Review of General Psychology 2010, Vol. 14, No.

2, 122140

2010 American Psychological Association 1089-2680/10/$12.00 DOI: 10.1037/a0019438

Videogames and Young People With Developmental Disorders

Kevin Durkin
University of Strathclyde
Young people with developmental disorders experience difculties with many cognitive and perceptual tasks, and often suffer social impairments. Yet, like typical youth, many appear to enjoy playing videogames. This review considers the appeal of videogames to individuals with autism spectrum disorders, attention decit hyperactivity disorder, and specic language impairment. It examines how they respond to the various challenges that play entails with particular reference to sensory, cognitive, and social dimensions. It is argued that research into how these young people engage voluntarily with this dynamic and challenging medium offers great potential to extend our empirical and theoretical understanding of the disorders. Many gaps in our current knowledge are identied and several additional themes for possible future research are proposed. Keywords: videogames, developmental disorders, autism, Asperger syndrome, ADHD, specic language impairment, dopamine

Children with developmental disorders face considerable difculties and present many challenges to their caregivers and teachers. Depending on the nature of the disorder and the individuals particular constellation of impairments and abilities, the childrens communicative skills are often limited, their cognitive processing is atypical, their behavior can be difcult to regulate, their affect may be volatile, they do not always interact successfully with other people, their attention spans can be eeting and their working memory impaired. Yet many observational and anecdotal reports indicate that these children are often drawn to videogames, sometimes play them for long periods, andto the wonder of those who live with themappear to be able to sit still and concentrate while doing so. To the extent that this is the case, it prompts many questions about the relationship between these young people and this relatively recent but now ubiquitous technology. Why should videogames appeal to children with disorders, who often struggle with many other tasks? Even if the games do have attractions for these individuals, how do their conditions affect their abilities to engage with them? What is the nature of their uses and experiences with the medium? Can their interactions with games help us to learn more about their disorders, needs and potentialities? Is game playing advantageous to them or harmful? Could their interests be built upon for developmental, cognitive, educational, social, or therapeutic benet? Surprisingly, psychologists working in developmental disorders have been slower than young people themselves to seize upon an activity of manifest appeal to many and have not investigated in detail the nature of the childrens voluntary interactions with one of the richest and most popular of the new media. Nevertheless, some pioneering work has been undertaken. Furthermore, much research in the currently very active eld of developmental disorders is relevant to the above questions, even if videogames were

not the central concern of the investigators. For example, increasingly, researchers are using computer-based tasks, with game-like features, to tap aspects of processing in children with disorders. Laboratory games, for good theoretical/experimental reasons (cf. Alloway, Rajendran, & Archibald, 2009; Ozonoff et al., 2008; Pennington & Ozonoff, 1996; Rhodes, Coghill, & Matthews, 2006), often attempt to isolate performance demands that, in full videogame play, may occur as part of much more complex and noisier scenarios; nevertheless, the ndings from such studies can inform and guide study of neglected topics relating to childrens actual behavior and interests. This paper attempts to review the current state of our knowledge about the place of videogames in the lives of young people with developmental disorders, and to identify the (many) gaps that call for future research. First, a brief overview is provided of the nature of the disorders under discussion. Next, we consider the available evidence pointing to enthusiasm for videogames among these populations. This is followed by summaries of what we know and do not know about why both typically developing and exceptional young people are attracted to videogames. Then, we focus on the experiences videogame play may present to young people with developmental disorders, considering in turn, sensory, cognitive, and social dimensions. The potential for positive or negative uses of the games is noted. Finally, several additional themes for possible future research are identied.

Developmental Disorders: An Outline

There are various developmental disorders, sharing some features but differentiated on others (Hulme & Snowling, 2009; Pennington, 2006; Rutter & Sroufe, 2000). This review will focus primarily on three disorders: Autism Spectrum Disorders (generally referred to here as ASD though, where appropriate, Asperger Syndrome, or AS, will be distinguished), Attention Decit Hyperactivity Disorder (ADHD), and Specic Language Impairment (SLI). These disorders are selected partly because each provides intriguing challenges to psychological theory, and partly because they include two of the most common childhood disorders (ADHD
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Kevin Durkin, Department of Psychology, University of Strathclyde. Correspondence concerning this article should be addressed to Kevin Durkin, Department of Psychology, University of Strathclyde, 40 George Street, Glasgow, G1 1QE, Scotland. E-mail: kevin.durkin@strath.ac.uk

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and SLI), All are currently the foci of wide-ranging research literatures, and hence there is much to draw on in considering the implications for childrens uses of media. They are also of interest because each disorder is associated with specic difculties decits in particular skillsalongside typical, or even superior, abilities in some areas. (Hence, they are distinct from general intellectual impairment, which will not be considered here; see Adelman, Lauber, Nelson, & Smith, 1989, for a valuable discussion of videogame uses in this context.) However, many of the issues to be discussed in this paper are relevant to other developmental disorders and it is certainly to be hoped that future research will expand and deepen our understanding of how children with many different conditions relate to videogames. As Hulme and Snowling point out (2009, pp. 2 3), scientic interest in children with developmental disorders is extensive because understanding their characteristics and processes informs the broader study of the human mind and development in general. By the same token, from the perspective of researchers interested in the psychology of videogame use, individuals with developmental disorders are (or should be) of interest because studying exceptional engagement and responses in this relatively underexplored domain may contribute to our wider understanding of typical performance. It may also help to shed light on features of each disorder and illuminate the potential of individuals in activities that they nd motivating. It should be stressed that, while these are advocated as desirable goals, the relative paucity of research directly investigating videogame play in atypical (or even typical) children means that we are some distance from realizing them (but see Markopoulos, Read, Hoysniemi, & MacFarlane, 2008; Subrahmanyam, Greeneld, Kraut, & Gross, 2001, for broader reviews of children as computer users).

Characteristics of ASD, AS, ADHD, and SLI

Autism spectrum disorders (ASD) are neurodevelopmental disabilities present from early childhood (Frith, 2003). The diagnostic criteria are that the child manifests qualitative impairments in reciprocal social interaction, and in verbal and nonverbal communication, relative to developmental level, accompanied by a markedly restricted repertoire of activities and interests. Children with autism often show poor use of eye gaze, delayed or absent language, lack of interest in other people, and a tendency toward repetitive, idiosyncratic movements. They tend to have few, if any, friends (Bauminger, & Kasari, 2001). Poor understanding of others mental properties is common in autism, reected in poor performance in Theory of Mind tasks (Baron-Cohen, 1995; Yirimiya, Erel, Shaked, & Solomonica-Levi, 1998; Frith, 2003). From early childhood, individuals with autism engage less in pretend play (Jarrold, 2003) and throughout development tend to have impaired imaginative abilities (Honey, Leekam, Turner, & McConachie, 2006; Low, Goddard, & Melser, 2009; Scott, Baron-Cohen, & Leselie, 1999). They are often reported to have a very literal orientation toward language and symbols that other people interpret as standing for something else (Rajendran & Mitchell, 2007). Estimates of the incidence of autism are controversial; recent data indicate around 1.16% (Baird et al., 2006), though the prevalence of traits resembling those found in ASD is higher, continuously distributed in the general population (Skuse et al., 2009). ASD is a lifelong condition.

