Ask the Mediatrician

My 17-year-old is having serious anxiety since he started playing Call of Duty--is there a connection?

Q: My 17-year-old son started playing Call of Duty a few months ago. Since that time, he has had more trouble than usual falling asleep and has been waking up in the middle of the night. Last night, he woke me saying he felt like he was having a panic attack—racing heart and hyperventilation. I hadn’t associated it with his Call of Duty play, but when we talked about it last night, I realized that the timing lined up. Is there any evidence of violent video games bringing on stress or anxiety in young players?
     —Shoot or Scare, in Vancouver, British Columbia, Canada

A: Dear Shoot or Scare,

The key question is this: Did your son realize the association between the time when he started playing Call of Duty and his increased general anxiety punctuated by panic attacks?

The research shows that at his level of brain development, your son is more likely than an adult to have increased fear/anxiety after playing violent video games, but less likely to have the insight necessary to make the connections. He will be address this problem more effectively if he “discovers” the relationship himself and devises a solution. If he has not made the association, it will work better if you explore with him what might be stressing him at the moment, gently steering him toward his own observations rather than telling him yours.

The reason that kids get so involved with Call of Duty (the biggest selling video game to date) and other action games is that they are designed to put players on high alert—to get their adrenaline flowing and their hearts racing, ready for unexpected turns of events. Adolescents seek new experiences and sensations—it is an integral developmental task at your son’s age. Video games are one way in which they can vicariously experience fear and mastery of that fear in a situation that is not life-threatening.

Gently encourage your son to stop playing for two weeks or so and see whether his anxiety lessens. If it does, he may want to decide whether playing the game is worth living with the symptoms. If it doesn’t, the adrenaline rush of gaming may have unmasked an underlying anxiety—he may want to take a closer look at what else is happening in his life, and consider seeking help from a talk therapist to develop effective coping strategies. See this related post for more information.

Enjoy your media and use them wisely,
The Mediatrician®

Am I overreacting if I don't want my husband to play games like Grand Theft Auto with our 5-year-old?

Q: My husband plays X-box games rated for those over 16 or over 18, like Call of Duty, Grand Theft Auto, and Modern Warfare. He allows our 5-year-old son to play these games with him. I do not know anything about X-box, but I feel they are not suitable for a child that is so young. Am I over-reacting like my husband suggests? 
-Fear of Gaming, in Ireland

A: Dear Fear,

Trust your parenting instincts on this—you know your child better than anyone. Your concerns are not an over-reaction, but are supported by scientific research.

In video games, players gain or lose points for behaving in certain ways. They practice those activities over and over again, getting better and better at these “behavioral scripts.” While your husband’s adult brain can tell what’s fantasy and what’s reality, your son’s can’t—and won’t be able to for at least 3 more years. Instead, he will use these experiences to build his understanding of what the world is like and how people behave in it.

Using virtual violence as entertainment makes children of all ages less sensitive to the real-life suffering of others. It makes world seem more violent, which leads to anxiety—especially among the youngest users. And although they are unlikely to go out and do the things in real life that they do in video games, some users will think and behave more aggressively. If your son is having trouble with nightmares or aggression toward other kids, it could be related to playing these games.

Even if he isn’t visibly experiencing these kinds of problems, though, talk with your husband about what you’d like your son to learn and what kind of person you want him to become. Then brainstorm fun activities they can do together to accomplish those goals. And remind him that your son’s childhood is fleeting—their time together will build both memories and the person your son will be, so choose them mindfully.

Enjoy your media and use them wisely,
The Mediatrician®

With video games, how can I help my kids know when enough is enough?

Q: I'm a pediatric nurse practitioner, and we have three boys ages 5, 7, and 9. Several parents/patients have told me that they have the same problem as I do enforcing video game time limits. Certain kids just seem “addicted” and can’t wait until they get more. Do you have any visual time charts, contracts, or other concrete examples of how to work with your kids on knowing when enough is enough? 
-PNP Parent in Bozeman, MT

A: Dear PNP Parent,

Try approaching this issue with a positive rather than restrictive approach. Instead of limiting video game time, focus on creating a daily schedule with your sons where there is enough time to do everything that is important to them.

