psychiatry and video games

Psychiatry and Video Games:Research Implications for Game

Designers

Paul Ballas, D.O.Medical Director, Green Tree School Clinic

Attending Psychiatrist, Friends Hospital

Disclosures

• No financially relevant disclosures• Scientific Advisory Board: Federation of

American Scientists “Immune Attack!”

AcknowledgementsNoguchi Research Institute

Osaka City University

AcknowledgementsDiscovery Health Channel / AMA

AcknowledgementsThomas Jefferson University Hospital

Philadelphia, PA

Outline

• Introduction• Psychiatric implications through the prism

of one diagnosis: ADHD• The concept of dosing• Chronobiology in video game research• Implications for designing pro-health and

pro-social games• Recommendations for the ADHD

population

Introduction

• It takes 17 years for a treatment proven effective to find it's way into the mainstream.

• Video games can provide consistency and compliance in a way that therapy cannot.

• Playing video games utilizes well recognized cognitive skills.

• State of technology and distribution now available for a revolution in pro-health games.

ADHD

• Real• Common• Important

ADHD

• The DSM-IV categorizes ADHD into four subtypes:– predominantly inattentive– predominantly hyperactive impulsive– combined inattentive, hyperactive-impulsive– and not otherwise specified [4b].

ADHDInattentive type: has six or more of the following symptoms for 6 months,

and they must be maladaptive and inconsistent with their current development level:

1.Makes careless mistakes or does not pay close attention to details2.Has problems maintaining attention during tasks or play3.Does not appear to be listening when spoken to directly4.Has difficulty completing assignments or following through with

instructions, not due to problems understanding instructions or to oppositional behavior

5.Has problems organizing activities and tasks6.Is reluctant to participate in tasks requiring sustained mental effort. • Often loses objects required to complete tasks• Is easily and often distracted by extraneous stimuli1.Is forgetful in daily tasks

ADHD

Hyperactive-Impulsive type: six or more of the following symptoms for 6 months, and they must be maladaptive and inconsistent with their current development level:

1.Often squirms in his or her seat or fidgets with hands or feet2.Frequently leaves his or her seat in class or other situations in

which continued sitting is expected3.Climbs or runs around excessively in situations in which this is

inappropriate4.Has problems playing or doing leisure activities quietly5.Appears to be “driven by a motor” or “on the go” often6.Talks excessively• Blurts out answers to questions before they are completed• Has problems waiting his or her turn1.Often intrudes on or interrupts others

ADHD

• Some form of clear, clinically significant impairment in occupational, social, or academic function occurs.

• To meet DSM-IV criteria, impairment must– occur in two or more settings– the symptoms must have been present before

age 7 years– Symptoms cannot exist exclusively as part of

the course of another mental illness.

ADHD


ADHD• Real– The most studied psychiatric condition in children– One of the most studied psychiatric conditions

overall.– Since 1936, Over 200 studies have shown the

effectiveness of treatment with stimulant medication.

– Stimulant medication has been used to treat ADHD longer than antibiotics have been used to treat infections.

ADHD


ADHD

• Common:– 5 – 8% of children– 50% persist into adulthood.– 5/19/10: The Houston Chronicle reported 4

million American women are estimated to have ADHD.

ADHD

• Common:– Simultaneously over and under diagnosed. – Under:•Highly genetic, and undiagnosed parents less likely to

identify symptoms.•Families with ADHD less likely to bring a child to

clinical attention unless there are behavioral problems.

– Over:•Often sleep deprivation, PTSD, and depression are

misdiagnosed as ADHD.

ADHD


Leading Causes of Death in the United States - 2006

Rank 1-4 5-9 10-14 15-24

1 Unintentional Injury

1,610 Unintentional Injury



16,229

2 Congenital Anomalies 515 Malignant Neoplasms 459 Malignant Neoplasms 448 Homicide 5,717

3 Malignant Neoplasms 377 Congenital Anomalies 182 Homicide 241 Suicide 4,189

4 Homicide 366 Homicide 149 Suicide 216 Malignant Neoplasms 1,664

5 Heart Disease 161 Heart Disease 90 Heart Disease 163 Heart Disease 1,076

Source: CDC.gov

ADHD

• Important: Mortality– Children:•Most common causes of death:

– #1: Unintentional injuries age 1 -44– #1 cause of injury death is MVT: children age 5 – 9 and 15

- 19. – #2 cause: poisoning, often prescription opioids.

– #2, 3: Homicide and Suicide age 15- 34

•ADHD increases impulsivity, inattention, and hyperactivity.