In this paper, as in many discussions of these disorders, Asperger Syndrome (AS) will be considered alongside ASD, though it should be noted that there is controversy over whether it should be treated as a subtype or a distinct condition (Frith, 2003, 2004; Macintosh & Dissanayake, 2004; Matson & Wilkins, 2008; Ozonoff, Rogers, & Pennington, 1991). AS is characterized by social impairment and isolated idiosyncratic interests (as with classic autism), without a history of language impairment (unlike classic autism) (Klin, McPartland, & Volkmar, 2005). Peer relations tend to be poor in childhood and adolescence (Howlin, 2004; Klin et al., 2005; Whitehouse, Durkin, Jaquet, & Ziatas, 2009). Although they exhibit social difculties, individuals with AS tend to pass Theory of Mind tasks and to perform better than children with autism on tests of comprehension of mental terminology (Ozonoff et al., 1991; Ziatas, Durkin, & Pratt, 1998). ADHD is dened as a persistent and developmentally inappropriate pattern of inattention, hyperactivity and impulsiveness. It is a common disorder, estimated to affect over 5% of children (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Children with ADHD show decits on various tasks of executive function (Pennington & Ozonoff, 1996; Rhodes et al., 2006). Compared to typically developing (TD) controls, children with ADHD show slower, less efcient and more variable responses to the inhibitory demands of stop-go tasks (Castellanos, SonugaBarke, Milham, & Tannock, 2006). They tend to experience difculties in peer relationships and schoolwork, and are prone to risk taking and additional psychopathology (Barkley, Fischer, Smallish, & Fletcher, 2006; Tannock, 1998). Their performance on theory of mind tasks does not indicate impairment in that domain (Charman, Carroll, & Sturge, 2001; Perner, Kain, & Barchfeld, 2002). In many cases, symptoms of ADHD persist into adolescence and adulthood (Barkley, 2006; Faraone, & Biederman, 2005; Fischer & Barkley, 2006; Tannock, 1998). SLI involves marked difculties with language in children whose IQs fall in the normal range, in the absence of sensory impairment (e.g., deafness) or frank neurological damage (Bishop, 1997; Leonard, 1998). At around 5 years of age, the population incidence is approximately 7% (Tomblin et al., 1997), making this one of the most common childhood disorders. While SLI was initially investigated with a focus on developmental psycholinguistic characteristics, it has become increasingly evident that the disorder has broader ramications for social and educational experiences and attainments (Conti-Ramsden & Durkin, 2008; Joffe, Cruice, & Chiat, 2009). Children and adolescents with SLI are at greater risk than TD children of difculties in peer relationships and poorer quality friendships (Brinton, & Fujiki, 2002; Durkin & Conti-Ramsden, 2007). However, they do not show impairments in Theory of Mind tasks (Leslie, & Frith, 1988; Miller, 2004; Perner, Frith, Leslie, & Leekam, 1989; Ziatas et al., 1998). A signicant proportion of young people have persisting difculties with language, and related processes, throughout development (ContiRamsden, 2008) and into their adult lives (Clegg, Hollis, Mawhood, & Rutter, 2005;Tomblin, Freese, & Records, 1992). The above is intended as a summary for heuristic purposes only. While these familiar and widely used categories will be adopted here, researchers and clinicians in this eld recognize that diagnosis itself is often complex and sometimes controversial; many children fall into gray areas, exhibiting some but not all symptoms of a particular disorder. There is considerable comorbidity

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among disorders (e.g., a child may have both ADHD and SLI, or either of these could be comorbid with another disorder). Within any one diagnostic category, there is heterogeneity of symptom combinations and variation in severity (e.g., individuals with ASD can range from those with no speech and very low levels of intellectual ability through to high functioning with islets of exceptional ability). Each of the disorders has identiable subtypes (e.g., the predominantly hyperactive-impulsive, predominantly inattentive, and combined subtypes of ADHD, Barkley, 2006, or the receptive, expressive, combined subtypes of SLI; see Bishop, 1997, and Leonard, 1998, for fuller reviews of these and additional categories). Individuals with disorders undergo development, changing their levels of abilities, their interests and behaviors over the course of childhood and adolescence. As with any other children, those with developmental disorders vary in terms of the experiences and support they encounter. The ongoing efforts to understand each of these disorders entails attention to genetic, neural, cognitive, behavioral, social, and environmental factors, and their interrelationships. (Bishop, 1997, 2006; Castellanos et al., 2006; Conti-Ramsden, 2008; Happe , Ronald, & Plomin, 2006; Leonard, 1998; Pennington, 2006; Tannock, 1998).

Why Are Typically Developing Young People Attracted to Videogames?

Children and adolescents are attracted to videogames for multiple reasons. In general terms, games are appealing because they meet psychological needs and they help young people to address developmental tasks (Durkin, 2006; Olson, 2010; Raney, Smith, & Baker, 2006; von Salish, Oppl, & Kristen, 2006). Games are entertaining almost by denition (cf. Vorderer, Bryant, Pieper, & Weber, 2006), and typically developing (TD) young people use them for enjoyment purposes, mood regulation, and to escape everyday stressors (Durkin & Aisbett, 1999; Kubey & Larson, 1990; Jansz, 2005; Raney et al., 2006; Sherry, Lucas, Greenberg, & Lachlan, 2006; von Salisch et al., 2006). Games provide cognitive and perceptuo-motor skills challenges, and gamers report consistently that these challenges are powerful attractions (Durkin & Aisbett, 1999; Klimmt & Hartmann, 2006; Sherry et al., 2006; von Salisch et al., 2006). Playing videogames can be highly social; social interaction, especially with peers, is increasingly motivating from childhood to adolescence, and young people indicate that their preferred mode of play is in company (Durkin & Barber, 2002; Kubey & Larson, 1990; von Salisch et al., 2006; Sherry et al., 2006). Of course, it should be stressed that players and games vary enormously. Not only are there countless different games on the market, which can be delivered via different formats, but different individuals can play them and respond to them in different ways as a function of their skills, interests, cognitive capacities, developmental status, knowledge, and values.

scarce, because nonparticipation can be as revealing as participation; in fact, though, the evidence suggests that videogames are popular with atypical children. Most children above the age of about 5 years and almost all contemporary teenagers play videogames (Lee, Bartolic, & Vandewater, 2009; Lenhart et al., 2008). For example, in a nationally representative sample of 1100 American 12- to 17-year-olds, Lenhart et al. (2008) found that 99% of boys and 94% of girls played. Neither of these studies was concerned specically with the developmental abilities of the participants but sampling was random and nonexclusionary; hence it is reasonable to suppose that this research strategy would enlist a proportion of young people with developmental disorders corresponding to their frequencies in the general population. More direct evidence comes from many observational, interview-based or clinical reports on children and adolescents with ASD or ADHD that mention the young peoples enthusiasms for videogames (Attwood, 2006; Chan & Rabinowitz, 2006; Dawe, 2006; Fischer & Barkley, 2006; Jennes-Coussens, Magill-Evans, & Koning, 2006; Shaw, Grayson, & Lewis, 2005; South, Ozonoff, & McMahon, 2005; Winter-Messiers, 2007). Furthermore, laboratory and survey studies conrm that participants with ASD are strongly attracted to screen-based entertainment, including interactive virtual reality displays and videogames (Mineo, Ziegler, Gill, & Salkin, 2009; Shane & Albert, 2008). Bioulac, Ar and Bouvard (2008) compared the videogame play of samples of children (aged 10 to 12 years) with or without ADHD, and found no evidence of differences concerning the frequency or duration of play. The two groups did not differ with regard to the type of game played (both enjoyed adventure games, role playing games, logic games). Fischer and Barkley (2006), working with a large sample of participants with ADHD followed from childhood to age 20, found that there was no difference between the clinical group and age-matched typical controls in terms of amount of videogame play (it was popular with both groups), though interindividual variability was much more marked among the ADHD participants. There are fewer clinical/observational reports on the videogame interests of children with SLI. However, Durkin, Conti-Ramsden, Walker, and Simkin (2009) found, in a large sample of adolescents with SLI, that their interest and frequency of play was comparable to that of TD adolescents. It would be useful to obtain additional survey data comparing directly the videogame interests, preferences and engagement of children with developmental disorders. Nevertheless, the available evidence is strongly indicative that these young people do not differ radically from their typical peers in terms of attraction to the games and amount of time spent with them.

Why Are Young People With Developmental Disorders Attracted to Videogames?

The relationship between children with developmental disorders and videogames is likely to be at least as complex as that sketched above for TD youngsters. The diversity of children with developmental disorders and the plurality of their circumstances mean that it is implausible that they all orient in the same way to particular phenomena or experiences. At present, a basic descriptive question to which we do not have a very elaborate answer is why people with developmental disorders, and hence difculties in some as-

Do Young People With Developmental Disorders Play Videogames?

When considering the possible implications of videogame play among children and adolescents with developmental disorders, it is of interest to determine to what extent they do play. Note that the topic would still be meaningful even if such engagement was

