Video gaming among children and adolescents enjoys near-universal popularity today, with over 90% of children older than two engaging in game play (National Institutes of Health, 2023).  Yet kids are video gaming on a wide variety of platforms (game consoles, PCs, handheld devices, VR) and in many different genres (strategy, sandbox, role-playing, first-person shooter, sports,  educational and more).  Which features of popular video games are conducive to positive impacts like improved concentration and creativity? Which features may be contributing to digital addiction, depression, and anxiety? Are certain children more vulnerable to negative outcomes than others?  How can games be designed with child health in mind?

Children and Screens held the #AskTheExperts webinar “State of Play: The Ins and Outs of Healthy and Problematic Video Gaming” on Wednesday, March 20, 2024. A panel of leading gaming experts, neuroscientists, psychiatrists, and researchers discussed the most recent findings on the nuanced dimensions of video game play and its possible effects on youth.


  • Douglas Gentile, PhD

    Distinguished Professor in Liberal Arts and Sciences, Department of Psychology, Iowa State University
  • Nick Ballou, PhD

    Postdoctoral Researcher, Oxford Internet Institute
  • Adam Gazzaley, MD, PhD

    Founder & Executive Director, Neuroscape; David Dolby Distinguished Professor of Neurology, Physiology and Psychiatry, University of California San Francisco
  • Kishonna Gray, PhD

    Associate Professor, University of Kentucky
  • Alok Kanojia, MD, MPH

    President & Co-Founder, Healthy Gamer

The ubiquity of youth video gaming has raised concerns about children’s health and safety among parents, many of whom are uncertain about how they should monitor its use. Research indicates there are many factors at play when determining the effects of video games on children, making it challenging to answer the question: “Are games good or bad?” In this #AskTheExperts webinar, a panel of experts dove deeper, sharing the latest research and clinical insights to provide actionable tips for healthy gaming.

0:00 Introduction

Kris Perry, MSW, Executive Director of Children and Screens: Institute of Digital Media and Child Development, introduces the webinar and panel moderator, Douglas Gentile, PhD, Distinguished Professor of Psychology and Director of the Media Research Lab at Iowa State University. Dr. Gentile briefly discusses decades of experience researching the various dimensions of video games, and reasons for its surrounding controversy. He sets the stage for the rest of the panel by discussing 5 dimensions of video games that can have varying effects on players. These five are the amount of time spent, the game content, structural aspects, contextual aspects, and mechanical aspects.

08:34 Nick Ballou, PhD

Nick Ballou, PhD, Postdoctoral Researcher at the Oxford Internet Institute, discusses how the player and environment co-determine gaming’s impact on children’s mental health. Ballou discusses 13 game, context, and player factors that can influence the relationship between games and mental health, and the challenge these present in current research to draw causal conclusions. He emphasizes that this complexity makes it challenging to give one size fits all advice.

14:28 Kishonna Gray, PhD

Kishonna Gray, PhD, Associate Professor of Writing, Rhetoric, and Digital Studies and Africana Studies at the University of Kentucky, briefly discusses her ethnographic approach to studying video game play and dismantling myths surrounding video games. She introduces the idea of intergenerational play as a means to build relationships in the home. Gray also explains the harms of harassment campaigns and why some children may be spending long periods of time gaming.

18:40 Adam Gazzaley, MD, PhD

Adam Gazzaley, MD, PhD, Distinguished Professor of Neurology, Physiology, and Psychiatry and the Founder and Executive Director of Neuroscape at UC San Francisco, delves into the neuroscience of video games. He discusses the critical element of the interactive experience and the role of experience-dependent plasticity. He also shares his research on intentional video game development and the potential for video games as a therapeutic treatment.

23:08 Alok Kanojia, MD, MPH

Dr. Alok Kanojia, aka “Dr. K,” psychiatrist and President of Healthy Gamer, discusses the effects of gaming on brains in terms of addiction. He discusses the relationship between video game play and development of the emotion regulation system, and shares signs that someone has developed a problematic relationship with gaming. Dr. K provides tips on healthy gaming by sharing insights gleaned from his clinical experience and lived experience as a former problematic gamer.

30:40 Q&A – Individual Differences

Gentile asks the panel to discuss the role of individual differences and if they can provide a better understanding of the nuances of video game effects. Panelists discuss the balance between population effects and individual effects, and specific individual or group differences that are critical to consider.

38:16 Q&A – Boundaries & Monitoring

Panelists discuss how parents can establish boundaries that help achieve healthy gaming across development. Gentile summarizes the four main ways parents can monitor their children’s gameplay.

50:24 Q&A – Neurodiversity

Dr. K discusses some unique considerations for neurodiverse youth when it comes to healthy gameplay. Gray shares some resources and communities that can support gaming youth with disabilities.

55:12 Q&A – Comorbidity

Panelists discuss the challenges of comorbid mental health challenges and gaming addiction, including the different types of cases they have seen in research or clinical practice and how comorbidity influences approaches to care.

01:07:45 Q&A – Improving Game Design

Drs. Ballou and Gazzaley examine the challenges for limiting “engaging” design as a primary goal for game developers, and highlight a few other problematic game design elements that should be a focus for future intentional design.

01:16:44 Q&A – Warning Signs

Dr. Gentile and Dr. K share warning signs that parents can watch for if they are concerned about problematic gaming. They also emphasize the importance of being involved from the beginning of game play instead of waiting for problems to occur.

01:20:17 Final Takeaways

Panelists share their final thoughts and considerations for the audience.

[Kris Perry] Hello and welcome to today’s Ask the Experts webinar “State of Play: The Ins and Outs of Healthy and Problematic Video Gaming.” I am Kris Perry, Executive Director of Children and Screens Institute of Digital Media and Child Development. One of the most common questions we hear from our audience is whether video games are good or bad for kids. This is an incredibly difficult question to answer, but we have brought together a fantastic expert panel to do so. With a slightly different format from our usual events, today’s panelists are going to briefly review some of the latest science on the nuanced dimensions of video game play and outcomes for youth. And then together, they will discuss how you can apply these considerations to healthy gameplay. Without further ado, let’s meet today’s moderator, Dr. Doug Gentile is an award winning research scientist, educator, author and distinguished professor of psychology at Iowa State University, where he leads the Media Research Lab. He is the author and editor of many books and over 150 peer reviewed scientific papers, including studies on the positive and negative effects of mass media on children in several countries, video game addiction and mindfulness practices for reducing anxiety and increasing happiness. He was honored with the Distinguished Lifetime Contributions Award to Media, Psychology and Technology by the American Psychological Association, and he was named one of the top 300 professors in the United States by the Princeton Review. Welcome, Doug.


[Dr. Doug Gentile] Thank you very much. So I’d like to set the stage for our panelists by talking about one way we could think about this question of are video games, good or bad? This is a question I get a lot, and I always think it’s the wrong question. And so much of my early research looked at things like violent games and aggression and on video game addiction. So those sound bad, right? But then I also have studies on prosocial games, increasing prosocial behaviors or on laparoscopic surgeons who play games being better at advanced surgical skills.

So those sound good. And as I looked at, you know, the full literature, it became clear to me that these aren’t the same type of effect. And there are at least five dimensions on which video games can have important psychological effects. So I’d like to list these five. And our panelists, we’ll certainly reference some of them and perhaps add to them as we go on this afternoon.

The first is amount – just how much time kids are in front of the screen, how much time they’re spending with video games, and amount seems to be most related to things like school performance. The more time they’re spending on games, they’re not doing homework and their school performance does seem to suffer. It seems to be related to some physical health outcomes, such as risk for obesity and video-induced seizures as well as perhaps addiction.

But it doesn’t seem to be related to things like aggressive behavior or prosocial behavior. When we look at the content of the games, this is the second dimension. That seems to be very much related to certain specific behavioral outcomes. So aggressive games do predict more aggressive thoughts, feelings and perhaps behaviors. Prosocial games predict increased empathy and increased helpful and cooperative behaviors. If you’re doing educational games, Reader Rabbit does improve reading skills. Math Blaster does improve math skills. So those are the two main things that most people think about when they think about all of the research on this. but there are at least three more dimensions. The third one is what we could call structure. How things are actually structured on the screen changes their psychological impact. I’ll give you an example from TV and film literature. If you see a man and a woman go into a bedroom and close the door and there’s a fade to black, we take away a very specific meaning of what we think happened behind that door. But if you see the same men and women go back into the same room and close the door and it cuts to the next scene, we don’t take away the same meaning of what we think happened. So how it’s structured, a fade edit or a cut edit, it actually changes its psychological impact. Similarly, when you’re playing, say, a violent game, you’re practicing paying attention to the whole screen all at once and noticing tiny little changes of movement all around it. And there’s a lot of good research showing that when you play those types of games, you actually get better at widening your useful field of view, noticing smaller and smaller changes. The fourth effect is the context. We could mean this both the in-game context and the out of game context. So if you’re playing a massively multiplayer online game all by yourself, they’re just certain parts of the game you’ll never get to see because you need to have a team to be able to go into them. So whether you’re playing alone or with friends, the content that you’re allowed to see can change what types of experiences you can have in that game. Similarly, if you’re playing sitting with, you know, your friends or your family, that can enhance some of the effects. So, for example, if you’re playing violent games and your friends are all cheering you on for being violent, that could enhance the aggression effect. It also possibly could mitigate it because perhaps you go into it with a different motivation to more prosocial motivation to help your team. So the context might totally change the psychological effect. This is an unanswered question, by the way, in the literature. So for those of you looking for a dissertation project, there’s a good one for you. And the fifth dimension is the mechanics.

