The public bandies about the term “addiction” freely, talking about being “addicted to e-Bay” or “addicted to food.” Players of the online game series EverQuest half-jokingly refer to it as “Never Rest” and “EverCrack” because of its supposedly addictive qualities. The vignette below presents the case of an adolescent who plays video games up to 12 hours a day. Although many parents and some physicians would refer to this type of behavior as an addiction, is that really the case?

Case Vignette: Video Game Play as a Marker of a Psychiatric Disorder

Ben is a 15-year-old boy who has been hospitalized for depression and for cutting himself. He is failing in school, not because he is not smart, but because he cannot reduce the time he spends playing Worlds of Warcraft. He spends 10 to 12 hours a day playing the game—until somebody makes him get off the computer. His parents have put controls on the computer to limit its use, but he has figured out ways to bypass them. He pretends to go to sleep and gets up in the middle of the night to play.

In psychotherapy, Ben revealed that his use of games was “to distract himself” and “to feel happier and not be so upset about things.” It became apparent that his game use was, in part, related to untreated depression. With a combination of medication management and individual psychotherapy, the depression improved, and so did his game use. However, the long-standing involvement with games had to be replaced by other hobbies and social activities, and this has become a focus of therapy and work in his daily life.

The AMA has recently considered whether Internet and video game addiction should be considered formal diagnoses and added to the next edition of DSM. In its recent report, “Emotional and Behavioral Effects, Including Addictive Potential, of Video Games,” the AMA refers to such behaviors as video game overuse. It concluded that more research is needed before making specific recommendations.

Alcohol and heroin addiction clearly meet the criteria for addiction. Do video games? Unfortunately, the best answer we can give is that we do not know. Some “video-game addicts” may be struggling with a compulsion similar to an obsessive-compulsive disorder. Although their game playing may be interfering with their lives, the underlying mechanism may be different from that of someone addicted to a drug. Others may simply be more sensitive to the variable-ratio reinforcement schedule that is inherent in many games. Thus, video-game overuse may have more in common with compulsive gambling than with drug addiction.

Some supposedly addicted game players may be behaving normally—but not in the ways that the adults around them believe to be normal. For example, many young children and adolescents have difficulty with transitioning between activities, especially when the initial activity is pleasurable. Is this a sign of addiction? No. It is a reflection of normal brain development. But parents sometimes misinterpret this type of behavior as anything from spite to laziness.

Adults also may unconsciously apply different standards to different behaviors. If a child plays basketball or plays the piano for 4 hours a day, we may describe him as a dedicated athlete or musician. But if that child takes the same approach to playing video games, spending hours each day at the computer, and reveling in the details and strategies of play, we may worry about an addiction.

The danger in calling video game playing an addiction is that if it is not, we might miss an underlying problem such as depression. On the other hand, if we do not identify the behavior as a video game addiction when that is what is really going on, we may be distracted by other behavioral problems and miss the opportunity to treat the underlying cause.

Advice for parents

What can clinicians tell parents about the use of video games? First, we all need greater knowledge about the form, content, and epidemiology of video game use, and media in general. Research is needed on whether all violence in games has the same impact; how developmental stages influence game use; whether game play may be a healthy form of sublimation; and how much playing is too much. Second, parents should become familiar with Entertainment Software Rating Board (ESRB) age symbols and “content descriptors” found on game boxes and advertisements. Parents also need to know that potentially important information, such as the context, target, and goals of the violence in their children’s games, is not provided by the ESRB; they may need to ferret out more details to help their children make appropriate choices.  The Table presents suggested guidelines that can be offered to parents to help them establish a plan for the use of video games at home.

It should be noted that for most well-adjusted adolescents—who are doing well in school, sports, other extracurricular activities, at home, and with peers—there can be minimal limits on video games. Parents need to consider what is best for the optimal development of their child, commensurate with their own set of values and ideals.

Mental health professionals need greater knowledge about the role and function of media in family life.18 The ubiquitous presence of multimedia content has elevated media literacy from a nice-to-have frill to an important basic skill for our children. Clinicians should routinely incorporate media use (and misuse) in their histories. What exposure is there to television, movies, the Internet, and video games at home? Are these media supervised or unsupervised? What access to media do children have at home and with friends?

Watching or playing for just 1 or 2 hours will probably not provide enough information to understand the content of a game. Checking game reviews and images on a commercial Web site (such as Gamespot.com) can help parents determine whether that game is a good match for their child. Ratings are not enough. For example, the difference between T (teen, for those aged 13 years and older) and M ratings may not be violence, but whether blood and bodies disappear—making violence look clean and consequence-free.

Parents may also visit nonprofit game sites such as Commonsense Media (http://www.commonsensemedia.org), which offer reviews and evaluations of games, including issues such as sexual content, violence, language, message, social behavior, commercialism, drug/ alcohol/tobacco use, and educational value. The Coalition for Quality Children’s Media, a collaboration among the media industry, educators, and child advocacy organizations (http://www.kidsfirst. org) can help parents become more familiar with the video games their children are playing. GetNetWise (www. kids.getnetwise.org), a coalition of industry and advocacy groups, offers an online safety guide that provides advice tailored to children’s ages and likely activities (including chat, e-mail instant messaging, and newsgroups). The site also reviews the technologies available to families to restrict access to Internet content.

Finally, parents can help by encouraging critical thinking, including talking to their children about alternative, nonviolent solutions to problems. They can also encourage skepticism; for example, by talking about the consequences of media story lines if they were to happen in real life.

Cheryl K. Olson, ScD, Lawrence Kutner, PhD, and Eugene V. Beresin, MD
Dr Olson and Dr Kutner teach in the department of psychiatry at Massachusetts General Hospital (MGH) and Harvard Medical School, Boston, and are codirectors at the Center for Mental Health and Media. Dr Beresin is professor of psychiatry at Harvard Medical School and director of the Child and Adolescent Psychiatry Residency Training Program at MGH and McLean Hospital and Medical Director of the MGH Child Psychiatry Outpatient Clinic in Boston. The authors report no conflicts of interest concerning the subject matter of this article.

  * Olson CK, Kutner LA, Warner DE, et al. Factors correlated with violent video game use by adolescent boys and girls. J Adolesc Health. 2007;41:77-83.
  * Roberts DF, Foehr UG, Rideout V. Generation M: Media in the Lives of 8-18 Year-Olds. Menlo Park, Calif: Kaiser Family Foundation; 2005.

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