Does Fortnite cause ADHD?

“Does Fortnite cause ADHD?” was one of the questions a parent in my practice recently asked me. She was wrestling with whether to put her son on Concerta for ADD (Attention Deficit Disorder). He is a very bright boy and has always done well academically. His first year of high school has been challenging, with a drop in marks and an increase in anxiety and moodiness. His teacher had mentioned ADD, saying that there was a huge discrepancy between his IQ and his marks and that he seemed to “zone out” in class.

These are typical symptoms of  ADD. ADD, or ADHD when there is hyperactivity involved, usually presents in younger kids. But sometimes bright kids can cruise through for longer, and their diagnosis can be missed until the work starts becoming more demanding. My patient’s question stemmed from the fact that her son was able to focus for hours on Fortnite (a popular action-adventure video game), but seemed unfocused after ten minutes of homework. She was wondering how he could he have ADD when he could focus on a game for so long? Could the game be causing it?

She was also concerned because it seemed as if all the boys in her son’s class were on Concerta or Ritalin. These were the same boys with whom her son was gaming all day. Surely not all of them needed to be on medication to function in a class?

Her observations are very astute. These are the very questions with which researchers and doctors are grappling. Between 2003 and 2011 the diagnosis of ADD/ADHD has increased by 43%, and it keeps rising. We need to ask why.

Any parent will tell you that they always regret letting their kids have a screentime binge because they are left with irritable, oppositional kids afterwards. We know that screen time affects our kids, but does it make them sick? A study published this year in the Journal of American Medical Association found a clear link between symptoms of ADHD and heavy screen use. They could not say if it caused ADHD, or if kids with ADHD use screens more, but they could show a clear link.

Let me be clear. When we look at all the studies on causes of ADD/ADHD, genetics comes out tops. It’s just how the brain is wired. Environmental factors (including screentime) and childhood development seem to influence the presentation, that is, how severe it is. But if a child has it or not, is just a roll of the genetic dice.

When there is ADHD/ADD, then treatment with appropriate medication can be nothing short of miraculous. I have seen kids go from failing, feeling stupid, constantly irritating their friends and always being in trouble to thriving academically and socially. I have a patient that stands out. He barely passed matric and hated school. When his son was diagnosed with ADHD, he realised that he too suffered from it. He started Concerta and discovered a passion for learning. He now has degrees in history, philosophy and is currently doing business science. I can’t help wondering how different his life would have been had he been treated properly from a young age.

But back to my patient’s son. He is one of those “borderline ADD” kids who present later in life. It is sometimes seen with bright kids; they cruise until the workload gets too much and then symptoms present. Does he need medication for his symptoms? Well, I’m not sure yet. He may well fulfil the diagnostic criteria on rating scales, but he also games three to four hours a day.

The neuroscience behind these games, particularly first-person shooter action-adventure games, is multipronged in how it affects the brain. Especially the young, developing brain. Adrenalin and stress hormones are released, putting the body into fight or flight mode. This state of arousal can make a child seem jumpy and irritable, conversations with mom or a math’s class seem mundane by comparison. These games have intermittent rewards which cause spikes in dopamine. Dopamine release feels good, increases focus and sets up craving for these “hits” (and results in incessant nagging in parents’ ears) It is also the same pathways involved with addiction. Lastly, but very importantly, light emissions from screens disturb melatonin’s action which in turn disturbs sleep.

Considering this, I advised my patient first to try to greatly reduce non-work screen time for a term, and then to revisit the ADD question.

Easier said than done because you can’t just remove what a child has been doing for several hours a day, without replacing it with other activities. But what I told her of the neuroscience echoed her own intuition. Already marks have greatly improved. We will see in time if the other ADD symptoms settle a bit.