to the editor: I enjoyed reading the Medicine and Society feature,¹ "Counseling Patients on Mass Media and Health," written by Dr. Primack in American Family Physician.

I would like to point out the rising influence of video games on today's youth. The video game industry is an estimated $10 billion-per-year business, worth more than the television or film industry. According to recent surveys, television ratings between the hours of 5 p.m. and 11 p.m. have decreased among teenagers, while video game use has increased during this time slot. In a 2001 consumer survey distributed by the Interactive Digital Software Association, respondents ranked playing video games as the best form of entertainment ahead of watching television, surfing the Internet, or going to the movies.

Todays video games are becoming exponentially more complex with astoundingly realistic graphics, intricate plots, and lengthy playing times. Some games have million dollar production budgets and massive marketing campaigns. In addition, video games are geared more and more toward the adult population, including such themes as war, murder, drugs, and sex.

Video games are regulated by the Entertainment Software Rating Board (ESRB), an independent, voluntary rating system established in September 1994 after much congressional pressure. The ESRB applies age-specific ratings ranging from "Early Childhood" (three years and older) to "Adults Only" (18 years and older). In addition, the ESRB provides content descriptors for the games, indicating the presence of violent content, sexual themes, and mature language. However, two studies^2,3 have demonstrated that a significant amount of violent content exists in games rated "E for Everyone" (six years and older) and "T for Teen" (13 years and older). The same holds true for other adult themes such as sex, drugs, and gambling. It is apparent that the rating system is not foolproof and perhaps should be modified to avoid exposing young children to age-inappropriate content.

A number of adverse health effects have been linked to video game use in children, ranging from obesity⁴ to the possibility of violent and aggressive behavior.⁵ Video games also appear to have the potential for addiction, with reports of children playing certain games for more than 40 hours per week. There has even been a case⁶ of a 15-year-old boy who developed tendonitis after playing video games for up to seven hours a day using a vibrating joystick. However, some studies show potentially beneficial aspects to video game play, including improved hand-eye coordination and visual attention.

What can physicians do? We should counsel parents on the unsuitable material to which their children may be exposed during video game use. I also recommend that the total amount of time playing video games be limited to one to two hours per day. In addition, parents should consider playing the games with their children and being aware of all the games they may be purchasing.