Search online for “hourly calendars,” and print a copy for each child. Then, ask them to think about all the things they need to do in a day—like eating meals as a family, school, homework, active play (outside, if at all possible), spending time with friends, and getting enough sleep—and help them remember others that they forget. For each task, have them choose a color, think through how long it will take, and color in the time blocks needed.

They will see their time filling up with important activities, and they will see what time is still left. Talk about what they can do in that time. Perhaps they can spend some of it playing video games, but offer them attractive alternatives as well, like organized sports or hobbies. In this way, they will have some ownership of mindful, directed “down time” rather than simply sliding into video gaming.

By focusing on what they do want and need to do in their limited time, you can avoid making video games a forbidden fruit. Whatever choices they make, remember that they will learn from what they experience, so exercise your judgment about the content of any media they use.

• For information on video game addiction, take a look at this post: My 10-year-old son is miserable since I took away Call of Duty--what do I do?
• For ideas on creating a family media agreement, click here.

Enjoy your media and use them wisely,
The Mediatrician®

My 10-year-old son is miserable since I took away Call of Duty--what do I do?

Q: My 10 year old used to be an avid skateboarder and baseball player—until Call of Duty on XBOX Live arrived. I didn’t in my wildest dreams think that he would become addicted to a video game. I have a 21 year old who played all of the games but was never ruled by them. Since my awakening, I have removed the game, but my son is miserable. How long does it take to deprogram him?
—Problem Gaming, in Kansas City, MO

A: Dear Problem Gaming,

More and more young people are being referred to me for Internet or video game behaviors that are causing real problems in their lives. It sounds like your 10-year-old son falls into that category. Unfortunately, time away from the game may not be enough to deprogram him—he probably needs professional help.

Even though our healthcare system that doesn’t recognize video game addiction as a formal problem, there are still steps you can take to help your son. You’ve already taken the first step: removing the game (though if he is indeed addicted, he will find other ways to keep playing). The next step is to find and make an action plan with a therapist who understands this kind of problem.

In the meantime, when talking about this with your son, frame this as a health issue, not as an issue of misbehaving. Your son's excessive game play could be a symptom of another issue—like social anxiety or depression—and it could be his way of taking refuge in a world he can control. Explain that you see how miserable he is, and that although he may not understand yet, the goal here is not to punish him but to make his life better.

For more information about signs, symptoms, and treatment, click here. Also check out this related post: My teen daughter's addiction to technology is ruining our family life--what should I do?

Enjoy your media and use them wisely,
The Mediatrician®

Could my 14-year-old son's anxiety be related to playing video games?

Q: Is there a connection between excessive video game playing and increased anxiety levels? My son is 14 and has some basic anxieties like walking the dog at night that I feel are made worse by the first-person shooter games he plays. I’d love to understand if you have seen any connections here.
-Grappling with Gaming, in Westfield, NJ

A: Dear Grappling,

As a parent, you are the best monitor of your son’s well-being. If you have seen an increase in his anxiety that has paralleled his increase in first-person shooter (FPS) game play, then it is probably worth seeing what happens if he cuts back on or eliminates playing these games. Research supports what you are observing—it has found that children and adolescents frequently respond to media violence with increased fear and anxiety, because action entertainment makes violence seem more prevalent than it actually is.

Suggest that your son stop playing video games for a while. This will be easier said than done—he will not want to stop playing, and he will probably resist in every way he can. Talk about your concerns with him, and remind him that his resistance may, in fact, indicate that he might be developing an addictive relationship with gaming. If nothing else, he will stop because he wants to prove he can. Then pay attention to his behavior and see whether his anxiety diminishes.

