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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 10hours per day (projecting

forward, over 20years 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 researchagenda.

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

areseeking.

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 eightweeks 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 sixweek,

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 perse 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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