Video Games, Use Of Frederick Shic Yale Child Study Center, Yale University School of Medicine New Haven, CT, USA

Reference: Shic, F. (2013). Video Games, Use of. In F. R. Volkmar (Ed.), Encyclopedia of Autism Spectrum Disorders (pp. 3255–3265). Springer New York.

Hyperlink:

the internet, or reading an Encyclopedia of Autism entry); for video games, the goal typically lies within the game itself or is defined by the game (e.g. “to win” the game, to solve a puzzle, or to “beat” another player) . It is important to note that the line between video games and other forms of interactive electronic media is somewhat indistinct. It could be argued, for example, that some computer-based interventions are, in fact, video games, since they rely on games (in particular, other video games) as a basis for design (e.g. the game of Memory, played with emotional faces, for individuals with autism). Nevertheless, the term “video game” is sometimes avoided by researchers who wish to highlight the advantages and potential of this media format and who wish to avoid the perceived negative connotations associated with, e.g., video game violence or obsessive video game play that serves no positive remedial goal.

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Historical Background: Definition: Video games are electronic media with 3 key attributes: they display content visually, they are interactive, and they are typically used for entertainment or have entertainment-like qualities. Video games encompass a wide array of formats, applications, and designs, ranging from simple hand-held gaming devices depicting black and white rasterized characters, to fully immersive virtual reality simulators. In general, video games are separate from electronic screen media, because electronic screen media do not necessarily require an interactive component. Video games are separate from computer-assisted instruction and computerbased intervention, as video games are typically associated with entertainment, and computerassisted instruction and computer-based intervention involve a therapeutic or didactic element or intention. Similarly, a distinction can be drawn between software, in general, and video games (which can be a specific type of software), as the goal in most software is typically to facilitate an external goal in the most efficient way possible (e.g. summing numbers, looking up information on

History of Video Games One of the first reports of video games was filed in a patent, “Cathode-ray tube amusement device”, in 1947 by Goldsmith and Ray (Goldsmith Jr & Ray, 1948; Mitra, 2010). This patent described a game system in which a cathode-ray tube was used as the face of the console, displaying a single moving point, representing a missile fired towards drawn figures overlaid upon the tube. Over the next two decades, other video games slowly emerged, driven by advancements in computer technologies and increasing sophistication with computer programming. Notable games during this time included “OXO”, a tic-tac-toe program written as part of a University of Cambridge Ph.D. dissertation, by Alexander Douglas in 1952; “Tennis for Two”, a tennis game played on an oscilloscope screen at Brookhaven Nation Labs, by William Higinbotham in 1958; and “Spacewar!”, a two-player vector-based space combat game designed to showcase the Digital Equipment Corporation’s recently developed computer, the PDP-1, by MIT students Steve Russell and others in 1962 (Burnham, 2001; Donovan, 2010).

Through the 1960s, video games were primarily viewed as sophisticated but impractical novelties, due to their size and expense. However, as the cost and size of electronics and microprocessors began to rapidly decrease, video games became more viable as a form of entertainment. In the 1970s, beginning with the successes of coin-operated arcade systems such as Pong, video games came into vogue and rapidly became significant segments of the entertainment market (Donovan, 2010). After commercial successes in the late 1970s by companies such as Atari, by the early 1980s video games had moved into the home in the form of consoles and personal computers, ushering in the modern era where video games have never diminished from public consciousness (Donovan, 2010; Kent, 2001). Video games have continued to innovate and redefine themselves (Donovan, 2010). In the early 2000s, internet games became popular, allowing players to participate in games that are social, with tens or thousands of other players at the same time. Simultaneously, mobile devices like cell phones began to allow gaming on devices that were cheap and portable and therefore ubiquitous. Today, this interconnectivity and ubiquity of access defines some of the most modern aspects, and modern challenges, of video game technology.

