Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial

Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in... Background: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment. (JMIR Serious Games 2018;6(2):e9) doi: 10.2196/games.8902 KEYWORDS gamification; mobile health; ecological momentary intervention; cognitive behavioral therapy; child anxiety treatment; SmartCAT; childhood anxiety disorders elements to engage people in nongame contexts [19]. Among Introduction children, the use of gamification is particularly effective in addressing the problem of lack of motivation [20]. When Background integrated with mHealth apps, gamification can potentially make The results of multiple independent randomized clinical trials tedious activities on mHealth apps more engaging to children, provide evidence that cognitive behavioral therapy (CBT) is an thus increasing their motivation to use them. efficacious treatment for childhood anxiety [1-7]. CBT typically Goal of This Project requires 10 to 20 weeks of weekly sessions with a CBT therapist [8] and emphasizes the importance of CBT skills rehearsal, The purpose of this project was multifaceted. First, we exposure tasks, and practice beyond office visits (homework) redesigned our existing mHealth system, titled [9-13]. Markedly, about 40% of anxious children receiving CBT “Smartphone-enhanced Child Anxiety Treatment” (SmartCAT), treatment show little recovery from primary anxiety diagnoses, consisting of a smartphone app (SmartCAT app), a therapist despite evidence suggesting CBT is an efficacious treatment portal (SmartCAT portal), and a two-way communication [8]. One possibility is that treatment requires a willingness to connecting them [21]. This redesign included gamification learn and practice CBT skills beyond therapy sessions. techniques as well as a number of interactive skill-builder modules to increase user engagement or retention and facilitate Although homework is routinely assigned, many anxious learning. Second, we evaluated the utility of the redesigned children struggle with homework completion [14] possibly SmartCAT as an adjunctive component to CBT treatment in an because of a lack of therapeutic commitment or motivation [15]. open clinical trial. User engagement data (ie, time spent on app Unlike adults who are often self-referred, children are usually and app use) and the app retention (app use per session) at brought to therapy by their parents or caregivers. As a result, posttreatment were used to assess the utility. Finally, the these children are not always considered to be “voluntary effectiveness of gamification was evaluated by comparing user participants” in therapy and may view homework as unfavorable engagement data with the previous version of SmartCAT [16]. Therapists note that other noncompliance factors include without gamification. forgetfulness and lack of understanding of CBT skills [14]. Overcoming Barriers to Home-Based Skills Practice Methods for Children User-Centered Design Mobile health (mHealth) technologies present potential solutions A user-centered design (UCD) approach was used to gather to overcoming barriers to fostering home-based skills practice requirements and iteratively design the system, leveraging the for children. First, the “always-carried” and “always-on” nature SmartCAT 1.0 system that had been previously pilot-tested of smartphones creates an opportunity to deliver CBT [21]. In this version, the app notifies patients to initiate a “skills interventions to children in natural settings during their everyday coach” module, which then cues patients to complete a series lives, an approach referred to as “ecological momentary of questions about recent emotional events and to apply skills intervention” (EMI) [17]. EMIs can provide skills coaching to learned in therapy toward coping with that event. Throughout anxious children in the real world outside of sessions, when it this study, the skills coach was scheduled from the portal by is most needed. Anxious children can also access training the therapist to launch automatically once per day (either at a materials in situ at their convenience throughout the day. fixed or random time depending on patients’ desire) and be Second, the increased processing and sensing capability of completed more frequently if desired by the patient. It could smartphones allows for more sophisticated, interactive, and also be activated at “opportune” moments when patients were engaging health intervention apps. This provides an opportunity experiencing acute anxiety. After completing a skills coach for developers to make context-aware mHealth apps that can entry, patients were rewarded with digital points that could be automatically detect when and where children require skills “cashed in” for a prize. coaching during real-world emotional situations. Although the skills coach in SmartCAT 1.0 was actively used, Despite this potential, the repetitive tasks (eg, self-monitoring averaging 5.36 times per session, children and therapists and self-management) that characterize most mHealth apps can suggested several potential improvements including developing be exhausting and may lack intrinsic rewards [18]. An more interactive and fun ways for the children to learn and alternative to traditional mHealth apps is the use of gamification, practice CBT skills in daily life and also improving rewards to one of many persuasive approaches that uses game design http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al increase the rates of CBT skills practice. On the basis of this used as an appropriate way to provide an interactive yet feedback, we redesigned and developed a new system using the fun learning environment beyond the weekly in-person iterative, user-centered approach described below. sessions. Ultimately, game-based learning provides a type of game play that has well-defined learning outcomes. The SmartCAT addresses barriers to home-based skills practice Moreover, research suggests that games can effectively for children by (1) Providing automatic cues to children to model the learning process in that games require players to practice skills at prescribed times and places, even when they be active and to provide immediate feedback as a result of forget to initiate skills practice on their own; (2) Motivating players’ decisions during game play [24]. To facilitate the children to practice skills; and (3) Providing interactive ways learning of coping skills, several CBT components—such to learn the skills and offering in situ learning exercises to as emotion and somatic symptoms identification, cognitive increase understanding of skills as well as daily personalized restructuring, and problem solving—were translated into home-based exposures. To achieve