Impact of Video Games on Children and Adolescent Health

Over the past few decades, video games have played an increasing role in children’s lives; However, quality research on the health effects of video game use has lagged. Recent high-quality studies have made the understanding of this association clearer.

Physicians should have a basic understanding of the effects of video game use on the health of children and adolescents and should be able to guide patients and caregivers on appropriate use. With the recent addition of gaming disorder to the International Classification of Diseases, 11th Revision, clinicians must know how to identify and detect pathological gambling.

Over the past few decades, video games have become a favorite pastime for many children, and their use continues to increase.1 The percentage of American children who play video games is estimated at over 90%, increasing to 97% by the age of 12. to 17 years old.2 In 2021, the average 8 to 12 year old played about 1.5 hours of video games daily, and the average 13 to 17 year old played for almost 2 hours. 3 Video games occupy an important part of children’s days, making them a potential driver of child health and development in both positive and negative ways.

As researchers find new connections between play and well-being, it is important for pediatricians to be familiar with the effect of this almost ubiquitous activity. In recent years several articles have reviewed the literature on screen time and social media use in children. 4, 5, 6

This review summarizes the expansive topic of childhood video game use and its unique implications for health and development for the purpose of educating pediatricians. Some facets of this issue are politicized and hotly debated, with parents, researchers, game producers and legislators holding different, sometimes conflicting, opinions.7

However, high-quality research over the past decade has clarified our understanding of some of these effects. It should be noted that most research in children has focused on adolescents, with less robust literature on preadolescents. Additionally, some of the research discussed in this article was conducted in adults and it is debated whether it is relevant in the absence of reliable studies in children.

Researchers have long known about the adverse effects that screen time can have on the health of children and adolescents.

The relationship between excessive screen time and obesity itself is well documented.8

Spending time in front of screens has the potential to increase BMI through several mechanisms, including increased sedentary time, increased snacking and decreased satiety signals, sleep disruption, and exposure to food advertising. .9 Although the data on media use, such as television and video viewing, is clear, the data is more mixed for video games. A 2020 review found 26 articles on the association between video games and obesity.10

The authors concluded that there was inconsistent evidence for the relationship between video games and obesity, with 14 articles finding no association and 12 articles finding a positive association between video game use and weight gain. Compared to resting while sitting, gaming increases heart rate, blood pressure, and overall caloric expenditure.11 However, this is likely mitigated by findings from several studies that video game players consume more snacks, more fatty foods and more sugary drinks than non-gamers.11, 12, 13

Gamers are exposed to fewer food and product promotions than traditional media, although mobile phone and tablet games often contain ads. In general, the association between playing video games and obesity is less clear than for more passive media use, such as watching television, but the net effect is probably a slight tendency toward weight gain and unhealthy eating.

This does not include newer physically active games, or "exergames," which have shown promise in promoting a variety of healthier behaviors.10 An example that most people have heard of is Pokémon Go, a game which relies on the player’s movement through the real world by walking or running to progress.

By combining exercise (something kids should do) with an engaging activity like achievement in a video game (something kids want to do), you increase enjoyment of the less preferable activity. As of 2019, Pokémon Go players had traveled a staggering 14 billion miles catching and hatching the small animated creatures known as Pokémon.14

A 2021 systematic review found that playing Pokemon Go had measurable positive effects on physical, mental, and social health.15 There are now many exergames available, from Pokemon Go to the ever-popular Dance Dance Revolution series to newer, more accessible virtual reality systems. ; all have the potential to increase activity in previously sedentary patients. When used regularly, exergames have been shown to have beneficial effects on weight loss, exercise program adherence, and even depression. 16, 17, 18

Using screens close to bedtime is also known to decrease both the quantity and quality of sleep.

