Children and adolescents most often play active videogames, or exergames, in a social environment. Social play may enhance the potential benefits of an exergaming experience, much like group exercise and team sports are observed to improve physical activity-related outcomes above those of solitary exercise. Two ubiquitous elements of exergames are cooperation and competition. Previous literature suggests that cooperative and competitive aspects of exergames may affect physiological and psychosocial changes. Competitive play has been found to increase energy expenditure and aggression in short bouts of exergaming. Cooperative exergaming has been found to increase motivation, promote continued play, enhance self-efficacy, and increase pro-social behaviors. In one study, a cooperative exergaming condition also resulted in significant weight loss for overweight and obese adolescents. Individual player differences such as individual preferences, competitiveness, weight status, age, gender, and ethnicity may moderate effects. Although the current volume of literature on competition and cooperation in exergaming is small, social exergames hold promise as an engaging alternative to traditional physical activity interventions and may promote a broad range of positive outcomes for children and adolescents. Principles of cooperation and competition are applicable for developers of health-promoting games. Future research is needed to further understand the mechanisms of how competition and cooperation in social exergaming impact physiological and psychosocial outcomes.