ADHD• Important– Teenagers:•more fatal car accidents•more traffic violations•Lower academic achievement•ADHD is associated with higher risk of MVA•Stimulant medication significantly reduces this risk.

– Adults:• Increased risk of drug and alcohol abuse•Less employment, lower salaries•Less marriage, higher divorce rate

ADHD and Video Games

• The relationship between symptoms of ADHD and the playing of video games is not well understood. – This ambivalence has been reflected by

statements made by The American Medical Association and American Academy of Child and Adolescent Psychiatry [1,2].

ADHD and Video Games

• American Medical Association [1]: • “The health effects of video gaming on ADHD

remain controversial, with some research pointing to video game usage as a risk factor, and other research suggesting video games as a useful treatment.”

Ambivalence in Research

• Historically, research has focused on the negative consequences of playing video games.– Meta analysis over the last five years have

shown inconsistent associations between violent video game play and violent behavior.

Relationship between aggression and video game play

•Complicated by various studies suggesting that exposure to video game violence can increase, reduce, or have no influence on aggressive behavior.

• In 13 studies published between 1984 and 1996 playing video games can result in increased aggression, no aggression, or an increased calming effect [3].

•A more recent review of the literature found an association between violent video games and short-term aggressive behavior. – however, due to study limitations the authors found it difficult to

establish a causal effect between playing video games and long-term aggressive behaviors [4].

•Recent meta-analysis shows more consistent correlation between violent video games and violent behavior

•The association akin to the relative risk of poverty.•This association has been disputed.

Recent Research Findings

• Recent studies are illuminating the possible benefits to children playing certain games, especially in ADHD.

• Children with ADHD may be using video games as a form of self-medication [5].

• Video games may boost self-esteem in a population of children who derive little of it from their schoolwork or family life [6].

• Additional research has shown that for boys with ADHD, interactive games can improve classroom learning and social relationships [7].

Recent Research Findings

• For preschool children, evidence indicates that the presence of a computer in the home of can:– improve school readiness – cognitive development

• These improvements occurred regardless of: – the frequency of access video games– ownership of video games in the household– the socioeconomic status of the family– the developmental stage of the child [8].

• Some evidence suggests that action video games may briefly improve certain cognitive functions [9].

Neurology and Video Games

• Some correlation seems to exist between the neurotransmission involved in video games and ADHD.

• The dopamine hypothesis of ADHD implicates variants in dopamine receptor subtypes and dopamine transmission in the pathology of ADHD.

• Decreased dopamine release in the corticostriatal pathway has been observed in individuals with ADHD [10,11].

• Some evidence indicates that video game play is associated with dopamine release and low-function D2-receptor polymorphism [12,13].

Dosing: Effects of Video Games and Computer Use on Attention

•Research suggests that playing video games may improve attention but daily computer use can actually worsen attention [15].

– 101 children, aged 9 to 12 years had their attention measured by the Stroop test before and after playing a nonviolent motor-racing game.

– improved test scores with game play for 0.6 ± 1.1 h/d– unaltered with game play for 1.3 ± 0.9 h/d– scores worsened with game play for 1.6 ± 1.4 h/d

Dosing: Effects of Video Games and Computer Use on Attention

• Risk factors for worsened post-test scores included:–daily duration of computer use–diagnosis of the inattentive type of ADHD–male gender– younger age.

• These findings suggest that in the short term, computer games can have a positive effect on attention in certain children, but this effect deteriorates with increasing daily computer use, which can even worsen attention[15].

Dosing: Effects of Daily Video Game Playing onChildren With ADHD

•Spending more than 1 h/d playing video games can be detrimental to children with ADHD [16].

•In a survey of 72 adolescents and 72 parents, playing video games for more than 1 h/d was related to:

– more symptoms of ADHD– more severe symptoms of ADHD– lower grade-point average [16].

Dosing: Effects of Daily Video Game Playing onChildren With ADHD

•Of note, no association was found among time spent playing video games, exercise, and oppositional or aggressive behaviors.

•This research suggests an association between playing video games for more than 1 hour and inattention.

Chronobiology: Video Games and Sleep

•Playing video games before sleeping can worsen sleep by:

– shortening rapid eye movement sleep– delaying bedtime– increasing sleep latency– reducing the amount of time spent in bed [17].


•Effects of light•In a small study of adults who played video games before going to sleep, increased sleep latency and decreased rapid eye movement sleep were observed compared with those who performed simple tasks in front of a bright display.

