Is gaming tied to violence?

On August 26, two prominent gamers were killed and 11 more were injured when a fellow competitor opened fire during a Madden 19 tournament at The Jacksonville Landing. As families, friends and the gaming community mourn, concerns are being raised once more about the relationship between violence and video games.

"Violent video games have not been found to correlate with violent behavior or criminal behavior," said Raj Loungani, MD, MPH, child, adolescent and adult psychiatrist with the Wolfson Children's Center for Behavioral Health, a division of Baptist Behavioral Health. "In fact, some studies have shown that in the months after popular violent video games are released aggravated assault and homicide rates tend to drop, perhaps due to some aggression-reducing catharsis from playing games instead of engaging in criminal activity. For most people, gaming is a harmless hobby that is healthy and relaxing. It's only cause for concern if it leads to neglecting other activities or your responsibilities. That's why the gaming disorder diagnosis has the criteria it does."

In June, the World Health Organization (WHO) declared gaming disorder a mental health condition in its latest edition of the International Classification of Diseases. In order for someone to be considered addicted to video games, they have to meet a few criteria:

• Gaming takes precedence over other activities, such as homework, exercise or sleep.
• Gaming persists even when negative consequences occur, such as a drop in grades.
• Gaming impairs functioning and disrupts daily life, like a reduction in sleep or physical activity.
• These criteria must be met for at least 12 months.

Dr. Loungani says many parents worry their son or daughter could be addicted to gaming. Here, he answers some of the burning questions parents have about violent games, their child’s gaming habits and the most popular game of today: Fortnite.

How long should a child or teenager play video games each day?

I recommend a limit of one hour per day of video games for school-aged children and no more than two hours per day for teenagers. The American Academy of Pediatrics recommends limiting total screen time — including gaming, TV, computers and other electronic devices — to one to two hours per day. That is much less than the 6.5 hours per day actually spent by the average kid in America!

Gaming is not only here to stay, it is rapidly growing in popularity with eSports growing by 40 percent over the past year to $700 million in revenue, and to a projected $1.5 billion dollar industry by 2020. With this steep rise in popularity and accessibility to video games, further research is certainly required to investigate the links between gaming, mental health, and outcome measures – both positive and negative.

Does gaming addiction affect the brain the same way as a drug or alcohol addiction?

Gaming addiction is like addiction to substances like drugs or alcohol, or other addictions like gambling, in that video games directly activate the brain's reward system by increasing levels of dopamine. They potentially flood a gamer's brain with up to 10 times the normal level of dopamine.

With dopamine levels so elevated, over time more and more video gaming is needed to feel the same pleasurable effect. Repetitive gaming, like drug or alcohol use, may produce such an intense activation of the brain's reward pathway that gamers begin to neglect normal activities, like sleeping, eating, or physical activity in favor of playing, leading to significantly reduced level of functioning. That's why some call games like Fortnite ‘digital heroin!’

As with substance use and gambling disorders, in gaming disorder there is a preoccupation or obsession, as well as physical and psychological dependence. There may be cravings and withdrawal symptoms like impaired mood, sleep, motivation, or even physical symptoms like carpal tunnel syndrome, dry eyes, migraines, backaches, nausea or constipation when not playing. The gamer may use video games to relieve anxiety or guilt as a way to escape. When these symptoms are present for gamers, playing video games is no longer a harmless hobby. It can result in clinically significant impairment or distress that must be treated for the gamer's well-being.

What behaviors should cause concern for parents?

There is no set number of hours per day or week of gaming that signifies that a child or adolescent is addicted to video games. That said, most parents start to worry when their child's gaming creeps into 15 to 30 hours per week. As with all disorders, the extent of a problem depends on how gaming is affecting other areas of the young person's life.

Is playing video games taking precedence over basic activities of daily living like sleeping, eating, and hygiene? Is it replacing in-person socializing with family and friends with primarily interfacing with others online? Is the child or teen neglecting to attend to responsibilities like schoolwork and household chores? Is the young person gaming more often over time and procrastinating by using video games? When not playing, is he obsessing about video games and displaying changes in mood, sleep, motivation, or experiencing physical overuse or withdrawal symptoms? If the answer to any of these questions is yes, there is good reason to be concerned and seek help.

