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The title of this piece is the tag line from Grand Theft Auto III (GTA)¹, a console game marketed at young men aged 18 and over.

Regrettably, the appeal of this and similar games covers a much wider demographic and these games are the primary pursuit of many children as young as eight years old. One of the mainstays of this type of game 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.

For example, the character in Call of Duty² (COD) opens fire in a busy airport, killing innocent bystanders in order to progress to the next level. I was informed of this by a boy of 11 who, reflecting on his hobby in a therapy session, told me: ‘I don’t know what I would do if I was ever in a real airport with a gun.’ God forbid, I thought. The latest blockbuster in the Call of Duty series is Black Ops³, which sold more than seven million copies within 24 hours of going on sale. In this game, according to the marketing hype, players are able to ‘turn down the blood and turn off the profanity to suit their needs’. There can be no argument that the amount of blood and profanity a child ‘needs’ is zero, yet the pre-pubescent boys who spend their free time playing these games seem most unlikely to censor them.

Equally concerning is the sexual content of many console games played regularly by young children. In GTA III, the character acts out sexually explicit scenes. In GTA IV⁴, he picks up prostitutes and selects from three levels of service: masturbation, fellatio and full sexual intercourse. Many of the boys who access these games are still in junior school and spend several hours a day playing them in bedrooms, behind closed doors, often with their parents’ knowledge and consent. I wonder if these parents would be as consenting to their young sons watching pornographic films.

Mental health issues

A recent study of 10- and 11-year-old children conducted by Bristol University found that playing computer games for more than two hours a day increases the risk of mental health problems by 60 per cent⁵. This is a scary statistic but, like most statistics, it does not really mean very much to most people. My own observation is that players of (most) console games are rewarded for action, speed and progressing to higher levels by fair means or foul (legal ‘cheats’ are readily available online). I hear from countless parents and teachers about their children’s inability to concentrate, about their uncontrollability and about their academic failings. I wonder aloud about the link between their computer habits and observable behaviour. I also hear about children who are described as violent to siblings and peers, who use sexually explicit language and who seem devoid of empathy. I speak to children about their interests, and learn that they enjoy games in which they are vicariously rewarded for killing, and that the role of female characters is merely to provide visual and sexual gratification.

I hear the argument touted vociferously that there is no direct link between the playing of console games and violent behaviour, but my clinical experience highlights numerous risk factors. As with most experiences, context is paramount. Many of the children I work with have grown up in families where boundaries are, at best, permeable. 

Many have witnessed aggression and violence and have experienced trauma, neglect and abuse of all kinds. These children are twice as likely as those who are not deprived or disadvantaged to develop a formal mental illness. In order to escape their despicable realities, many of the children I meet in the consulting room have retreated into a fantasy world of console games. In doing so, they form identifications with fantasy characters who are fighters, killers and abusers, in order to defend against their own vulnerability. With a gun in their (virtual) hand and a (virtual) female companion to provide sexual gratification at the push of a button, these children can, at last, feel truly omnipotent.

Is this really ADHD or ASD?

Child and Adolescent Mental Health Services (CAMHS) are receiving a growing number of referrals of violent and aggressive boys who are unable to concentrate, are failing academically and have no impulse control. In many cases, the referrer is seeking a diagnosis of, and treatment for, Attention Deficit Hyperactivity Disorder (ADHD). A similar, yet distinct, type of referral relates to children who are described as destructive, aggressive, and lacking in empathy, obsessional, hypervigilant and overly sensitive. The referrer in these instances is often seeking a diagnosis of Autistic Spectrum Disorder (ASD).

In both types of referral, a mental health diagnosis is sought in order to explain the child’s behaviour and, in many cases, a drug to control it. And I can see why. These children present with the clinical symptoms learned by professionals by rote from diagnostic screening tools and manuals such as DSM-IV⁶ or looked up on the internet by baffled parents. I recognise and support the merits of thoughtful, accurate diagnosis and treatment, but to label a child in haste is tantamount to imposing one’s own version of reality onto an already identity-confused individual. To do so is, in effect, saying I shall view you and define you in this particular way and completely ignore your own experience of who and what you are⁷.

It is also worth noting that Fetal Alcohol Syndrome, a widely under-diagnosed condition, looks very much like ADHD and in some cases ASD. In my opinion, 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 is also likely to leave the child exposed to further risk and potentially irreversible damage.

Clinical observation

I am lucky, as are the children whom I assess, in that I work as part of a multidisciplinary team of mental health professionals. During thorough assessment, we have noticed remarkable similarities in the family backgrounds and experiences of the children I have begun to think of as ADHD-like and ASD- like. The majority of ADHD-like children we meet, predominantly latency-aged boys, have witnessed domestic abuse and been allowed to play age- inappropriate console games. The same is true in many of the ASD-like children referred to our service. This suggestion is not the result of subjective, self-serving research; it is a clinical observation that has presented over time from the ordinary caseload of referrals made to an ordinary CAMHS service. My guess is that similar observations are being made in clinics up and down the UK.

What follows is a clinical case study that is an amalgamation of dozens of children I have assessed for therapy. It is presented as an amalgamation for two reasons: to maintain the anonymity of the children and because their stories are so similar.

The case of Darnell

Darnell is a nine-year-old boy referred to CAMHS for a mental health assessment by his GP. The referral letter states that Darnell meets every one of the criteria for ADHD and is so extreme in his presentation that a diagnosis is inevitable. Darnell is described as hyperactive and inattentive. He is alleged to bully his peers, particularly girls, with sexualised language and aggression. He cannot be left unattended with his younger sister, Jess, who is four. He is failing academically and has been suspended from school on numerous occasions and faces permanent exclusion if his behaviour cannot be tamed.