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pects of engagement with the world, nd videogames attractive. However, there are some useful pointers in the available literature. Swettenham (1996) suggests three main reasons why children with autism are attracted to computers. The rst is that the computer involves no social factors. The second is that the computer is consistent and predictable. The third is that it allows the child to take active control and to determine the pace of activity. It is important that Swettenham was referring to computers, rather than to computer games or videogames, but his points remain relevant in this context. Each of the above descriptions bears on but is qualied in relation to videogame play. Videogames can be, but need not necessarily be, social. They can be played with others and they can serve as the focus for peer discussions. It is very likely that, because of their marked social impairments, many children with autism would elect for solitary play but this does not appear to have been investigated in detail. For individuals with AS, the picture may be a little more complicated, as discussed later. In respect of consistency and predictability, videogames vary considerably; it is possible that these criteria guide the game choices of children with autism or their game strategies (e.g., they may exploit a repetitive option where TD players would seek variety or skill challenge). Again, we lack evidence. In respect of Swettenhams third suggestion, interactivity and control are attractive to most videogamers (cf. contributions to Vorderer & Bryant, 2006). It would be useful to obtain evidence to conrm that this is the case for children with autism, too, though it would not identify a distinctive orientation. In an interview study with adolescents with ASD, WinterMessiers (2007) found evidence that these children, like TD youth, can be motivated by the skills challenges of videogames. One interviewee explained: I know I play too much games . . . but. I have two reasons why: one cause I learn how to do some things through games that . . . in normal life I cant begin to formally learn . . . and two, I like to escape to a fantasy reality. People with autism often manifest obsessive interests with specic phenomena (Baron-Cohen & Wheelwright, 1999; Klin, Danovitch, Merz, & Volkmar, 2007; South et al., 2005). Videogames are sometimes listed among these interests. Videogames can be chosen for their intrinsic appeal and/or for their complementarity to some overriding interest (e.g., a child fundamentally obsessed with astronomy might be attracted to videogames that involve intergalactic travel). Klin et al. offer the interesting observation that sometimes the interests can color the ways in which young people with autism relate to the rest of their world and to other people. For example, a child with an obsession with trains might use the lexicon of railway travel to describe people. We do not have evidence that this happens with the lexicon of videogames, but case studies could provide useful information. Klin et al. (2007) present evidence that the pursuit of obsessive interests frequently interfere with other aspects of the lives of young people with autism. The extent to which this is the case for those children with obsessive interests in videogames has not been reported, though it seems likely that at least some would be at risk of the consequences often alleged, though little documented, of excessive preoccupation with gaming. However, there is no evidence available at present to suggest that adolescents with ASD are markedly different from the typically developing in this regard. Young people with ADHD may be attracted to videogames for similar reasons to TD children. However, a stronger motivation in

this population may be that at least some games (or some parts of games) are attractive because they satisfy the childrens need for rapid reinforcement. While reinforcement is a powerful motivator for much of human behavior, children with ADHD have an unusually high requirement for immediate reward (Douglas & Parry, 1994; Luman, Oosterlaan, & Sergeant, 2005; Tripp & Alsop, 2001) and will opt to minimize delay even at the expense of pursuing larger but longer-term goals (Sonuga-Barke, Taylor, Sembi, & Smith, 1992). Videogames now offer reinforcement schedules far more elegantly than a Skinner box. These considerations lead to testable predictions that could be addressed in surveys of use and laboratory performance. Games in which a pleasing outcome is attained swiftly are appealing to most players (Millar & Navarick, 1984) but should be especially so for children with ADHD. Such games include shoot-em-ups and some sports games. In contrast, games which involve lengthy and intricate procedures to reach a longer term goal (e.g., strategy games, quests, mysteries) should be less attractive to children with this disorder. To date, less research is available to inform us why young people with SLI are attracted to games. Recall that these children fall in the normal intelligence range. Several motives can reasonably be assumed to coincide with those of TD youth. Durkin et al. (2009) found that one respect in which adolescents with SLI exceeded TD adolescents was in playing ofine games. As might be expected, this was a popular activity with both groups but, while 74% of the TD adolescents reported this use, 88% of adolescents with SLI did. There was no difference in the proportion of individuals in each group who played online games (approximately 66%). The authors suggest that the greater use of off-line games in the SLI group might reect preferences for less challenging and less time pressured formats. However, the study did not examine actual game choices. In sum, just as there are various reasons why TD youth are attracted to video games, so there are likely to be multiple motivations among young people with developmental disorders. Motives have not been investigated systematically and no studies appear to be available which have simultaneously compared across developmental disorders. Nevertheless, the initial evidence suggests that some motives are shared with TD youth and some are specic to particular disorders. It is also possible that children with autism nd features of games attractive that are perceived as irrelevant by other players, and it is very likely that there are individual differences in this respect. At present, we simply lack the relevant evidence. The fact that many children with autism are attracted to videogame play reminds us that, in their everyday behavior and preferences, they are telling us something about recent developments in their interests and activities that science has yet to catch up with.

How Do Young People With Developmental Disorders Experience and Respond to Videogames?
Video game play engages various capacities, including sensory, cognitive, and social. A lot of visible activity is ongoing. Targets, threats, opportunities, diversions, and irrelevancies can occur at different places, simultaneously or consecutively, and signaled in many different ways. Attentional demands can be both focal (e.g., operating the actions of a weapon or an avatar) and peripheral

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(e.g., monitoring a goal while operating in a different part of the environment, keeping alert to the risk of attacks from unpredictable locations). Young people with developmental disorders are often impaired or function differently in respect of these demands.

Sensory Stimulation
William James would have been intrigued by the blooming, buzzing confusion of videogames. So are children with autism. This is interesting because children with autism are prone to suffer sensory disturbances, over- and underarousal in response to visual, auditory, and other sensory stimuli (Gepner & Fe ron, 2009; Leekam, Neito, Libby, Wing, & Gould, 2007; ONeill & Jones, 1997; Ornitz, 1989; Tsatsanis, 2005). These reactions can be rewarding or distressing to the child and are also associated with repetitive or other unusual behaviors; they occur from early childhood onward (Tsatsanis, 2005). Consider this summary of reports on (many) children with autism:
often uctuating unpredictably between [hyper- and hyposensitivity]; sensory distortions, where for example depth may be wrongly perceived or still objects perceived as moving; sensory tune-outs where sound or vision may suddenly blank out and return again; sensory overload; multichannel perceptions where for example sound may also provoke sensations of color and smell; difculties in processing information from more than one channel at a time, and indeed, difculties in identifying the channel through which stimulation is being received in the rst place (ONeill & Jones, 1997, p. 284).

How do young people with a developmental history of such experiences relate to the disparate and unpredictable worlds they can encounter in videogames? Do they nd some games aversive? Candidate games for this category might include those with sensory-tune-outs, unpredictable movements, rapid concatenations and fragmentations of multicolored stimuli interwoven with strange noises, packed with mischievous or threatening alien beings. On the other hand, some games may offer very welcome sensory experiences, compatible with the childrens attraction to repetitive, familiar stimuli, and especially stimuli that they can control. Some children with autism are attracted to bright lights, shiny phenomena, or twisting or spinning objects (Leekam et al., 2007)all of which can be found in videogames. Individuals with ASD see the world differently (Dakin & Frith, 2005, p. 497). They sometimes demonstrate superior performance to TD individuals on visual perception and search tasks (Frith, 2003; Happe & Frith, 2006). For example, individuals with ASD tend to nd the hidden gure more easily than do TD peers in the Childrens Embedded Figures Test (Jolliffe & Baron-Cohen, 1997; Shah & Frith, 1993; Pellicano, Maybery, Durkin, & Maley, 2006). There is considerable debate as to whether the superior performance reects a bias to focus on the details (local elements) of a conguration rather than its overall (global) meaning, as proposed by Friths weak central coherence account (2003; cf. Happe & Frith, 2006, for a review and modied position), or superior target discrimination abilities (ORiordan, Plaisted, Driver, & Baron-Cohen, 2001) or to the disruptive consequences of overdeveloped low-level perception (Mottron, Dawson, Soulieres, Hubert, & Burack, 2006). On the other hand, there are visual tasks in which participants with ASD tend to perform less well, including processing of visual

motion (Dakin & Frith, 2005). For example, Pellicano, Gibson, Maybery, Durkin, and Badcock (2005) found that 8- to 12-year-old children with ASD performed as well as TD comparisons on a Flicker Contrast Sensitivity test, presumed to tap lower-level dorsal stream functioning, but revealed a decit on a Global Dot Motion task, which tests functioning at higher levels of the dorsal cortical stream. In a Global Dot Motion task, participants view dots moving, predominantly at random, on a screen; in different trials, the proportion of dots moving in the same direction is varied and thus the task reveals the threshold at which participants can detect the direction. Pellicano et al. found that TD children required 11% in the same direction, whereas ASD participants required 22%. In most videogames, dot motion would exceed the latter threshold for detection of coherence, though there are lots of competing movements in games that may render some screen environments problematic for individuals with motion detection impairments. Blake, Turner, Smoski, Pozdol, and Stone (2003) found that while children with autism performed as well as control participants on a global-form task (detecting a target in an environment rich in distracters) they performed signicantly worse on a biological motion task requiring perception of human activity in point-light animations. The authors attribute the nding to compromised neural mechanisms for integrating local motion signals into meaningful global representations. Recent neuropsychological evidence based on participants responses to images of biological motion indicates lower levels of brain activity in adults with ASD, relative to controls, in the inferior, middle and superior temporal regions, (Baron-Cohen, Wheelwright, Stone, & Rutherford, 1999; Herrington et al., 2007). In principle, video game displays should present considerable challenges to the human visual processing system, because they contain potentially overlapping and noisy distributions of signals. If human motion is difcult to recognize, the antics of cyber creatures in strange worlds may be more so. Many videogames call for high levels of attention and search skills. The player has to monitor multiple locations on screen and decide how and when to react to visual information. These challenges should be particularly marked for persons with ASD but we know little of how this is reected in their videogame experiences and performance. Children with ADHD also tend to show variable sensory sensitivity compared to TD children (Dunn & Bennett, 2002; Mangeot et al., 2001; Parush, Sohmer, Steinberg, & Kaitz, 2007). Those with ADHD perform less well than controls on tasks involving speeded processing of colored stimuli and evidence indicates that color perception is partially impaired in these children (Tannock, Banaschewski, & Gold, 2006). Although we could speculate that this impacts on experiences of some videogame environments, direct empirical evidence is scant (see Lawrence et al., 2002, 2004, for further discussion). There is evidence to indicate that the marked sensory abnormalities associated with ASD are not prevalent in children with SLI (Leekam et al., 2007). However, children with SLI have been found to experience information processing limitations, especially in working memory (Conti-Ramsden & Durkin, 2007; Leonard et al., 2007), speed of information processing (Kail, 1994; Miller et al., 2006), visuospatial performance (Bavin, Wilson, Maruff, & Sleeman, 2005; Finneran, Francis, & Leonard, 2009; Miller, Kail, Leonard, & Tomblin, 2001; Miller et al., 2006), and auditory