As you’re using the controller, you learn how to use the controller, you learn how to use the keyboard or the mouse or the Xbox controller and how to navigate the spaces. So in fact, although we’re talking about these five dimensions as theoretically distinct and I believe they are, they aren’t easy to separate in the real world because as you move your thumbs on the controller, what you see changes are the structure on the screen changes. As the screen changes, you change what you’re doing with your thumbs. This feedback loop between the mechanical and the structural side of things is what we talked about is hand eye coordination. So the question of our games, good or bad? Well, kind of depends which of these five you care about. If your kid is spending a lot of time playing Grand Theft Auto, the lot of time probably means poorer school performance. The violent content probably means increased aggressive thoughts and feelings and possibly behaviors. Because it’s both a driving game and a shooting game, their mouse and keyboard targeting skills should improve, as should their ability to gather information off of the full screen. If they’re playing with friends that might enhance or mitigate the aggression effect. And if they’re playing on a mouse and keyboard, their mouse and keyboard skills improve. So is it good or bad? Well, it depends which of those five dimensions you care about, and that’s why there seems to be this controversy in the field about games when in fact there really isn’t when you realize the studies that people care about usually focus on one of those dimensions, not all five. And they don’t look at how the same game can have both positive and negative effects. So that’s the framework that I’ve asked our panelists to at least talk about their work and how it may relate to or extend that. And I’d like to first introduce Dr. Nick Ballou, who’s a post-doctoral researcher at the Oxford Internet Institute, where he works on pioneering collaborations with game companies like Nintendo and Unity to understand how video games affect mental health, both for better and for worse. He’s deeply involved in the open research movement, which seeks to make research on games more trustworthy. Nick, over to you.


[Dr. Nick Ballou] Thanks very much for having me and for the introduction. I am going to build very nicely off of what Doug has just presented to you. And I will talk about actually a few more things I like. I think Doug has laid a nice foundation for five different aspects of games that we might think are important in the determination of the mental health impacts of playing games. I think there are actually several more. And crucially, I think that they work together in ways that make it really difficult for us to study. So taking a super high level overview, my take on the kind of state of the art in game psychology research at this point, we have lots of ways that these games can affect mental health for better and for worse. We’ve identified about 13 of those. We’re working on a review paper where we try to kind of group the different effects that have been studied over the course of our field’s history. The problem is in many of these cases, the data really are correlational. So we talk a lot about relationships. We talk about prediction and risk factors, but we struggle to make strong predictions about when games will affect players. We struggle to make causal statements about the exact circumstances where games and other features of the player and the environment come together to determine some kind of mental health impact. One thing that I do feel pretty comfortable saying at this point is that in general, the latest research shows that playtime is less important than the quality of that play.

There are people who play eight, 10 hours a day. You look at people like speedrunners or streamers that have really healthy, positive relationships with games and gaming communities despite really high play time. So we tend to look more so at the quality of the play than the quantity per say. So why don’t we know more? Why don’t I have a stronger kind of take to lead you off with? Because we have lots of these factors that combine to produce effects. It’s really difficult to isolate any of these individual things because they work together. So we have the game. We have those things that Doug talked about, and I’ll share some similar ones in a second. We have the context in which that game is played and we have the player themselves and who they are as they go into the game. So going through really quickly, because I don’t want to go over time, we might consider things like maybe in addition to or in parallel to Doug’s features, you might consider things like the business model, how is the game monetized? What kind of… does it have Micro-Transactions are loot boxes as areas of prominent concern that we might talk about later. We might talk about the genre or the particular game within that genre.

We might talk about the mode, whether they’re playing in FIFA, the effects of playing something like Ultimate Team, which is kind of this more competitive multiplayer mode with trading card packs and this randomization elements would have very different effects from a solitary career mode play. We might look at particular design elements or features and of course the contents. When we look at the context in which the game is played, I think looking at how much is an important starting point, but it’s not the only thing that’s important. With regards to time, we might also look at when the play takes place. There was an interesting paper recently that showed that gaming that occurred after school and on weekends was not associated with lower school performance inI think an Australian sample, but gaming before school on weekdays was associated with lower school performance. So we might look at when the play occurs rather than just how much of it and we might look at what the player might have done instead of gaming. During that time, what were the kinds of other activities available to them? Were they gaming instead of doing homework or were they gaming instead of reading a book or watching a show or other kind of similarly interchangeable activities? We might look at the spatial context for where the play is occurring, what the body is doing, the physical position of the play, and of course the social context being a huge one. What communities or relationships are is the person interacting with or enacting through their gaming. Swiftly along to the last one, kind of broad player factors that also work together with these other things to determine the impacts of games, we might look at play style. What is the person doing? What kind of roles are they adopting in the game? Are they taking a more of a leadership role or a follower role, or are they playing a support role? Things like that. The purpose, the motivations, why they play, what they want to get out of the game when they go into it….the personality and demographics I should include in there as well. Who is the player? What are some of their identity characteristics or traits that might impact how they experience games? And ultimately this all comes together to produce some kind of emotional effect. How does the player feel as it’s happening? And you can give the same game in the same context to different people and they’ll have a different emotional reaction to it. And it may be that emotional reaction that has those downstream consequences that we’re interested in. So summing up very quickly, games are really complicated. They’re hard to study. We’re trying to isolate these things that are kind of inherently interconnected. There are at least 13 ways, probably many more, that games might have mental health impacts and I have a paper that I can share that we’re working on to try to identify these, although we have a long way to go before that’s kind of finalized by any means. As a result of these things, lots of impacts, complicated games, it’s really difficult to give one size all advice. I think we’ll try to do our best on this panel here, but it’s really difficult. But at a fundamental level, reflection and transparency about your play can be a really good starting point. And I have some questions that we can ask ourselves, so you can ask your children or other players around you that can maybe help guide them towards healthy gaming and we’ll hear more about that as well, I think. Thanks very much. And I’ll pass back to Doug.


[Dr. Doug Gentile] Thank you, Dr. Ballou. Next, we’re going to hear from Dr. Kishonna Gray is an Associate Professor of Writing Rhetoric and Digital Studies and Africana Studies at the University of Kentucky. She’s the author of Intersectional Tech Black Users in Digital Gaming,

has a book under contract entitled Black Game Studies. Dr. Gray


[Dr. Kishonna Gray] Appreciate you. I’m really glad to share space with you all. You know, I’m not going to echo or like repeat everything that folks have said right here, but it’s really good advice and really fantastic. One of the things that I love the best about this is it’s showing the different range of methods that we’re all approaching to study and make sense of these things. And one of the things that I do, you know, I do – I engage in ethnographic kind of qualitative work, you know, so I have these extended interviews and I do a lot of observations and I kind of watch people and, you know, I engage with young folks and families. And one of the things that I found myself thinking about the question that Kris asked and also with everybody saying, hey, we probably need to ask different questions, but games are good and bad. You know, they’re both. But what is it, right? And I think what I spend my time doing, especially with families and parents and guardians, is trying to dismantle the myths associated with a lot of the gaming. But also in addition to that, I also engage in that intergenerational play with them. So, you know, a lot of times like in a lot of settings, the young folks are engaged with gaming and then parents or guardians are in another space. I bring them all together because I find myself realizing that the key and the power to making sense and understanding games is relationship building. So I know I even have a gaming with granny event…and so  there were some kids in particular, I think Nerf Nana was the resounding sound because Granny actually was pretty good at the games. But whenever I do engage with some of the harms because families do want to know what is happening to my kids in these spaces, I often find myself talking about the harassment campaigns, especially because in the communities that I study and engage in, these are mostly black and brown communities. You know, a lot of queer and trans communities, so a lot of the parents of these kiddos want to know…are my kids safe when they go online? And sometimes I have to say, no, they’re not. But this is what you can do to ensure their safety and ensure that they build the capacities to be able to protect themselves. And I think,  I’ve been looking at this work for like a long time, and a lot of the platforms, you know, the streaming platforms think about Discord and Twitch and YouTube, they have done a great job at building the capacities for safety, such as removing the comments section, being able to have the power to remove certain comments inside threads, being able to create bots and filters, so there have we have built the capacities, for safety and protection, but a lot of times we have to piecemeal together, you know, some protection. So there are so many resources, you know, that are out there so parents and guardians can know how they can equip their kids. And also the things that I do in some of my spaces is activate allies in this space. So, for instance, there was a group of young white kids that are like, hey, we don’t want our friends to experience racism. How can we be active? How can we do that bystander kind of engagements, you know, to make sure that we’re not just looking silently and watching silently, but that we’re active in ensuring that they’re protective. And some of the things that I help…. because a lot of parents want to know why are the kids spending so long in those spaces? I have to let them know. I’m like, that’s the spaces where they have community. This is where they’re safe to be themselves. This is where they’re safe to be out. This is where they’re safe to be trans. These are where they’re safe to do those things inside there. And so I help, you know, parents understand, you know, how those spaces allow for some certain protection around anonymity. You know, there’s also endless narratives inside the games that they’re playing. But that socialization and that community building are really key, especially for a more marginalized and more vulnerable population so they can engage. I really appreciate you all. Thank you for your time.