Types of Video Games The taxonomy of video games is a complex subject (e.g. see Wolf, 2002; Apperley, 2006). However, one useful classification scheme involves the discussion of video game “genres”. A review by Yuan, Folmer, and Harris (2010) identifies the following (non-exhaustive and non-mutuallyexclusive) categories of games: 1) first-person shooter; 2) strategy games; 3) sports games; 4) roleplaying games; 5) puzzle games; 6) racing games; 7) dance/rhythm games; 8) adventure games. Another distinction in video games is that of “serious video games” versus “non-serious video games”. Serious video games represent games intended to fulfill a role other than (or in addition to) pure entertainment, with the typical assumption that they will foster some specific skill acquisition or broader learning (Rego, Moreira, & Reis, 2010; Susi, Johannesson, & Backlund, 2007).

Others, however, argue that such a distinction is artificial, and that even games not originally intended to be “serious” can be used for serious intentions, such as education (Breuer & Bente, 2010; Squire, 2003).

The Demographics of Video Games and Video Game Players Today, video games collectively represent a more than $67 billion a year industry globally, putting them on equal footing with the music and film industries (Gartner, Inc., 2011). In the United States, video game platforms are popular and widespread. Consumer spending for the video game industry in the US in 2010 was $25 billion, with 72% of households playing (Entertainment Software Association, 2011). More males than females play video games, but recent estimates by the Entertainment Software Association (2011) suggest that a sizeable 42% of game players are women and that women 18 and older are a group of game players three times larger than boys 17 years of age and younger. Yet despite this, it is well known that women, along with minorities, are underrepresented as characters in video games (Terlecki et al., 2010; Williams, Martins, Consalvo, & Ivory, 2009). Furthermore, research has found that the representation of women in video games is often sexually stereotyped, potentially contributing to feelings of inadequacy and the internalization of stereotypes especially by young females (Dietz, 1998; Dill & Thill, 2007).

Positive and Negative Effects of Video Games Video games can have both positive and negative qualities (Kirriemuir & McFarlane, 2004; Lee & Peng, 2006; Mitchell & Savill-Smith, 2004) and, as with other forms of media, video games have had their share of controversy. One of the first video games to generate bad publicity for the fledgling industry was the video game Death Race (Exidy, 1976), a game where players controlled a car and received points for driving over people (Donovan, 2010). This began a long disagreement over the

potential role of violence in video games in encouraging or exacerbating aggressive or violent tendencies, a disagreement that continues to this day (Mitchell & Savill-Smith, 2004). While some meta-analytical research suggests that violent video game play is causally linked to increases in realworld aggression and decreases in prosocial behavior (Anderson & Bushman, 2001; Craig A, 2004) other researchers challenge these assertions (Ferguson, 2007, 2010). Some perspectives argue that violent video games might be a cathartic experience for players, allowing players to release pent up aggression, anxieties, and energy, though evidence to this effect is scant (Lee & Peng, 2006). Similarly, the widespread popularity of video games, and in particular, internet video games, has resulted in increasing focus on the phenomenon of video game addiction (Young, 1998). A recent review of internet gaming addiction (Kuss & Griffiths, 2011) suggests that individuals with video game addiction share similarities with individuals with other forms of addiction in terms of neural activation patterns (e.g. see Ko et al., 2009), atypical personality traits (e.g. bipolar disorder and depression; see Shapira, Goldsmith, Keck Jr., Khosla, & McElroy, 2000; Young & Rogers, 1998), and poor maintenance of real-world social relationships (Allison, 2006). Yet, Kuss and Griffiths (2011) point out that gaming addiction exists on a continuum of severity, where most video game players do not exhibit concerning levels of video game play. The flip side to video game addiction is that the games are designed, of course, to be as fun as possible. While addictions that interfere with daily living are certainly an unfortunate consequence, they can be seen as the natural extension of the continuum of the qualities that make certain games popular—namely, their addictive nature. What makes one game more playable and replayable than another has been a constant question for video game designers (Salen & Zimmerman, 2004). One useful perspective involves the concept of “flow” (Csikszentmihalyi, 1991). Flow is a state in which a person operates at his or her peak ability, with focused motivation and full involvement dedicated to overcoming or completing a challenging task. The ability to evoke flow in its users has been described as an attribute of highly successful video games (Chen, 2007), with play that walks a fine line between anxiety and

