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Empirical Evidence for the Outcomes of Therapeutic Video Games for Adolescents With Anxiety Disorders: Systematic Review

Empirical Evidence for the Outcomes of Therapeutic Video Games for Adolescents With Anxiety... Background: Extant evidence suggests that the proportion of adolescents suffering from anxiety disorders (ADs) has increased by up to 70% since the mid-1980s, with experience of anxiety at this stage associated with significant negative short- and long-term life outcomes. The existing therapeutic interventions (eg, cognitive behavioral therapy, CBT; attention bias modification, ABM) have proven to have clinically measurable benefits in reducing anxiety, but their efficacy is often compromised by social and practical barriers. The growing discrepancy between demand for, and access to, clinical interventions for anxiety has led to the development of a range of eHealth (health care practice supported by electronic processes and communication) and mHealth (versions of eHealth using mobile devices) interventions. One such protocol is therapeutic games, which aim to provide clinical frameworks in dynamic, adaptable, and personalized virtual environments. Although some evidence exists to suggest therapeutic games are associated with reductions in subjective anxiety and observed stress reactivity, there is currently, to our knowledge, no systematic review of the adherence to, and effectiveness of, therapeutic games for adolescent anxiety. Objective: The aim of this review was to establish the effectiveness of therapeutic games in making clinically measurable reductions in anxiety symptoms in adolescent samples. Methods: A systematic search of the existing academic literature published between 1990 and July 2017 was conducted using the databases Journal of Medical Internet Research, Journal Storage, Psychology Articles, Psychology Info, ScienceDIRECT, and Scopus. Records linked to empirical papers on therapeutic games for anxiety using adolescent samples were evaluated. Results: A total of 5 studies (N=410 participants) met the inclusion criteria, and 3 gamified anxiety interventions for adolescents were identified. The papers included a mixture of randomized controlled trials, quasi-experimental studies, and usability studies comprising quantitative and qualitative measures, with varying degrees of mixed methods. Extant evidence shows potential for therapeutic games to create clinically measurable reductions in symptoms of anxiety in adolescent samples, though findings are complicated in some cases by a low sample size, and in other cases by research design and methodological complications, including anxiety reductions in control groups caused by a control-game selection. Conclusions: Although research in this field appears to be extremely limited, as demonstrated by the small number of papers meeting the inclusion criteria for this review, early findings suggest that therapeutic games have potential in helping to engage adolescents with anxiety and lead to clinically measurable reductions in symptoms. (JMIR Serious Games 2018;6(1):e3) doi: 10.2196/games.9530 KEYWORDS anxiety disorder; video games; adolescent; CBT; eHealth; mental health; mobile health http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott evidence-based early intervention strategies reduce the Introduction probability of negative life outcomes [24], practical barriers to treatment (eg, cost) and social barriers to treatment (eg, stigma) Anxiety Disorders and Adolescence mean as many as 50% of people in the United Kingdom The term anxiety disorder (AD) represents a category of experiencing anxiety do not seek treatment [25]. For those who psychological disorders characterized by feelings of anxiety seek treatment, waiting lists via Improving Access to about future events, and fear reactions to current events [1], in Psychological Therapies (IAPT) referrals can be lengthy, leading addition to increased attentional biases toward threat detection to high dropout [26]. In addition, educational institutions and [2]. ADs are the most prevalent of the psychiatric disorders [3], universities often fail to provide adequate support [27], with affecting approximately 117 million young people worldwide; the existing services unable to meet the rising demand [28]. As it is the sixth leading cause of disability, with the largest a result, in adolescents, it is estimated that less than 20% of longevity among young people aged 15-34 years [4], with a individuals affected by ADs receive treatment [29], with fewer range of factors such as misdiagnosis, health care avoidance than 20% of those seeking and receiving treatment being behaviors, and hardiness, meaning these statistics change provided with interventions supported by scientific evidence relentlessly. [30]. The extant evidence suggests that the proportion of adolescents The growing discrepancy between demand for, and available suffering from ADs has increased by up to 70% since the provision of, mental health services has led to the development mid-1980s and that nearly 300,000 young people in the United of a range of alternative methods for delivering clinical Kingdom have a diagnosable AD [5]. The onset of AD increases interventions for anxiety [31]. eHealth (health care practice significantly during the adolescent years [6], in part as a result supported by electronic processes and communication) and of conflicts regarding existential identity [7], educational mHealth (versions of eHealth using mobile devices) models pressures and high self-expectations [8], negative peer (eg, computerized cognitive behavioral therapy) aim to mitigate comparisons or perceived relational victimization [9], and the impact of both practical and social barriers to treatment by over-demanding intrusive parenting [10,11]. Experience of AD utilizing ubiquitous mediums to broaden the reach of clinical in early life is associated with negative short- and long-term models [32-34]. One such medium is therapeutic video games, implications for social, academic, financial, and health a derivative of serious games. Due to the improved realism in performance [12] and predicts adult anxiety and substance abuse simulated artificial environments and capabilities of disorders [13]. contemporary hardwares, Web-based therapies are more comparable than ever to in vivo forms of treatment [35]. The For the individual, adolescence is both a source of increased gamification of clinical models may be particularly suitable for opportunity and increased pressure and risk [14]. Increased younger people, as they often reflect the typically more visual, social expectations of developing autonomy in self-regulation rapid, and multi-tasking learning styles of a generation with a and self-determination of behavior, coinciding with diminishing lifelong exposure to and familiarity with technology [36,37]. assistance from adults, require the adolescent individual to Therapeutic games afford a flexible and personalized learning develop and coordinate effective emotional and cognitive environment that allows for exploratory learning and behavior capabilities in relatively short time frames. These time frames, practice [38], allowing Web-based environments to be adapted however, do not always correlate well with progress made in in terms of content and challenge to the requirements of the brain maturation [15,16]. Functional magnetic resonance user, which is likely to be conducive to an enhanced learning imaging data also point to a tendency toward an increased experience [39,40]. As games utilize both intrinsic and extrinsic response to emotionally loaded stimuli at this age [17,18]. motivational elements in active and realistic learning Neuroimaging data point to a biomaturational explanation for opportunities with immediate opportunities for feedback, they the increased prevalence of AD in the adolescent years [19]. have already been shown to be capable of eliciting Furthermore, naturally occurring consolidation of neural improvements in self-awareness and self-management behaviors pathways during adolescence may explain the tendency of in people with chronic physical health conditions [41]. In terms experience of AD at this age to lead to negative outcomes in of the benefits of therapeutic games for mental health and later life, leading some to describe AD as a potential gateway well-being, the extant evidence suggests they may be effective disorder [20]. Therefore, effective treatment of adolescent AD across a variety of disorders, including reducing is critical in the mitigation of both its impact at the point of psychopathological symptoms associated with gambling experience and the potential long-term ramifications [21]. disorders [42], and as an effective preliminary treatment to CBT Therapeutic Interventions for Anxiety Disorders for bulimia nervosa [43]. Although the current literature presents Cognitive behavioral therapy (CBT) has been shown to be highly conflicting evidence regarding the health benefits versus health effective in the treatment of ADs [22], reducing or eliminating hazards of video game platforms [35,44], therapeutic games symptoms through the development of effective behavioral utilize a popular platform to achieve clinically measurable health adjustment and coping strategy enhancement. Attention bias improvements and behavioral changes [45]. modification (ABM), an emerging technique derived from Research Questions neurocognitive models of anxiety, has also been noted for having Therapeutic games provide young people with a dynamic, significant potential to enhance both pharmacological and adaptable, and personalized learning environment in which they psychological interventions for anxiety, as well as being an are afforded an opportunity to seek relevant information and effective standalone intervention [23]. However, although http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott guidance in an exploratory manner, receive immediate feedback, versus posttest design to allow for comparison. All searches and utilize unlimited opportunities for repeat engagement [38]. were limited to anxiety. As a result, therapeutic games should offer a more accessible Adolescent sample was defined using American Psychiatric platform for rapid learning and adoption of scientifically Association criteria (10-19 years). As a result, papers that used validated therapeutic techniques. a sample of participants aged between 10 and 19 years were Although some evidence exists to suggest that therapeutic games considered eligible. Papers that used samples including can be linked with reductions in subjective anxiety and observed participants aged 8 or 9 years were considered eligible if the stress reactivity [46], research to date often combines adolescent mean age for the sample was over or very close to 10 years. samples with either child or adult participants, limiting the Papers published in English or German were selected and capacity of the current data in terms of its applicability to the subjected to the inclusion criteria as outlined above. In line with unique nature of anxiety experienced at this life stage. PRISMA guidelines, a specific date range was established. Furthermore, to the researchers’ knowledge, there is currently Studies published between January 1990 and July 2017 were no stated set of guidelines available for the development of selected. This date frame was chosen as papers first studying therapeutic games, to which developers are required to adhere, the effect of video games in the context of health education nor is there a definitive protocol established for their scientific were published in the 1990s [41]. evaluation. Exclusion Criteria Consequently, it is unclear whether the potential benefits of Papers regarding opinion pieces, existing literature reviews, therapeutic games establish themselves in anxiety in adolescents, conference posters, and design documents for therapeutic games and if so, whether any benefits are modulated by the therapeutic were excluded from the review. Study protocols were also framework employed. A systematic review was conducted to eliminated from the review as they would be unable to provide assess the effectiveness of therapeutic games in enhancing outcome measures. Pilot studies were included in the review engagement with clinical interventions, and their efficacies in provided the 4 criteria discussed above were met. making clinically measurable reductions in AD symptoms in adolescent samples. Quality Assessment For the purposes of consistency, one researcher oversaw the Methods initial coding of the papers. Quality assessment of papers meeting the inclusion criteria was assessed using the mixed Databases Searched methods appraisal tool (2011) [47]. The mixed methods Relevant papers were identified by performing a comprehensive appraisal tool is designed for systematic reviews, including a literature search of the following databases: Journal of Medical combination of quantitative, qualitative, and mixed methods Internet Research, Journal Storage, Psychology Articles, studies, and has been noted for its reliability and efficiency as Psychology Info, ScienceDIRECT, and Scopus. a quality assessment protocol, and capability to concomitantly appraise methodological quality across a variety of empirical Search Terms and Selection of Papers for Inclusion research [48]. In line with PRISMA guidelines, an interrater The following search terms were used to address the variety of process was adopted and the degree of agreement was assessed, games that might be played, and the variation in terms used to to reduce risk of bias. describe them: all (“serious game” OR “video game” OR “therapeutic game” OR “online game”) AND all(“adolescen*” Primary Outcome Measure OR “teenage” OR “youth” OR “young adult*”) AND “anxi*.” To assess the extent to which therapeutic games elicit reductions For further detail regarding search terms, definitions, and in AD symptoms, papers were studied for comparisons between variation of input, see Multimedia Appendix 1. measures of anxiety symptoms at pre- versus postintervention. Paper abstracts were initially scanned to determine eligibility. If eligibility could not be determined from the abstract alone, Results or if the paper was deemed as potentially relevant from the Papers Meeting Inclusion Criteria abstract, the full-text paper was studied for its relevance to the review. A total of 2259 records were identified through database searches. After papers published in languages other than English Inclusion Criteria or German, and duplicate instances of papers were removed, In line with the Preferred Reporting Items for Systematic remaining papers were assessed using the inclusion and Reviews and Meta-Analyses (PRISMA) guidelines, clear exclusion criteria outlined above (N=2222). Initially, abstracts inclusion criteria were established to determine the eligibility were searched to assess a paper’s eligibility for inclusion. If of papers for inclusion in the review. Only studies meeting the abstract information alone was not sufficient to determine following criteria were considered eligible for inclusion: papers whether a paper met the criteria, the entire paper was studied. linked to therapeutic games for ADs; studies conducted on Figure 1 shows the number of academic papers from each adolescent samples; empirical research using a randomized database identified using the search terms and the number of controlled trial (RCT) design, quasi-experimental design, or papers meeting the inclusion criteria. correlational design; and studies using a control group or pre- http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott Figure 1. Outcome of literature search. design [49,52], 1 used a quasi-experimental design [50], and 2 Quality Assessment Outcomes were exploratory evaluations and usability studies [50,53]. Of Papers meeting all of the inclusion criteria (N=5) were then the papers reporting qualitative data (N=3) [51-53], all used quality assessed using the procedure described above. interview techniques to obtain varying amounts of qualitative Subsequent to these papers meeting the quality criteria, they feedback. were included in the review. The mean rating for the papers Of the 2 papers focusing on the therapeutic game “Dojo” was 75%, and the modal rating for the papers was 75%. [51,52], one study focused on a pilot study to evaluate Owing to the small number of papers meeting the inclusion perceptions and feasibility of the game [51], whereas the other criteria, all papers included in the review were subsequently paper concerned an RCT comparing the game to “Rayman 2: coded again for interrater reliability. The interrater reliability The Great Escape,” in terms of their relative abilities to reduce for the total scores was 0.8, showing good agreement between adolescent anxiety [52]. the 2 coders regarding paper quality. In terms of quantitative data, one paper focused on the Overview of Papers Included in the Review neurofeedback game “MindLight” [49] using an RCT to compare the game to “Max and the Magic Marker” in terms of Of the 5 studies selected as meeting the criteria for inclusion in their relative abilities to reduce adolescent anxiety. the review, 2 relied solely on quantitative measures [49,50] and 3 used a mixed-methods approach [51-53], with differing One paper used a mixed-methods approach to qualitatively balances of reliance on quantitative versus qualitative data. Of evaluate impressions of the game “gNats Island” using a sample the papers reporting quantitative data (N=5), 2 used an RCT of 6 adolescents [53]. Pre- and posttreatment, and 6-week http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott follow-up, measures of anxiety were assessed quantitatively person experiencing a difficult time, and navigates 3 rooms, using a range of clinical measures to indicate symptom levels headed by a “dojo master” thematically designed to represent for anxiety and a range of other mental health conditions. different emotions: anger, frustration, and fear. In each room, the “dojo master” trains the player in a relevant coping skill for The final paper included in this review utilized a quantitative the emotion, after which the player undertakes a task (eg, in the approach to assess the efficacy of an augmented reality (AR) fear room, the “dojo master” trains the player in deep-breathing therapeutic game [50]. A quasi-experimental design was adopted exercises), then challenges them to collect bones in a labyrinth for this study, recruiting participants to experimental (AR while attempting to evade a powerful and frightening angry exposure therapy) and control (no game exposure) conditions ghost. The player’s heart rate can be monitored and used by the in 2 separate phases. game