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Everyone just knows that violence is on the rise, especially among kids. Everyone just knows that violent video games have something to do with it. Except violence isn't on the rise, as we showed in our "Sky isn't falling episode". And there's really no evidence that video games are the cause of violence anyway. Step away from my video games!

Those of you who want to read more and see references can go here:

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
Everybody knows that violence is on the rise in America. Everybody knows that video games are the cause of violence.

But violence isn't really on the rise, as we showed in our sky is falling episode and video games, well, there's really no evidence that they have anything to do with violence. That's the topic in this week's Healthcare Triage.


Full disclosure: I love video games, even the violent ones. When my kids came to me last fall to ask if they could work towards an Xbox One when it was released, I had to break the news that dad had already pre-ordered one months earlier. Take that into account when you watch this.

Putting aside my personal feelings about video games, there's still no evidence that they cause violence. People who want to blame violent video games for IRL violence point to a literature that they believe supplies evidence for a link. But almost none of it does.
Much of it shows an association or a link between violent video games and aggressive thoughts or violent imagining in the short term. But I counter that reading a sad book would lead you to sad thoughts in the short term, but no one would say that causes depression.

Moreover there's a problem here. Studies in controversial areas like this, are often subject to publication bias. In this case the term describes the fact that it's sometimes much easier to get a study with a positive result published than a negative one. If that's the case then a review of the literature is not really capturing the truth, it's only showing one biased side of the story.

It's not easy to prove this is occurring, after all it's possible that reality has bias and therefore studies leaning in one direction are showing you what is really true.

There are analytic techniques we can use though, to see if publication bias is occurring. In 2007 Christopher Ferguson published a meta-analysis of the studies of violence and video games, and found significant evidence of publication bias. In other words a study that shows a link between violence and video games was much more likely to be published than studies that didn't, and this can skew our view of the literature.

But let's go further into the literature he reviewed. The link between video games and aggressive behavior is really non-existent. The link between video games and aggressive thoughts is more robust, but again, that's not the same thing. Dr. Ferguson offered a number of suggestions in his paper to strengthen the future research in the area.

Then he conducted such a study. He randomized 103 young adults to play no video game, a nonviolent video game, a violent video game where they played the "good guy" and a violent video game playing the "bad guy". Then they all had to do a frustration test. In other words they had to engage in some activity which would make it more likely that they would get frustrated and perhaps aggressive. And his study showed no link between playing the games and aggression.
But those kids who had a history of playing violent video games in real life had fewer hostile feelings and decreased depression during the frustration test. They had fewer hostile feelings and less depression.

It's not easy to do good research in this area. That's partially because so many people play video games, more over there's so many other things going on and unless you control for them, the associations shown are questionable.
In 2012 researchers conducted a study of more that 6500 8th graders and went the extra mile to control for other factors. When they did, they found that the association between video games and behavior became much, much smaller.

PewDiePie will be happy to know that the country of Sweden published their own review of the literature in 2012. They found 161 manuscripts describing 106 unique empirical studies. They found 55 review articles of some sort. Of the 106 empirical studies, 71 were laboratory studies examining how playing video games affected aggression. But of course those studies couldn't measure actual aggression, just how people thought. And thoughts lasted from four to thirty minutes. They couldn't and didn't measure long term actual behavior.

23 of the studies were cross-sectional surveys. Basically they're surveys asking about video game playing and aggressive thoughts. Any links between those things however were washed out when other factors, like mental state, family relationship and self-esteem were considered as well.

The remaining 12 studies were longitudinal in nature, or surveys collecting data repeatedly over time. 11 of them purportedly showed a connection between video games and aggression. But only three of the 12 had any data on family relationships and mental well being. And of those three, two of them found that those factors accounted for the relationship.

In other words the Swedes found that the research was flawed and that any connections were not to any actual violent behavior. No evidence at all.

I'm not going to discount the fact that there is gun-related violence here in the United States way more than anywhere else in the world. I'm also not going to discount the fact that here in the US we spend billions of dollars on video games. But lots of countries spend more.

Here's a chart of gun-related murders versus video game spending pr. person in developed countries. Can you see a relationship between video game spending and gun-related violence? 'Cause I can't.

Now look, I'm not saying that violent video games are so devoid of negative ramifications that everyone should go play them whatever their age. Many are not appropriate for kids. They're rated and parents should use discretion and smarts in allowing their children to be exposed to them. I don't think that anyone is advocating that five-year-olds should be playing Call of Duty. And parents who allow that are making a questionable decision.

What I often hear in public discussions is that some people believe that video games are so bad for kids that we need to think about going further. What will they do? Come up with sanctions? Ban them? Should we put them in a pile and burn them?

I should come as no surprise that after playing hours of first person shooters people who play them think aggressive thoughts. What matters is if they act on them. When I watch the Walking Dead I admit it sometimes disturbs me. I don't let my kids watch it, but the line is different for everyone. My daughter watched Annie and she had nightmares about Miss Hannigan for a week. She got over it, it's part of growing up.

When you get all fired up about video games and kids, what do you want?

Seriously, answer the question. Do you want parents to think harder about how they parent? That's fine, but don't go to Congress to get that done. If you're looking for something from them, it's regulations and laws. What are those? Would you censor? I admit I'm incredibly uncomfortable with that. Many of my favorite books contain violence and the thought of people coming for them is absolutely chilling. Speaking as a pediatrician, as a father, as well as an American. Censorship is the nuclear option. You better have solid evidence to support you before you do it.