boredom (Cowley, Charles, Black, & Hickey, 2008). These flow states have been described as extremely meaningful, enjoyable, and illuminating experiences; the ability of video games to instill a flow state into players could, from this point of view, be described as a positive experience. For example Bowman (1982; as discussed in Squire, 2003) analyzed the Pac-Man video game in the context of flow, and identified qualities that promoted flow states during its gameplay: “skills and challenges are progressively balanced, goals are clear, feedback is immediate and unambiguous, and relevant stimuli can be differentiated from irrelevant stimuli.” Bowman suggested that educators should aim for these qualities to design learning environments that are engaging. Yet, detractors of video games would be quick to point out that video game play involves consumption rather than creation, resulting in no tangible benefits to either the player or the world at large. Such arguments parallel historical arguments against other forms of media, such as television viewing, and there is a real concern that to some extent excessive video game play may be displacing other activities such as schoolwork. These concerns are supported by some studies, especially for violent games played by excessive video game players (Gentile & Gentile, 2007; Harris & Williams, 1985), but seem to be a lesser concern for the majority of video game players, who do not play excessively (Christopher J., 2011; Gentile & Stone, 2005). For example, a study by Durkin and Barber (2002), which looked at 1,304 16-year old high school students, found that video game play was associated with positive attributes (e.g. positive mental health and friendship networks) rather than negative ones (poor school performance). A similar concern has been raised regarding the possibility that video game play may be displacing sports and other physical recreation (Kirriemuir & McFarlane, 2004; Vandewater, Shim, & Caplovitz, 2004). On the other hand, the evolution of video game technologies has seen the advent of games that can place physical demands on players, e.g. by requiring players to swing a paddle or to dance. Studies of these more physical video games suggest that they can generate the same level of physical activity as light jogging or walking (Maddison et al., 2007). It can be argued that video games are in of themselves neither good nor bad, but rather that

Oregon Trail, such as Reader Rabbit (The Learning Company, 1984) and Math Blaster (Eckert & Davidson, 1987), were edutainment titles, structured in order to make drill-and-practice exercises more palatable to young children. Yet, this strategy has left some video game theorists and computer education experts wanting. For example, Mitchel Resnick criticizes modern edutainment software companies as being unnecessarily rigid in their views regarding learning and education, preferring instead a playful approach towards learning that focuses on intrinsic rather than extrinsic rewards (Resnick, 2004). Similarly, Simon Egenfeldt-Nielsen noted that edutainment computer games are easily identified by reward structures that are completely disconnected from the educational aspects of the game (Egenfeldt-Nielsen, 2007) and is likewise critical of their superficial perspectives on learning. Superficial or not, in the 1980s educational video games gained great popularity, in part due to the increasing availability of computers in the classroom (Becker, 1991) and in part due to the attractive notion of combining the “tedium of education” with the fun of games. Most studies examining whether video games could indeed foster learning showed positive results (for reviews, see Egenfeldt-Nielsen, 2006; Kirriemuir & History of Educational Video Games and McFarlane, 2004; Mitchell & Savill-Smith, 2004; Edutainment Squire, 2003). For example, Din and Coleo (2001) showed that children playing educational video Though computers had been used for educational games designed for kindergarten students improved purposes before (see Suppes, 1966), one of the their ability to spell and decode words when earliest widely-used educational video games, compared to control children; similarly, Thomas, Oregon Trail, was created by Don Rawitsch, Bill Cahill, & Santilli (1997) showed that an adventure Heinemann, and Paul Dillenberger in 1971 as a demonstration for a history class that Rawitsch was video game designed to teach safe-sex skills to high-risk adolescents was effective in improving teaching (Lussenhop, 2011). This video game was knowledge as well as perceptions of self-efficacy. an all-text adventure presented as an exercise in Critics of the educational video game literature, resource management (Perron & Wolf, 2008). however, argue that learning is only the first bar to Later, while working for Minnesota Education be hurdled in elevating video games as a useful tool Computing Consortium (Haugo, 1973), Rawitsch expanded upon the educational aspects of the game, in the classroom experience (Egenfeldt-Nielsen, 2006, 2007), and that a more appropriate creating an early precursor of modern day video comparison is to show that video games provide game “edutainment”. The term “edutainment” , a combination additional gains in comparison to more standard forms of teaching. of “education” and “entertainment”, represents As with video games in general, programs that perform educational functions while educational video games continue to evolve. providing the entertainment value of regular games Egenfeldt-Nielsen (2007) describes a model where (Okan, 2003; Resnick, 2004). Many of the most three generations of video games in education popular educational video games that followed correspond to the evolution of psychological and such distinctions are made in their use, abuse, and interpretation. Video games, from one point of view, are just a particular form of game; games in turn, are a specific form of play. Developmental psychologists have long argued that play is important for children (e.g. Bruner, Jolly, & Sylva, 1976; Piaget, 1962; Vygotsky, 1978), and modern views place games and play as developmentally critical to cognitive development, abstract thinking, self-identity, and social and cultural learning (Bornstein & O’Reilly, 1993; Johnson, Christie, & Wardle, 2005; Pellegrini & Smith, 1998). Similarly, the role of games in fostering or facilitating learning has been examined (Boocock & Schild, 1968; DeVries & Edwards, 1973; James, 1966; though see Inbar & Stoll, 1970). However, it is clear that the intentions of the designers of games are paramount. Games developed for learning, e.g. educational video games, are one set of games that seek to achieve positive goals for their users. Yet even within this domain, grounding the design of video games from developmental points of view and learning theory may be necessary in order to help designers achieve the most positive impact (Verenikina, Harris, & Lysaght, 2003).