to increase or decrease game difficulty. Outcomes of Therapeutic Games on Adolescent In one study, “Dojo” was assessed by means of a pilot study Anxiety using a mixed-methods approach [51]. This study was conducted Schoneveld et al [49] utilized an RCT design to examine the in 2 residential treatment centers offering 24-hour care for anxiety-reduction effects of the game “MindLight”—a game youths with severe mental health problems. A total of 8 designed for children and adolescents using a combination of adolescents (mean 14.38 [SD 1.60]) took part in eight 30-min age CBT and ABM [49]. In this game, users are guided through sessions playing “Dojo” on a laptop. These sessions took part relaxation techniques (CBT) and must use a glowing light on twice a week for 4 consecutive weeks—though 3 participants their headset (their “mind light”), which reacts to activity experienced a 2-week break due to scheduling conflicts. The collected from an electroencephalogram (EEG) they wear during participants rated statements regarding game satisfaction on a play, to help them navigate the in-game world and defeat 5-point scale, and they were also offered the opportunity to monsters they encounter. Nonplayable characters (NPCs) provide comments. The Dutch language version of the SCAS become gradually more difficult to ignore, and players must was used to measure anxiety. Reported satisfaction with “Dojo” remain calm (keep their “mind-light” bright) to “decloak” the was high, and both participants and mentors reported high threats (eg, turn a scary cat into a friendly kitten). The game compliance and positive changes in anxiety. The participants also rewards players for attending to and quickly responding to did, however, suggest that “Dojo” became repetitive and would positive stimuli and disattending or moving away from negative have preferred more game rooms. stimuli (ABM). Following this study, Scholten et al [52] then utilized an RCT A total of 136 children aged between 8 and 13 years (mean 9.93 design to examine the anxiety-reduction potential of “Dojo” in [SD 1.33]) were selected after screening for elevated anxiety comparison with “Rayman 2: The Great Escape,” which was and randomized to either an experimental or control condition. chosen as a control game. A total of 138 adolescents (11-15 Experimental participants took part in five 1-hour sessions, years, mean 13.87 [SD 0.91]) were tested both pre- and age scheduled twice a week, in which they played the game postintervention, with a 3-month follow-up (N=126) using the “MindLight” in groups of 7-19 participants at a time. Control SCAS-C. The participants also provided feedback about game participants undertook the same program in terms of time experience and game expectations before the intervention. The allocated to game playing, and group size, but the therapeutic intervention took place over 3 weeks, consisting of two 1-hour game was substituted for a control game “Max and the Magic sessions a week. All the participants accessed their games after Marker.” Self- and parent-reported anxiety levels were assessed school hours in the same room regardless of condition, using pre- and postintervention, followed by a 3-month follow-up, separate computer terminals and headphones to hear game sound using the child and parent versions of the Spence Children’s and diminish distractions. Results indicated that anxiety Anxiety Scale (SCAS-C and SCAS-P) [54]. Latent growth curve symptoms significantly decreased at follow-up in both modeling revealed a significant slope for all models, indicating conditions (total anxiety symptoms: beta=.70, SE=0.04, P<.001; levels of anxiety decreased significantly over time. personalized anxiety symptoms: beta=.63, SE=0.05, P<.001). Intention-to-treat linear regression analysis found no significant Latent growth curve models revealed a steeper decrease of effect, however, of game condition on anxiety outcome. personalized anxiety symptoms in “Dojo,” but not total anxiety Qualitative feedback revealed that “MindLight” was more symptoms. anxiety inducing than “Max and the Magic Marker,” suggesting Coyle et al [53] studied the therapeutic game “gNats Island” “MindLight” was successful in achieving its intended emotional using a series of trials. “gNats Island” is a gamified CBT exposure effects. Furthermore, no difference was found in intervention derived from a paper-based CBT manual for 19 perceived difficulty of the 2 games studied, or their perceived adolescents (total sample aged 11-16 years, 12 males, 7 appeal to other children. “MindLight,” however, was reported females). Players navigate a 3D animated tropical island in by the participants as less appealing to themselves and less which they meet a series of NPCs, which introduce mental likely to induce flow, a common issue with serious games when health concepts using a spoken conversation, embedded they are compared with their more entertainment-focused animations, videos, and questions regarding the player’s own counterparts [55]. situation (to which players can respond by a multiple-choice The therapeutic game “Dojo” appeared in 2 of the papers question). Players carry an in-game notebook to answer further selected for review. “Dojo” is a first-person questions posed by NPCs and record new ideas. Negative emotion-management game that takes place in a secret temple automatic thoughts are represented in-game as “gNats,” which below an urban subway. The player assumes the role of a young http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott sting players to cause negative thinking. Catching, trapping, designed without this primary purpose in mind, other research and swatting gNats are used to represent identification and is based on clinician’s impressions of games, or feedback from challenging of negative thinking. adolescents while in the presence of a clinician, who may also be a member of the design team, creating the potential for bias. In one study, therapists independent of the design team used “gNats Island” with adolescents referred to the psychology team Of the RCTs that exist, these are limited in number (N=2) at the participating hospital experiencing clinical ADs. [49,52]. Furthermore, both these studies reported reductions in Adolescents played the game alongside a clinician who acted anxiety in control groups, with no significant differences in as a partner. Results from questionnaire feedback indicated that anxiety reduction found between the 2 conditions. Authors note adolescents found the game more fun and engaging than “just that control condition games may have inadvertently utilized talking,” and assisted in avoiding perceptions of confrontation game mechanics that trained resilience and coping skills despite in direct face-to-face interaction. Quantitative data indicated a this not being their intended or primary purpose [49], or that decrease in anxiety scores both during and postintervention. No participants may have vicariously acquired coping strategies further statistical data are provided in this study. from their peers in the experimental group, playing their games in the same room at the same time [49,52]. In a second study, a member of the design team used the game with 15 adolescents experiencing issues including anxiety, but In addition, as neither study utilized a waiting-list control group also depression, anger management, and issues relating to autism or comparison to established nongaming therapy for further spectrum conditions. Although some participants used the game comparison, and although the therapeutic games tested seem to in a structured manner, in six 1-hour sessions over 6 weeks, have potential, it is difficult in either case, despite their healthy others used the game flexibly as determined by clinician sample sizes, to establish the extent to which specifically assessments of their individual needs. Qualitative feedback designed therapeutic games may have additional capacities for showed that after the intervention stage had finished, the anxiety reduction in adolescents. As other findings offer no participants preferred to explore the Web-based world, follow-up results, offer pre- versus posttest as control [53], or suggesting “winding down” time may be as important as offer a “wait-list” control but use a game designed for multiple engagement with therapeutic elements of game play. The conditions [50,53], there is a scope for further research to further participants also rated modules 4 and 5 of the game lower than examine the capabilities of specifically designed therapeutic previous elements. Notably, difficulty levels of the game at this games to reduce anxiety in both short term and long term. point had increased, and a core component of CBT had been Current research has also focused on the evaluation and introduced, suggesting pacing at this stage of the game may not exploration of the benefits of therapeutic games in relatively have been as effective as required. Low graphical fidelity of the controlled environments using hardwares such as EEG, AR game was noted by users, but not reported as a barrier. hardware, and heart rate monitoring, which are impractical in The final study eligible for inclusion in this review was everyday environments. Intervention sessions in this field are conducted by Li et al [50] and investigated the effectiveness of routinely scheduled in classrooms [49,52] or clinical “PlayMotion” hardware (which creates Web-based environments environments, sometimes with a practitioner present to guide via AR) using a quasi-experimental design. A total of 122 the interaction [50,51,53]. Although initial findings suggest that children aged between 8 and 16 years (mean 11.85 [SD 2.20]) engagement with therapeutic gaming may assist in clinically age measurable reductions in anxiety symptoms over time, it is not admitted to an oncology ward in a large hospital in Hong Kong clear how effective such games may be in real-life environments. were assigned either to experimental (PlayMotion) or control It is also unclear how such games may have potential to assist (routine nursing care with no engagement in Web-based at the point of symptom experience, either as a distraction interactions) conditions. The participants were recruited in 2 technique or coping mechanism, in an everyday manner. As phases, with all patients admitted in phase 1 assigned to control highlighted previously, access to, and efficacy of, clinically (N=70), followed by a 1-month washout, followed by phase 2, proven interventions for anxiety is limited by practical and in which all patients admitted were assigned to the experimental social barriers to treatment [24], lengthy IAPT referrals [26], condition (N=52). Engagement with the Web-based intervention or inadequate support from their educational institution [27,28]. consisted of 30-min sessions for 5 days a week, with 4 As a result, as many as 50% of individuals who may benefit do participants per group. Anxiety was measured using the not receive any form of therapy [25], with figures significantly SCAS-C, with results indicating no change in anxiety symptoms higher for adolescents [29]. Therapeutic games that successfully after 7 days. manage to breach these practical and social barriers to treatment, overcoming the need for hardwares impractical to day-to-day Discussion life, may be significant in helping to mitigate the short- and Principal Findings long-term implications of one of the most prevalent psychological disorders in a population that is difficult to treat. Although therapeutic games show early signs of promise in helping to alleviate symptoms of anxiety in adolescent samples, A further theme of the current research concerned the structure a number of issues and limitations of the extant evidence have and format of delivery of the existing interventions. For instance, emerged. First, although some evidence utilizes RCT protocols in Scholten et al’s [52] RCT to assess “Dojo,” participants to establish a clear comparison between therapeutic games reported that the duration of the intervention was “too long,” designed specifically for anxiety reduction and control games specifically with regard to maintaining concentration and http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott motivation after approximately 4 sessions. Authors suggested comparison. Furthermore, although some studies to date have that this was potentially a product of “Dojo” being a small game. utilized a follow-up time point, others have not. As a result, the Once adolescents finished the available rooms, as most did after long-term benefits of the use of therapeutic games for adolescent 3-4 sessions, they were required to repeat the rooms until the anxiety is currently unclear. end of the intervention period. Although repeating the rooms Future research would also benefit from further consideration may be seen as a reinforcement of their learning, this repetitive of the applicability and efficacy of therapeutic games in more play may also have caused boredom. Murphy et al [56] suggest ecologically valid settings. Current research to date has explored that although some degree of repetition may be beneficial in the use of therapeutic gaming in systematically controlled improving learning and future experience of flow in video environments. Consequently, the potential of using games in games, repetition without learning anything new, or repetition day-to-day life or at the point of symptom experience remains without experience of even subtle changes in gameplay, can unknown. As noted previously, therapeutic games that disrupt flow and inhibit perceptions of “mastery.” This may successfully manage to breach practical and social barriers to explain wider research in the field, which suggests that programs treatment, with engaging games capable of repeating concepts with shorter durations tend to have better outcomes [57]. of clinical value while maintaining flow, will be of value to the field in establishing the potential of this protocol. Limitations Despite the initial number of studies found through search terms Finally, no current legislative body or code of conduct exists being extensive, the final number of papers successfully meeting for the development and regulation of “therapeutic games,” nor the inclusion criteria was low (N=5). Accordingly, although is there currently a standardized procedure or empirical protocol this was somewhat expected due to the stringency of the criteria for their scientific evaluation. In such an unregulated used in this review, there is further research using therapeutic environment, there is substantial potential, therefore, for misuse games for young adults, which may be of interest in the of the term “therapeutic game” on the part of a more development of games for anxiety aimed at older adolescents. commercially driven developer. The capricious nature of the In addition, while the mean age of participants in papers results presented in the investigations included in this review included in this review was between (or just below) 10-19 years, could be argued to be a product of such methodological the studies used individual participants aged below 10. As a variability, rather than an indication of inconsistencies of result, the data are partially affected by the presence of therapeutic games as effective treatments for anxiety symptoms. participants who do not qualify as adolescents, but rather as Consequently, future research should aim to establish a valid children, making current research to date problematic in and reliable model for the assessment and verification of establishing the extent to which currently available therapeutic therapeutic games, with the view to developing a trustworthy games may be beneficial for older adolescents on the brink of quality-approved protocol. early adulthood. Conclusions Furthermore, this review considered papers with a publication This review aimed to assess the effectiveness of therapeutic date of up to and including July 2017. Due to the fast-paced games in making clinically measurable reductions in AD nature of technology development, particularly with regard to symptoms in adolescent samples. Although research in this field software applications, of which games are an example, the appears to be extremely limited, as demonstrated by the small relevance of this review in terms of its ability to answer the number of papers meeting the inclusion criteria for this review, research questions posed may be time-limited. early findings suggest that therapeutic games have potential in helping to reduce anxiety levels in adolescents. By utilizing this Future Research protocol in a medium that facilitates overcoming the existing As noted by authors of papers included in this review, this is barriers to treatment, therapeutic games may be a valuable an emerging area of interest in the field, and subsequently, there facilitator in reducing the short- and long-term implications of are several avenues of exploration yet to be fully explored. one of the most prevalent psychological disorders in a population Further research would benefit from full RCT studies ensuring that is difficult to treat. appropriate control games are selected, or by using a waiting-list control as a second control condition, to allow for more rigorous Acknowledgments The authors would like to thank the authors of all data used in the review. Conflicts of Interest None declared. Multimedia Appendix 1 Search term definitions and variations of input. 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A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects. J Consult Clin Psychol 2009 Jun;77(3):486-503 [FREE Full text] [doi: 10.1037/a0015168] [Medline: 19485590] Abbreviations ABM: attention bias modification AD: anxiety disorder AR: augmented reality CBT: cognitive behavioral therapy eHealth: health care practice supported by electronic processes and communication IAPT: improving access to psychological therapies mHealth: versions of eHealth using mobile devices NPC: nonplayable character RCT: randomized controlled trial SCAS-C: Spence Children’s Anxiety Scale-Child version SCAS-P: Spence Children’s Anxiety Scale-Parent version Edited by G Eysenbach; submitted 29.11.17; peer-reviewed by A Rathbone, L Sheets; comments to author 11.01.18; revised version received 12.01.18; accepted 17.01.18; published 28.02.18 Please cite as: Barnes S, Prescott J JMIR Serious Games 2018;6(1):e3 URL: http://games.jmir.org/2018/1/e3/ doi: 10.2196/games.9530 PMID: 29490893 ©Steven Barnes, Julie Prescott. Originally published in JMIR Serious Games (http://games.jmir.org), 28.02.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 10 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Empirical Evidence for the Outcomes of Therapeutic Video Games for Adolescents With Anxiety Disorders: Systematic Review

