After several weeks of playing up to ten hours a day, the child started acting out scenes from his favorite game, and at times he seemed to believe he was actually in the game. Eventually he began acting out scenes in his sleep — a visible sign his brain was completely imprisoned, not to mention that sleep was not offering any relief. While searching for answers, his mother came across an article I’d written about screen-time and psychosis and promptly removed all video games as well as his computer. When she contacted me for a consultation a couple of months later, the worst of his symptoms had resolved, but the boy was continuing to hear voices, and he wound up requiring antipsychotic medication. In the months that followed, it became clear that the boy had a budding mental illness, likely schizophrenia. There was no family history of the disorder, but the child did have some vulnerabilities — learning disabilities and social problems — that, when combined with excessive gaming, was enough to create a tipping point.
When I first wrote about screen-time-related psychosis in Psychology Today in 2012,41 I received a backlash of criticism and skepticism from several neuroscientists. But the first case report was published in 1993 (involving a Nintendo game), and multiple cases involving computer games and Internet-related psychosis have been reported since.42 More recently, researchers have become interested in how excessive technology use might trigger psychotic symptoms. In 2013, an extensive report was published on so-called Game Transfer Phenomenon, a process in which gamers experience game-related visual hallucinations during real-life situations.43 It may be that these visual hallucinations — thought to be a sensory imprint of sorts — are more “benign” than other forms of psychosis I mention here. They are certainly more common and, for the most part, don’t cause distress. (When the article came out, I was shocked at how many of my male friends admitted to having experienced them after long bouts of gaming.) Nevertheless, gamers and parents should interpret the presence of any psychotic phenomenon as a cautionary red flag.
How might screen-related psychosis occur? One factor likely at play here is dopamine regulation. Drugs and medications that increase dopamine (stimulants) are capable of producing psychosis, and many medications used to treat psychosis block dopamine. As you now know, gaming releases dopamine. Other factors may be sensory overload and the brain’s inability to discern a virtual environment from the real one — especially as gaming environments become increasingly vivid and lifelike. This last factor may particularly be true for a child’s brain and psyche, which are not yet solidly formed. Unfortunately, we are seeing an increased incidence of violent crimes in which young people act out particular video game scenes or role play a video game character. The perpetrator is often in a semi-dissociative state, which has been initiated and perpetuated by repeated exposure to virtual environments for years. Many of these cases don’t “make the news” because the incidents involve minors, but they’re occurring much more often than the general public realizes.
Because the consequences of psychosis can be so dire, parents should take extra screen-time precautions in a child with the vulnerabilities mentioned above, particularly if the child has trouble separating fantasy from reality, has a history of violent behavior, or has a family history of serious mental illness such as schizophrenia. Most physicians and mental health clinicians will not suspect video games or computer use when a patient reports psychotic symptoms, so it’s likely that this screen-related phenomenon is largely under-reported — which is a horrible shame, considering that it’s treatable with strict screen elimination.
Disruptive and Defensive: Behavior and Social Issues
Behavior is essentially the outward manifestation of all the other issues we’ve been talking about. Typically, it’s a child’s behaviors that drive parents and teachers to the edge of the proverbial cliff — leading a parent to seek treatment. Socially, a multitude of important issues exist in relation to electronic media usage, such as identity development, sexting, and cyberbullying, to name a few. Here we’ll look primarily at the impact of electronic media on behavior and social skills in the context of ESS — in other words, at how the physiological effects of screen-time translate to social problems in your child. With its core components of hyperarousal and mood dysregulation, ESS can affect relationships with peers and family, stunt social development, and diminish capacity for empathy and intimacy. Figure 6 below shows how this might occur.
Figure 6. How screen-time effects translate to social dysfunction
Oppositional-Defiant, Argumentative, and Impulsive Behaviors
“I say black and he says white.”
“I could say, ‘The sky is blue,’ and she will start arguing with me.”
“When we ask him to do something, his whining and arguing is so annoying that we just wind up doing it for him.”
“When we enforce a consequence, she becomes so enraged that she wears us down and we give in.”
“He doesn’t listen and just does what he wants.”
These are comments frequently expressed by parents in my office, and research suggests that there’s a link between amount of media consumption and such disruptive behaviors.44 Although “oppositional-defiant disorder” is an actual diagnosis listed in the DSM, in practice these symptoms are virtually always related to something more specific, such as ADHD or trauma.
Opposition and defiance are strategies children will use to exert some control over their environment when they feel stressed or inept in some way — it’s a sign of a disorganized state of mind. These behaviors are often secondary to attentional or learning issues, hyperarousal, overstimulation, or poor sleep. Saying “no!” harks back developmentally to age two, when a child realizes that saying no gives him or her power over caregivers. Even as adults, when we feel overwhelmed, we might interrupt someone with a knee-jerk “no” before the person can even finish the question. Arguing is another common behavior indicative of poor attention or irritable mood* that’s made worse by interactive screen-time;45 arguing is a major source of parental frustration and exhaustion. Arguing may actually be a way for an unfocused child to raise arousal or dopamine and norepinephrine** levels, plus it serves to engage the parent — which can help a disorganized child feel more anchored. When a parent complains that a child is oppositional, argumentative, and irritable, especially if these symptoms seem to be worsening over time, my “index of suspicion” for ESS is very high.
In a classic example, a mother was telling me how her six-year-old twin boys weren’t watching cartoons in the morning anymore; she and her husband had decided to get rid of cable TV to save money, and she knew that cartoon watching could affect attention. But their hectic morning routine had become a daily nightmare when it came to getting the boys ready for school. They’d argue and stall, refusing to dress themselves, put on shoes, or brush their teeth, crying, “I can’t!” — all while refusing any offer of help. Inadvertently, the mother mentioned that because they weren’t getting up to turn the television on anymore, she and her husband were able to sleep in a little longer in the mornings, despite the fact that the kids continued to get up earlier than they did. “So what do the kids do instead of watch cartoons?” I asked. “We let them play on our phones,” she replied. Mystery solved! The boys’ daily fifteen or twenty minutes of phone play was enough to disorganize their nervous systems and set the tone for the day. She and her husband began taking turns getting up early, stopped the phone play, and smoother mornings soon followed.
Another ESS behavioral symptom we’ve already touched on is poor impulse control. Impulsiveness refers to the tendency to act without thinking, such as hitting a sibling without regard for consequences, running into the street without looking for cars, continually interrupting others, and so on.