What should parents do if they feel their child might be addicted to video games?

There is growing evidence that children and teens addicted to video games — anywhere from 2 to 12 percent overall — may experience a host of social, emotional, and behavioral problems. If you notice the symptoms I've described, please seek an evaluation by your primary care doctor or a behavioral health specialist. There are various evidence-based treatment modalities available for gaming addiction, as well as for any related conditions like depression, anxiety, ADHD and disruptive behavior disorders. We want to support parents and caregivers to maximize their child's or teen's level of functioning as soon as possible.

Why do you think Fortnite is becoming such a sensation among kids but such a problem for parents?

Fortnite plays to the brain’s vulnerabilities. It rewards you based on a variable-ratio schedule, which is the most effective reinforcement strategy. It’s why gambling and lottery games are so addictive. I don’t know when I’m going to pull that slot machine lever and win big, and since I am winning here and there, I want to keep playing to get the rush of the next win. Fortnite plays to that same rush of not knowing when you’ll earn a reward or win a round, tantalizing you to keep playing. Add to that the beautiful graphics and shared experience by players interacting in a common quest and livestreams on YouTube, ever-evolving pop references like game characters performing iconic dances from "dabbing" to the Backpack Kid's "floss" dance, and we have ourselves not just the biggest game of the year, but a cultural phenomenon that's responsible for most of the gaming disorder cases in recent memory.

It would be great to talk to the creators and learn how much they studied about what humans and our brain's reward pathways crave and what’s most addictive to us!

What are some good tactics to regulate your child’s video game activity?

First and foremost, it’s important to manage gaming behaviorally. As a parent or caregiver, the main thing is to ensure strong supervision, particularly for younger children, and to monitor what your child is exposed to. If you can, play the game with your kids or stay with them while they play, so it becomes a bonding activity, and you can also discuss the game’s content.

We should generally discourage kids younger than 2 years old from screen time, though the occasional Baby First program or FaceTime or Skype call is not going to be detrimental. Yes, grandparents everywhere can breathe a collective sigh of relief! Preschool-age kids and younger, in particular, model what they observe, so they should not play games with gratuitous adult content — including excessive violence, sexuality, substances, criminality, or profanity. You can check the Entertainment Software Rating Board age and content ratings assigned to select suitable games.

Another recommendation is to keep game systems in the common room instead of the bedroom, so it’s easier to supervise the kids and they’re less likely to sneak in more time playing. Kids that have TVs in their room tend to spend about 1.5 hours per day more on their screens than those that don’t! If your child tries to sneak extra time gaming, you may need to unplug and physically remove the TV and game systems, but please don't give in and not follow through with enforcing the rules and consequences for the limits you’ve set.

You can use gaming and overall screen time as a reward for completing chores and homework, performing hygiene, physical activity, practicing music or arts, and other adaptive behaviors you want to reinforce. Likewise, taking away your child's gaming or screen time may be a suitable punishment when he or she does not meet your clear expectations of behavior. A good rule of thumb is don't take away prosocial activities like sports, music, arts, or volunteering as a punishment, while gaming and total screen time lend themselves nicely to be negotiable for behavioral modification.

How can parents set limits on gaming without creating conflict with their child?

Set clear expectations for your child in terms of sleeping, eating, hygiene, physical activity, chores, education and employment. Then use gaming as a reward he or she can earn for meeting these expectations, as a fun activity performed in moderation to de-stress. Note that when you reduce gaming time, you need to replace it with something else — perhaps special time as a family — riding bikes, going to the park or beach, or playing a board game or puzzle together. These activities can be as fun as video games but of course healthier in terms of social, physical, mental and creative engagement.

How is video game addiction treated?

Like any addiction that hijacks the brain's reward pathway, it’s not easy for most gamers to just quit playing cold turkey. In treatment, we seek to understand what video games the gamer is interested in and why. For instance, online roleplaying games like World of Warcraft allow you to interact with a community of like-minded gamers and explore a cosmic fantasy world. In games like Minecraft and The Sims, you're allowed the freedom and creativity to build almost anything your heart desires, and you set your own goals with no end in sight. What does the gamer's game of choice tell you about what he or she might be craving?