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processing (Bishop & McArthur, 2004; Rosen, 2003). They also have difculties with ne motor movements (Hill, 2001; Miller et al., 2006). Finneran et al. point out that disadvantage in visuospatial performance is demonstrable even in controlled laboratorytype environments which purposefully remove potentially distracting stimuli. It is a reasonable hypothesis that some of the problems could be exacerbated in fast-paced videogame contexts but, again, we lack direct evidence. In sum, the sensory world presents challenges to individuals with developmental disorders. In some cases (especially ASD), experience and integration of the senses appear to be markedly different to what we know of typical experience; in most (including ADHD and SLI), speed of processing is compromised relative to typical performance. The fact that many of these young people are nonetheless attracted to the videogame medium is of considerable interest. Careful analysis of behavior and responses in this context has the potential to reveal much about limitations and strengths in complex but motivating environments.

Reward and Dopamine Release

Because videogame play is, for many, a pleasurable activity and because it can involve rewards delivered on somewhat unpredictable schedules, researchers have been interested in the role of dopamine in responses to play. Dopamine is a neurotransmitter in the central nervous system known to be closely associated with reward-seeking behaviors (Arias-Carrio n, & Po ppel, 2007; Previc, 1999). Some evidence (from healthy adult participants) suggests that during action videogame play striatal dopamine is released, and the more so as performance improves (Koepp et al., 1998). Individuals with ADHD are believed to have a dysfunctional dopamine system, resulting in difculties in sustaining attention, hypersensitivity to environmental stimulation, and compromising the ability to self-regulate and maintain goal directed behavior (Hulme & Snowling, 2009; Nieoullon, 2002; Solanto, 1984; Sikstro m & Sderlund, 2007). Researchers have speculated that videogame play stimulates dopamine release in young people with ADHD (Han, Lee, Na, Ahn, Chung et al., 2009; Houghton et al., 2004; Sikstro m & Sderlund, 2007). Han et al. found slight reductions in Internet game play over several weeks as initially drug-na ve participants were treated with methylphenidate; the investigators interpret the change in play frequency to a diminished need for dopamine release via videogame activity. An alternative possibility is that exposure to methylphenidate interferes with the everyday processes of videogame play. A related feature of videogame play is that it can provide negative feedback. The player can make decisions or commit errors that result in setbacks, losses or catastrophic outcomes, such as the demise of ones avatar or abrupt termination of the game. Neuroimaging studies of adults have identied a component of the anterior cingulated cortex, labeled error-related negativity (ERN), that is typically more negative after participants make an error and/or receive feedback to indicate error (Frank, Woroch, & Curran, 2005; Gehring et al., 1993). Associated modulations in dopamine activity are believed to precipitate learning (subsequent error avoidance). Frank et al. found evidence that ERN magnitude following error was predictive of the degree to which adult participants learned from the negative consequences of their decisions in a forced-choice task. In an interesting experimental study with

8- to 12-year-olds with ADHD and TD comparisons, van Meel, Oosterlaan, Heslenfeld, and Sergeant (2005) investigated feedback-related negativity (which they term FRN) in the course of a computer game where a players choices could result in positive rewards (nding treasure and winning money) or negative outcomes (nding a bomb and losing money). The results indicated more pronounced FRN in the ADHD participants, which the authors interpret as suggesting that rapid evaluation of negative outcomes is exaggerated in children with this disorder. The study did not test for the extent to which participants modied behavior in response to the feedback, but the evidence suggests that children with ADHD experience more aversive reactions than do TD children to error and frustration (Barkley, 2006; Wender, 1995). This is consistent with the inference that young people with ADHD will prefer games with immediate and attainable rewards to those with complex demands and longer-term goals. Note, however, that many games can also provide immediate negative feedback, and van Meel et al.s ndings suggest the possibility that these should be particularly aversive to children with ADHD. Abnormalities in dopamine production have also been found in individuals with autism (Gadow, Roohi, DeVincent, & Hatchwell, 2008; Nieoullon, 2002; Previc, 2007). It has also been argued that impairments in language production, working memory, phonological and temporal processing (all associated with SLI; see below) are associated with aberrant dopaminergic activity (Previc, 1999). It would be of interest to determine the extent to which participants with ADHD, ASD, or SLI respond similarly to the potential of videogames to affect dopamine activity. It seems probable that there are some similarities but also that there are differences, reecting the likelihood that the underlying causes of dopaminergic dysfunction may be different among these conditions (Courchesne, 1997; Nieoullon, 2002; Previc, 2007), and that there is considerable individual variation among those with ASD (Gadow et al., 2008). As noted above, there is evidence of comorbidity among these disorders. Investigations which compare dopamine responses to videogame activity across participants with different disorders, or different combinations of disorders, could be valuable in uncovering variabilities in the specic implications of each condition for everyday behavior. Further research is needed to conrm any relationship between videogame activity and dopamine release, and any distinctive effects for persons with particular disorders. Such work could address the provocative question of which is better for children with ADHD: Ritalin or videogames? Certainly, there is a need for closer examination of which environmental opportunities and tasks can be benecial to those with developmental disorders, and computerized tasks, including videogames, have the attractions that they can be manipulated to achieve optimal levels of engagement relative to individuals arousal potential and cognitive functioning (cf. Sikstro m & Sderlund, 2007). Although there are interesting issues to be explored in this context, some cautions need to be borne in mind. First, dopaminergic activity is not the only brain activity engaged by videogame play; the effects of dopamine release and interactions with other functions are controversial (Arias-Carrio n, & Po ppel, 2007). Second, many other forms of human activity can be rewarding and most likely impact on dopamine release. Indeed, reading and writing poetry have been shown to have this effect on adult participants (Schommartz, Larisch, Vosberg, & Muller-Gartner,

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2000), but there is little evidence of children with ADHD engaging in excessive amounts of reading, writing or poetry appreciation: these children tend to be at risk of poor literacy skills (Carroll, Maughan, Goodman, & Meltzer, 2005). In short, it is unlikely (and it has not been proposed) that dopamine-release is the sole motivating factor in videogame play among young people with developmental disorders, though it may be part of a complex equation.