Playing video games at night is associated with longer time to fall asleep, decreased total sleep, and architectural changes in rapid eye movement and slow wave sleep in children. There may also be an association between late-night gaming and attention and memory the next day. These effects may be mediated by several mechanisms, including disruption of normal melatonin secretion due to light exposure, psychomotor stimulation by more exciting games, or sleep displacement by gaming. 19, 20, 21, 22

Several small studies have found that playing fast-paced violent games and playing for a prolonged period (>2.5 hours) is associated with significant disruptions in sleep compared to shorter, more relaxed games. 23, 24

Sleep deprivation has been associated with a multitude of undesirable health effects, including decreased executive functioning skills and academic performance, irritability and mood disorders, and physical inactivity.25 Having a screen in the child’s bedroom, in addition to the effects on sleep, decreases parents’ ability to monitor play activities and has been independently shown to be related to obesity and decreased academic performance. 26, 27

Physical play has clear advantages over virtual play, including developing fine and gross motor skills and reducing screen time.

Young children show deficits in learning from screens compared to direct interaction with other humans.28 The dangers of excessive media use in young children are well known, and the benefits of hands-on play cannot be underestimated.4

Not all screen time is equal, and the active attention and participation asked of the player makes video games more cognitively stimulating than watching television. Virtual play cannot replace physical play, although there is some value in solving puzzles and overcoming obstacles even through a screen.

There is experimental evidence in older children and adolescents that consistent video gaming can improve a variety of cognitive domains, including problem solving, working memory, information processing, and flexibility.29

Action games can improve visual processing and reaction times.30, 31, 32 Puzzle games, memory games, and strategy games can improve other aspects of executive functioning. 33, 34, 35 Like playing a sport, video games strengthen connections through repetition. There is evidence that some of these skills transfer to the real world, as one small study found that training with action games improved reading skills in children with dyslexia.36

The ability of games to promote cognitive development depends on the context of the game and the age of the child. Many principles from the American Academy of Pediatrics (AAP) policy statement and Young Minds and Media 2016 can be applied to video game use.4 Parents should monitor children’s gaming activities, keep video games away from to eat and sleep, and avoid violent and fast-paced games in young children.

When possible, games should be enjoyed together to promote learning. For example, open-ended games like Minecraft and Roblox are great for fostering creativity, but as with physical play, students can get the most benefit when playing with an adult who can provide direction, context, and opportunity for socialization.

The AAP’s most recent screen time guidelines recommend that children under age 2 stay away from most screens; this should also apply to video games. Children ages 3 to 5 should limit themselves to 1 hour per day of media use, including video games.

Setting limits is also important for school-age children and teens, and more liberal playtime should be balanced with other essential needs. Families should create and consistently follow plans for video game use that ensure adequate sleep (8 to 12 hours per night depending on age), physical activity (1 hour daily), time for school work, and in-person interaction with family and friends. friends.37 Reasonable limits on play may be different among children depending on their ability to meet these needs.

The relationship between the use of video games and attention problems has been widely studied. A 2018 systematic review found a statistically small relationship between screen use and behaviors related to attention deficit hyperactivity disorder (ADHD).38 This association is theorized to be stronger for video games than traditional media due to the highest levels of commitment and arousal. Most studies have been cross-sectional, making it difficult to establish causality.

A recent longitudinal study found that video game use predicted ADHD symptoms in adolescents, but existing ADHD symptoms did not predict future video game use, suggesting a causal link.39 Children with ADHD are also more likely to use video games excessive play, with longer average play times and more addictive behavior.40, 41 Therefore, children with ADHD and their guardians may benefit from education about appropriate play, in particular, setting limits to ensure that video games do not interfere with other necessary activities.

The link between gaming and mental health is complex. The overall effect on emotional well-being appears to be related to many factors, including time spent playing, motivations for playing, and whether playing is done alone or socially. Many studies have found associations between excessive gaming and negative psychosocial outcomes.42

“ Excessive gaming” is generally used to represent a state of addiction that affects other aspects of a gamer’s life, which will be discussed later. People who engage in moderate video game use have improved affective symptoms compared to those who engage in moderate gaming. they play them excessively or not at all.43,44 One study of college-age men found that they played more video games when they were stressed, lonely, or bored, with no significant effects on BMI or GPA, suggesting a healthy means of socialization and relaxation.45

A variety of commercial video games have demonstrated effectiveness in reducing stress and anxiety in both adolescents and young adults, even with brief gaming sessions.46 In 1 study, players reported feelings of stress relief, reduced anxiety, and a "sense of purpose" of achievement in games.1 In addition to the amount of play, the motivations for playing are important. Gambling for pleasure or social purposes improves psychological symptoms compared to gambling solely for escapism or achievement.47

Overall, playing video games can have positive effects on children’s mental health, but they should be enjoyed in a healthy way. This means that one must consider not only the amount of time they spend playing, but also why they are playing and whether they are truly enjoying their experience.