We typically utilize a form of cognitive behavioral therapy, or CBT, the psychotherapeutic approach which is considered the gold standard for children and adolescents in treating other mental health conditions like depression, anxiety, and disruptive behavior disorders.

With video game addiction, we monitor the thoughts and feelings the child associates with gaming. Just as people self-medicate with drugs and alcohol, they may do so with video games, so we want to identify any underlying causes for the gaming addiction. For example, is the child gaming excessively to cope with untreated depression, anxiety, or ADHD? CBT and possibly medication may greatly help such gamers regain and maximize their level of functioning.

We work with the parents to develop and set clear expectations, rules and consequences for their children. For instance, how much time for playing video games is allowed and what needs to be done first? If the parents’ expectations are met and rules are followed, a reasonable reward may be 30 additional minutes of gaming time this evening. Failing to meet expectations or follow rules, on the other hand, may result in 30 minutes less of getting to play.

Can playing video games be beneficial?

In moderation, video games have been found to have some positive effects: improving hand-eye coordination, reaction time, creativity, visual-spatial and problem-solving capacities; increasing the ability to pay attention while filtering out distractions; improving reading comprehension for those with dyslexia; sparking a child's interest in the social sciences, as many games use historical events and maps to drive their stories; and curbing cravings for overeating or using substances — though not surprisingly, the more time kids or adults spend sedentary in front of screens, the more likely they are to be overweight or obese. Video game technologies like virtual reality have helped people recover from PTSD and get over phobias by providing exposure therapy, as well as helping substance users deal with triggering moments.

There are some educational games that can make learning more interesting or fun, such as Reader Rabbit, The Magic School Bus, and LeapFrog Leapster.

Playing video games can certainly be a relaxing or distracting coping skill to reduce stress, with one major study tracking gamers' heart rates over six months showing certain video games were associated with reducing the adrenaline response by over 50 percent. Experiencing the range of pleasant and unpleasant emotions in a gaming context has been found to help people regulate emotions, learn to cope with various situations, and challenge themselves. Some studies have shown that kids who play moderate amounts of games — less than an hour per day — have fewer emotional issues and are more likely to help others than kids who don't play games. Just about every one of my child and adolescent patients lists video games as one of his or her coping skills and hobbies, while only a handful meet the criteria for gaming disorder.

Also, while video game addiction can often be socially isolating in terms of real-world relationships, gaming offers a new form of socializing in which players interact and collaborate in various problem-solving endeavors, which can certainly have benefits in terms of developing social connections — particularly for those with autism. I have had many patients with autism spectrum disorder or social anxiety disorder who thoroughly enjoy discussing with others online and in-person about the video games they love, even as they are struggling to communicate elsewhere.

Some physicians have responded to the WHO’s announcement by saying there isn’t enough research to make gaming disorder an official diagnosis. Others say it’s about time. How do you feel?

Diagnoses provide a language to name and talk about the problem. Video game addiction is an emerging area of research that certainly warrants more studies. Gaming disorder has not been endorsed as an official diagnosis by the American Medical Association, American Psychiatric Association or American Academy of Child and Adolescent Psychiatry. However, internet gaming disorder is included as a “Condition for Further Study” with a request for additional research in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the APA in 2013.

In addition to further research, if including the gaming disorder diagnosis in the 11th edition of the International Statistical Classification of Diseases (ICD-11) leads to increased recognition and treatment of those who have been gaming excessively and excluding daily activities and interests, it's a positive. It’s important to recognize if any behavior, not just gaming, is being performed excessively or compulsively and hinders the person's overall level of functioning, and to not hesitate to seek help from your primary care doctor or a behavioral health specialist to attain the right treatment. “Everything in moderation” is generally a healthy philosophy.

If you are concerned about how your child’s video gaming is affecting them, make an appointment with a pediatrician or behavioral health specialist to find solutions.