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The title of the original article, ‘Where lunatics prosper’, was the tagline from Grand Theft Auto III (GTA),¹ a console game for adults aged 18 and over. One of the mainstays of this and similar 18+ games, regularly played by some children as young as six, is violence. Injury and death are portrayed in graphic detail as dying bodies are hurled through the air, and bullets cut through flesh, splattering blood across the screen. A character in Call of Duty (COD)² opens fire in a busy airport, killing innocent bystanders so that he can progress to the next level. I was informed of this by an 11-year-old boy who told me, ‘I don’t know what I would do if I was ever in a real airport with a real gun.’ God forbid.

According to the marketing hype for Black Ops,³ from the COD series, players are able to ‘turn down the blood and turn off the profanity to suit their needs’. There is no question in my mind that the amount of blood and profanity a child ‘needs’ is zero, yet the prepubescent boys who play these games seem most unlikely to censor them. The other feature of these games is graphic sexual content. In GTA III, the character/gamer acts out sexually explicit scenes. In GTA IV,⁴ he picks up prostitutes and selects from three levels of service: masturbation, fellatio and full sexual intercourse. Boys aged 16, 12, eight, even six, spend several hours a day orchestrating graphic, and sometimes violent, sex with prostitutes. Once they’re done, they can choose to pay for the services, or kill the women who provide them

I wonder how they’ll behave when they grow up and meet a real woman for sex in real life? Usually, parents consent to and purchase the 18+ games for their children because the children are too young to do so. I think the content is far more impactful than watching porn, which the same parents are likely to object to; at least with porn, the viewer is merely a voyeur; with gaming, they are an actively participating protagonist.Ìý

I maintain that children living in an environment furnished with chaos and violence are likely to present as chaotic and violent, or emotionally shut-off, or socially isolated, and sometimes this can resemble the characteristics of attention deficit hyperactivity disorder (ADHD) or autistic spectrum condition (ASC). I remain troubled by the popularity of 18+ games among under-18s, and by both the computer-generated and off-screen chaos and violence which furnishes many of their worlds. This isn’t about attacking gamers, or jumping on the overcrowded bandwagon peddling the notion that gaming is the root of all evil, and nor is it about diminishing the value of thoughtful, holistic assessment and diagnosis. Misunderstanding often fuels sensationalist headlines, and I don’t want to fall prey to that either; I want instead to encourage a consideration of the internal and external realities of young people whose presentation resembles ADHD or autism. Ìý

Risk factors

A study of 10- and 11-year-old children, conducted by Bristol University, found that playing computer games for more than two hours a day increased the risk of mental health problems by 60%.⁵ This is a scary statistic but, like most statistics, it does not really mean very much to most people. I’m not someone who thinks that all gaming is all bad for all players, but I do have concerns about some types of game played by some young people. Gamers are often rewarded for action, speed and progressing to higher levels by fair means or foul (legal ‘cheats’ are readily available online). When parents and teachers lament children’s inability to concentrate, and despair about their uncontrollability and academic failings, I wonder about gaming. When I hear about boys who are violent to siblings and peers, who use sexually explicit language and who seem devoid of empathy, I speak to them about their interests. In many instances, I learn that they enjoy adult games in which they are vicariously rewarded for killing and having sex, and where the role of females is merely to provide visual and sexual gratification. Often, the children are gaming for several hours every day and all weekend, often fuelled by caffeine from energy drinks.

As with most things, context is paramount, and my clinical experience highlights numerous risk factors. What if the children who are playing violent and sexually violent games are growing up in families where boundaries are permeable, or where they have witnessed aggression and violence, or experienced trauma, neglect or abuse? The evidence suggests that these children are four times as likely as those who are not deprived or disadvantaged to develop a formal mental illness.⁶ (When I first wrote this article 12 years ago, the statistic was twice as likely). In order to escape their despicable realities, children retreat into a fantasy world, often online. In doing so, they form identifications with fantasy characters who are fighters, killers and abusers of women, in order to defend against their own vulnerability. With a gun in their (virtual) hand and a virtually naked female to provide sexual gratification at the push of a button, these children can, at last, feel omnipotent.Ìý

Is there really a problem?

The escalation continues in the number of referrals to mental health services for boys (in particular) who are unable to concentrate, are failing academically, have no impulse control, and a tendency to act out with violence or aggression. ‘Do they have ADHD?’ the referrer asks. What about the children who are lacking in empathy, obsessional, hypervigilant and overly sensitive? Should we diagnose them with autism? In both types of referral, a mental health diagnosis is sought in order to explain the child’s behaviour and, in some cases, a drug to control it. It makes sense – the children present with clinical characteristics listed in diagnostic manuals such as DSM-IV,⁷ or looked up on the internet by baffled parents. I recognise the merits of thoughtful diagnosis and treatment, but to label a child in haste, and without an exploration of context, is tantamount to imposing one’s own version of reality on to an individual whose sense of reality is already confused. It’s like saying, ‘I shall view you and define you in this particular way, and completely ignore your own experience of who and what you are’.⁸ It is also worth noting that fetal alcohol syndrome (FAS), a widely under-diagnosed condition, looks very much like ADHD and in some cases, ASC. Any mental health assessment is incomplete if we ignore the child’s family and environmental experiences. To do so may result in a neat diagnosis, but it can also leave a child exposed to risk and potentially long-term damage.