[Dr. Douglas Gentile] Thank you Dr. Gray.  As you’ve noticed, this is a slightly different webinar format. We’re just doing very brief presentations. Then we’re going to have a real discussion among all of our panelists after these very brief presentations. And next up is Dr. Adam Gazzaley.  He is the David Dolby Distinguished Professor of Neurology, Physiology and Psychiatry, and the founder and Executive Director of Neuroscape at UC San Francisco. Dr. Gazzaley is the co-founder of Akili and Jazz Venture Partners. He’s filed multiple patents, notably the invention of the first FDA approved video game. He’s authored over 180 scientific articles and delivered hundreds of invited presentations. He co authored the 2016 book The Distracted Mind Ancient Brains and a High Tech World. Over to you, Adam.


[Dr. Adam Gazzaley] Thank you. Thanks for having me here today. It’s great to give a short talk after you have already heard some great ones so I don’t have to repeat everything. And I thought those messages were really critical to question what is the question? And you could see the complexity in trying to answer a simple query of are video games good because there are all those components that interact and and have all the different outcomes that you can imagine with so many different ingredients. I want to go in the opposite direction. I want to actually simplify the concept of video games rather than talk about the complexity. So I would say, you know, from my perspective as a neuroscientist that it’s an experience, it’s a unique experience, right? It’s a digitally delivered interactive experience that has engagement as one of the critical elements of it. But it is an experience. And if you think about it as an experience, it plays by the same rules as other experiences. So we know in neuroscience a well founded principle is that our brains have this phenomena, this process called experience-dependent plasticity, and that means that experiences change your brain and it does so at every level – the structure, the chemistry, the function, physiology, all those aspects of your brain are constantly changing in response to experiences. This is the entire basis of learning. And in that sense, video games are just another type of experience with their own, you know, details, but not in some ways different than education itself as a type of experience with therapy. And therefore it can be thought of as a tool to change your brain intentionally. Now, it may do it unintentionally. And you heard examples about how playing video games, especially with the factors that Doug outlined, if there’s lots of amounts of game play and depending on the context and the quality of the content that you’re being delivered, it could change your brains in all sorts of different ways. But what I’m really interested in is how can we intentionally develop design and then validate, test carefully, just like we would any other intervention to help people to see if games can be delivered at a higher level? And this is something that has been of interest to people for many, many years. You’re probably well, the listeners are probably familiar with educational video games and its goal to help them, you know, improve learning. I’ve been interested in how video games could essentially be delivered as medicine and as you heard, we have created the first FDA approved video game. This is a game that was designed from scratch to have the elements of it, the mechanics, the interactive aspects of it, the contents, the context, all of those features were designed into the game and how it’s delivered, and then it’s tested to see if it can have a positive outcome. In this case, we showed that this video game can improve attention in children and adults, and it’s approved by the FDA as a treatment for inattention in young adults… excuse me, children and adolescents that have ADHD. So from a very high level, you know, video games are experiences. They can have an effect as any experience can. And that effect is going to be influenced by all the factors that you’ve heard. But what’s important to note is that they can also be designed intentionally to have outcomes other than enjoyment or fun, which is certainly an important one. Entertainment is an important part of life, but we’re now learning that video games, when designed, intentionally can deliver all these really important outcomes. So I’ll leave my comments there. Thank you.


[Dr. Douglas Gentile] Thank you very much. Our final panelist is Dr. Alok Kanojia. He’s a Harvard trained psychiatrist specializing in the intersection of technology and mental health, often known as Dr. K on the Internet. Dr. Kanojia is the President, co-founder of Healthy Gamer Mental Health Platform that provides content expert wellness, coaching and community to young people. He’s also the author of How to Raise a Healthy Gamer. You heard about this book earlier. 


[Dr. Alok Kanojia] Thank you so much. So first of all, I’m honored to be here with this amazing group of panelists. I’m somewhat familiar with some of their work, and this is just an absolutely stacked panel. So I think what I’ve been called in to kind of talk about is a little bit about the development of how gaming affects people’s brains, what to really sort of focus on in terms of addiction and then how we can sort of develop healthy gamers. So in my day job, the bulk of my clinical practice was addiction psychiatry. And so I noticed I struggled with video game addiction myself in college and kind of failed out of college and all that good stuff or bad stuff. And so one of the things that I really struggled with when I was training was trying to figure out, okay, like what are video games doing to people? And I trained back in between 2010 and 2018. And so I think things were not quite as prevalent back then. And so here’s sort of what I’ve learned, and it’s really nice to hear so many of my fellow panelists actually corroborating what I’ve learned because I’m never sure if I’m actually right or if other people are finding different things. But what we sort of know, there are a couple of key features that we kind of look at. So everyone’s well familiar with dopamine, right? So we know that video games release dopamine, but there are a couple of other effects that we see are really problematic. So the first is that they change our attention span. So if you look at sort of what a video game does, a video game doesn’t require you to stay engaged. The whole point is that unlike something like a book where you have to force yourself to pay attention, video game developers are competing to try to keep people as engaged as possible. And so what we tend to see, we’re seeing a rise in the rates of ADHD diagnosis, which is why some of these things, like Akili, have become increasingly important. And so as ADHD is going up, as the rates of diagnosis are going up, as our attention spans shrink, we’re starting to see this kind of as a result of gaming because people don’t have to focus their attention. The second thing that we tend to see a lot of, in addition to the dopaminergic stuff, is actually emotional circuitry. So if we look at video games, we know that playing a video game, much like many other addictive substances or behaviors, suppress our amygdala and our limbic system. So these are the parts of our brain that experience negative emotions. And so what we kind of see with unhealthy gaming is a cycle of, let’s say I’m being bullied at school, let’s say I’m not doing great in my classes, so how do I manage those negative emotions? I’m going to shut them off through video gaming. And then this creates a vicious cycle because if we really look at the evolutionary purpose of negative emotions, negative emotions are powerful motivators for corrective behavior. So if I feel, you know, afraid of a snake, that fear is there to help me stay alive. And in the case of a lot of these corrective behaviors, if I feel ashamed of, let’s say, my appearance or my performance in school, the purpose that we feel that shame for is to study harder, is to work harder, is to maybe go to the gym or something like that. But once we remove that negative emotional circuitry, we remove the corrective behaviors. We also see another interesting aspect, which is a growth in Alexithymia. So, Alexithymia is the inability to detect your internal emotional state. And so what we see in a lot of unhealthy gamers is that they’re not even aware of what they’re feeling. And what we see is that a lot of parents are kind of stuck on the front lines or teachers are stuck on the front lines of children and adolescents and even young adults who have this emotional turmoil going on. We see the tantrums, we see the manifestations in terms of depression or anxiety, but the gamers themselves are not aware of what they’re feeling and they can’t take corrective action. So what we sort of tend to see is these three neuroscience effects of shortened attention span, suppression of our negative emotional circuitry, and even some degree of Alexithymia creates all kinds of problems. And in the clinical setting, what we really look for is how do you know if someone has a problem or not? What we really look for clinically is impairment to function. So whether you’re talking about a substance use disorder or a behavioral addiction like pornography addiction, video game addiction, shopping addiction, sex addiction, what we’re really looking for is some kind of impairment. So is the behavior interfering with our ability to do schoolwork? Is it interfering with our professional lives? Is it interfering with our physical health? Is it interfering with our mental health? Is it interfering with our relationships? And if it’s impacting those in a very impairing way, that’s when we really know that we’re dealing with an addiction. The last thing to kind of consider is…our approach at Healthy Gamer is to help people become healthy gamers. So if you look at a lot of the world of addiction psychiatry, sobriety is the goal, right? So if we’re talking about someone who’s an alcoholic or uses opiates, the goal is sobriety. But I think when we’re looking at these technologies, this is sort of different, right? These are closer to behavioral addictions where when I’m working with a patient with, let’s say, sex addiction, the goal isn’t celibacy or abstinence for the rest of your life. It’s a way to form a healthy relationship with it. And so this is kind of the bulk of where our work is. We work with, you know, tens of thousands, if not hundreds of thousands of gamers. And now we’ve worked with many of their parents. And what we’ve sort of found is that the core problem that we see is that as a parent, you’re trying to restrict this game and then your child is fighting against you. The main thing, the one lesson I’ve learned as an addiction psychiatrist is that… or practicing addiction psychiatry, is that you can’t force sobriety on someone else. So our whole approach is helping parents connect with their child…for the both of you to get on the same team, and we use evidence-based methodologies like stages of change and motivational interviewing, so we’re really forming that alliance so that both we all are working together on certain communication techniques which parents didn’t need, let’s say, 30 or 40 years ago because of the way that technologies even shape shaping our ability to communicate. So as people become more dm oriented, text oriented, we’re starting to see atrophy of some of these parts of our brain that really pay attention to things like tone and body language. So parents need to learn a new communication style, get on the same page, and then finally, we sort of teach a lot around healthy boundary setting. And the real paradox here is that a lot of parents will really do things that they think are good, which is actually making the problem worse. And so what we’ve sort of found is that we’ve been pretty effective at helping gamers and then now we’ve been pretty effective at helping parents. And that’s kind of our approach is get on the same page, learn how to communicate for this new generation. And then lastly, how to set effective boundaries.