Video games also offer a way for children to explore new identities. For example, a child who was assigned a certain gender at birth may play a video game as a character with a different gender expression. They can then explore this identity in an environment they consider safer. Some games even offer romantic relationships with same-sex characters, which can offer a unique opportunity to LGBTQ teens who may not be ready or able to express their sexuality in the real world.

The potential for negative psychological effects must also be considered. A central question of gaming research over the past 4 decades has been whether violent video games can make children more aggressive. This issue is often at the forefront of media and policymaker discussions about video games, and came to a head in the late 1990s and early 2000s after a series of mass shootings and the popularity of The Grand Theft Auto series , with the first title being banned in Britain, Germany and France due to its "extreme violence". A violent game is one that allows players to kill or inflict serious harm on human or human-like characters.

This definition is broad and applies to games that depict intense violence and gore, such as the Grand Theft Auto and Call of Duty series.48 It can also be applied to more child-friendly games, such as Minecraft, which has a content warning about "fantasy violence", and Fortnite, which contains violence but no blood.

Video game content warnings and age ratings will be discussed later in this document. Several meta-analyses have found a significant relationship between violence in video games and aggressive behavior of players. 49, 50 In its updated 2020 resolution on the topic, the American Psychological Association (APA) recognizes a link between violent video games and increased aggression (using insults, threats, yelling, pushing), lower awareness and lower empathy, but not actual violence or criminal behavior.51

This report has been criticized by some experts. A 3-year longitudinal study found that violent video games had no effect on aggression when controlling for other factors, such as depression, exposure to family and peer violence, and antisocial personality traits.52 There are concerns about publication bias; More recent studies with preregistered hypotheses have found weaker associations between violent video games and aggressive behavior than previous work.

Despite the controversy, the APA maintains that this association has been shown consistently over time. Playing style appears to matter, as several studies have shown that self-reports of aggression are lower when playing video games with social aspects, such as multiplayer games with cooperative play. 53, 54

Post-game aggression may also be influenced by the context in which violence occurs, as players who engage in violence out of a moral character (against "bad" people) experienced lower levels of aggression than players who exercise violence through an immoral character (against “good” or “innocent” people). 55, 56 More quality studies are needed to further explore this relationship. There is enough evidence to suggest that playing violent video games can contribute to aggression, but the APA ruling states that "attributing violence to violent video games is not scientifically sound and diverts attention from other factors that contribute to violence."

Video games also have a strong potential for addiction.

For many, they offer a tempting escape from real life, along with attractive design and satisfying reward systems. Problems arise when players gamble excessively and compulsively.

The proposed symptoms of gaming disorder (or Internet gaming disorder) are largely based on the criteria for substance use disorder and include a preoccupation with gaming, mood symptoms such as irritability, and sadness when withdrawing. gambling (withdrawal), increased amount of time spent gambling (tolerance), and failed attempts to quit smoking.57

The International Classification of Diseases, 11th Revision (ICD-11), published by the World Health Organization and entered into force on January 1, 2022, includes gaming disorder and the Diagnostic and Statistical Manual of Mental diseases. Disorders, Fifth Edition (published by the APA in 2013) includes Internet Gaming Disorder simply as a "condition for further study." 58

The ICD-11 requires "marked distress or significant impairment in personal, family, social, educational, or occupational functioning" for gaming disorder to be diagnosed. Gambling disorder is a type of behavioral addiction and can be compared clinically to gambling disorder. There remains a lack of consensus on the assessment and symptoms of problem gambling, making prevalence estimates difficult.59

A recent study of more than 100,000 gamers found that approximately 2% had disordered gaming behavior when assessed using the new World Health Organization framework.60 The best estimates of prevalence among adolescents are even higher, 3.3% to 4.6%, with boys affected at a 5:1 ratio compared to girls. 61, 62 Problematic gambling behavior is more common in male adolescents and those with ADHD, and other co-occurring disorders such as depression and anxiety should be considered. 40, 63, 64