At assessment, we met with Darnell, his mother and Jess. Mum was heavily pregnant and showing signs of bruising to her face. We were told that Darnell is uncontrollable and that he refuses to do as he is told, telling his mother he hates her and that she should ‘f**k off’ and is ‘a slag’. He has said that he wants to kill her and also that he wants to die. Darnell’s mother confided that ‘he has always been like this’ and that even as a baby he was ‘difficult’, whereas Jess is, and was, much easier. Jess did indeed remain calm and unusually quiet throughout the two-hour assessment. Darnell sneered and groaned. He broke some of the toys and devoured a packet of tissues by chewing them up and spitting them out.

Family history

We learnt that Darnell was an unplanned baby. His mother was 18 and had been in a relationship with John, Darnell’s father, for only a few months when she discovered she was pregnant. We wondered if John had been supportive and were told that ‘he did what he could’ but that 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. His mother told us that John drank a lot ‘because of stress’ and would sometimes become aggressive. He once punched her in the stomach when she was pregnant and she gave birth with a black eye. She believed that John loved her and wanted their baby. Following Darnell’s birth, the violence ‘got really bad’.

The relationship ended when John drove their car, under the influence of drink and drugs and with baby Darnell and his mother as passengers, under a truck. She thought they would all die. John went to prison for ‘driving under the influence’ but she thought it was important to maintain contact between Darnell and his father and so regularly took him for prison visits in his early years.

Darnell’s mother began a relationship with John’s friend, Jason, who ‘was really supportive at first’ while John was in prison. But he raped her and she became pregnant with Jess, telling no one the details of the conception. She has been in her current relationship with Jamie for eight months and he is the father of her unborn child. Jamie was described as ‘like a third child’ and Darnell’s mother admitted that they have heated arguments and sometimes ‘use each other as punch bags’ to ‘let off steam’.

Darnell alone

When I spoke to Darnell alone, he told me that he hates Jamie because he is mean to his mum and he is lazy and won’t play football. Darnell has learnt that if he is naughty at school he gets to go home and that way he can make sure his mum is OK. Yesterday the police came again because Jamie had hit his mum because he thinks the baby is not his. Darnell said he tried to be good because he is frightened he will 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 is not OK for grown-ups to hurt each other or to make children feel frightened. Darnell admitted that he sometimes feels sad, but ‘not frightened because I’m not gay’.

I asked Darnell what he likes to do when he isn’t at school and was given the inevitable response of ‘Xbox’. Fearing the answer, I asked Darnell which games he likes to play. He became excited and animated for the first time during the assessment. He said he liked the GTA and COD games and had just got Black Ops for his ninth birthday. I commented on how lively his expressions had become and wondered aloud what it was that Darnell enjoyed about these games. He said simply: ‘Sex and killing.’

Reasons for misdiagnosis

‘Darnell’ is illustrative of countless young boys whose lives consist of real and virtual violence and who often present as ADHD-like. Their lives are messy, unsafe and without boundaries, and so it should be no surprise that they present as chaotic, at risk and uncontrollable. These children ‘create havoc at home and school ... as if they were spilling out all over the place’⁸. Children like Jess are also damaged by their experiences and remain at risk but, unlike Darnell, many of them go unnoticed. These children 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 CAMHS clinics presenting as ASD-like.

Children are damaged beyond measure by exposure to violent and sexual imagery and language, be it in the home or on the screen. Adults who allow this to happen are guilty of social and emotional neglect, or what has recently been termed ‘urban neglect through technology’⁸. 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 many children, this provides a mirror to their external lives, such that fantasy and reality become inextricably tangled. In the absence of a suitable father role model, the process of identity formation for pre-pubescent and adolescent boys becomes enmeshed with on-screen characters who are an exaggerated version of themselves⁹. These boys crave ‘raw, loud and angry ... because they need it to be strong enough to match and master their [own] anxiety and anger’¹⁰.

However, society is, on the whole, turning a collective blind eye. Instead, the media spotlight highlights the potential impact of provocative clothing for 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. If this trend continues, trials for murder, rape, paedophilia and domestic abuse are more likely to draw attention to female attire than male console game addiction. This feared future will indeed be a place ‘where lunatics prosper’¹. •

Jeanine Connor works as a child and adolescent psychodynamic psychotherapist in Tier 3 CAMHS and in private practice. She is also an author, examiner and lecturer.

References

1 Grand theft auto III. Rockstar Games. 2001. 2 Call of duty. Activision. 2003.
3 Black ops. Activision. 2010.
4 Grand theft auto IV. Rockstar Games. 2008.
5 Page AS et al. Children’s screen viewing is related to psychological difficulties irrespective of physical activity. Pediatrics. 2010; 126(5).
6 Diagnostic and statistical manual of mental disorders. Fourth ed. New York: American Psychiatric Association; 2000.
7 Mollon P. Releasing the self: the healing legacy of Heinz Kohut. London: Whurr; 2001.
8 Jennings S. Healthy attachments and neuro-dramatic- play. London: Jessica Kingsley; 2011.
9 Taransaud D. You think I’m evil. London: Worth Publishing; 2011.
10 Jones G. Killing monsters: why children need fantasy, super-heroes and make-believe violence. New York: Basic Books; 2002.

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