than typically developing individuals (see also Simmons et al., 2009), and that they appear to have superior performance on some visual tasks but not others. The absorbing, repetitive, and rewarding nature of computers and computer games has the potential to harm or help individuals with ASD. In the home, nontherapeutic games might encourage social disengagement by displacing social interaction, as is seen in excessive video game players who are otherwise typically developing. Anecdotal reports on ASD video game use and social disengagement are not uncommon, and have been supported by survey data. A study in 2011 by Mazurek, Shattuck, Wagner, & Cooper found that 41% of youths with ASD spend most of their free time playing video games, a higher percentage than for other developmentally disabled youths, and high in comparison to the 18% of youths in the general population who are considered to be high users of video games. Compared to adolescents with typical development, adolescents with Asperger syndrome are less likely to use cell phones for social communication and more likely to use them for non-communicative activities, like games (Durkin, Whitehouse, Jaquet, Ziatas, & Walker, 2010). Interestingly, a survey of 23 youths with Asperger Recreational Use of Video Games in Syndrome found that several many of them listed Individuals with ASD video games as an apparent special interest. But interviews revealed that the youths often used video Video games have many qualities that make them games and other more socially acceptable interests attractive to some individuals with ASDs. An early to mask a separate special interest that was assessment of computers in use with autism listed perceived to be less socially acceptable (Winterthree reasons why computers are attractive to Messiers, 2007). These individuals often used children with autism: computers are nonsocial; they video games as a social bridge to help them interact are consistent and predictable; and the child can with typical individuals. control and determine the pace of an experience (Swettenham, 1996). Other aspects of video interfaces that appeal to individuals with ASD are Therapeutic Use of Video Games in Individuals less parallel to the attractions for typically with ASD developed individuals. For example, Mineo and colleagues (2009) studied the use of multiple forms Computer games have shown the potential to cause of electronic-screen media among students with brain function changes in typically developed ASD and discussed the attraction of electronicindividuals. In particular, action video games have screen media for individuals with ASD in the been have been shown to induce a broad class of context of qualities such as: the de-emphasis on changes such as contrast sensitivity, spatial language skills, the constrained viewing area resolution, visual attention and visuomotor requiring limited attention, its visual modality, and coordination (Spence & Feng, 2010). However, the ability to repeat experiences over and over. others have pointed out methodological Also, Durkin (2010) has also noted that the sensory shortcomings in studies showing benefits of action experience of children with autism may be different video games (Boot, Blakely, & Simons, 2011).