[Dr. Douglas Gentile] Thank you so much. So I’d believe we now can have all the panelists’ cameras on. And I guess I’d like to start and open up the question… in most of my work, for example, and a lot of the work out in the field focuses on game characteristics. Most of you, however, also mentioned characteristics of the gamer. And I think this is… and other intersectional aspects of this community and family. So I know we’re not going to be able to unpack all of that here today, but how do we focus on individual differences? How much do individual differences matter? It might be the case that a particular game is healthy for one player, but not for another. How can we know and how should we be focusing both our research and the way we talk to the public and professionals about this so that they can understand these nuances? 


[Dr. Kishonna Gray] Yeah, I wasn’t sure of the order in which we needed to respond, but I’ll just jump in here first because I guess I want to highlight that if we don’t do that, then what will we continue to get? So a lot of times a lot of companies use a lot of approaches and want to create  a universal kind of experience, but we have to unpack and dissect what that universal experience looks like. Usually they have an imagined audience in mind. They have a target demographic in mind, and usually those experiences are very ableist because they don’t take into account neurodivergence and so they don’t they don’t account for those kinds of issues, but they also don’t account for other cultural differences. So a lot of… in my work and a lot of the scholars that are especially in the black digital culture space recognize that a lot of these approaches, you know, value Western thinking, white thinking, Eurocentric kind of thinking, masculine thinking, and they don’t really incorporate these other kinds of approaches. So I don’t think we need to go all the way extreme and think about individual approaches, but we need to think more holistically about how these might impact different cultures and what these engagements might do if we don’t start thinking in more kind holistic intersectional kinds of ways.


[Dr. Adam Gazzaley] Maybe I’ll just add one point there. In addition to, you know, big differences in populations, there’s all the individual differences even of people within a population. And we see that in our research is…you know, the most obvious finding of looking at almost any data set is the heterogeneity of it. Right. And as scientists, we’re always like, is the heterogeneity limited enough that we could find significant differences, but it’s always there. There’s never… everyone’s affected in the same way, so you could see that with games that are designed to do good, like the cognitive games that we create or games that are designed just as entertainment tools. You could also see just an incredible amount of variability. And I think it’s an important, really important point. It’s a hard one to study because the intersection between all the differences that an individual could have going into a game from their own mental makeup, the environment that they’re in, combined with all those different factors in games, creates a multidimensional problem that is really hard to tease apart in research, but when from a personal perspective of a parent making a decision, obviously you should be thinking about the type of game how much of the game, all the features that Doug outlined really nicely, but also who your child is and how they interact with these and then it’s also… not only is it not a one size fits all, it’s not something that is static. It could be a dynamic process where your child changes over time. I have two little kids right now. So this is very, very personal for me. And you know, what happens on Monday of this week is different from Monday of next week. And so you got to, you know, stay flexible and dynamic and observe that. My last point is, yes, you know, critical empirical, controlled research is great, but in a lot of ways we don’t have all the answers and we may never have all the answers. It’s so complex. So some of it is an N-of-1 of study that a parent is doing with their child, and it’s going to take careful observation. And so being an observer and a sort of a scientist in your own right and watching the effects and observing them as opposed to just passing them along, I think is really critical to help understand the individual differences, particularly those of your child and how it interacts with the video games.


[Dr. Nick Ballou] I’ll just add one last  point on that is that some of these things are kind of stable. We have things like LGBTQ identity and neurodiversity that are kind of stable. Country of origin is a big one that the research literature essentially very rarely addresses. We mostly study Western populations, but there are other things that are not stable. They change over time. I can give a personal example. There are times that I pick up a game purely because doing work is hard or doing chores is frustrating and I want to avoid those things and I might pick up the same game the next day because I want to feel a sense of connection to the characters in that story.

So my motivation going into that game is varying day to day. Those individual differences at the trait level are kind of stable, but the effect that that game is going to have on me in those two circumstances is very different. So it’s even another layer of complexity on top of that, it’s how people are changing over the course of their day and what they want out of those games when they’re playing them.


[Dr. Alok Kanojia] If I can just kind of chime in. So I want to just support what my fellow panelists are saying. So in my experience, I think, you know, the key challenge that we sort of face is what are these universal aspects that apply? What is our universal approach and how do we individualize that? And I think what we’ve sort of found is that just like Dr. Gray was saying and Dr. Gazzaley have been saying, is that there are individual differences. And so if you look at, for example, the University of Toronto, I think they have some really fascinating research on personality types and video gaming. And we’ve also seen that if you look at, you know, for example, women who get addicted to video games are more likely to be interested in the community aspect. Men who get addicted are more likely to be interested in the competitive aspect. People on the autism spectrum who play specifically massively multiplayer online RPGs and World of Warcraft are more likely to have behavioral meltdowns and tantrums. There’s a lot of individuality. So I think that the approach that we need to take… or this is the approach that we’ve decided to take, is to really try to equip parents, for example, with a set of skills so that you can individually work with your kid. So these are like core of like communication skills, understanding the core neuroscience, understanding the core psychology and then tailoring it. I love this phrase of N-of-1. So tailoring things, specifically, taking this general information and adapting it to your particular circumstance. And that’s when we see, by far the best outcomes. Instead of telling all the parents you should do this, …it’s we’re going to equip you with a set of skills so that you can modify things to your specific household, whether it’s an intact household or a divorced household. There are so many different variables, and it’s really about equipping people with the tools to solve their individual situation. 


[Dr. Douglas Gentile] All right. Thank you all. We’re getting some questions in the Q&A about boundary setting. And given that you’ve all in one way or another referenced, you know, this is about trying to find healthy gaming rather than saying games are good or bad. What’s your advice for boundary setting? You know, several years ago, the American Academy of Pediatrics used to have guidelines for parents saying no screens up until basically age three, one hour a day of entertainment screens for elementary school age children. You know, no more than 2 hours of entertainment screens. So if they are on the screen for school, that’s fair. You know, that’s free…for secondary school age… and political pressure kind of made them back off of those numbers. I still think they were good numbers, honestly. And there are data out there that support those as numbers. But I guess I’m interested, you know, what would you say is… how are our parents best able to set boundaries that really help their children achieve healthy gaming?


[Dr. Alok Kanojia] Sure, yeah. So I think it’s a great question. So what we really try to do is we try to emphasize restraint over restriction. And so our approach is as a parent, what’s the job of parents? The job of a parent is to prepare your child for the world that they’re going to live in. And so what this means is that as your child gets older and older and older, they will have free access to technology. So our approach is really about, you know, the boundaries that you set should be aligned towards accomplishing the goals that are important to the child and important to you. So what we start with is by recommending that parents speak to their child about why do you want to play this game? What is enjoyable to you about it? What do you like about… what’s challenging in the real world? What do you like in the real world? And to find some kind of common ground. Once you find that common ground, then you can set boundaries kind of around that. And even as a parent, you can say, okay, I get that you want to play with your friends. I get that everyone is playing Fortnite. That’s totally fine. I want to support that. At the same time, it is my job as a and responsibility as a parent to make sure that you go to bed on… or get sufficient rest, take care of the things that you need to do and how can we work together so that you can have fun and we can get these kinds of things sorted out that need to be sorted out like school or physical health or whatever. And we sort of find that that’s a really good place to start. And then two other tips that we found are very, very effective based on our internal research is first…that parents are way too ambitious. So parents think about the goal where they want to go, which is…, so if I mean… I was this way when I was failing out of college, I literally got, you know, like a 1.4 GPA my first year and what did I want next year? A 4.0. Right? I have to fix the problem, but it is completely unreasonable for… let’s just focus on passing.  So parents are so terrified that every month that goes by, every year that goes by, my child is falling further and further and further behind, which causes them to be overly ambitious. So what we recommend is the 25% rule, which is take where you want to go, take where you are, find a halfway point, and then find the halfway point between the halfway point in where you are and start small and start winning together. And then once you have victories, then you can start to become more ambitious over time because dealing with something like an addiction is, you know, the time scale is very long. And so we strongly, strongly recommend starting small and going for wins.