Rather than jump to conclusions and hasty diagnoses, I think it’s more helpful to consider what the ADHD-like and ASC-like presentations might be telling us. In my clinical experience, latency-aged boys (in particular) who have been allowed to play age and developmentally inappropriate console games, and/or have witnessed chaos or abuse at home, are highly likely to present as aggressive, with an inability to concentrate, show little or no impulse control, and/or obsessional, hypervigilant behaviour and be lacking in empathy. All behaviour is a communication – it’s the job of anyone who supports children to take notice of what it’s telling us, not simply label it.Ìý

Case study

Nine-year-old Darnell was referred for a mental health assessment by his GP who stated that he met every one of the criteria for ADHD and a diagnosis was inevitable. He was described as hyperactive and inattentive, aggressive to his peers, particularly girls, and he used sexualised language and behaviour. He could not be left unattended with his four-year-old sister for fear he would hurt her. He was failing academically and had been suspended from school on numerous occasions, with a threat of permanent exclusion if his behaviour could not be tamed.Ìý

At assessment, I met with Darnell, his sister Jess and their mother Becky, who was heavily pregnant and showed signs of bruising to her face. She told me that Darnell was uncontrollable and refused to do as he was told. He said he hated her, she was a slag, and he wished she would just f*ck off. Becky told me that Darnell had previously stated that he wanted to kill her, and also that he wanted to die. She said that even as a baby, he was ‘difficult’, whereas Jess was always a much easier child. Jess did indeed remain calm and unusually quiet for a four-year-old throughout the assessment, whereas Darnell sneered and groaned. He broke one of the toys, perhaps on purpose, and devoured a packet of tissues by chewing them up and spitting them out.Ìý

I learnt that Darnell was an unplanned baby. Becky was 18 and had been in a relationship with his father for a few months when she discovered she was pregnant. They lived separately with their own parents for most of the pregnancy, until they moved into social services funded accommodation prior to Darnell’s birth. Becky reported that Darnell’s father drank a lot ‘because of stress’, and was sometimes violent. She said he punched her in the stomach when she was pregnant, and she gave birth with a black eye. She believed that he loved her and wanted their baby, but following Darnell’s birth, the violence ‘got really bad’. The relationship ended when he went to prison, and she began a relationship with his friend who had been ‘really supportive at first’. But then he raped her, and she became pregnant with her daughter, telling no one the details of the conception, but telling me matter-of-factly in front of both her children. Becky had been in her current relationship for eight months with a man who was the father of her unborn baby, whom she described as ‘like a third child’. She admitted that they had heated arguments, and sometimes ‘use each other as punch bags to let off steam’.Ìý

When I spoke to Darnell alone, he told me that he hated his mum’s partner because he was ‘f*cking mean’ and a ‘lazy c*nt’. Darnell had learnt that if he played up at school, he could go home, and make sure his mum was OK. He told me that the police came again yesterday because mum’s partner hit her because he thought the baby wasn’t his. Darnell repeated that his mum was a slag. He said he tried not to be too bad because he was scared he would be taken into care like his older brother, a child I had not been aware existed, but who I later learnt was in foster care due to emotional and physical neglect. I expressed my concern about Darnell’s situation, stating very clearly that it was not OK for grown-ups to hurt each other, or to make children feel frightened. He admitted that he sometimes felt sad, but ‘not frightened because I’m not f*cking gay’.Ìý

I asked Darnell what he liked to do when he wasn’t at school and he gave the inevitable response of ‘Xbox’. Fearing the answer, I asked which games he liked and he became animated for the first time during the assessment, and said he liked GTA and had just got the new one for his ninth birthday. I commented on how excited he seemed and wondered aloud what it was that he enjoyed about the games. He said simply, ‘Sex and killing.’Ìý

Urban neglect

Darnell is illustrative of countless young boys whose lives consist of real and virtual violence who present with ADHD-like behaviours. Their lives are messy, unsafe and without boundaries, and so it should be no surprise that they present as chaotic, at risk and uncontrollable. They ‘create havoc at home and school ... as if they were spilling out all over the place’⁸ because they are communicating their lived and online experiences. Children like Jess are also at risk but many go unnoticed. They are compliant and expend their energy ensuring that there is no mess and no chaos as an antithesis to their messy and chaotic lives. They are often hypervigilant to noise and notice everything. As they get older, they may switch off emotionally and end up in GP surgeries and mental health clinics presenting with ASC-like behaviours.

Children are harmed by exposure to violent and sexual imagery and language, be it in the home or on the screen. Adults who allow this to happen may be guilty of social and emotional neglect, or what has been termed ‘urban neglect through technology’.⁹ Psychodynamic literature emphasises the importance of infant-caregiver attachment, yet for many children, early ‘care’ is provided by a screen portraying sex and violence. For some children, this provides a mirror to their external lives, so that fantasy and reality become inextricably tangled. In the absence of an alternative father role model, the process of identity formation for prepubescent and adolescent boys becomes enmeshed with on-screen characters, who are an exaggerated version of themselves.¹⁰ These boys crave ‘raw, loud and angry ... because they need it to be strong enough to match and master their [own] anxiety and anger.’^11Ìý

Society has, on the whole, turned a collective blind eye. Instead, the media spotlight continues to highlight the potential impact of provocative clothing on young girls, which, it is argued, leads to their premature sexualisation. Yet, the spotlight has merely flashed over their male counterparts who, while their female peers play dress-up, are simulating oral sex and bloody violence. Twelve years after this article was first published, reports of murder, rape and domestic abuse remain more focused on female provocation than on male gaming habits. The future I feared is indeed a place ‘where lunatics prosper’.Ìý