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Evidence-Based Reviews

Video games: When does play become pathology?

Most kids have fun and don’t get ‘hooked,’ but some boys may be at particular risk.

Vol. 6, No. 12 / December 2007

Nick, age 13, enjoys playing video games, but his parents think he may be “addicted.” His primary care doctor has referred Nick to you for evaluation.

Nick has played video games since age 7 and likes to share ideas with friends about to “beat” difficult games. Lately, though, he plays an online role-playing game, mostly alone, on the computer in his bedroom. Nick hasn’t seen his friends outside of school for 6 weeks.

Nick’s parents say he is growing short-tempered, and his grades have fallen for several months. He seems to worry a lot but becomes angry and storms out of the room when they try to talk with him about it.

Like Nick, 70% to 90% of American youths play video games, according to the American Medical Association (AMA).1 Most boys and girls find the games fun, entertaining, or relaxing (Table 1) and do not encounter difficulties as a result of their play.2 In some cases, however, they may:

  • spend excessive time playing video games
  • model inappropriate behavior from games
  • over-invest in online relationships.

This article describes developmentally appropriate characteristics of play in general—and aspects of video game play in particular—to help you educate families about normative and excessive video game play.

Table 1

Top 10 reasons why children say they play video games


  1. It’s just fun
  2. It’s exciting
  3. Something to do when bored
  4. Challenge of figuring things out
  5. To compete and win
  6. Helps me relax
  7. Nothing else to do
  8. Like guns and weapons*
  9. Create my own world
  10. Learn new things


  1. It’s just fun
  2. Something to do when bored
  3. It’s exciting
  4. Challenge of figuring things out
  5. Nothing else to do
  6. To compete and win
  7. Create my own world
  8. Learn new things
  9. Helps me relax
  10. To forget problems

* Response likely reflects the number of survey respondents living in a suburban/rural environment in which hunting is a popular leisure activity.

Source: Reference 1

An addiction?

Originally researchers believed video game play was not addictive and viewed excessive play as high engagement. More recently, efforts are being made to understand:

  • how to classify excessive video game play that impairs psychosocial adjustment
  • whether substance abuse models are appropriate for describing and treating pathologic video game play.

In June the AMA examined the emotional and behavioral effects of excessive video game play and decided that evidence is insufficient to conclude that this activity is an addiction.1 The American Psychiatric Association (APA) stated that it does not consider “video game addiction” as a mental disorder at this time because it is not listed in DSM-IV-TR. The APA’s DSM-V task force may consider whether to include this proposed disorder in the update due to be published in 2012.3

What is normative play?

Play is a motivating way for children to make sense of the world. By re-creating themes, relationships, places, or events in play children can control things that outside of play might be intimidating or overwhelming. Through play, children can explore situations in a setting that feels safe.4,5 Video games offer children play opportunities to explore roles and worlds that otherwise are unavailable to them.6

Video game play is one of the most popular leisure-time activities for middle-school students. Our group7 recently surveyed >1,200 students age 12 to 15 about their video game play and found:

  • One-third of boys and two-thirds of girls played video games for ≤2 hours/week.
  • One-third of boys and 11% of girls played video games 6 or 7 days each week.
  • Boys played more than girls, with 45% of boys playing for ≥6 hours/week.
  • 12.6% of boys played ≥15 hours/week.
  • One-half listed ≥1 games rated M for mature (Table 2)7 among 5 games they played most frequently in the preceding 6 months.2

These findings on the frequency of play are similar to those of a Kaiser Family Foundation national study of children and adolescents age 8 to 18.8 Thus, for middle school students, we could define a normative range of time playing video games as 10 minutes to 1 hour/day. Averaging >1 hour/day could be considered excessive. M-rated video game play is common among adolescents and might be considered normative—although not necessarily developmentally appropriate.2

Pathologic behavior. Excessive video game playing can be viewed as pathologic if it involves an overwhelming need to play video games, with negative feelings and behaviors related to this need that lead to distress or functional impairment.9,10 Charlton et al11 define pathologic video game play as incorporating high engagement plus core addiction characteristics such as interference with work or social life, failure to sleep, etc. In video game play, peripheral DSM addiction characteristics—such as high cognitive salience—may indicate high engagement. Characteristics of pathologic video game play, as identified by this group, are listed in Table 3.11

Table 2

ESRB video game ratings system and content descriptions*


Content may be suitable for:


Early childhood

Age 3 and older; no material that parents would find inappropriate

Atari/others’ Dora the Explorer (series), Knowledge Adventure/Vivendi Universal’s Jump start (series)


Age 6 and older; minimal cartoon, fantasy, or mild violence and/or infrequent use of mild language

Disney Interactive Studios/Buena Vista Games’ Hannah Montana (series), Taito Corporation’s Bubble Bobble

Everyone 10+

Age 10 and older; more cartoon, fantasy, or mild violence, mild language and/or minimal suggestive themes

Electronic Arts’ Need for Speed: ProStreet, Ubisoft’s Rayman Raving Rabbids 2


Age 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling, and/or infrequent use of strong language

Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar (MMO), Sony Online Entertainment’s EverQuest (series; MMO)


Age 17 and older; may contain intense violence, blood and gore, sexual content, and/or strong language

Microsoft Corporation’s Halo (series), Rockstar Games’ Grand Theft Auto (most games in the series)

Adults only

Age 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity

Vivendi Universal’s Leisure Suit Larry: Magna Cum Laude Uncut and Uncensored, Rockstar Games’ Grand Theft Auto: San Andreas

* On video game boxes, look for rating symbols on the front and content descriptions on the back.