[Dr. Nick Ballou] I’ll just add one quick one that I found really practical and useful. I don’t have children myself yet, but my boss does. He has a seven year old and a nine year old and they are now old enough to reflect on their media use. Of course, children that are very young, that’s going to be difficult, but once they’re kind of five, six, seven and beyond and able to think about what they find enjoyable or what they want to do when they pick up a game or another piece of technology, he now has them. He essentially sets no restrictions. He says you can play games as much as you want as long as you get the other important things in your life done. So go to school, do your homework, do your chores, get enough sleep, etc. He thinks that usually ends up to be about an hour or two a day that they have left over that they could use for games or other things. When they pick up the game, they have a little diary and they have to fill in the start time, the time, what they played…I think one thing they like about it, one thing they didn’t like about it and what they would have done if they hadn’t played a game. So apparently his daughter always says if she hadn’t played a game, she would have watched The Simpsons.

And this is kind of really I find this to be a really interesting and useful way to train your children, to be reflective about their media use during that kind of self-awareness, about what they want out of it, whether they’re actually getting that out of it, and whether they’re maybe straying into a realm where it might become problematic and can help you have some some data for your end of one study to monitor that as well.


[Dr. Douglas Gentile] Thank you. Dr. Gazzaley?


[Dr. Adam Gazzaley] Yeah, I agree with what has been said, just like one small point, and sometimes I try to demystify video games and not make them seem so, you know, unique compared to other types of experiences. And, you know, even I explain to my three year old… every thing we do has restrictions and limitations. Even the things we think are great, like eating and being at school and exercising. That’s just the way life is. You need to put constraints around the good things as well as certainly the bad things and  then have a structure to your day that makes sense. So I do try to, you know, not keep giving it like this special space because then it winds up becoming more of an issue than maybe it should be. It’s just yet another thing. We need to make a decision about how much you engage in, just like how much you engage in playing outside your friends is not unlimited. And then at least for me, this is not based on research, this is my own personal experience with my three year old. I have started exposing her to some educational games that, that you know, fall in the category, learning math and reading. And for me, I only let her do it when I do it with her. And that places a burden on me, which is now we’re both in this together and I have to find the time in the morning to sit down and do it with her. But it has been incredibly positive. I built therapeutic, you know, video games, not these types of games, but it’s been really a bonding experience for us to learn how to do them together. And I found that very, very helpful. And she doesn’t even usually want to do them without me anymore. It’s just something that we do together. So I did create a burden for myself, but that also does restrict the time because I don’t have all that much time stuff. Anyway, a personal anecdote. 


[Dr. Douglas Gentile] Thank you. Dr. Gray?


[Dr. Kishonna Gray] Yeah, I just wanted to quickly say that some of the successes that I found in the work that I do is to have parents and the children or guardians and the children, enter into this compromised negotiation space where the kids are a part of how much they might engage, and when they might engage. And then they come to the table saying, you know… the young folks identify what their needs are. Their needs are mostly wants. They just want to play the game. They want to engage in their friends. And then the parents are like, well, this is what I want, what I need. And so come up with an approach, like a compromise that works. And then students feel empowered. The parents feel like they also still have a say. But I think this diminishes and dismantles some of the tensions of parents always feeling like they’re having to tell their kids what to do. And this also helps the young folks develop the decision making process to make better decisions for themselves as well. 


[Dr. Douglas Gentile] Thank you. Yeah, I’d like to, you know, unpack some of the themes that came across your different answers here. You know, in the literature, there are four main ways parents can monitor their children’s media. One is co viewing or co playing. So you sit and watch with them or play with them. The second is setting limits on how much time they’re allowed to play. The third is setting limits on the content. So using the ratings and choosing, you say, educational games over violent games or things like that. And the fourth is what’s called active mediation in the literature. If you’re keeping track of your lucky psychological jargon scorecards. And what you’ve heard mostly here is people talking about active mediation, where you have a discussion with your child about why they were like what they like, why they don’t like, what they don’t like, why you want them to see certain things or not other things whose point of view is being shown, whose point of view isn’t being shown, what effects could be playing this type of game have on people? What effects do you notice on yourself you’re having getting them to reflect critically on the media? The literature is very clear. That is the absolute best for kids. That is a powerful protective factor for children. Most parents don’t know how to do it, though, because they haven’t been trained in critical media studies. They haven’t been trained how to watch the media that way and ask those questions. Usually when parents say anything, they usually just give their opinion, I like this or I don’t like that. That’s very low quality active mediation. So the best active mediation is done with questions. But, what about if, you know, a parent doesn’t know how to do that, doesn’t feel comfortable doing that? What is the effect of, say, just setting limits on amount and content? I’ll show you perhaps… probably the favorite study I’ve ever done in my life with… we had 1400 families of third through fifth graders and we followed them across a school year. And we asked… we talked to the parents, we talked to the teachers, we talked to the school nurses, we talked to the children, we got a lot of data about these families. And if parents set limits on amount and content of screen media at the beginning of the school year, you saw some immediate effects that, yes, they were always kids were consuming less total screen time and they were also exposed to less violent media. When we followed these same children out to the end of the school year, those whose parents had set limits on amount and content by at the beginning of the school year, they were getting better sleep, which in turn related to lower weight gains or lower risk for obesity. They were getting better grades in school. They were more prosocial in their behaviors as rated by teachers, which is kind of remarkable because the teachers don’t know what family rules for media are at home. But they can see the effects, you know, they can see the behaviors in the classroom. And they were less aggressive, again, as rated by teachers. Now, the two things that fascinate me about this are, first of all, those aren’t the same type of outcome variable. You’ve got physical health, school performance and social wellness. Those three different types of outcome variables don’t usually co-occur. But this one simple thing of setting limits on amount and content of screen media influences all of them. So it is a protective factor that extends out wide, both in time and across a wide range of health and wellness indicators. The more interesting thing to me, though, is no parent will ever know they’re having this effect because you’re not going to know that your child gained less weight than he would have or is getting better grades than she would have or is more prosocial than he would have been. You only know what your child is. So what parents can see for themselves is the fight over the rules, but they can’t see the effect that having those rules is having. And data like this show that these you know, it’s worth having rules and it’s worth, you know, holding them firm because it has a powerful protective factor effect. So the best, of course, is if you can get into this habit of having these discussions with your child. But even if you don’t do that, just setting limits does seem to be a very powerful protective effect factor for children’s health and wellness. You know, it’s come up a couple of times in, you know, things you’ve said and there’s certainly some questions in the Q and A about neurodivergence.  What about people who are on the autism spectrum, ADHD? Are the effects similar, different? Should we be handling them differently? Do they have fewer protective factors because, say, they’re on the spectrum and so we have to be a little more vigilant. What are your thoughts about this aspect?  Dr. Kanojia, you’ve had your hand up for a while. I wasn’t sure if you wanted to say something else or if you all…