•The combination of a bright display and playing a video game decreased sleep quality subjectively [18].

– Some evidence indicated that physiologic variables that change as a result of playing video games can be affected by whether the game is exciting or boring and whether the display being used is bright or dark [18].


• One study showed that secondary school students who spent more time playing games and using the Internet:– spent less time in bed– had a delayed bedtime [19].

• Another study showed that playing an exciting video game before going to bed resulted in:– a small increased sleep latency– decreased subjective sleepiness– increased heart rate– decreased theta power on electroencephalogram [18].


• This suggests that the increase in sleep latency resulting from playing video games may be related to increased activity in the autonomic and central nervous system.


•Additionally, nighttime exposure to bright light and even light of low intensity affects circadian rhythms [20–23].

•Evidence suggests a dose dependent relationship between light intensity exposure early in the biological night and alertness [24].

•HD TV’s, do they produce higher illumination?

Effects of ADHD Treatment onVideo Game Playing

• Children with ADHD tend to play video games less after being treated [3].

• In a study of 62 drug-naive children with ADHD, after 8 weeks of treatment with OROS methylphenidate hydrochloride:– Internet usage time and scores on an Internet addiction scale

were reduced [3]. – The changes in the Internet addiction scale score were

correlated with omission errors from the Visual Continuous Performance Test and changes in inattention and total scores on an ADHD rating scale.

– There was significant difference in the number of omission errors made among children rated severely, mildly, and not Internet addicted.

Video Game Playing

• has been shown to release dopamine • use visual working memory• may be a means by which children with ADHD

self-medicate, as other studies have suggested that alcohol and nicotine use may be efforts to self-medicate [25,26]

Asking Children With ADHD to StopPlaying Video Games

•Children with ADHD have more problems when asked to stop playing video games [27].

•A small study of children with ADHD and age-matched control participants showed that children with ADHD had more problems playing video games than the age-matched controls [27].

Asking Children With ADHD to StopPlaying Video Games

•It was noted that when hyperactive children had to stop playing games:

– they were more likely to react with tears, refusal, anger, or violence.

– No difference between the duration or frequency of video game playing between children with ADHD and control children.

– Neither group reported any negative effect of game playing on schooling or missing meals [27].

Video Games and Meal Skipping

•Appetite suppression is a common side effect of stimulant medication.

•Lack of appetite and skipped meals are often concerning to clinicians who treat children with ADHD with stimulant medication.


• Adolescents who play video games four or more times weekly are more likely to skip meals [28].

• A study of 2546 adolescents showed that 1 in 10 respondents skipped a meal at least once weekly as a result of playing computer games or watching TV [28].


•The teenagers most likely to skip a meal to watch TV were those who watched 5 or more hours daily, boys, and first-year students [28].

•The teenagers who played video games 4 or more times per week were 10 times more likely to skip at least 1 meal/wk.


•A total of 25% of the teenagers in this sample reported eating faster at least once weekly to play computer games or watch TV.

•The risk of eating faster increased progressively with the teenager’s use of media.

•This study suggests that playing video games and watching TV does tend to displace the amount of time spent at meals.

Summary of research•Research historically has explored the negative effects of playing video games on children, particularly those with ADHD.

•However, it is important that the psychiatric community does not ignore the potential psychiatric benefits of gaming technology in the treatment of ADHD.

•If certain parameters are monitored, such as ensuring game play does not interfere with sleep or good mealtime behavior, it is conceivable that games could be developed that could treat ADHD effectively.

Proposal for ADHD Video Games•Research has shown that neurofeedback is a legitimate treatment of ADHD [29]

•Gaming technology incorporating electroencephalogram technology as a game control was introduced recently [30].

•Future research should explore this and other video game technology as a potential treatment for ADHD and other psychiatric disorders.

Proposal for ADHD Video Games

• In research parameters, acknowledge the aforementioned research.

• Employ prosocial video game format.• Employ point/token system recognized as

effective in ADHD Children• Meaningful reward for children with ADHD.• Target important outcomes of video games.

Example of Target Outcomes

• Automobile insurance company develops a pro-social driving game using token economy. Should the user achieve 100,000 points, they received $50 refund from annual premium.

• Insurance company can track traffic violations and car accidents of people who did or did not play the game.

Conclusions

• Screen for ADHD in game testers and research subjects, it will likely have an impact on your results.

• Expand the early research on parameters of the impact of video games on people with ADHD

• Design games for the ADHD population, likely to have a significant impact on this population.

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