If he doesn’t think he can stop gaming or the anxiety doesn’t go away—that is, if either piece is limiting his life in some way—then it would be good to have him evaluated by a therapist. And remember that anxiety can affect a teen’s well-being in subtler ways, such as through increased distraction, which could appear to be ADD/ADHD.

Finally, encourage your son to pursue other activities he enjoys. Increasing physical activity and getting outdoors can reduce anxiety and increase quality of life in all kinds of ways.

Enjoy your media and use them wisely,
The Mediatrician®

Will sitting close to the TV hurt my kids' eyes?

Q: I have an son who’s 11 and a daughter who’s 9½, and for many years, they have sat close to the TV when watching. I have asked them to sit farther away, and they do move back maybe a foot…but they always go back to viewing the show close up, even if the screen is a 40” color flat screen. Any studies that show why? Any concerns? My wife and I sit 8 to 10 feet from the TV.
-Up Close and Personal, in Rochester Hills, MI

A: Dear Up Close,

Concern about sitting close to TV screens, like concern about reading in low light, is founded more on what our parents told us when we were little than on research. The worries about sitting close dates from the (not so long ago) time when TVs were actually “tubes”—cathode ray tubes, that is—and people were uncertain about how the cathode radiation emitted might affect a viewer’s eyes. Today’s TVs flatscreens only emit the light you see, which removes that concern. And there’s no evidence that sitting close to either kind of screen hurts your eyes.

That said, the fact that your children sit so close to the TV may be a sign that they are near-sighted and that this distance is where they best resolve the pixels of color, light, and darkness into a coherent image. Bring them in for an eye exam to see whether they need glasses.

If their eyes are fine, then they probably sit close because they like having the screen fill their peripheral vision. That shouldn’t cause any problems. Just make sure that they aren’t staring at screens all the time—that can cause eye strain and, of course, will take time away from all of the other activities they need to accomplish in a day to be happy and healthy.

Enjoy your media and use them wisely,
The Mediatrician®

How can I find educational video games for an 8-year-old boy who likes war stuff?

Q: Do you have suggestions for how to find appropriate media, such as educational video games, for different ages, such as an 8-year-old boy who likes war stuff? I’d like to help direct him to more creative sites. 
-Seeking solutions, in Burlington, VT

A: Dear Seeking,

It’s not always easy to know which video games will be exciting and engaging for a child and will teach him things you’d like him to learn. And you’re right: he will learn from whatever he plays, so your impulse to direct him toward games that teach positive lessons is a good one.

Remember that many boys of this age are interested in “war stuff,” and it’s actually developmentally appropriate for them to sort out how to resolve conflicts and master the complexities of winning and losing at this point in their lives. This often why they might like books about war and war-based games, like football and chess.

That said, there is a distinct difference between playing first-person shooter video games and reading war stories or playing chess, where the images of conflict are created in the player’s imagination. Video games are created by adult imaginations, informed by greater life experience and psychological defenses—and the best-selling games, which generate the greatest marketing “buzz”, are increasingly graphic and realistic. Because the player is not creating the images from his own experience bank, he may have difficulty handling or even forgetting these intense and scary virtual experiences.

The trick is to understand with him what he likes about war games—whether it’s that they allow him to role-play, that he likes being part of a developing storyline, or that they challenge him to strategize or solve problems—and then to look with him for games that present these challenges but that set game conditions and teach skills you want him to experience.

To do that, when he mentions a specific game, ask, in a non-judgmental way, “What do you like about this game?” Then, take a look at some parent-oriented reviews, many of which will give you more information about the game than the marketing or even the ESRB rating. You can take many games out of your library or demo them at a game store or on a website. If you think the game is a good match for him, great! If not, use the parent reviews to look for another that he’ll like and that educate him in the ways you’d like to educate him.

Enjoy your media and use them wisely,
The Mediatrician®

Do you have any last-minute tips for holiday shopping?