[Dr. Alok Kanojia] I would be happy to talk about it. It’s a huge part, but I didn’t put my hand down earlier, so apologies y’all. So yeah, but it’s a huge part of our community. So we have a very large neurodiverse community, ADHD and autism spectrum. We work with a lot of parents who are struggling in this way. One of the things that we sort of discovered is that, you know, like a fourth of the book, for example, is about specific diagnoses and how those impact gaming specifically. So I think a couple of things to keep in mind. The first is if we look at something like ADHD or autism, so gaming is like a double edged sword. So if we look at someone who’s on the autism spectrum, oftentimes they struggle to form connections because due to their neurodiversity they’re not as good as at reading tone. They really enjoy highly structured environments. They… so there’s almost like the rules of socialization are sometimes difficult for children on the autism spectrum. And that’s what’s so great about gaming is that all the rules are laid out, the teams get set. You don’t have to worry about body language and tone. You can communicate via, you know, typing out messages. So in some ways these are very protective and at the same time they can also be very, very damaging actually. So we know… I talked earlier about there are some studies that show that playing certain kinds of video games will worsen things like behavioral tantrums, outbursts. And we kind of see the same thing with ADHD, where on the one hand it’s really, really nice because these are kids in my clinical experience who… they go to school right? And the teacher tells them like, just pay attention, or the teacher tells them like if you worked harder, you would live up to your potential. And so these children, it’s really fascinating. If you look at the research, if you look at a comorbid population. So if we look at people who have ADHD and depression, 3% of children who get depression will develop ADHD later in life. 70% of children who develop ADHD can develop depression later in life if you’re looking at a comorbid population. So having ADHD early in life is a very strong risk factor factor for developing depression. And why is this? It’s because these kids recognize that I’m just as smart as everyone else, but I cannot function the way that they do in a neurotypical schooling environment, I cannot excel the way that I believe I should and then enter something like gaming, where now you can compete, right? Because now your brain is sort of wired into this game. You select the games that you can kind of focus and pay attention to. So kids with ADHD are very, very drawn into gaming and it can sort of lead to negative impacts. And at the same time it can be a strong source of enjoyment and fulfillment. I also work with e-sports professionals and streamers of whom have five or six times the likelihood of the general population of having ADHD. But in a streaming environment, in a pro gaming environment, these actually can be adaptive advantages and so it’s really a double edged sword.And I think people just need a treat…You know, these whether it’s a child or adolescent or young adult, you really have to take an individual approach.


[Dr. Kishonna Gray] I wanted to just highlight, you know, just a few services and I’m not sure if when I put the information in this chat here if it gets to the rest of the group, but if that could be shared to them. So I wanted to just speak a little bit to the services for physical disabilities. I think that’s one of the things that we talk about less inside these spaces. But I know there are a lot of groups like Matthew Iske, you know, he directs the Unified E-sports League that actually focuses on… how do we get more physically disabled youth inside the gaming space. And also Steven Spohn from the AbleGamers group and also Quad Guides, you know, a group of  quadriplegic folks who are thinking about accessible technologies and how the technology of the space keeps them out and what they have to do, you know, to basically participate and engage. Because I know a lot of  parents of physically disabled youth think that their young folks can’t participate and engage, but there are resources out there. So I just want to make sure that folks in the space know about those resources too.


[Dr. Douglas Gentile] Thank you for those answers. There are several questions about, say, this comorbid aspect. You know, for example, does depression lead to gaming disorder or addiction or vice versa? And it’s a really complicated question to try to answer. You know, you need longitudinal studies with really large populations. There are a couple of these… does it seem the gaming tends to lead to depression? Gaming before the Depression in most of those studies. But I think truly they’re comorbid in that. And we know this about mental health, when you get one disorder, you often get others and they push each other around. So saying, you know, this is the primary one and this is the secondary one, doesn’t to me make a whole lot of sense, honestly, because a therapist has to treat the whole patient. And if all they did is treat well, what was the first problem you had? The patient’s not really going to get better, at least not nearly as quickly as if they treated the, you know, the whole set of comorbid issues. But how do you guys like to talk about this issue of comorbidity? Because I think it is one that is holding back the public’s ability to accept, say, you know, gaming addiction is a real problem because they say, well, it’s, you know, just a symptom of the Depression. But as long as we keep thinking about this, as you know, there has to be a first one and a second one. As long as we think of this as you know, there has to be one core issue rather than understanding. That’s not really how the brain works in a lot of circumstances. I think it’s a way of kind of keeping us from really confronting some of the issues of gaming that are that are important in their own right, even if they are comorbid. But what are your thoughts?


[Dr. Kishonna Gray] I don’t want to take up space because I’m not a clinician. I’m not in the therapeutic space, so I don’t want to take up space, but I do want to let folks, especially who are providing services to young folks and families in the space, I think the model that we have to have is incorporate some of these folks who provide these services into what we do. So, you know, like I said… I mentioned earlier that I do a lot of work with families. I have therapists on staff. I have a social worker there because I think we have to approach a lot of these things kind of holistically. And so a lot of the families that I serve are under-resourced, they’re underfunded.

You know, they’re socio economically disadvantaged. And so there are a lot of, you know, like you said there, there are some comorbid things happening. And I’m just a professor studying games, you know, so I don’t want to assume that I know anything about the space, but I do know that folks have needs that need to be fulfilled. Right? So I’m thinking about food insecurities, mental health challenges that aren’t addressed, stigmas related to mental health, especially in the black and brown community. It’s a lot of  stigmas and pressures to not even go and be treated and be seen. I know there are a lot of families that said that that was stuff that white people did. And so we have to dismantle a lot of those things. And I want to make sure that families get the resources that they need and be culturally sensitive, you know, to also those challenges to make sure that they get served and the youth get served as well. So for folks who are building out these capacities, make sure that if you’re working with families and things, make sure you have folks that are there that can address their needs as opposed to just being extractive and researching them and studying them and then taking stuff from their community and not giving anything back.


[Dr. Nick Ballou] I’ll also  just make a quick comment because I’m not a clinician either, but I do… I can imagine two different classes of players for whom some kind of have depressive symptoms or under an underlying mental health condition and gaming is a symptom that emerges from that. And even if you treat the gaming, that underlying problem will still exist.

That is something that I think happens for a lot of players. And I can imagine the opposite, where players who don’t really have a lot of problems find themselves sucked into a pattern of gaming that kind of gets out of control that they struggle to regulate that leads to problems in other areas of their life. And even if you solve those other problems, that underlying dysregulated or problematic gaming is still there. So I think there are feedback loops that are going kind of in both directions with each… either starting, that would be impossible and we might be able to think about ways of identifying one versus the other. I would imagine, for example, a player who is kind of treating an underlying mental health condition with their gaming might report, for example, that gaming is an escape for them, a place where they can escape from the problems and stressors of day to day life, more so than someone for whom gaming is causing problems elsewhere in their life, who might report something like wanting to achieve high levels of achievement in the game, be the best, compete with their friends, things like that. So we might look at the motivations as one way of differentiating where the problem has begun and which problems are kind of following on from that. 


[Dr. Douglas Gentile] Dr. Gazzaley?


[Dr. Adam Gazzaley]  Yeah, I was just going to make the point that, you know, this is the most complex of all questions in some ways because we’re… it’s sort of going back to something we talked about earlier. You have this intersection between someone’s own cognitive and mental health makeup at the time, the environment that they’re in, and then it collides with these complicated experiences. And again, I’m going to generalize beyond video games. I mean, we could be having a very similar discussion with social media use, right. And that these are going on, you know, in parallel that, you know, you have this intersection between where a child or anyone is at that moment and what they are exposed to. So the environment is incredibly influential on these factors, but it doesn’t happen in a bubble or as an island, it happens in the context of what that person’s, you know, current makeup is or their current level of mental health, or the environment they’re in, or the support that they have. And it could be, you know, removed from video games. It could be the school environment is not supporting them in a way that is helping and it’s worsening. It doesn’t have to be about video games. And so, you know, the long story short is that it’s very hard, I think, to have, you know, universal conclusions about these things and that that is where health professionals working with the child, adolescent or adult that is struggling either with addiction or the intersection of their depression and anxiety and whatever experience they’re engaging in at a high intensity for a long period of time, like video games or something else, has to just be disentangled in a very personal way. So I always maybe being a health health care professional myself, I’m always, you know, thinking about the fact that there is great value to population research, but there’s also, you know, going back to that N-of-1 , you know, really thoughtful time between someone that has a lot of experience in dealing with these situations and the individual that’s suffering is going to be necessary to disentangle the situation and to help that person as much as possible.


[Dr. Douglas Gentile] Yeah, let me pull out one theme a little bit and then I’m going to hand it over to Dr. Kanojia to wrap up this question. A lot of… and I think it’s very typical motivation… how we use media. We use media as a coping strategy, as a way of de-stressing or whatever, and there’s nothing necessarily wrong with that. But I think as long as we’re not recognizing that games or social media or technology can have problems that, you know, isn’t necessarily a good thing. So, for example, here at my university, Iowa State, we’ve got lots of first year freshmen in, they’re in a dorm with a bunch of other boys who also like to play games. And so they stay up really late playing and then they’re tired in class, so they don’t do as well on the test. So to deal with the stress of not doing so well, they play more games and then they are so tired, they don’t even bother to go to class and they start failing, to which their response is to play more games. If they bother to go down to student counseling services, they walk in, they say, I’m worried about my grades. The therapist very appropriately asks grade relevant questions. You know, tell me about how you take notes, tell you about your study habits. The therapist doesn’t ask about games because the patient didn’t present with a problem about games. The patient never talks about games because to him, they’re part of the solution. And so no one asks about the actual issue and these students just flunk out. And this is why for me, you know, this is such a big deal to… let’s get people at least knowing this can be a real problem on its own, separate from your stresses or your depression or other things. Because if we don’t even ask about it, we may miss a really important piece of the puzzle. Dr. Kanojia, we’ll let you wrap up this discussion. 