Barnes, Steven; Prescott, Julie
JMIR Serious Games , Volume 6 (1) – Feb 28, 2018
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Abstract

Background: Extant evidence suggests that the proportion of adolescents suffering from anxiety disorders (ADs) has increased by up to 70% since the mid-1980s, with experience of anxiety at this stage associated with significant negative short- and long-term life outcomes. The existing therapeutic interventions (eg, cognitive behavioral therapy, CBT; attention bias modification, ABM) have proven to have clinically measurable benefits in reducing anxiety, but their efficacy is often compromised by social and practical barriers. The growing discrepancy between demand for, and access to, clinical interventions for anxiety has led to the development of a range of eHealth (health care practice supported by electronic processes and communication) and mHealth (versions of eHealth using mobile devices) interventions. One such protocol is therapeutic games, which aim to provide clinical frameworks in dynamic, adaptable, and personalized virtual environments. Although some evidence exists to suggest therapeutic games are associated with reductions in subjective anxiety and observed stress reactivity, there is currently, to our knowledge, no systematic review of the adherence to, and effectiveness of, therapeutic games for adolescent anxiety. Objective: The aim of this review was to establish the effectiveness of therapeutic games in making clinically measurable reductions in anxiety symptoms in adolescent samples. Methods: A systematic search of the existing academic literature published between 1990 and July 2017 was conducted using the databases Journal of Medical Internet Research, Journal Storage, Psychology Articles, Psychology Info, ScienceDIRECT, and Scopus. Records linked to empirical papers on therapeutic games for anxiety using adolescent samples were evaluated. Results: A total of 5 studies (N=410 participants) met the inclusion criteria, and 3 gamified anxiety interventions for adolescents were identified. The papers included a mixture of randomized controlled trials, quasi-experimental studies, and usability studies comprising quantitative and qualitative measures, with varying degrees of mixed methods. Extant evidence shows potential for therapeutic games to create clinically measurable reductions in symptoms of anxiety in adolescent samples, though findings are complicated in some cases by a low sample size, and in other cases by research design and methodological complications, including anxiety reductions in control groups caused by a control-game selection. Conclusions: Although research in this field appears to be extremely limited, as demonstrated by the small number of papers meeting the inclusion criteria for this review, early findings suggest that therapeutic games have potential in helping to engage adolescents with anxiety and lead to clinically measurable reductions in symptoms. (JMIR Serious Games 2018;6(1):e3) doi: 10.2196/games.9530 KEYWORDS anxiety disorder; video games; adolescent; CBT; eHealth; mental health; mobile health http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott evidence-based early intervention strategies reduce the Introduction probability of negative life outcomes [24], practical barriers to treatment (eg, cost) and social barriers to treatment (eg, stigma) Anxiety Disorders and Adolescence mean as many as 50% of people in the United Kingdom The term anxiety disorder (AD) represents a category of experiencing anxiety do not seek treatment [25]. For those who psychological disorders characterized by feelings of anxiety seek treatment, waiting lists via Improving Access to about future events, and fear reactions to current events [1], in Psychological Therapies (IAPT) referrals can be lengthy, leading addition to increased attentional biases toward threat detection to high dropout [26]. In addition, educational institutions and [2]. ADs are the most prevalent of the psychiatric disorders [3], universities often fail to provide adequate support [27], with affecting approximately 117 million young people worldwide; the existing services unable to meet the rising demand [28]. As it is the sixth leading cause of disability, with the largest a result, in adolescents, it is estimated that less than 20% of longevity among young people aged 15-34 years [4], with a individuals affected by ADs receive treatment [29], with fewer range of factors such as misdiagnosis, health care avoidance than 20% of those seeking and receiving treatment being behaviors, and hardiness, meaning these statistics change provided with interventions supported by scientific evidence relentlessly. [30]. The extant evidence suggests that the proportion of adolescents The growing discrepancy between demand for, and available suffering from ADs has increased by up to 70% since the provision of, mental health services has led to the development mid-1980s and that nearly 300,000 young people in the United of a range of alternative methods for delivering clinical Kingdom have a diagnosable AD [5]. The onset of AD increases interventions for anxiety [31]. eHealth (health care practice significantly during the adolescent years [6], in part as a result supported by electronic processes and communication) and of conflicts regarding existential identity [7], educational mHealth (versions of eHealth using mobile devices) models pressures and high self-expectations [8], negative peer (eg, computerized cognitive behavioral therapy) aim to mitigate comparisons or perceived relational victimization [9], and the impact of both practical and social barriers to treatment by over-demanding intrusive parenting [10,11]. Experience of AD utilizing ubiquitous mediums to broaden the reach of clinical in early life is associated with negative short- and long-term models [32-34]. One such medium is therapeutic video games, implications for social, academic, financial, and health a derivative of serious games. Due to the improved realism in performance [12] and predicts adult anxiety and substance abuse simulated artificial environments and capabilities of disorders [13]. contemporary hardwares, Web-based therapies are more comparable than ever to in vivo forms of treatment [35]. The For the individual, adolescence is both a source of increased gamification of clinical models may be particularly suitable for opportunity and increased pressure and risk [14]. Increased younger people, as they often reflect the typically more visual, social expectations of developing autonomy in self-regulation rapid, and multi-tasking learning styles of a generation with a and self-determination of behavior, coinciding with diminishing lifelong exposure to and familiarity with technology [36,37]. assistance from adults, require the adolescent individual to Therapeutic games afford a flexible and personalized learning develop and coordinate effective emotional and cognitive environment that allows for exploratory learning and behavior capabilities in relatively short time frames. These time frames, practice [38], allowing Web-based environments to be adapted however, do not always correlate well with progress made in in terms of content and challenge to the requirements of the brain maturation [15,16]. Functional magnetic resonance user, which is likely to be conducive to an enhanced learning imaging data also point to a tendency toward an increased experience [39,40]. As games utilize both intrinsic and extrinsic response to emotionally loaded stimuli at this age [17,18]. motivational elements in active and realistic learning Neuroimaging data point to a biomaturational explanation for opportunities with immediate opportunities for feedback, they the increased prevalence of AD in the adolescent years [19]. have already been shown to be capable of eliciting Furthermore, naturally occurring consolidation of neural improvements in self-awareness and self-management behaviors pathways during adolescence may explain the tendency of in people with chronic physical health conditions [41]. In terms experience of AD at this age to lead to negative outcomes in of the benefits of therapeutic games for mental health and later life, leading some to describe AD as a potential gateway well-being, the extant evidence suggests they may be effective disorder [20]. Therefore, effective treatment of adolescent AD across a variety of disorders, including reducing is critical in the mitigation of both its impact at the point of psychopathological symptoms associated with gambling experience and the potential long-term ramifications [21]. disorders [42], and as an effective preliminary treatment to CBT Therapeutic Interventions for Anxiety Disorders for bulimia nervosa [43]. Although the current literature presents Cognitive behavioral therapy (CBT) has been shown to be highly conflicting evidence regarding the health benefits versus health effective in the treatment of ADs [22], reducing or eliminating hazards of video game platforms [35,44], therapeutic games symptoms through the development of effective behavioral utilize a popular platform to achieve clinically measurable health adjustment and coping strategy enhancement. Attention bias improvements and behavioral changes [45]. modification (ABM), an emerging technique derived from Research Questions neurocognitive models of