Q: I'm doing last-minute holiday shopping, and I still don't know what to give! How do I know what to choose for the children in my life? The choices are overwhelming!
-Holiday harried, in Medford, MA

A: Dear Holiday harried,

Never fear! Even as time grows short, you still have time to take a breath and think about what to give the children on your list this holiday season--whether you're giving media or non-media gifts. No matter what you choose, remember to keep the CHILD first:

• Creativity: Think creatively about who the child is & customize your gift.
• Homework: Do your homework to make sure the gift matches the child.
• Imagination: Stimulate their imagination with gifts they can use creatively.
• Learning: Encourage learning with gifts that peak their curiosity.
• Donate: Teach about giving by helping a child make a donation.

Take a look at our media shopping gift guide if you're considering giving media gifts. If you're looking for non-media gifts, check out our non-media gift ideas. And remember, some of the most meaningful gifts are free.

Enjoy your media and use them wisely,
The Mediatrician® 

What does the new AAP policy say about screentime for babies?

On Monday, the American Academy of Pediatrics came out with a revised policy on media for kids two and younger. The recommendations for this age group are much the same as they were in 1999—that it is best for their developing brains and bodies to avoid both screen use (such as placing a toddler in front of a TV or video) and background media (such as leaving the TV on in the same room where a baby is playing)—but there is new scientific evidence to support these recommendations.

We already knew that newborn brains develop in response to whatever is in their environment. New research from the past 12 years suggests that interacting with people, exploring the physical world (like stacking blocks or “reading” board books), and playing in open-ended ways are great for that development. And no matter how “educational” their content, screen media can’t provide that kind of environment.

That said, screen media aren’t toxic for babies—they’re just not really what they need. And other kinds of media, like music and books, can be great for kids of this age group. The updated AAP policy statement also recognizes that there are good screen media options for preschoolers, whose brains have developed to the point where they can learn from electronic screens.

The reality, of course, is that sometimes you just need get the laundry done or get dinner on the table, so you need a way to occupy your baby or toddler. While you’re taking care of the business of life, try some of these non-screen activities that can occupy and optimize their brain development.

Enjoy your media and use them wisely,
The Mediatrician®

How do I get my 4 year old’s grandpa not to play violent video games with him?

Q: My father-in-law bonds with my 4-year-old son by playing video games. Recently, he bought a LEGO pirates game, rated for 10 year olds, and the two play it for about an hour every time they see each other. I love that they spend time together, but since they started playing this game, my son has become more violent. My father-in-law doesn’t see the problem, even though I’ve tried talking with him about it. Is there research that might help convince him to choose other bonding activities? 

-Baffled over bonding in Palo Alto, CA

A: Dear Baffled,

You know your child better than anyone else, so you are most sensitive to a change in his behavior—and you are in the best position to guide him toward the person you want him to become.

Research agrees with your observations, showing that video games are excellent tools for teaching whatever they focus on. They can teach players to build a city—or to see violent acts as okay, as may be true in your son’s case. The fact that these games are such good teachers might help explain why research has linked playing violent ones with increased aggressive behavior, increased attention problems, and decreased helping behaviors.

Thus, there are good reasons to help your father-in-law shift how he connects with your son. First, point out the important role he plays in your son’s life—because he is a trusted and loved role model, your son will see anything he brings as something he endorses. So if he wants to connect through video games, encourage him to choose games that offer information and skills that he wants his grandson to have. And don’t rely on the age recommendations on the labels—research shows that games are often rated by the industry ratings as less violent than they actually are. Instead, look at parent-oriented reviews  for ideas.

Finally, encourage your father-in-law to connect with his grandson through creative, hands-on activities like playing with real building blocks and developing stories about them together. Such imaginative, open-ended play is a great way to build your 4 year old’s brain, and it’s a great way for him to connect with his grandfather.

Enjoy your media and use them wisely,
The Mediatrician®