[Dr. Alok Kanojia] Thank you so much. So I think, you know, as some of my colleagues mentioned, you know, they’re primarily researchers. I’m primarily a clinician. I’m not nearly as accomplished in research as any of you all. So the bulk of my work is working with people. And so I think, you know, what I find is that if we look at addiction psychiatry, you know, there’s this concept of dual diagnosis. And what that sort of means…Let’s take an analogy of alcohol. So alcohol is something that suppresses our emotions in the moment and leads to low mood over time. So when we have someone who suffers from depression and alcoholism, what we find is they feel depressed, they feel even suicidal. They will drink alcohol to numb themselves in that way. And just like Dr. Gentile mentioned, they’ll kind of use this as an antidote, but then this worsens the problem. And it’s hilarious that, you know, the example you used was literally my life. I mean, I failed out of college because I was skipping classes. And as the thought of failure became overwhelming, I would spend 14, 16, 18 hours a day playing games and that was like literally my first year of college. And we also hear this really sad story of someone who comes in, sees a psychopharmacologist, a psychiatrist for a 45 minute intake, they meet criteria for major depressive disorder. The psychiatrist never asks about gaming. They get prescribed an SSRI, they get sent home, come back and see me in a month. They pop their pill every day, but that gaming is not addressed. So I think the way that I kind of see it is…I think it’s in some ways simple because we know clinically what the right answer is, is that you have to deal with both of these things at the same time. So you have someone who, let’s say, has depression. And just like my colleagues have mentioned, this creates negative feelings and now we have a substance. So, in order for anything to be addictive, it needs to do two things. It needs to give pleasure and take away pain. And so what we see in gaming is this is just a new form of doing that. And as we give some pleasure to someone who’s depressed, that feels almost self-medicating, we remove their pain temporarily. But what the gaming really does is does not fix their circumstances, doesn’t give them things to be proud about. And so then this creates a vicious cycle that then feeds the depression. So  I’m kind of of the mind that from a clinical perspective, you know, it sort of doesn’t matter to me which came first. I think from a clinical perspective, it’s that both of these need to be addressed and we need to understand how gaming amplifies the negative effects of depression and how depression amplifies the negative effects of gaming and sort of tackle both of those.


[Dr. Douglas Gentile] Great. Thank you very much. So we’ve got some questions about brain development, plasticity. Perhaps if there are developmental periods we should be mostly concerned about, but I want to frame this question a little broader than that. One of the things I’ve noticed when I try to talk to people about what the research on game effects is, is that people like some of the research and don’t like some of the other research and they want to argue that. So they will, you know, they’ll say, look, educational games are so good for children, but there’s no way violent games could have any effect. But all games are educational, right? Anything you practice. Your grandmother was a great neuroscientist. She told you practice makes perfect. She was basically right. So, most of the effects we’re talking about here have a learning component. Even the addiction has a learning component. Dr. Kanojia  just showed you where it is too…is  for something to be addictive, it has to give pleasure. So that’s positive reinforcement and take away pain. That’s negative reinforcement. And those two things are just part of how the brain learns. So anything we do, we’re going to learn from. Are there certain aspects we should be more concerned about than others? Are there certain developmental periods we should be more concerned about than others? Let me ask Dr. Gazzaley to start this off.


[Dr. Adam Gazzaley] Yeah, this is sort of a full circle for me. It’s sort of how I began my comments in that, you know, games are experiences and that is, you know, a core aspect of thinking about them from my perspective. And that experiences drive learning. And they are, you know, a powerful driving force of our brains’ plasticity. They are heightened during developmental stages, but they persist throughout life. So, you know, experiences have been used as ways of improving brain function for thousands of years, like meditation and mindfulness practices. Therapy is a form of experience as a treatment, and video games can be therapeutic when applied intentionally and designed and tested and monitored. But they don’t have any… I would say directionality, on their own or any morality, right? They’re like all tools. They cut both ways, right? I would say fire can cook your dinner or burn your house down. And even there are…you know, a molecule viewed as medicine or as poison in the wrong doses are applied wrong. So I like to think of video games as experiences and when putting it in the context of ways of helping you, then it is a tool like all others, and tools have to be used intentionally and they have to be monitored because they cut both ways. And so, you know, all of it is thinking about, you know, if you’re talking about a video game during childhood, then you have to recognize the fact that experiences drive plasticity. And plasticity is heightened in childhood and all experiences are going to have large effects and that the effects of the games are going to depend upon the features that you presented, Doug, right? What are the mechanics? What is the content?  How long are you doing it? What are your intentions about doing it and the structure of it? So, you know, I think that it’s really where we started this conversation from is thinking about video games as a type of experience, a very particular type of experience, a powerful one, because it’s engaging and it’s accessible and it’s fun. Those make for very powerful experiences, but it is like all others in that it will have an impact, especially during childhood, and it will depend upon both the composition of that individual at that time, their environment and then the factors of those games. So that’s why, you know, I think we always struggle in this field. There is no simple answer to this question, but thinking about these is another experience and another potential tool, it doesn’t mean that all games have to have these types of positive outcomes. There’s certainly nothing wrong with entertainment, games and fun and play, but it is an important conversation to have thinking about children and the limited amount of time that they have in all, you know how busy kids are these days with how many classes and things that are occupying that time. So thinking about games intentionally as tools that promote learning is a really important conversation.


[Dr. Douglas Gentile] Thank you. A couple of you work with game developers and have done some yourself. We’ve got a question… for your game designers, how do you find that balance between all of these pushes and pulls? I mean, many of the game designers I’ve met use the word addictive as a positive statement about a game which I…you know, I think they don’t actually mean that in any clinical sense. But again, those same features that make you really want to play and enjoy playing, is there a way to balance this out? What are your thoughts?


[Dr. Nick Ballou] I can take a first stab. I think it’s helpful to think about this in other contexts. We wouldn’t really imagine making movies less entertaining, right? We’re like, This is too. This cast is too strong. There’s too much… the plot is too good, the script is great, the costumes are too nice. We should take Game of Thrones or Succession or whatever the prestigious drama of the day is off the air. And I think realistically, even if we talk about ways that we might make games less compelling for players, they’re very unlikely to get… to ever get actions by game developers, and regulators are unlikely to enforce that.


[Dr. Douglas Gentile] I think we can make I think we have a name for less compelling games we usually call them educational.


[Dr. Nick Ballou] Chocolate covered broccoli. Yeah, so I think but there are some cases where I think certain features do have…we  can recognize them by their effect on players being negative. So we take something like the Battle Pass, which is a new monetization strategy.

You buy a subscription for a game for a month or three months, something like that, and then the game gives you rewards on a schedule. So the more you play, the more rewards you earn. And if you don’t play a sufficient amount of time or log in every day for that period for which you have the subscription, you will lose out on those rewards. So you’ll find lots of players describing…I actually don’t really want to play this game right now, but I feel like I have to. And the design features that have that effect on players where people can recognize, I don’t really want to be doing this, but I want to…but I need to anyway, because have some kind of investment in there are the ones that we might want to look out for and try to reign in, where possible. The majority of ones that make games compelling for 98% of people and may be problematic for the remaining two are probably not going anywhere anytime soon.


[Dr. Adam Gazzaley] Yeah, I don’t have so much…I agree with all that. I think that game designers are going to want to make the games fun and engaging and sticky as all designers do, and trying to change that doesn’t make a ton of sense to me. I think that there are some mechanics that are very close to what we would call gambling mechanics, like some reinforcement strategies that are just considered unhealthy, and that’s something that we should definitely monitor. But, you know, at the end of the day, it’s the delivery of these that really has to be monitored, I believe.  For example, with our game, we work really hard on making it fun and engaging. I wouldn’t say it’s the most fun game you’ve ever played, but given that our primary objective was to improve attention, I think we did fairly well and we continue to work in that direction. But then we limit gameplay. So how we positioned it to the FDA and in all of our clinical trials and how we sell it to children, is that you could only play it 30 minutes a day. You can’t play it more than that. The game shuts off. You can’t play the game seven days a week, so you can only play it five days a week and you get it in a month allocation. So we’re basically dosing it and monitoring it as if it was any other type of medicine that it has a dosage and you should think about it. Now maybe that’s a little more extreme than you could do with a game that’s targeting entertainment, but going back to, you know something we’ve been discussing all along, is that as certainly as parents, you need to create the structure of where these games fit into larger life activities that a child is engaged in. And as an adult, you should also be fitting it into that larger structure. We can enforce it through the FDA, but I think that to answer your question, game designers are going to apply their art and their skills and their craft to make fun, engaging medium, and they should. And then we have to think about the delivery and how we control that.