educational perspectives and beliefs. EgenfeldtNielsen notes that the first generation can be defined by a behaviorist viewpoint that sees drilland-practice in the context of extrinsic reward (i.e. most edutainment titles) as a sufficient route by which to inculcate learning. The second generation is defined by a cognitive approach, a view that sees intrinsic motivation and internal mental states as central to learning (e.g. games which encourage a discovery process such as Super Tengrams; see Sedighian & Klawe, 1996). Between the second and third generations, there is a constructionist perspective, which is similar to the cognitive approach, but emphasizes the role of tangible objects and experience, as exemplified by “microworld” simulation video games, such as SimCity (Games & Squire, 2011). The third generation, according to Egenfeldt-Nielsen, is the sociocultural approach, one which sees educational video games themselves as only one piece of the educational puzzle, with a broader context that includes teachers, other students, and the transformation of knowledge through exploration, examination, play, and discourse.

Computers have also been used to target brain training in subgroups of typical individuals. In infants, computers have been used to train visual attention (Wass, Porayska-Pomsta, & Johnson, 2011). In the elderly, cognitive training has been used to attempt to maintain or improve cognitive abilities (Schmiedek, Lövdén, & Lindenberger, 2010), although another study showed a failure of such training to generalize to closely-related untrained tasks (Owen et al., 2010). Because of the increased attraction for computers, video games, and other electronic screen media shown by many individuals with ASD, some educators have suggested that video games (educational or otherwise) might be an effective tool in the therapy and education of individuals with ASD (see Computer based intervention assistive technology specifically, but also Video modeling/Video self modeling and Video Instruction). Whereas computer-assisted instruction (CAI) has been used to understand and treat deficits associated with autism since the late 1960s and early 1970s (Colby, 1968, 1973), the use of a video game approach (Chaffin, Maxwell, & Thompson, 1982) for therapeutic goals has been a relatively recent research focus. The distinction between computer-assisted instruction (CAI) and computer games is not easy to make. A natural approach is to assert that games involve “play,” and instruction does not. However, CAI often crosses the line into video games. For example, the study of TeachTown, a CAI program, used animated games as rewards for correct responses (Whalen et al., 2010). Its reinforcers were designed by professional video game designers (Whalen, Liden, Ingersoll, Dallaire, & Liden, 2006), and the program has been described as a suite of “gamelike tests” (Wilkinson, Ang, & Goh, 2008). Video games and CAI have been used to teach foundational social skills to teach children with ASD in several studies. The typical goals of such training are to teach kids to look at faces (Trepagnier et al., 2006), to identify emotions or faces (Beaumont & Sofronoff, 2008; Tanaka et al., 2010), to express emotions (Cockburn et al., 2008), and to play collaboratively with other children (Battocchi et al., 2010; Gal et al., 2009). Though skill and knowledge acquisition are the main use of video games for individuals with ASD, games can also be used as rewards in conventional therapy, and as adjuncts to conventional therapy.