Providers should be aware of gaming disorder as an entity while also considering diagnosis assignment and referral to treatment. Cases of false positives in healthy players can cause strains on the parent-child relationship, inappropriate treatment, and stigma. The association between time spent gaming and the severity of disordered gaming behavior is not perfectly linear, and someone who plays 30 hours a week may have a healthier relationship with video games than someone who plays 20 hours a week.60

Patients who meet the criteria for gaming disorder play an average of 35 to 40 hours per week. Treatment centers have been established in some East Asian countries,65 but at this time patients in the United States must be referred to cognitive behavioral therapy or family therapy services with the understanding that there is a lack of randomized controlled research on the effectiveness of Treatment Options.66, 67 In-office strategies, such as motivational interviewing and assessments, brief intervention, and referral to treatment, may also be used.

There are currently several gaming disorder screening tools that have been validated in preliminary studies, examples of which are the Ten-Item Internet Gaming Disorder Test (IGDT-10) and the Gaming Disorder Scale (GADIS), with versions for teenagers and for parents. 68, 69, 70 The IGDT-10 is based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition framework, and the GADIS is based on the ICD-11 framework. The IGDT-10 can be administered more quickly and has a simpler scoring system.

Advantages of GADIS include greater emphasis on negative consequences and the availability of a caregiver questionnaire for patients who may have unreliable self-assessments. A version of GADIS was also developed specifically for adolescents (ages 10 to 17). Both are screening tools and should be used in conjunction with clinical interviews for diagnosis.

In our increasingly digitalized and globalized world, we rely on technology to be close to people. This change has accelerated over the past 2 years during the coronavirus disease 2019 pandemic, with more people using social media and online video games to communicate with friends and family.1

Many children use video games as a tool to build and maintain relationships with their peers. A 2021 online survey found that more than half of teens prefer video games as a way to stay in touch with friends over video calls or social media.71 Cooperating in a game environment to achieve goals can be more stimulating than other forms of online socialization.

In the Journal of Cyberpsychology, Behavior, and Social Networking , psychologist Brenda Wiederhold compared this “virtual meeting place” to a shopping mall or playground during pre-pandemic times.72 As more traditional types of in-person games become became less feasible, children engaged in more social games with friends and family to fill the void.

Online video games provide an accessible tool that can help children meet their social needs. Playing video games with friends can be a normal part of social development for today’s children, just as playing tag on the playground was for previous generations.

Compared to playing alone, being socially active in gaming has been associated with lower levels of depression and addiction, even in those who game a lot.63

Other benefits include an increase in pro-social behaviors, such as cooperation and empathy, and a decrease in aggression after playing violent video games with social components.53, 73, 74, 75 There are clear benefits to playing with others, and the Cooperative play (working with others toward a common goal) has emotional and social advantages over competitive play (trying to defeat others).76

There is no strong evidence that certain levels of gaming negatively affect family closeness, activity participation, or school engagement.44 However, online gaming should not completely replace in-person interaction; One study found that social connections were stronger when friends interacted both online and offline. 77 Families can also benefit from playing video games together. Parents who take an active interest in their children’s games have more opportunities to play together, which has known social and developmental benefits compared to playing alone.78

Social games exist in many forms. It can be 2 people playing together in the same room, known as “couch co-op,” or it can be 2 people far away from each other who have never met. Social video games can also serve more specific roles.

Cooperation in games can help develop social behaviors that may be difficult for some children to develop in real life, such as those with autism spectrum disorder, social anxiety, or other socialization disorders/avoidant behaviors. People who have trouble finding friends in real life can find other people with shared interests in a game. The types of social video games and popular examples are as follows:

• Cooperative games (play with others): Minecraft, Animal Crossing, Stardew Valley, Farming Simulator series, Lego series, Overcooked series, Cuphead

• Competitive games (play against others): Smash Bros. Super Series, Mario Kart series, Mario Party series, Wii Sports, Fall Guys, Rec Room

• Cooperative and competitive elements (can play with others and against others): Roblox, Rocket League, AmongUs, Pokémon series, Fortnite*, Overwatch*, League of Legends*, Sea of ​​Thieves*, Valorant*, Apex Legends*, Call series of Duty*, Halo series*