anxiety, has also been noted for having Therapeutic games provide young people with a dynamic, significant potential to enhance both pharmacological and adaptable, and personalized learning environment in which they psychological interventions for anxiety, as well as being an are afforded an opportunity to seek relevant information and effective standalone intervention [23]. However, although http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott guidance in an exploratory manner, receive immediate feedback, versus posttest design to allow for comparison. All searches and utilize unlimited opportunities for repeat engagement [38]. were limited to anxiety. As a result, therapeutic games should offer a more accessible Adolescent sample was defined using American Psychiatric platform for rapid learning and adoption of scientifically Association criteria (10-19 years). As a result, papers that used validated therapeutic techniques. a sample of participants aged between 10 and 19 years were Although some evidence exists to suggest that therapeutic games considered eligible. Papers that used samples including can be linked with reductions in subjective anxiety and observed participants aged 8 or 9 years were considered eligible if the stress reactivity [46], research to date often combines adolescent mean age for the sample was over or very close to 10 years. samples with either child or adult participants, limiting the Papers published in English or German were selected and capacity of the current data in terms of its applicability to the subjected to the inclusion criteria as outlined above. In line with unique nature of anxiety experienced at this life stage. PRISMA guidelines, a specific date range was established. Furthermore, to the researchers’ knowledge, there is currently Studies published between January 1990 and July 2017 were no stated set of guidelines available for the development of selected. This date frame was chosen as papers first studying therapeutic games, to which developers are required to adhere, the effect of video games in the context of health education nor is there a definitive protocol established for their scientific were published in the 1990s [41]. evaluation. Exclusion Criteria Consequently, it is unclear whether the potential benefits of Papers regarding opinion pieces, existing literature reviews, therapeutic games establish themselves in anxiety in adolescents, conference posters, and design documents for therapeutic games and if so, whether any benefits are modulated by the therapeutic were excluded from the review. Study protocols were also framework employed. A systematic review was conducted to eliminated from the review as they would be unable to provide assess the effectiveness of therapeutic games in enhancing outcome measures. Pilot studies were included in the review engagement with clinical interventions, and their efficacies in provided the 4 criteria discussed above were met. making clinically measurable reductions in AD symptoms in adolescent samples. Quality Assessment For the purposes of consistency, one researcher oversaw the Methods initial coding of the papers. Quality assessment of papers meeting the inclusion criteria was assessed using the mixed Databases Searched methods appraisal tool (2011) [47]. The mixed methods Relevant papers were identified by performing a comprehensive appraisal tool is designed for systematic reviews, including a literature search of the following databases: Journal of Medical combination of quantitative, qualitative, and mixed methods Internet Research, Journal Storage, Psychology Articles, studies, and has been noted for its reliability and efficiency as Psychology Info, ScienceDIRECT, and Scopus. a quality assessment protocol, and capability to concomitantly appraise methodological quality across a variety of empirical Search Terms and Selection of Papers for Inclusion research [48]. In line with PRISMA guidelines, an interrater The following search terms were used to address the variety of process was adopted and the degree of agreement was assessed, games that might be played, and the variation in terms used to to reduce risk of bias. describe them: all (“serious game” OR “video game” OR “therapeutic game” OR “online game”) AND all(“adolescen*” Primary Outcome Measure OR “teenage” OR “youth” OR “young adult*”) AND “anxi*.” To assess the extent to which therapeutic games elicit reductions For further detail regarding search terms, definitions, and in AD symptoms, papers were studied for comparisons between variation of input, see Multimedia Appendix 1. measures of anxiety symptoms at pre- versus postintervention. Paper abstracts were initially scanned to determine eligibility. If eligibility could not be determined from the abstract alone, Results or if the paper was deemed as potentially relevant from the Papers Meeting Inclusion Criteria abstract, the full-text paper was studied for its relevance to the review. A total of 2259 records were identified through database searches. After papers published in languages other than English Inclusion Criteria or German, and duplicate instances of papers were removed, In line with the Preferred Reporting Items for Systematic remaining papers were assessed using the inclusion and Reviews and Meta-Analyses (PRISMA) guidelines, clear exclusion criteria outlined above (N=2222). Initially, abstracts inclusion criteria were established to determine the eligibility were searched to assess a paper’s eligibility for inclusion. If of papers for inclusion in the review. Only studies meeting the abstract information alone was not sufficient to determine following criteria were considered eligible for inclusion: papers whether a paper met the criteria, the entire paper was studied. linked to therapeutic games for ADs; studies conducted on Figure 1 shows the number of academic papers from each adolescent samples; empirical research using a randomized database identified using the search terms and the number of controlled trial (RCT) design, quasi-experimental design, or papers meeting the inclusion criteria. correlational design; and studies using a control group or pre- http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott Figure 1. Outcome of literature search. design [49,52], 1 used a quasi-experimental design [50], and 2 Quality Assessment Outcomes were exploratory evaluations and usability studies [50,53]. Of Papers meeting all of the inclusion criteria (N=5) were then the papers reporting qualitative data (N=3) [51-53], all used quality assessed using the procedure described above. interview techniques to obtain varying amounts of qualitative Subsequent to these papers meeting the quality criteria, they feedback. were included in the review. The mean rating for the papers Of the 2 papers focusing on the therapeutic game “Dojo” was 75%, and the modal rating for the papers was 75%. [51,52], one study focused on a pilot study to evaluate Owing to the small number of papers meeting the inclusion perceptions and feasibility of the game [51], whereas the other criteria, all papers included in the review were subsequently paper concerned an RCT comparing the game to “Rayman 2: coded again for interrater reliability. The interrater reliability The Great Escape,” in terms of their relative abilities to reduce for the total scores was 0.8, showing good agreement between adolescent anxiety [52]. the 2 coders regarding paper quality. In terms of quantitative data, one paper focused on the Overview of Papers Included in the Review neurofeedback game “MindLight” [49] using an RCT to compare the game to “Max and the Magic Marker” in terms of Of the 5 studies selected as meeting the criteria for inclusion in their relative abilities to reduce adolescent anxiety. the review, 2 relied solely on quantitative measures [49,50] and 3 used a mixed-methods approach [51-53], with differing One paper used a mixed-methods approach to qualitatively balances of reliance on quantitative versus qualitative data. Of evaluate impressions of the game “gNats Island” using a sample the papers reporting quantitative data (N=5), 2 used an RCT of 6 adolescents [53]. Pre- and posttreatment, and 6-week http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott follow-up, measures of anxiety were assessed quantitatively person experiencing a difficult time, and navigates 3 rooms, using a range of clinical measures to indicate symptom levels headed by a “dojo master” thematically designed to represent for anxiety and a range of other mental health conditions. different emotions: anger, frustration, and fear. In each room, the “dojo master” trains the player in a relevant coping skill for The final paper included in this review utilized a quantitative the emotion, after which the player undertakes a task (eg, in the approach to assess the efficacy of an augmented reality (AR) fear room, the “dojo master” trains the player in deep-breathing therapeutic game [50]. A quasi-experimental design was adopted exercises), then challenges them to collect bones in a labyrinth for this study, recruiting participants to experimental (AR while attempting to evade a powerful and frightening angry exposure therapy) and control (no game exposure) conditions ghost. The player’s heart rate can be monitored and used by the in 2 separate phases. game to increase or decrease game difficulty. Outcomes of Therapeutic Games on Adolescent