One class of computer games is those that are extensions of non-computer games into the computer realm. Gal (2009) and Battocchi et al (2010) are examples of computerized interventions that use tablet input to build on the ideas of collaborative play therapy, where two children must collaborate to accomplish goals on the tablet device. One potential advantage of such computerized therapies is that the computer can easily be tailored to special interests of individuals with ASD to increase interest and engagement. Such tailoring has been used for interventions using non-computer based games (Baker, 2000). Morris (2010) describes successful use of such tailoring for a computer-based exposure therapy, in which an individual with ASD was at first uninterested in the computer therapy, but became deeply engaged by a specifically tailored version of the software that used images of his special interest: newborn babies. They created software to quickly produce background-free images from the internet that are tailored to any specific special interest. They used this software to customize computer games to the specific special interests of 9 individuals with an ASD diagnosis and showed that 7 of them preferred to play the customized versions. Several groups have used video games or video game concepts in larger studies of individuals with ASD (Hopkins et al., 2011; Tanaka et al., 2010; Whalen et al., 2010). Hopkins and colleagues (2011) developed a computer-based social skills training program called FaceSay and employed it in a 6-week randomized control study of 49 highfunctioning and low-functioning children with ASD. The results of this study showed that FaceSay was useful in teaching low-functioning children with ASD emotion recognition skills and improving their social interaction. High-functioning children in the study gained in these skills as well as in face recognition ability. Tanaka and others (2010), used a suite of video-game like programs designed to teach face processing skills to children with ASD (the Let’s Face It! battery), and showed that after just 20 hours of intervention using the programs, children in a treatment group (N=47) showed improvements in critical face processing skills compared to controls (N=37). Whalen et al. (2010) used a combined CAI/behavioral intervention approach called Teach Town: Basics in a 3-month intervention study using 40 minutes of activity per school day for 22 children with ASD, comparing to

a control group that received regular school instruction (N=25). Whalen found that the intervention group receiving Teach Town: Basics showed gains in receptive language and expressive vocabulary compared to the control group. These three studies provide evidence that video games may be an effective tool in providing services to individuals with ASD.

Concerns, Limitations, and Recommendations

Technology is advancing rapidly, and with these advances, the promise of video games and automatic instruction for individuals with ASD seems to grow larger daily. Today, tablet devices, like the iPad, use finger touch as the basis of a look-and-touch interface that is intuitive for young children and accessible to people with developmental disorders (Henderson & Yeow, 2012). Console controllers like the Wii and the Kinect use input based on sensing body motion; the use of such body motion in games is highly intuitive and immersive and may provide a physical aspect to video games, with potential benefits to skill generalization. Simultaneously, internet accessibility is becoming ubiquitous, increasing the possibility that individuals with ASD may be able to develop social networks and foster social development through non-traditional means. From the research point of view, future directions include: more large and well-controlled studies of the efficacy of video games, including studies of generalizability of skill acquisition; more concerted efforts to understand the nature of what makes video games appealing to certain individuals with ASD, and how to manage their potential for abuse; and a continuing focus on the educational role that video games may play for individuals with ASD, with particular attention towards how video games should be tailored to the characteristics of an individual on the spectrum.

There is good evidence that video games may provide a teaching format that helps individuals with ASD learn. However, as highlighted by Egenfeldt-Nielsen (2007), to show that learning is taking place through video games is only the first step in proving the efficacy of video game formats as a therapeutic aid; the careful choice of control conditions (e.g. comparably intense and welldesigned non-video-game therapies) will be critical in identifying the advantages and disadvantages of video games in individuals with ASD. In particular, it is important to note that research shows that video game use, and more concerningly, excessive video game use, may be more prevalent in individuals with ASD than in individuals with other developmental issues. For very attractive, fun, video games, there is a concern that over time, despite initial intentions, their use by individuals with ASD may become repetitive and more purely stimulatory, ceasing to provide social, References communicative, and other educational gains. Furthermore, there is the possibility that skills mastered through CAI and educational video games Allison, S. E. (2006). The Development of the Self in the Era of the Internet and Role-Playing Fantasy may not translate or generalize to real-world Games. American Journal of Psychiatry, situations. Though the promise of this technology is 163(3), 381-385. doi: great, the dangers are also real, and care must be 10.1176/appi.ajp.163.3.381 taken to monitor the utility and pitfalls of this Anderson, C. A., & Bushman, B. J. (2001). Effects of technology. For this reason, it is recommended that Violent Video Games on Aggressive Behavior, video games used for treatment purposes in Aggressive Cognition, Aggressive Affect, individuals with autism be part of a combined Physiological Arousal, and Prosocial Behavior: A Meta-Analytic Review of the Scientific intervention, under the supervision of experienced Literature. Psychological Science, 12(5), 353clinicians.

Future directions

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