Cognitive Dimensions
Game play involves a range of cognitive abilities. Greeneld (2009, p. 69) maintains that videogames are important sources of cognitive socialization, often laying the foundation for knowledge acquisition in school. Here, we consider the videogame experience of children with developmental disorders in terms of executive functions, visual perspective taking and awareness of others. Executive function. Much research into developmental disorders has focused on aspects of executive function (EF). This is a somewhat imprecise concept (Castellanos et al., 2006; Pennington & Ozonoff, 1996); but it is generally understood to encompass the cognitive processes that control the use of other skills and behaviors. Executive functions are necessary for goal-directed behavior. Examples include the abilities to plan a sequence of actions, to initiate, modify and cease specic behaviors, to coordinate lower level actions and to adjust behavior in the light of altered circumstances. Decits in executive function have been reported for children with ASD (Hill, 2004; Ozonoff et al., 2004; Pennington & Ozonoff, 1996), ADHD (Barkley, 1997; Martinussen & Tannock, 2006; Pennington & Ozonoff, 1996; Rhodes et al., 2004; 2006; Sergeant, Geurts, & Oosterlan, 2002) and specic language impairment (Bishop & Norbury, 2005a, b; Hoffman & Gillam, 2004). The patterns of functional impairment vary across studies and among participants. One challenge to investigators of EFs, pointed out by Rabbitt (1997) and Brown (2006), is that the conventional psychological strategy of attempting to test a process by isolating a single variable that is deemed to reect its operation is by denition inappropriate in this context, as EFs are presumed to manage the integration of lower order cognitive processes. Brown (2006, p. 41) argues that A persons ability to perform the complex, selfmanaged tasks of everyday life provides a much better measure of his or her executive functioning than can neuropsychological tests. Brown stresses that, for a given individual, EF performance is likely to show situational variability and that individuals with ADHD seem to have some specic domains of activity in which they have no difculty in performing these various functions that are, for them, so impaired in virtually every other area of life. Often this is described by ADHD patients as simply a function of the level of their personal interest in the specic activity. This situational variability of the symptoms can be viewed as symptoms of the evidence that the impairments of the brain involved in ADHD are not with these fundamental cognitive functions themselves, but with the central management networks that turn them on and off. Several studies have found evidence that children with ADHD can achieve satisfactory performance on some EF tasks when tested in motivating conditions (including computerized, game-like formats) that they fail to demonstrate on standardized tests (Morein-Zamir, Hommersen, Johnston, & Kingstone, 2008

Parsons, Mitchell, & Leonard, 2004; Pascualvaca, Fantie, Papageorgiou, & Mirsky, 1998). The potential relevance of videogames to the study of performance under motivating conditions is compelling. It is debatable whether all videogames call on the players EFs, but most do. Certainly, most require at least some degree of planning, application of working memory and contextual memory, set shifting, inhibition of prepotent responses, and sufcient procedural uency to adapt swiftly to changes in stimuli and uctuating moment-bymoment task demands. It might be expected that some of these demands could hinder the videogame performance of children with ASD. Relatively little research has addressed this directly, but Russell and Hill (2001) report a computer-game task that they devised to test childrens abilities to monitor their own actions. Participants were required to control (via a mouse) the movements of a dot on screen. The target dot was surrounded by various distractor dots that moved in different directions, out of the players control. The children had to both direct and identify the target dot. The game was played at various levels of difculty. The investigators assumption was that if children with ASD had an action-monitoring executive function decit, then they should nd it difcult to match proprioceptive information with the visual information on screen. In general, the participants with high functioning autism (HFA) performed reasonably well on this task (though not quite as well as TD controls), leading the authors to conclude that there was no evidence of an autism-specic decit in action monitoring. Other ndings indicate that the executive functioning of children with HFA may be less compromised when tested in game-like computer environments. The Wisconsin Card Sorting Task (WCST) is one of the most widely used measures of executive function in children. Using the standard administration procedures (matching stimulus cards with decks of cards based on implicit sorting criteria), it usually reveals a decit in children with ASD compared to typical controls (Ozonoff, 1995). Ozonoff examined the performance of participants with autism using the standard procedure and a computerized version of the task. In the latter condition, differences between those with ASD and TD controls were attenuated. Ozonoff suggests that the computer version reduces some of the social and verbal demands of the standard WCST. Ozonoff and Strayer (1997) found that high-functioning children with ASD were unimpaired, relative to age- and IQmatched normal controls, on two tests of inhibition, a Stop-Signal task and a Negative Priming task. These studies indicate that participants with ASD can meet some of the EF demands of play in computerized environments. More research is needed to examine a wider range of EFs in a wider range of computer/ video game contexts. Poor performance, relative to TD children, on EF tasks, including the WCST, has also been reported for children with ADHD (Romine, Lee, & Wolfe, 2004) and SLI (Marton, 2008). More research is needed on the differences in performance in standard versus computerized versions of the tasks, and of responses to comparable demands in the contexts of richer, noisier but potentially more motivating entertainment videogames. A few studies have attempted directly to examine EF in videogame play by young people with ADHD. Lawrence et al. (2002) had 6- to 12-year-old boys with ADHD, and a comparison group of TD boys, play a relatively simple target video game, Point Blank, and

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a more complex one, Crash Bandicoot. The former is a shooting game. Although it presents varying levels of visuospatial demand, the key response is ring a bullet and the rewards are immediate (hits on target). The latter game involves manipulating a small animated creature through various hazards along a jungle pathway toward a designated checkpoint; at critical points, the player has to inhibit (pause) movement to avoid disaster and can execute various complex moves. Hence, Crash Bandicoot calls on EFs (inhibiting prepotent responses, inhibiting ongoing activity, nonverbal working memory, creation of novel responses) and requires strategic behavior, organized toward a delayed goal, under fast paced task demands. The results indicated that participants with ADHD were as able as TD participants to interrupt ongoing screen activity and inhibit prepotent responses. These pauses were effected at critical moments in the game (i.e., in the face of imminent hazards). This contrasts with impaired performance of children in laboratory tasks such as the stop-go signal task (see above). This is not to conclude, however, that in all respects the performance of children with ADHD was identical to that of TD boys. Lawrence et al. (2002) found evidence of less skilful adherence to rules governing spinning moves and more on task affective exclamations and self talk during the games, responses indicative of difculties in working memory. In a related study with a smaller sample, Lawrence et al. (2004) found that children with ADHD, playing Crash Bandicoot, completed fewer challenges than did TD comparison children. Furthermore, the number of challenges completed was related positively to the number of colors named correctly in the conict condition of the Stroop Color-Word Test and related inversely to the number of perseverative responses and errors on the WCST. These latter measures had been selected as indices of executive function. The authors interpret the pattern of ndings as indicative that impaired EFs and compromised speed of processing in ADHD is evidenced across a wide variety of activities and contexts, including some videogame play. In an independent study, Shaw et al. (2005) also used Crash Bandicoot (as well as another platform game, Frogger) to investigate the inhibitory performance of children with ADHD. Participants were 16 children with ADHD aged between 6 and 14 years, as well as a comparison group of 16 matched TD children. Computerized versions of tests of attention and impulsivity were also administered. These investigators employed a different coding method, focusing on the number of moves and of impulsive errors in the games. They found no difference between groups on either of these measures. The mean error rates were in the region of 6 7%. Performance on the Conners CPT II did indicate impaired inhibitory control in the children with ADHD. The authors conclude that these children may well have inhibitory difculties but that enjoyable video games provide a context in which their performance is enhanced. The Lawrence et al. (2002, 2004) and Shaw et al. (2005) had similar concerns and overlapped on choice of game. However, they had differences in measures and, to some extent, in outcomes. While the Lawrence et al. results indicate some difculties for children with ADHD in the videogame environment, they do not demonstrate complete incapacity, and these children performed well in some respects. In the Lawrence et al. studies, game play lasted for about 20 minutes, while in Shaw et al. it was about 14 minutes. It is possible that longer play is disadvantageous to participants with ADHD. Another difference was that in the Law-

rence et al. studies the participants were without medication for a minimum of 20 hours, while in Shaw et al. the period was only 4 hours, and the latter authors acknowledge there was a possibility that performance may have been affected by residual methylphenidate (p. 14). Taken together, these ndings indicate that children with ADHD can achieve satisfactory cognitive performances in videogames in respect of certain EFs but may also reect some decits in working memory. The ndings do not bear out some expectations from theories of ADHD which predict globally impaired inhibition, but nor do they establish that videogames provide a magical environment in which all difculties are mitigated. Clearly, it would be desirable to extend this kind of study to incorporate a wider range of measures and to include participants with other developmental disorders. Visual perspective taking and awareness of others. Many videogames entail awareness of the perspectives of other entities in the screen environment (and, in collaborative play, of other players). The player may need to appreciate how a scene looks to someone occupying a different standpoint in order to avoid attacks from enemies or to anticipate movements by other virtual or real parties. Visual perspective taking is delayed in children with ASD (Reed & Peterson, 1990) and children with SLI (Farrant, Fletcher, & Maybery, 2006). An important initial question is whether children with ASD recognize that entities represented within videogames can be animate (and therefore capable of having a perspective). Arguably, representation via games or virtual reality is more challenging than media such as TV or video (Parsons et al., 2004). Do people with ASD comprehend the distinction between a videogame environment and the real world? At least for adolescents with HFA, the answer appears to be a clear yes. Parsons et al. tested 12 participants in a virtual reality environment and found that they learned to use the equipment quickly and showed evidence of rapid learning of relevant procedural skills. Most, though not all, participants were able to articulate the differences among virtual reality, video and reality, often quite insightfully. Moore, Cheng, McGath, and Powell (2005) demonstrated that school-age children with autism achieved high levels of accuracy in identifying the emotions displayed by avatars. Rajendran and Mitchell (2000) found that adolescents with AS could interact, even engage in role play, via cartoon-like representations of characters in a computer screen. In brief video-based exposures to virtual reality characters, adults with HFA showed less experience of contact or desire to establish contact with the characters than did typical controls (Schwartz, Bente, Gawronski, Schilbach, & Vogely, in press). Participants with HFA were also less likely than controls to exploit gaze cues and meaningful facial expressions in the virtual characters, consistent with their well-attested decits in mindreading others gaze behavior in everyday life and experimental settings. Ames and Jarrold (in press) found that adolescents with ASD are less able to infer relationships among symbols signaled (in computerized tasks) by temporal co-occurrence. Good videogame players are often required to exploit and react quickly to temporal co-occurrence. In computer-presented examples of simple causality events (based on Mitchottes, 1946/1963, gestalts), Congiu, Schlottman, and Ray (in press) found that young adolescents with HFA did not differ from TD controls in their ability to infer perceptual causality (e.g., to recognize that one square hit or bumped into another

