non-social classes were associated with lower levels of psychosocial well-being,” the NIH report continued. “Importantly… all heavy gaming classes in both boys and girls were associated with more depressive symptoms. One possible explanation for this is heavy gamers feel depressed, and their heavy gaming does not relieve symptoms.”
Dr. Potenza of Yale said he and his team of researchers have tested certain medications to determine efficacy for gambling disorder, and while none are yet approved by the FDA with an indication for gambling and gaming disorder, “certain medications do appear to block impulses and appear to help with cravings. Some are helpful in clinical trials with gambling,” he said.
Some parents and heavy gamers, having seen the signs of addiction in their teens or in themselves, seek treatment, which appears to be in its early stages. Many of the treatment programs are modeled on gambling disorders and addiction, because of the similarity in the symptoms and behavior, and the belief that similar areas of the brain are triggered.
Depending upon the severity of the addiction, patients are treated on both an inpatient and outpatient basis. Meredith Watkins, MA, of the American Addiction Centers, said, “Inpatient facilities offer 24-hour supervision in a supportive, structured environment, which may be beneficial for individuals who haven’t been able to control their video game use. Outpatient treatment, which includes intensive outpatient programs and partial hospitalization programs, offers more flexibility for individuals who cannot enroll in inpatient treatment due to personal responsibilities or who are very motivated to recover from addictive behavior.
She went on, “Treatment for video game addiction focuses on behavioral modification therapies, such as Cognitive Behavioral Therapy (CBT), that guide the client away from the obsessive thoughts, patterns and obsessive habits of addiction. Group therapy is a valuable source of motivation and moral support, especially for individuals who have lost contact with friends or peers as a result of their game addiction. Family or marriage counseling can help educate loved ones about the disorder and create a more stable home environment.”
Inpatient facilities can range from noted drug addiction rehab centers, like Cottonwood in Tuscon, Arizona, which has added video game addiction treatment to its list of addiction treatments, to a few days in a local hospital, to recovery boot camps offering personalized, but at times austere, treatment programs.
While there has been an increase in the awareness of the behavior, gaming disorders haven't been studied as much gambling disorders, “which haven't been studied as much as substance disorders,” Potenza noted, particularly because there is a lack of funding. But he sees it just as addictive, and similar to gambling, “from an impulse control disorder.”
What are the similarities with other addictive substances that confirm Potenza's assumptions that gaming disorder is an addiction?
“What are the negative behaviors associated with the behaviors (of gaming)?” he asked, spelling out the impetuous urge, diminished or impulsive control – where people find less satisfaction from the behavior, which often occurs with addictive behavior, but they continue the behavior despite adverse consequences. When thinking of addictive behaviors, you must think of the impairments associated with them. I've seen hundreds of people in treatment for gambling addiction, with their finances, relationships, jobs, and trust with others impacted.”
Potenza added a caveat. “We need to be mindful that for most people, gambling and gaming are enjoyable endeavors – but for those people who do have problems, they can be significant.”
He said it's not an effort to stop gaming and gambling as an entirety.
“But there are people who are gaming 12 hours a day, and it's interfering with work and relationships,” he said. “There are stories about people dying in internet cafes after gaming for 24 hours a day” – notably in Asia. Potenza said S. Korea has called for these cafes to close for a certain number of hours a day because of the problem.
Another question some researchers are just beginning to look at – are playing violent video games making people depressed, suicidal, lack impulse control, suffer from anxiety – or are people who suffer from those conditions drawn to excessive play of violent video games?
Regis Carozza said that between 2012 and 2015, boys' depression in the United States increased by 21 percent, while girls' depression spiked by 50 percent. “Teenagers who spend more than three hours a day in front of screens are at increased risk of having at least one risk factor for suicide by 35 percent,” he said.
Stetson University's Chris Ferguson contends that “video game usage isn't the initial cause of a person's problem – it's actually the opposite. For most of these people, they're starting with a mental health problem, like depression, anxiety or something else, and they're turning to gaming. The games are a sort of coping mechanism, and they overdue it. They escape into it. Games are a lot of fun and real life isn't. Some of these people are getting treated for the symptoms – but taking away the video game is not addressing the real problem. Some kids get treatment they don't need, and healthy kids can get treatments they don't need.”
Barry Fishman of University of Michigan agrees.
“When somebody commits an act of violence and the media says they were a loner who played a lot of video games – it's the loner part I focus on,” Fishman said. “It's not a distinguished characteristic to play video games. They all play video games, and there's not riots in the streets. With a moral panic, it gives a scapegoat because it's much harder to say, 'Why are people alone and feeling isolated,' than to say these games are bad and we should ban them.”
“I am looking askance at the idea of video game addiction by the WHO, but to be fair, looking at something that ruins your life for 12 months – insert something for video games – makes total sense,” acknowledged Sam Srauy of Oakland University. “It may just be an evolving definition – and that's science.”