In one study, “Dojo” was assessed by means of a pilot study Anxiety using a mixed-methods approach [51]. This study was conducted Schoneveld et al [49] utilized an RCT design to examine the in 2 residential treatment centers offering 24-hour care for anxiety-reduction effects of the game “MindLight”—a game youths with severe mental health problems. A total of 8 designed for children and adolescents using a combination of adolescents (mean 14.38 [SD 1.60]) took part in eight 30-min age CBT and ABM [49]. In this game, users are guided through sessions playing “Dojo” on a laptop. These sessions took part relaxation techniques (CBT) and must use a glowing light on twice a week for 4 consecutive weeks—though 3 participants their headset (their “mind light”), which reacts to activity experienced a 2-week break due to scheduling conflicts. The collected from an electroencephalogram (EEG) they wear during participants rated statements regarding game satisfaction on a play, to help them navigate the in-game world and defeat 5-point scale, and they were also offered the opportunity to monsters they encounter. Nonplayable characters (NPCs) provide comments. The Dutch language version of the SCAS become gradually more difficult to ignore, and players must was used to measure anxiety. Reported satisfaction with “Dojo” remain calm (keep their “mind-light” bright) to “decloak” the was high, and both participants and mentors reported high threats (eg, turn a scary cat into a friendly kitten). The game compliance and positive changes in anxiety. The participants also rewards players for attending to and quickly responding to did, however, suggest that “Dojo” became repetitive and would positive stimuli and disattending or moving away from negative have preferred more game rooms. stimuli (ABM). Following this study, Scholten et al [52] then utilized an RCT A total of 136 children aged between 8 and 13 years (mean 9.93 design to examine the anxiety-reduction potential of “Dojo” in [SD 1.33]) were selected after screening for elevated anxiety comparison with “Rayman 2: The Great Escape,” which was and randomized to either an experimental or control condition. chosen as a control game. A total of 138 adolescents (11-15 Experimental participants took part in five 1-hour sessions, years, mean 13.87 [SD 0.91]) were tested both pre- and age scheduled twice a week, in which they played the game postintervention, with a 3-month follow-up (N=126) using the “MindLight” in groups of 7-19 participants at a time. Control SCAS-C. The participants also provided feedback about game participants undertook the same program in terms of time experience and game expectations before the intervention. The allocated to game playing, and group size, but the therapeutic intervention took place over 3 weeks, consisting of two 1-hour game was substituted for a control game “Max and the Magic sessions a week. All the participants accessed their games after Marker.” Self- and parent-reported anxiety levels were assessed school hours in the same room regardless of condition, using pre- and postintervention, followed by a 3-month follow-up, separate computer terminals and headphones to hear game sound using the child and parent versions of the Spence Children’s and diminish distractions. Results indicated that anxiety Anxiety Scale (SCAS-C and SCAS-P) [54]. Latent growth curve symptoms significantly decreased at follow-up in both modeling revealed a significant slope for all models, indicating conditions (total anxiety symptoms: beta=.70, SE=0.04, P<.001; levels of anxiety decreased significantly over time. personalized anxiety symptoms: beta=.63, SE=0.05, P<.001). Intention-to-treat linear regression analysis found no significant Latent growth curve models revealed a steeper decrease of effect, however, of game condition on anxiety outcome. personalized anxiety symptoms in “Dojo,” but not total anxiety Qualitative feedback revealed that “MindLight” was more symptoms. anxiety inducing than “Max and the Magic Marker,” suggesting Coyle et al [53] studied the therapeutic game “gNats Island” “MindLight” was successful in achieving its intended emotional using a series of trials. “gNats Island” is a gamified CBT exposure effects. Furthermore, no difference was found in intervention derived from a paper-based CBT manual for 19 perceived difficulty of the 2 games studied, or their perceived adolescents (total sample aged 11-16 years, 12 males, 7 appeal to other children. “MindLight,” however, was reported females). Players navigate a 3D animated tropical island in by the participants as less appealing to themselves and less which they meet a series of NPCs, which introduce mental likely to induce flow, a common issue with serious games when health concepts using a spoken conversation, embedded they are compared with their more entertainment-focused animations, videos, and questions regarding the player’s own counterparts [55]. situation (to which players can respond by a multiple-choice The therapeutic game “Dojo” appeared in 2 of the papers question). Players carry an in-game notebook to answer further selected for review. “Dojo” is a first-person questions posed by NPCs and record new ideas. Negative emotion-management game that takes place in a secret temple automatic thoughts are represented in-game as “gNats,” which below an urban subway. The player assumes the role of a young http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott sting players to cause negative thinking. Catching, trapping, designed without this primary purpose in mind, other research and swatting gNats are used to represent identification and is based on clinician’s impressions of games, or feedback from challenging of negative thinking. adolescents while in the presence of a clinician, who may also be a member of the design team, creating the potential for bias. In one study, therapists independent of the design team used “gNats Island” with adolescents referred to the psychology team Of the RCTs that exist, these are limited in number (N=2) at the participating hospital experiencing clinical ADs. [49,52]. Furthermore, both these studies reported reductions in Adolescents played the game alongside a clinician who acted anxiety in control groups, with no significant differences in as a partner. Results from questionnaire feedback indicated that anxiety reduction found between the 2 conditions. Authors note adolescents found the game more fun and engaging than “just that control condition games may have inadvertently utilized talking,” and assisted in avoiding perceptions of confrontation game mechanics that trained resilience and coping skills despite in direct face-to-face interaction. Quantitative data indicated a this not being their intended or primary purpose [49], or that decrease in anxiety scores both during and postintervention. No participants may have vicariously acquired coping strategies further statistical data are provided in this study. from their peers in the experimental group, playing their games in the same room at the same time [49,52]. In a second study, a member of the design team used the game with 15 adolescents experiencing issues including anxiety, but In addition, as neither study utilized a waiting-list control group also depression, anger management, and issues relating to autism or comparison to established nongaming therapy for further spectrum conditions. Although some participants used the game comparison, and although the therapeutic games tested seem to in a structured manner, in six 1-hour sessions over 6 weeks, have potential, it is difficult in either case, despite their healthy others used the game flexibly as determined by clinician sample sizes, to establish the extent to which specifically assessments of their individual needs. Qualitative feedback designed therapeutic games may have additional capacities for showed that after the intervention stage had finished, the anxiety reduction in adolescents. As other findings offer no participants preferred to explore the Web-based world, follow-up results, offer pre- versus posttest as control [53], or suggesting “winding down” time may be as important as offer a “wait-list” control but use a game designed for multiple engagement with therapeutic elements of game play. The conditions [50,53], there is a scope for further research to further participants also rated modules 4 and 5 of the game lower than examine the capabilities of specifically designed therapeutic previous elements. Notably, difficulty levels of the game at this games to reduce anxiety in both short term and long term. point had increased, and a core component of CBT had been Current research has also focused on the evaluation and introduced, suggesting pacing at this stage of the game may not exploration of the benefits of therapeutic games in relatively have been as effective as required. Low graphical fidelity of the controlled environments using hardwares such as EEG, AR game was noted by users, but not reported as a barrier. hardware, and heart rate monitoring, which are impractical in The final study eligible for inclusion in this review was everyday environments. Intervention sessions in this field are conducted by Li et al [50] and investigated the effectiveness of routinely scheduled in classrooms [49,52] or clinical “PlayMotion” hardware (which creates Web-based environments environments, sometimes with a practitioner