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and made it move). In contrast, the HFA group did show a lower tendency to attribute animacy to the on-screen agents spontaneously (although this increased after prompting). Schwartz et al.s, Ames and Jarrolds, and Congiu et al.s ndings together suggest the possibility that young people with ASD interpret agents within videogames in a differentless socialway than might typical gamers. This may have implications for game performance (e.g., if a gamer fails to interpret appropriately the gaze or intent of a threatening agent). The game experiences, or game preferences, of a player who persistently failed to exploit important cues could well be dramatically different from that of a player who is more sensitive to the relevant information. Little evidence is available on the attributions of animacy and perspective taking skills in videogames among children with ADHD or SLI. A reasonable assumption is that these children are less impaired in these respects than those with ASD. However, it remains to be investigated how rapidly they can attune and respond to cues to others perspectives in such contexts. In sum, videogames draw on various cognitive abilities. Young people with developmental disorders appear to rise effectively to some of the cognitive challenges the games present and may be motivated in these contexts to achieve levels of cognitive performance that they do not manifest ubiquitously. However, there are also aspects that remain difcult for them. Recent research has begun to develop paradigms and methods which allow for the careful analysis of cognitive performance at a moment-by-moment or move-by-move level and these could be exploited more widely in research across the developmental disorders.

Videogames and Social Relationships

It was noted earlier that videogame play can be a solitary or a social experience. It was pointed out that young people with each of the developmental disorders discussed here tend to suffer social impairments. Children who are different are also vulnerable to peer exclusion, and this is a widespread problem for those with developmental disorders (Deater-Deckard, 2001). These considerations prompt questions about how videogame play relates to the childrens social worlds. Preliminary evidence indicates that videogames can serve social functions for young people with ASD, in that they provide a focus for peer discussion and exchange of information (Carrington, Papinczak, & Templeton, 2003; Church, Alisanski, & Amanullah, 2000; Winter-Messiers, 2007). On the other hand, games do seem to be used sometimes as an alternative to peer interaction, or possibly as a source of solace in the face of its nonavailability. Durkin, Whitehouse, Jaquet, Ziatas and Walker (2010) asked TD adolescents and adolescents with AS to rank order their uses of several different functions of cell phones. The TD adolescents placed calling friends as their foremost use, and playing games was ranked fourth; the adolescents with AS ranked playing games second (their primary use was for texting and calling friends was ranked fourth). In TD youth, gaming is interwoven with issues of social identity and peer reputation management (Durkin, 2006). It is interesting there is some evidence that this may also be the case among young people with developmental disorders. Winter-Messiers (2007) found that some adolescents with ASD and AS declared themselves in peer company to be keen gamers, and did play and enjoy

video games. But, when pressed by interviewers, they admitted to more esoteric interests that may not be so socially prestigious in adolescent male circles: Uh, Im a gamer, uh, but my favorite video game, the only one I am actually good at, would be First Person Shooters . . . . But the truth is, I like frogs . . . . frogs, frogs, frogs, frogs! (p.146). Others described how they gauged peer reactions to their main interests and then, in the context of indifference or teasing, turned to the safer theme of videogames. While these social adjustments are probably not unique to adolescents with ASD, and probably not restricted to discussions involving videogames, they are intriguing because they do show sensitivity to others perspectives in young people with a condition associated with social impairment and poor peer relations. Winters-Messiers emphasize that decits in language, nonverbal communication, emotional regulation and ne motor skills diminished when children and youth related to their special interests, including videogames. Parsons et al. (2004) observed that participants with HFA in a virtual cafe environment tended to navigate very close to people in the cafe . They did not show difculties in manipulating around other, nonanimate aspects of the virtual environment, and did understand that the gures represented people. Parsons et al. infer that the participants had a weak understanding of appropriate behavior in respect of personal space. In short, careful analysis of performance within a virtual environment similar to those found in some videogames both illuminates unexpected capacities and highlights possible continuities between real world social behavior and virtual behavior. Less information is available in respect of social uses of games by young people with ADHD or SLI. Durkin et al. (2009) found that adolescents with SLI, in common with TD adolescents, showed a preference for social and entertainment uses (compared to educational uses) of new media, including games. However, the extent to which gaming was integrated into the participants social lives was not addressed. Adolescents with SLI face social difculties but do want to socialize (Wadman, Durkin, & ContiRamsden, 2008). This suggests, but does not conrm, that they would be likely to be aware of and seek to participate in peer enthusiasm for games. In sum, there is mixed preliminary evidence, chiey from young people with ASD or AS, concerning the ways in which videogames can be associated with social behavior and strategies. In some instances, adolescents with AS seem to orient to videogames in similar ways to TD adolescents. They know, or some know, that being interested in videogames can open doors to peer interactions and can affect ones status in the peer community There is also evidence that they may sometimes turn to games when social interaction with peers is not available or not motivatinga phenomenon also very common in TD youth (Durkin, 2006).

For Good or Bad?

There is little doubt that videogames are present in the lives of many young people with developmental disorders and are likely to remain present. This review has focused on what is known of the nature of the interactions between these individuals and games, and it has been stressed that much remains to be discovered. We turn now to the should, and related, questions: Should young people with developmental disorders be encouraged to play

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videogames or discouraged from doing so? Should videogames be exploited in therapeutic interventions with children with special characteristics and needs? Parents and educators of TD children are sometimes confronted with difcult decisions about videogames and their concerns underscore why this relatively neglected area calls for more extensive research attention. With respect to whether young people should play videogames, the answer offered here is a cautious yes: videogame play has the potential to make positive contributions to these childrens lives and development. Of course, as with all children, there are contentious issues concerning which games they should be playing or avoiding, and how much time should be devoted to this activity at the expense of others but, in general, videogames provide enjoyment, highly motivating opportunities for skills development, cognitive and imaginative stimulation. All of these are particularly important forms of support for children with developmental disorders. Evidence (from studies of individuals without disorders or disabilities) is accumulating to conrm that videogame play can offer an excellent environment for the development of perceptuomotor and spatial skills, for rule learning, for the facilitation of exible cognitive strategies (Castel, Pratt, & Drummond, 2005; Ferguson, 2007; Ferguson, Cruz, & Rueda, 2008; Green & Bavelier, 2003, 2006; Greeneld, 1984, 2009; Spence & Feng, 2010; Feng, Spence, & Pratt, 2007). There is extensive evidence that videogames, as well as other computer-delivered activity and training, can provide effective educational tools (Willoughby & Wood, 2008; Underwood & Dockrell, 2007). Questions remain about the transferability of some skills that can be honed in videogame contexts, but the short term effectiveness seems well supported and likely to be built upon in future applications and extensions. We cannot assume that ndings of benets of videogame play for typical adults or children apply automatically to young people with developmental disorders. Careful additional research is needed to test generalizability into these populations, and relatively little has been undertaken to date. The extent to which gains in performancein say, spatial, attentional, or motor skills can be promoted in atypical children via videogame play is of great importance because it speaks to both the modiability and the fundamental limitations of their impairments. For example, we noted earlier that children with ASD revealed a decit on a Global Dot Motion task, involving detection of motion by a target in the context of distractors moving in other directions (Pellicano et al., 2005). Pellicano et al. suggest that the early stages of visual processing may function normally in ASD, but that the neural mechanisms required for integrating local motion signals to form a global motion percept might be compromised. If this is an inherent decit with biological underpinnings, then it should be intractable. Several studies (with typical individuals) have shown that videogame practice can bring about improvements in visual spatial tasks (Green & Bavalier, 2003, 2006, 2007; Greeneld, DeWinstanley, Kilpatrick, & Kaye, 1994). Green and Bavalier (2007) were able to modify participants crowding thresholds (mitigating their vulnerability to the impact of closely packed distractors on target detection). Hence, comparable experimental tests of relevant videogame experience upon the visual spatial performance of children with ASD could contribute valuably to our understanding of the nature of visual processing in this disorder.

