cortices of dependent gamers that parallel
those recorded in alcoholics and individu-
als addicted to other substances of abuse.
It should be noted that addiction-related
distortions in reward systems involved in
learning processes contribute to broad-
ranging cognitive deficits in every other
studied form of addiction.
Our younger-age population is strongly
attached to screen-delivered media in a vari-
ety of forms. Most regular video-game play-
ers are also heavy consumers of other media;
on average they are engaged with screens
for more than 10hours per day (projecting
forward, over 20years of their life by age 60).
There is thus a massive and unprecedented
difference in how their brains are plastically
engaged in life compared with those of aver-
age individuals from earlier generations, and
there is little question that the operational
characteristics of the average modern brain
substantially differ from that of our ances-
tors. A better understanding of the conse-
quences of these differences in brain use for
societal and individual brain health should
be high on our researchagenda.
D.A.G. I began studying the issue of video-
game ‘addiction’ because I was highly
sceptical of it. I believed that people were
misusing the expression to mean ‘spends
a lot of time gaming’, because addictions
are not defined by how much one engages
in an action (for example, drinking), but
by how much it damages one’s life. I began
studying gaming from this more clinical
approach, using criteria adapted from those
for pathological gambling. Based on this
much stricter set of criteria — which assess
dysfunction in multiple areas of life (school,
social, family, psychological and emotional
functioning) — about 8% of US gamers
between 8 and 18 years of age could be
considered pathological or ‘addicted’. There
are now scores of studies showing that the
pattern of problems that pathological gam-
ers face are very similar to the problems that
people with substance or gambling addic-
tions have. Thus, the problem seems to have
some construct validity.
There are only two published lon-
gitudinal studies on this topic to date.
One focused on 881 Chinese adolescents
between 13 and 16, using Young’s 20-item
Internet Addiction Scale. Adolescents
were surveyed twice, nine months apart.
Pathological internet use predicted
increased risk of depression (but not general
anxiety) nine months later, after control-
ling for several potential confounding fac-
tors such as sex, age, family dissatisfaction
and illness, among others. A larger study
of 3,034 Singaporean children and adoles-
cents followed over two years gave some
of the first clear evidence of whether vari-
ables such as depression and poor school
performance are predictors of or are
predicted by pathological video gaming.
Because of the large sample size, this study
was able to classify gamers into four types:
those who never exhibited pathological
behaviour over the two years, those who
became pathological gamers, those who
were pathological at the start but stopped
being pathological, and those who were and
stayed pathological gamers. As in the first
study with Chinese adolescents, depres-
sion became worse if adolescents became
pathological gamers. Anxiety, social phobia
and school performance also became worse
in adolescents who became pathological
gamers. Interestingly, if they stopped being
pathological gamers, their depression,
anxiety, social phobia decreased and school
performance improved. These findings sug-
gest that these variables may be outcomes
of pathological technology use rather than
predictors of it. At a minimum, they sug-
gest that these variables are co-morbid with
pathological gaming, such that they can
influence each other.
To my knowledge, however, there haven’t
been any published studies looking at the
effects of gaming addiction on the brain,
although there are some demonstrating that
dopamine is released and that brain reward
centres are activated during video-game
playing.
Is there a place for using video or
computer games in education and
rehabilitation?
D.B & C.S.G. Some of the recent successes
using off-the-shelf games (which were
designed with no particular outcome in
mind, other than being a fun game) in the
rehabilitation of, for instance, amblyopia,
are certainly a cause for optimism. However,
although the idea of using video games in
educational and rehabilitative settings has
been around for decades, as a field we’re
probably still only in the very early stages
of learning how to effectively harness the
power of video games while simultane-
ously attempting to produce a desired
outcome. For instance, many of the earliest
educational video games were little more
than slightly dressed up flashcards — full
of sounds and interesting looking graph-
ics, but lacking most of the characteristics
that truly define a video game. Too often
those developing the games were individu-
als who knew a lot about the content they
wanted to teach, but very little about how
make a game compelling and fun. As more
true game developers turn their attention to
educational and/or clinical applications, new
fields are emerging in which educational and
medical practitioners are collaborating with
game designers to develop fun and attractive
activities that will guarantee time on task
and at the same time have the educational or
rehabilitation impact that experts in the field
areseeking.
D.H.H & P.F.R. There have been several trials
of video games in educational and rehabilita-
tion settings. In the rehabilitation of patients
with post-traumatic stress disorder following
motor vehicle accidents, the virtual-reality
experience (through a computer game)
of driving or riding in a car may improve
clinical symptoms and promote recov-
ery. In addition, several games have been
developed for screening or rehabilitation
of people with dementia. Furthermore, we
have reported that eightweeks of internet-
game play reduced delusional thinking and
extra-pyramidal symptoms in patients with
schizophrenia. In addition, pro-social video
games have been associated with increased
empathy and decreased reported pleasure
at another’s misfortune, compared with the
effects of neutral games in healthy subjects.
In a pilot study in adolescents with autism
spectrum disorders, we noted increased
social behaviour and increases in fusiform
gyrus activity in response to emotional
words and emoticons during a sixweek,
pro-social on-line game playing period.
Although existing research is limited, we
believe that a growing number of clinical
applications for video-game play will emerge
over time.
M.M.M. Video games perse don’t have a
special role to play in these arenas. Video
games exploit well-established principles
of motivation and learning that have been
established by experimental psychology and
neuroscience research. Those same princi-
ples have also been applied by us and by oth-
ers in designing ‘brain training’ exercises to
drive targeted, positively empowering and, if
necessary, ‘corrective’ behavioural and neu-
rological changes in the brains of children
and adults who are in need of help. These
forms of game-like training have already
strengthened or recovered the abilities and
improved the prospects and quality of life of
millions of individuals. There is, of course,
a convergence in the design of successful
PERSPECTIVES
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DECEMBER 2011
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VOLUME 12 www.nature.com/reviews/neuro
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