ESRB: Entertainment Software Rating Board

MMO: massively-multiplayer online role-playing game

Source: Reference 7

Table 3

Characteristics of ‘pathologic’ video game play

Feeling agitated when not playing

Feeling “addicted” to play

Not being able to decrease time spent playing

Not sleeping because of video game play

Missing meals because of video game play

Being late because of video game play

Having arguments at home because of video game play

Letting video game play interfere with social relationships

Letting video game play interfere with schoolwork

Spending excessive amounts of money on video game play

Source: Reference 11

CASE CONTINUED: Going with the ‘flow’

Nick says he enjoys playing with people he’s met through a massively-multiplayer online role-playing game (MMORG, or also called MMO or MMP). The “guild” he has joined is a small community that collaborates to complete quests in the game. Nick describes his character—a healer—as a key figure who supports fellow players by replenishing their in-game health. Everyone in the guild thinks he’s important, and he likes to feel respected. Nick says this is quite different from how people treat him in “real” life. He says he often feels worthless and scared that his friends and family don’t think he’s good enough.

Sometimes Nick gets caught up in the game and plays for several hours past bedtime. The next day he feels tired and unprepared for school. One of his teachers has reprimanded him for not turning in homework on time, and his parents are frustrated by his behavior.

Video game play facilitates the experience of “flow”—a mental state of positive energy and effortless focus experienced while immersed in an activity over which one feels a sense of control. Video game play incorporates components of a flow experience (Table 4), including clear, focused goals that are attainable yet challenging and require a high level of concentration. Individuals who engage in artistic, athletic, or meditative activities often report experiencing flow.12

Flow can distort one’s sense of time, setting the stage for frustration on both sides when parents want their video game-playing child to engage in other activities. Their efforts to redirect their child’s attention—whether effective or not—disrupt the pleasurable feeling of flow.

Table 4

Characteristics of flow experiences related to video games


Effect associated with video game play

Clear goals

Discernible objectives are appropriate to player’s abilities

Highly focused concentration

Allows player to become absorbed within a limited field of attention

Lack of self-consciousness

Player’s actions seem effortless

Distorted sense of time

Player lacks accurate sense of how long he/she has been playing

Direct and immediate feedback

Success and failure are quickly evident, allowing player to change strategies

Appropriate level of challenge

Difficulty is balanced with player’s ability


Player has sense of control and self-efficacy

Source: Reference 7

Types of games and devices

Role-playing games (such as Square Enix’s Final Fantasy series) involve players’ assuming identities and managing role-specific tasks and resources to progress through the game (for instance, a ranger befriending animals and tracking enemies in the wilderness).

Turn-based and real-time strategy games (such as Take 2’s Civilization series) and some simulation games (such as Atari’s Roller-Coaster Tycoon series) require players to manage resources to achieve larger goals—such as building an empire and negotiating with world leaders or constructing and maintaining a successful amusement park.

Video game play can be a social experience, involving friends or family in the same room or long-distance players online. Game consoles—such as Xbox 360, Play-Station 3, or Nintendo Wii—facilitate playing together in the same room, although they also support online play.

Games played on computers tend to be more solitary, although some games—particularly MMORPGs—also support online play. MMORPGs can connect hundreds or thousands of individuals around the world playing online. Examples include Blizzard Entertainment’s World of Warcraft or Midway Amusement Games’ Lord of the Rings Online: Shadows of Angmar. Most MMOs are intended for older audiences, but some (such as Walt Disney Internet Group’s Toontown) are designed for children.13

Maladaptive play

Children’s video game play becomes maladaptive or dysfunctional if it prevents them from engaging in developmentally appropriate activities and relationships—either because of excessive time spent playing or the possible influences of developmentally inappropriate content.14

Associated factors. Boys may be at particular risk of video game overuse. Compared with girls, boys spend more time playing—even normatively—and are more likely to play M-rated games.2 Sensation-seeking, boredom, animosity, poor academic achievement, and high family conflict also have been linked to excessive video game play.15,16 The 20% of middle school students who have a computer, game console, or television in their bedrooms are twice as likely as others to play video games ≥15 hours/week and to play M-rated games.2

Children who have experienced negative life events—trauma, family conflict, or social rejection by peers—also may spend excessive time playing video games. Gaming can interfere with more adaptive ways of coping with adversity, such as seeking support from friends and family.17,18 The draw of online relationships can be strong, especially for children who have grown up with video games and the Internet. Girls may be at particular risk for maladaptive online relationship patterns.19

Research has yet to show whether excessive video game play causes or results from these associated phenomena. Because any relationship that exists is probably transactional, pay attention to ways in which video game play may cause or result from distress or functional impairment when evaluating a patient for excessive video game play.

Violence and sexual content

Evidence is inconclusive but suggests that video games with violent content may influence children’s perceptions of aggression and violence, which may increase their likelihood of behaving aggressively or violently.20-22 Middle-school students who frequently play ≥1 M-rated games are somewhat more likely to:

  • engage in physical fights
  • beat someone up
  • vandalize property for fun
  • receive poor grades
  • be threatened or injured with a weapon.23

Suggested mechanisms include desensitization toward violence over time20 and adopting social learning cues from video games and applying them to life.21 This raises the question of cause and effect:

  • Does playing video games with violent content cause aggressive and violent behavior?
  • Or does a tendency toward aggressive or violent behavior lead to the playing of video games with violent content?

State or trait aggression may influence children to choose a video game with aggressive or violent themes.22 Alternately, children anxious about conflict may seek out violent games to obtain a sense of conflict resolution when real-life efforts are ineffective or impossible.

Video game play with violent content may be analogous to rough-and-tumble play in early adolescence. In this way, it may serve boys’ developmentally appropriate needs for establishing social hierarchy—especially because video games with violent content often involve competition.13 Predispositions toward aggressive or violent behavior—such as neurologic impairments that result in poor impulse control or conduct disorders—may be exacerbated by playing violent video games.24

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