Moore and Calvert (2000) found that young children with autism were signicantly more attentive to, and learned more words from, a computerized delivery of a vocabulary training package, as compared to a teacher-delivered version. The computer software was designed to provide sensory reinforcement and to exploit potentially attention-attracting features such as color, animation, music, and interesting sounds. Bosseler and Massaro (2003) showed similarly that children with autism could acquire vocabulary and grammar from a computer-animated tutor. These are promising examples of interventions exploiting the attraction of screen displays to children with autism, all the more notable given the difculties with language development experienced by many children with this disorder. There is also evidence from work with children with ASD that videogames and virtual reality environments can provide comfortable environments for role playing behaviors that are challenging in actual social contexts (Gelfond & Salonius-Pasternak, 2005; Grifths, 2003; Moore et al., 2005; Parsons & Mitchell, 2002; Swettenham, 1996; Whalen, Liend, Ingersool, Dallaire, & Liden, 2006; Wilkinson, Ang, & Goh, 2008). In respect of ADHD, Klingberg, Forssberg, and Westerberg (2002) found that computerized training on working memory tasks over a period of weeks resulted in gradual increases in the amount of information that 11-year-old participants could retain in working memory. Heinrich, Gevensleben, and Strehl (2007) report several studies in which children with ADHD showed improved behavioral and cognitive performance after neurofeedback was delivered via a computer game format. Amon and Campbell (2008) describe encouraging initial results from a pilot study of an attempt to use videogames to provide biofeedback to children with ADHD, aiming to facilitate the childrens awareness of their own internal state and of how to modify it (e.g., by self-calming behaviors). McGraw, Burdette, and Chadwick (2005) had sixth grade students with ADHD use the Dance Dance Revolution game and equipment, which involves dancing on foot pads in response to directional instructions provided by moving arrows on screen. The experimenters reasoning was that decoding and responding to the symbols, under sequence and time constraints with auditory cues, could facilitate pattern recognition and sound-word correspondence, thereby leading to improvements in reading scores. The results did not indicate pervasive gains but were suggestive of small improvements on a digit discrimination task and on a receptive coding test. This innovative intervention might be developed by strengthening the links between the game stimuli and reading task demands (not within the experimenters control in this case because they were working with commercially produced materials). Evidence, discussed earlier, that children with ADHD sometimes manifest superior executive function performance in videogame play than in other contexts (Lawrence et al., 2002, 2004; Shaw et al., 2005) is also encouraging. In respect of children with SLI, there has been considerable interest in the potential efcacy of using computer games in language interventions, most notably the Fast ForWord program (FFW-L; Scientic Learning Corporation, 1998). FFW-L involves interactive games using acoustically processed speech and speech sounds, intended to promote enhanced phonological awareness and grammatical understanding. Substantial improvements in receptive and expressive language scores have been obtained in children with language impairments who have undertaken this form of

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training (Tallal, 2000). However, the program reects particular theoretical assumptions about the underpinnings of SLI. Researchers who have compared FFW-L training with other forms of language therapy in randomized control trials have failed to nd a relative benet (Cohen et al., 2005; Gillam, Loeb, Hoffman, Bohman, Champlin, et al., 2008): that is, participants showed signicant gains in most conditions. In an interesting comparison condition, Gillam et al. used other computer games, and allowed participants some freedom of choice among them. These games were not predicated on a particular theoretical approach and varied in the extent to which they involved verbal content and other forms of auditory and visual stimulation but they proved equally effective to FFW-L. While these ndings question whether the FFW-L programs specic focus on auditory processing skills identies the core difculties of children with SLI (see Gillam et al., 2008, for discussion), they do indicate that computer game based training, including FFW-L, can make positive contributions in language therapy (comparable to conventional treatments) and it is possible that different games could be developed to address effectively other dimensions of language impairment. It is important to bear in mind that children with developmental disorders appear to share with their TD peers the experience of nding videogames enjoyable. This assumption is warranted on the basis of the popularity of the games and caregiver reports of engagement (summarized above), though it would be desirable to investigate directly the extent to which games are enjoyed and how they compare with other activities. Enjoyment is intrinsically important, particularly for individuals who often suffer obstacles and distress because of their impairments, but also because it can heighten the appeal of activities worthwhile for other reasonsthat is, enjoyment in videogame play can promote learning, perseverance and skills development (Ritterfeld & Weber, 2006; Sherry, 2004). Again, as discussed earlier, the dopamine release associated, for some young people, with enjoyable activity and mastery in videogames may contribute to successful learning outcomes and skill gains. Another possibility (not necessarily contradictory to the above) is that videogame play could sometimes be harmful to children with developmental disorders. Again, relatively little research has been addressed to this possibility, and ethical considerations preclude some strategies for testing it. Naturalistic observations may prove informative, though they are not numerous at present. In an exploratory study with small numbers of participants with ADHD and controls, Bioulac et al. (2008) found that parents reported that their ADHD children were less likely to stop playing of their own accord (59% ADHD vs. 90% TD controls). Furthermore, all controls stopped playing upon parental instruction, whereas only 66% of the ADHD group did so. These ndings could be taken to indicate that video game playing is more problematic for children with ADHD (and/or for their parents). However, no comparison activities were included and the sad reality is that much of the behavior of children with ADHD is problematic and challenging to their parents and teachers (Abikoff et al., 2002). For example, reported levels of medication compliance in children with ADHD range from 56% to 75% (Hack & Chow, 2004). In light of this, the fact that some 59% of children were able to regulate their own video game play and 66% stopped on instruction suggests a surprisingly compliant orientation in this potentially highly arousing context. Chan and Rabinowitz (2006) surveyed 9th and 10th grade students and their parents, measuring the young peoples amount

of videogame play, as well as other media use, and (using the Conners Parent Rating Scale,CPRS) parental ratings of their childrens oppositional behavior, hyperactivity, inattention, and total ADHD symptoms. Results included a signicantly higher level of inattentive and ADHD scores for those who played videogames for more than one hour. There was no relationship between oppositional behavior or hyperactivity and videogame use. The sample size was small (51 participants in the less than 1 hour per day group, and 21 in the more than 1 hour per day group). The authors interpret the ndings as showing an increase in ADHD and inattention symptoms in adolescents who play video games for more than one hour per day (presumably meaning higher than rather than increase, as the study was not longitudinal). As the authors stress, this correlational result could be interpreted as an effect of videogame play or a consequence of predisposition affecting leisure choices. The absence of group differences on oppositional behavior and hyperactivity, the facts that only two participants had been diagnosed by clinicians (criteria not reported) as having ADHD and that only eight participants passed the threshold for ADHD on parental ratings (the report does not indicate which level of use group these children fell into), do not support any conclusion of harmful consequences. Furthermore, 20 of the 21 participants in the greater than one hour group were boys, while 40 of the participants in the less than one hour group were girls. Meta-analysis of gender differences in ADHD symptoms indicates that boys score higher than girls on hyperactivity (Gaub & Carlson, 1997). Many studies have shown that boys play videogames more than girls do (Durkin & Barber, 2002; Ohannessian, 2009). Thus, Chan and Rabinowitzs nding appears most likely to reect a gender effect (see Ferguson, in press, on the need to take gender into account in examining putative videogame effects). We should not forget that the absence of video games in a contemporary childs life could signal problems or risk (Durkin, 2006). Young people who do not play may exhibit this unusual orientation because they have better things to do but, as the discussion here suggests, others may have cognitive or visuospatial impairments, negative affective reactions, or a sustained lack of connection with the peer community. Exploiting videogames to support and extend the development of young people with disorders, and to enhance their leisure time, is an attractive prospect not least because it affords means of delivering or supplementing interventions and of stimulating play in a relatively cost-efcient manner. It is not a substitute for other forms of support, nor is it likely to prove a panacea for all the difculties that these children face. Overall, considerable evidence indicates that videogames can be as engaging for children with disorders as they are for other players, and several studies indicate benets in respect of cognitive or social functioning. There is little evidence to indicate that children with developmental disorders are harmed by playing videogames, though a cautious interpretation could be that this is partly because the question has not been addressed extensively.

Future Research Directions

It has been stressed here that, while there are many intriguing and important questions to address concerning videogame uses by young people with developmental disorders, at present we have

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only partial information in respect of most of them. There is much to be done if we are to catch up with the behavior and interests of our research participants and the targets of our interventions and education. At several places, areas in which we need new evidence have been identied. In this section, some additional needs and topics will be outlined.