[Dr. Douglas Gentile] Great. So I think the last question we will wind up with here is about… what are the warning signs parents should be looking for that the games are perhaps having more harmful effects than that a parent would want?…which doesn’t mean that somehow they’ve become totally monolithically negative. Right? You know,  it’s not going to be simple, good and bad, otherwise, we wouldn’t need panels like this. This would be simple. But, you know, some of the things that, you know, I’ve seen in the literature are issues like, you know, if your child’s starting to give up activities that they enjoy – so they’re quitting sports, they’re quitting music, they’re quitting after school activities. If their grades are dropping, if they’re giving up friends or only seeking friends that also game, if their moods become worse, particularly if they have to stop gaming. These are some of the things that I’ve heard that parents notice when their children are starting to have a somewhat dysregulated approach to their gaming. But, what else should parents be paying attention to? Or is there a place where you say, you know, this is when parents should step in and do something. My answer to that would be they should have stepped in from the beginning. They should never give up control to what children are spending their time with. And that’s not just about games… that’s that you should be an involved parent. But of course, that’s not always possible with parents needing two jobs or things like that. So what is it parents should be paying attention to? Dr. Kanojia.


[Dr. Alok Kanojia]  I guess I’ll give this a start. So I know this answer may sound a little bit strange. So we’ve talked about and I agree with you 100%, that parents need to be involved from day one. This is not a wait until it’s a problem, especially in the world that we live in today. As Dr. Gazzaley mentioned, you know, it’s these game companies’ job to create as engaging games as possible. And they are competing with each other. And the person who makes the funnest game, the most addictive game is going to be the one that, you know, your kids are playing. So they’re competing against each other to create an addictive game and your kid is the one who loses. So the sign that I’ve sort of learned from my clinical practice, is the first sign is actually not anything in your kid, it’s something in the parent. So you know your kid. If you think inside…pay attention to your parental instinct, which, you know, has been honed over millions of years of evolution. Pay attention to your instinct. If you think something is wrong, that’s the first reason that you should investigate. Second thing to consider is, I think, a change. So I think you sort of alluded to all these. Right? So we’re looking for a change. So you used to know who your kid was. You kind of your kid grows up, they’re six or seven, they’re eight. And then something can happen where your child starts to change. They’re not hanging out with their friends. They’re not quite as engaged in school. We see that isolation, withdrawal and sort of an emphasis on gaming and gaming related behavior, which includes streaming and all this kind of stuff too is really like one of the other warning signs. So I’d say, first of all, trust your instinct. Second of all, if you see any impairment of function. Third of all, you know, a change, just a substantial change to their personality, the way that they’re behaving, things like that. And then the last thing, isolation and withdrawal and sort of overemphasis on the game.


[Dr. Douglas Gentile] Thank you. So, we’re out of time for dealing with questions. I’d like to ask each of you if you have any specific final thoughts that you’d like to offer or points from the full discussion that you’d like to really highlight as takeaways. Perhaps let’s start with Dr. Gazzaley. 


[Dr. Adam Gazzaley] Yeah, I would like to emphasize what I have been all along, that we have to just broaden our scope of thinking about video games. That they are experiences, very special experiences, but their experience is first and foremost and that they don’t fit an easy category because they have many different elements. Like all, you know, experiences, like sports, is a massive genre. Even things that aren’t quite experiential, like food you wouldn’t say, is food good or bad for you. And so that’s the first takeaway, is just to think really broadly about video games and hopefully I’ve been able to add a little flavor around video games when they’re intentionally and developed to accomplish an outcome and then test it. I mean, it took us 13 years to get from the game idea to FDA approval. These are… if you do it well and rigorous, they’re long processes and that process never ends…constantly studying and testing and evolving that video games can be more than entertainment and certainly the entertainment factor is critical, but I’m really excited about what I think is this next era of video games… and that’s been happening, Embracing them first and foremost…not first and foremost, but also as art forms. We’ve recently recognized that these are artistic expressions across all the dimensions of art and now looking at them as tools to really enhance what makes us human and not diminish us. This is really, I think, an exciting focus for the next decade. So I’ll leave my comments. 


[Dr. Douglas Gentile] Thank you. Dr. Ballou, any final thoughts? 


[Dr. Nick Ballou] Yeah, I’ll use my time for two things. One, I would love for the science to be able to give us better answers than we’ve been able to give. We’ve done a great job, I think

but there are even better answers to be found and given. And one of the reasons that we struggle to do that is because of data access. The games industry is really reluctant to work with independent researchers and hopefully that’s slowly changing. There are some positive signs, but write your local representatives. Argue where you can, for access that companies should be making technology use data available for researchers and look for studies where you have an opportunity to do that and participate because it really helps us out a lot. And the second one is to emphasize, we have talked quite a lot about negative effects. That tends to be where these discussions lead because we want to prevent the most harmful experiences, the most harmful cases of media use. But really the majority of people benefit… a lot of people, gaming is essentially neutral, right? It’s their gaming instead of watching a show, instead of reading a comic book and fundamentally they’re kind of using games in a way that is interchangeable with other activities. So for a lot of people, gaming is really not that impactful at all. And that’s fine. For others, they’re benefiting really positively. Games are a great way to feel a sense of meaning and appreciation with an emotional connection to characters. They’re a great way to relieve stress and be part of a pleasant environment and escape from kind of a less pleasant reality from time to time and in moderation. They are ways to satisfy our need to grow and develop and build new skills. Games are a way to learn effectively, like Adam has emphasized, and they do that in a really effective way. So games are good for the majority of people, and I hope that for you and your children that is and remains the case. 


[Dr. Adam Gentile] Thank you. Dr. Kanojia.


[Dr. Alok Kanojia] Yeah. So I just want to say…I think, you know, parenting nowadays is just really hard. If we think about how we parent, we learn how to parent from our parents. The challenge that I think we face as a generation is that our parents never taught us anything about healthy technology habits. And so parents are placed in this unique situation where I don’t think government regulations are sufficient enough. We’ve heard from Nick and Adam about how, you know, game companies are going to make addictive games. Like that’s what they’re going to do. They’re going to hide their data. This is a tool, right? And some people are not going to use it for the health of your child. So parents are left in this situation where this stuff has really invaded…

I mean, it’s like an invasive species that is colonizing our mind technology. The first iPhone is, I think, like less than 20 years old or something like that, right? It’s crazy how quickly this stuff has invaded our society and squeezed into every nook and cranny. We see problems at schools, we see problems at home. And so parents are like really getting crushed because they’re not getting sufficient support. The good news is that thanks to the work of amazing researchers like the people on our panelists, I completely agree with Nick that we need better science, but thankfully these people have been doing science. And that has given us some sense of an answer about how to move forward. Right?  We do have tools like Akili.. We do have tools like we developed a program and a lot of the stuff is in the book and you know, that’s based on the research of people like these panelists and the cool thing that we’ve been able to see is even though it feels really hard and all your kid talks about is the damn game all the time, it can be so overwhelming a parent. The good news is that there is a lot that you can do and the interesting paradoxical thing that we see is that as you work on this problem with your child over time, we actually see a strengthening of the relationship. Right? And I think. Dr. Gentile when he was sort of showing that that JAMA article sort of showed about how when you intervene early with games, you see a cascading effect of benefit for your child. And the challenge for parents, as you beautifully pointed out, is they don’t know that, right? All they see is the struggle. They can’t see the benefit. So I think even though it can feel really challenging and it is objectively very challenging, this is a new thing. No one has ever had to parent this generation of kids before. And it’s completely new. The good news is that there are a lot of people working really, really hard and we do see really, really good outcomes. So don’t give up hope and maybe game a little bit with your kid.


[Dr. Douglas Gentile] Yeah. So thank you for all of your comments. Dr. Gray apologizes. She had to leave for another meeting. I’ll just sum up by saying, you know, I think it’s easy for us to dismiss games as if somehow by calling them a game, it’s childish. I think, certainly, Adam, you pointed this out, they’ve become art. And by art, what I mean by that is great art can change you. It leaves the viewer changed. Well, what is that change? That is an effect of the game on you, so we should take that seriously. We should take the game seriously. We should take the research seriously. And I’ll hand it back to Kris Perry.


[Kris Perry] Thank you all for being here and for this enlightening discussion. As I mentioned, we have copies of Dr. K’s book, How to Raise a Healthy Gamer to give away today. Scan the QR code on the screen, click the link in the chat, or visit the Donate Now section of our website to make a donation of any amount and you will be entered in to win one of nine free copies of this great resource. Your donation supports the Institute’s free educational programs resources like this webinar. Find more resources at or follow us on these platforms and subscribe to our newsletter to stay informed. Please join us for our next webinar “Driven to Distraction: Media Use Attention and Cognition” at noon Eastern on Wednesday, April 10th. Thank you and be well.