present to guide via AR) using a quasi-experimental design. A total of 122 the interaction [50,51,53]. Although initial findings suggest that children aged between 8 and 16 years (mean 11.85 [SD 2.20]) engagement with therapeutic gaming may assist in clinically age measurable reductions in anxiety symptoms over time, it is not admitted to an oncology ward in a large hospital in Hong Kong clear how effective such games may be in real-life environments. were assigned either to experimental (PlayMotion) or control It is also unclear how such games may have potential to assist (routine nursing care with no engagement in Web-based at the point of symptom experience, either as a distraction interactions) conditions. The participants were recruited in 2 technique or coping mechanism, in an everyday manner. As phases, with all patients admitted in phase 1 assigned to control highlighted previously, access to, and efficacy of, clinically (N=70), followed by a 1-month washout, followed by phase 2, proven interventions for anxiety is limited by practical and in which all patients admitted were assigned to the experimental social barriers to treatment [24], lengthy IAPT referrals [26], condition (N=52). Engagement with the Web-based intervention or inadequate support from their educational institution [27,28]. consisted of 30-min sessions for 5 days a week, with 4 As a result, as many as 50% of individuals who may benefit do participants per group. Anxiety was measured using the not receive any form of therapy [25], with figures significantly SCAS-C, with results indicating no change in anxiety symptoms higher for adolescents [29]. Therapeutic games that successfully after 7 days. manage to breach these practical and social barriers to treatment, overcoming the need for hardwares impractical to day-to-day Discussion life, may be significant in helping to mitigate the short- and Principal Findings long-term implications of one of the most prevalent psychological disorders in a population that is difficult to treat. Although therapeutic games show early signs of promise in helping to alleviate symptoms of anxiety in adolescent samples, A further theme of the current research concerned the structure a number of issues and limitations of the extant evidence have and format of delivery of the existing interventions. For instance, emerged. First, although some evidence utilizes RCT protocols in Scholten et al’s [52] RCT to assess “Dojo,” participants to establish a clear comparison between therapeutic games reported that the duration of the intervention was “too long,” designed specifically for anxiety reduction and control games specifically with regard to maintaining concentration and http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Barnes & Prescott motivation after approximately 4 sessions. Authors suggested comparison. Furthermore, although some studies to date have that this was potentially a product of “Dojo” being a small game. utilized a follow-up time point, others have not. As a result, the Once adolescents finished the available rooms, as most did after long-term benefits of the use of therapeutic games for adolescent 3-4 sessions, they were required to repeat the rooms until the anxiety is currently unclear. end of the intervention period. Although repeating the rooms Future research would also benefit from further consideration may be seen as a reinforcement of their learning, this repetitive of the applicability and efficacy of therapeutic games in more play may also have caused boredom. Murphy et al [56] suggest ecologically valid settings. Current research to date has explored that although some degree of repetition may be beneficial in the use of therapeutic gaming in systematically controlled improving learning and future experience of flow in video environments. Consequently, the potential of using games in games, repetition without learning anything new, or repetition day-to-day life or at the point of symptom experience remains without experience of even subtle changes in gameplay, can unknown. As noted previously, therapeutic games that disrupt flow and inhibit perceptions of “mastery.” This may successfully manage to breach practical and social barriers to explain wider research in the field, which suggests that programs treatment, with engaging games capable of repeating concepts with shorter durations tend to have better outcomes [57]. of clinical value while maintaining flow, will be of value to the field in establishing the potential of this protocol. Limitations Despite the initial number of studies found through search terms Finally, no current legislative body or code of conduct exists being extensive, the final number of papers successfully meeting for the development and regulation of “therapeutic games,” nor the inclusion criteria was low (N=5). Accordingly, although is there currently a standardized procedure or empirical protocol this was somewhat expected due to the stringency of the criteria for their scientific evaluation. In such an unregulated used in this review, there is further research using therapeutic environment, there is substantial potential, therefore, for misuse games for young adults, which may be of interest in the of the term “therapeutic game” on the part of a more development of games for anxiety aimed at older adolescents. commercially driven developer. The capricious nature of the In addition, while the mean age of participants in papers results presented in the investigations included in this review included in this review was between (or just below) 10-19 years, could be argued to be a product of such methodological the studies used individual participants aged below 10. As a variability, rather than an indication of inconsistencies of result, the data are partially affected by the presence of therapeutic games as effective treatments for anxiety symptoms. participants who do not qualify as adolescents, but rather as Consequently, future research should aim to establish a valid children, making current research to date problematic in and reliable model for the assessment and verification of establishing the extent to which currently available therapeutic therapeutic games, with the view to developing a trustworthy games may be beneficial for older adolescents on the brink of quality-approved protocol. early adulthood. Conclusions Furthermore, this review considered papers with a publication This review aimed to assess the effectiveness of therapeutic date of up to and including July 2017. Due to the fast-paced games in making clinically measurable reductions in AD nature of technology development, particularly with regard to symptoms in adolescent samples. Although research in this field software applications, of which games are an example, the appears to be extremely limited, as demonstrated by the small relevance of this review in terms of its ability to answer the number of papers meeting the inclusion criteria for this review, research questions posed may be time-limited. early findings suggest that therapeutic games have potential in helping to reduce anxiety levels in adolescents. By utilizing this Future Research protocol in a medium that facilitates overcoming the existing As noted by authors of papers included in this review, this is barriers to treatment, therapeutic games may be a valuable an emerging area of interest in the field, and subsequently, there facilitator in reducing the short- and long-term implications of are several avenues of exploration yet to be fully explored. one of the most prevalent psychological disorders in a population Further research would benefit from full RCT studies ensuring that is difficult to treat. appropriate control games are selected, or by using a waiting-list control as a second control condition, to allow for more rigorous Acknowledgments The authors would like to thank the authors of all data used in the review. Conflicts of Interest None declared. Multimedia Appendix 1 Search term definitions and variations of input. 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J Consult Clin Psychol 2009 Jun;77(3):486-503 [FREE Full text] [doi: 10.1037/a0015168] [Medline: 19485590] Abbreviations ABM: attention bias modification AD: anxiety disorder AR: augmented reality CBT: cognitive behavioral therapy eHealth: health care practice supported by electronic processes and communication IAPT: improving access to psychological therapies mHealth: versions of eHealth using mobile devices NPC: nonplayable character RCT: randomized controlled trial SCAS-C: Spence Children’s Anxiety Scale-Child version SCAS-P: Spence Children’s Anxiety Scale-Parent version Edited by G Eysenbach; submitted 29.11.17; peer-reviewed by A Rathbone, L Sheets; comments to author 11.01.18; revised version received 12.01.18; accepted 17.01.18; published 28.02.18 Please cite as: Barnes S, Prescott J JMIR Serious Games 2018;6(1):e3 URL: http://games.jmir.org/2018/1/e3/ doi: 10.2196/games.9530 PMID: 29490893 ©Steven Barnes, Julie Prescott. Originally published in JMIR Serious Games (http://games.jmir.org), 28.02.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/1/e3/ JMIR Serious Games 2018 | vol. 6 | iss. 1 | e3 | p. 10 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Feb 28, 2018

Keywords: anxiety disorder; video games; adolescent; CBT; eHealth; mental health; mobile health

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