• Massively multiplayer online role-playing games (cooperative and competitive elements): MapleStory, Wizard101, World of Warcraft*, RuneScape*, Sea of ​​Thieves*, The Elder Scrolls Online*

• Socialization/chat games: VRChat*, Second Life*, Avakin Life

(* *These games contain content that may not be appropriate for children under 13 years of age)

Online experiences with other real players have the potential for more harmful interactions. Although traditionally more of an issue on social media platforms, cyberbullying also exists in online video games. According to the Centers for Disease Control and Prevention (CDC), more than 15% of high school students report being bullied online in the past year, and cyberbullying (similar to traditional bullying) can have negative psychological and social effects.79, 80

Cyberbullying has been associated with higher rates of depression and suicidality, social isolation , and difficulty trusting peers. Harassment in online games takes several forms: exclusion from playing with others, targeting a single player and intentionally causing them to lose the game, and verbal harassment, which can range from generally offensive language to personal attacks and bigoted slurs directed at sexuality, race, or gender.

Cyberbullying in games can come from people the victim may or may not know in real life, can be completely anonymous due to aliases, can occur at any time of day, and can invade safe spaces in the home that in-person bullying does not . can. Certain video games are famous for having a "toxic" player community ; that is, one that is more exclusive and less friendly, and other games have friendlier communities.81 In addition to cyberbullying, online multiplayer games have the potential to expose children to strangers with malicious intentions who could sexually or financially exploit them. the youngest players.

The 2011 AAP report on “The Impact of Social Media on Children, Teens, and Families” offers recommendations on Internet safety and cyberbullying. Several actions are recommended for pediatricians, including encouraging parents to talk to their children about online use and actively participating in monitoring their children’s online activities. Parents should know who their children are playing with, and children should be educated about online safety, including what bullying looks like.

Cyberbullying in online games is harder to track than on social media because there is often no record of in-game conversations or activities. Parents with children under 13 should be more vigilant, including keeping gaming devices in family areas and encouraging children to play without headphones.

Older teens may want more privacy while playing with their peers, but parents should engage in regular conversations with them about their experiences. Many online games have processes for reporting and banning players who behave inappropriately. Certain types of behavior must be reported to the child’s school or to authorities in the case of criminal behavior.

As mentioned, it is beneficial for parents to take an interested and active role in their children’s video games because this can strengthen family connections, enrich learning, and make gaming safer. It’s also important because children, particularly preteens, lack the ability to contextualize adult game content.

Games may include violence, strong language, or suggestive themes such as substance use, gambling, and sexual content. Younger children may have trouble enjoying these games safely, leading to problems with personal development and socialization.82 In addition to these adult issues, female representation in video games remains an issue.

As with media in general, female characters in games are often subject to subordination to male characters, objectification, and hypersexualization. With repeated exposure, this can lead to sexist beliefs in men and low self-efficacy and self-objectification in women.83

A caregiver can help by being present while the child plays to provide context about fictional representations compared to real-life social expectations and the importance of respect and consent. In addition to this more active role, there are tools to help parents make informed decisions about what games their children are exposed to. The Entertainment Software Rating Board (ESRB) is a self-regulatory organization established by the video game industry in 1994 to assign content ratings to all consumer video games in the United States.

The 3-part rating system informs parents about age appropriateness, specific content warnings, and interactive elements such as communicating with others online, sharing location data, or in-game purchases.48 The ESRB has several ratings : E (everyone), all ages; E 10+ (everyone over 10 years old); T (adolescent), everyone over 13 years old; M (mature), everyone over 17 years of age; and Ao (adults only), all over 18 years old.

This is the most widely used rating system for games available on the market, and parents should be aware of this system and know how to use it. However, independent game creators do not necessarily need to have a rating assigned to their game to sell it, particularly on mobile phone and tablet platforms, so knowledge of game content is still important.

Most gaming devices now come with parental control features, and even those with a cursory knowledge of the technology can set restrictions on adult content, unauthorized purchases, and the ability to communicate with others online. In addition to official rating bodies like the ESRB, websites like commonsensemedia.org and askaboutgames.com offer parent-focused reviews and ratings to help determine suitability.