Descriptive and Survey Information

Although many authors have noted, and some have explored, the uses of videogames by young people with developmental disorders, we lack systematic quantitative data on frequency and duration of use and on game preferences. Surveys can be difcult to administer with some of the relevant participants, though caregiver reports are accessible and could provide valuable information (cf. Shane & Albert, 2008). Given the heterogeneity of any one disorder, there is a need for ne-grained descriptive work, including individual case studies (Frith, 2004). In this respect, there are strong grounds for conducting detailed, descriptive studies of the videogame interests and behaviors of individuals with developmental disorders. For example, some individuals with AS have remarkable perceptual and/or memory abilities (Frith, 2004). Do they apply and exploit these in games, and if so, how? Are memories categorical (e.g., storing information about numerous games, characters, or versions of games) or are they process-related (e.g., recalling previous moves or on-screen events and relating them to current decisions)? Case studies in the neuropsychological tradition provide invaluable information on impairments, strengths and cognitive dissociations in developmental disorders (Baron-Cohen, Wheelwright, et al., 1999; Towgood, Meuwese, Gilbert, Turner, & Burgess, 2009) and this methodology could be exploited to advantage in the present context. If children with a developmental disorder are able to accomplish some complex tasks prociently within a videogame, this provides important evidence that has to be accommodated by theoretical accounts of the nature of the disorder.

learning style also exemplies repetitiveness and perseveration, which could be explained with reference to EF decits. But, more problematically for WCC and EF theories, they also entail an eventual understanding of a whole system of interrelated parts. Baron-Cohen et al. argue also that neither WCC nor EF accounts can explain the high levels of motivation and enthusiasm that are sometimes evident in these preoccupations. Clearly, these arguments could readily be extended to encompass videogame interests in some young people with ASD. Careful investigation of the nature of their play in videogame environments should speak directly to questions of whether and how the children systematize.

Narrative
Traditionally, one of the core organizing features of much media content is narrative structure (Ryan, 2004). Media tell stories factual, fantasy, moral, ideologicalwhich involve varying degrees of structure and coherence. Life itself presents or involves us in events with structure and much social interaction involves the construction and reconstruction of accounts of events we experience, witness or transmit. Learning to recognize, exploit, retell and create narrative structures is thus central to many of childrens encounters with everyday life and education (Nelson, 1996), and a large literature has investigated the ways in which TD children develop and extend the relevant cognitive skills from their preschool years and during their school years (Nelson & Fivush, 2004). Among other attainments in this regard, TD children develop skills in understanding causal connections among events and in relating actions to overarching goals of story protagonists (Low & Durkin, 1998; Linebarger & Piotrowski, 2009; van den Broak, Lorch, & Thurlow, 1996). Videogames are unusual in terms of their narrative properties (Brand, Knight, & Majewski, 2003; Lee, Park, & Jin, 2006). While conventional stories and TV programs have relatively predictable structures in which events unfold in a meaningful sequence, a high proportion of games have open-ended structure (Brand et al.). In contrast to most other narrative sources, videogames do not present a given, authored narrative but the story, if there is one, is experienced, directed and ultimately terminated by the player (Lee et al.). In many cases, the events take place in the present (i.e., the player is not hearing or telling about past events, but is enacting them). The story can range from very simple (Kill enemies) to very complex (as in games such as Sims, Myst). Relative decits in narrative skills, such as story comprehension and retelling have been reported for children with autism (BaronCohen, Leslie, & Frith, 1986; Colle, Baron-Cohen, Wheelwright, & Van der Lely, 2008; Diehl, Bennetto, & Young, 2006; TagerFlusberg, 1995), ADHD (Lorch, Berthiaume, Milich, & van den Broek, 2007; Renz et al., 2003), and SLI (Bishop & Donlan, 2005; Nippold, Manseld, Billow, & Tomblin, 2008). The difculties tend to relate to inferring causal relations, identifying important information, exploiting the goal structure of the narrative (see Lorch et al., 2007). Videogames thus provide an important new arena in which to examine narrative performance. Lawrence et al. (2004) found that participants with ADHD were more likely than TD participants to engage in overt description of their play and on-screen actions. This suggests a developmental lag in mastering the narratives of this genre. Little evidence appears to be available in respect of young people with ASD or SLI. However, using a

Systematizing
Baron-Cohen and his colleagues have argued that the excellent attention to detail found in many individuals with ASD predisposes them to show talent in particular domains (Baron-Cohen, Ashwin, Ashwin, Tavassoli, & Chakrabarti, 2009). The authors propose that talent in these individuals is underpinned by expertise in recognizing repeated patterns in stimuli. Identifying these patterns reects systemizing, whereby the individual infers the rules governing a system of relationships and becomes able to use them effectively to predict future behaviors or outcomes within the system. For example, a person with talent in arithmetic recognizes the rules that govern multiplication and can apply them to compute the product of a pair of numbers. According to Baron-Cohen et al., systemizing skills, or their precursors in obsessive interests, are reected by individuals with ASD in various domains, including motoric, collectible, spatial, and mechanical. Thus, some people with ASD become obsessed with learning routes, others acquire detailed sets of labels (e.g., of plants, or football teams), some develop expertise in taking apart and reassembling mechanical objects, and so on. These involve very good knowledge of details, a feature which could be explained in terms of WCC theory. The

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narrative production task in which participants described the activities of shapes in an animated cartoon lm, Bowler and Tomment (2000) found that children with autism were more likely than chronologically- or age-matched TD peers to involve themselves in the description of the on-screen actions (i.e., they did not maintain the same sense of distance from fantasy). Further research in this area will be of theoretical and practical signicance because of the integral role of narrative in many areas of education and sociocultural understanding, and also because the ubiquity of videogames means that they are likely to remain a common context for the exercise and development of narrative skills. Methodologies developed by Lorch and colleagues could provide a valuable framework for such investigations.

Conclusions
This review proposes that the experiences with videogames among young people with developmental disorders can inform our empirical and theoretical understanding of the childrens potentials and limitations. This eld has an excellent array of methodologies and conceptual frameworks which could, and should, be applied to what children actually do. There are many fascinating issues, still investigated only partially, in relation to the young peoples interactions with this now pervasive medium. Valuable initial work has been conducted on several fronts, and many exciting opportunities lie ahead. Asperger (1944) noted some time ago that the special interests and skills of persons with ASD may reveal much about the nature of their condition and about their potential achievements. The point is relevant in respect of other developmental disorders, too. Videogames are attractive to many young people with these disorders. If scientists and practitioners neglect these interests, we neglect phenomena and processes that are often of great importance to the young people whose conditions we seek to understand and whose well-being we wish to nurture. If, instead, we pursue these interests, we stand to tap into highly motivating activities that promise to tell us much about the dynamics of ongoing cognitive and perceptual activity, the nature of person-environment interactions, and in some circumstances may evoke optimal performance.

Fantasy, Imagination, and the Self

Individuals with autism tend to have impaired imaginative abilities. Yet, the ability to imagine things that have not been experienced directly is drawn upon extensively in many video games (Shapiro, Pen a-Herborn, & Hancock, 2006) and TD young players indicate that enjoyment of fantasy is among their principal reasons for playing (Sherry et al., 2006). For typical people, one of the most compelling features of videogames is that they are immersiveplayers become absorbed not simply in the arousing activities but in the interactivity and sense of spatial presence, of being there (Tamborini & Skalski, 2006). Many TD adolescents indicate high levels of identication with avatars. Blinka (2008) found that 37% of adolescents would rather be like my character and 25% agreed that I possess the same skills and abilities as my character does. Some 65% indicated that they sometimes think about situations from the game while not playing. Although this level of engagement may be commonplace, it depends on the ability of gamers to apply mental models to the objects, events and entities encountered in the game environment (Tamborini & Skalski, 2006). Young people with autism are impaired in these respects. They tend to be highly self-focused (Baron-Cohen, 2005); it is not clear whether their experiences in videogame environments leads to the same kinds of immersive identications experienced by TD youth, nor how adequately they are able to distinguish among virtual and real experiences subsequent to playing. Hobson, Chidambi, Lee, & Meyer (2006) note that children with autism fail to distinguish between their memories for experienced events and their knowledge of those events, acquired from others reports. For example, in an interview study several participants with autism recalled events from their own births. Hobson et al. suggest that this failure to distinguish memories from facts raises questions about other memories in persons with autism and about their abilities to take into account their own affective stances at the time of particular experiences. Again, case studies stand out as a viable initial methodology to investigate how young people with ASD in particular experience the relations among self, avatars, screen characters and screen events. How do young people with this disorder assimilate fun with Sonic the Hedgehog or adventures in Camp Wolfenstein? Do they have a sense of being there? If they have problems differentiating knowledge from experience, how do they reconcile the very different features of the real and videogame worlds?

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Received December 28, 2009 Revision received December 28, 2009 Accepted January 16, 2010

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