this goal, a UCD approach game formats. Audio or video recording were also used to was used to identify key components of the system by involving improve such coping exercises such as deep breathing or CBT therapists and children in the process. Because it relaxation.ing, and problem-solving was translated into emphasizes user perspective or context, UCD is an appropriate game format.nts such as emotion and somatic symptoms method for achieving a balance between fun and function (in identification, cognitive rest formal terms, between the internal goal of the system and the Step-based plan for dealing with anxiety: the “Coping Cat” treatment goal of improving skills understanding) [22]. program is a structured CBT program that was developed The UCD process was conducted in three steps. The initial step at Temple University’s Child and Adolescent Anxiety of this UCD process was the development of design principles Disorders Clinic [25,26]. Notably, CBT skills training is based on user information captured and interpreted by therapists one of the two key components of the Coping Cat program. that deliver CBT to anxious children. The therapists served as Here, anxious children learn several basic skills that are the interface between the users (ie, anxious children) and the then integrated into a plan for dealing with anxiety called designer or software developer. Meetings with therapists were the FEAR plan. The FEAR plan comprises four concepts conducted to brainstorm and identify design ideas and criteria. addressed in the following, easily remembered anagram: Such ideas as including interactive features, treatment (1) Feeling frightened? This step aims to increase awareness engagement and adherence, and educational content were of physical symptoms of anxiety; (2) Expecting bad things addressed. These design ideas and criteria were then translated to happen? Here, the focus is on recognizing anxious into design principles, which were in turn used to evaluate the self-talk; (3) Attitudes and actions that will help. In this system. The results from the design principles development step step, participants develop behavior and coping talk to use provided general guidelines for implementation by software when anxious; and (4) Results and rewards. This final step developers for the iterative system development step. comprises a self-evaluation and administration of reward Continuous input or feedback was provided by two therapists for effort. during the system development process. A formative usability Exposure tasks: another important component of CBT is study involving the children in the study was conducted skills practice, which involves having the children following the system development process to collect feedback experience anxious distress in real anxiety-provoking and discover usability problems. Revisions were made before situations. Exposure tasks tailored to the children’s fears the system was implemented as part of the clinical trial. are conducted once the children demonstrate an understanding of the concept within the FEAR plan (based The initial UCD process revealed a conceptual model for the on the therapist’s clinical judgment). To facilitate exposure system that includes seven key components. By implementing task practice, a list of in vivo tasks that the children need these components in the system, CBT treatment outcomes can to conduct were included. The therapist collaborates with hopefully be improved. The individual and specific components the children to prepare the list [27]. of the system are outlined as follows: Therapist-patient interaction: to support therapist-patient Reminder: home-based skills practice is often less impactful interaction beyond office visits, a Health Insurance because of children forgetting to practice CBT skills beyond Portability and Accountability Act–compliant messaging the clinic. According to behavioral learning theory, behavior system is required. Using this feature, a participant can depends on internal (thoughts) or external (environmental) compose a message on his or her phone, and the message stimuli or cues [23]. This means that noncompliant will be sent to a Web-based portal rather than the therapist’s behaviors such as not remembering to practice CBT skills private phone. This protects the private space of the can be modified by introducing repetition of external stimuli clinician and allows the communication to be part of the or cues such as reminders. treatment record. 2. 6. Game- or multimedia-based coping skills learning: CBT Reinforcement through gamification: one way to improve for anxious children aims at reducing anxiety and preventing homework compliance is by providing positive relapse. As CBT is a skills-based treatment, much of the reinforcement in the form of rewards (eg, small toys, work associated with treatment involves teaching children accessories or makeup, and gift cards) for completing new behaviors, concrete problem-solving skills, and homework [16,28]. In many manual-based CBT treatment strategies for challenging anxious thoughts and beliefs. To (eg, the Coping Cat program), therapists acknowledge or improve the learning process, game-based learning can be praise participants’ efforts to engage in exposure challenges http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al (eg, talking with 5 people) by rewarding them with Determine interesting activities to move patients toward collectible cards (eg, baseball card), stickers, or small toys. the end goals: identify activities that are aligned with the Gamification techniques, which add gameful (rule-based goals. The activities should also capture the interest of the and goal-oriented) experience, can provide positive person. From a self-determination theory perspective, reinforcement to anxious children by rewarding their efforts interest can be defined as an affect that occurs in the in completing homework. interaction between a person and an activity [ 30]. Interest Usage monitoring: as part of clinician-directed CBT organizes people’s attention and activity. When people treatment, the therapists are required to monitor a experience interest (being intrinsically motivated), the participant’s adherence to treatment regimens and activities. energy necessary for action is readily available because The therapist can then use the monitoring data to determine they are rewarded with spontaneous affective or cognitive the treatment regimen for the upcoming week. experiences accompanying their behavior. Ryan and Deci [31] explain that intrinsic motivation can be maintained by The CBT components of the model were translated into several satisfying three psychological needs: skill-builder modules that include an in vivo skills coach, a i. Competence: the need of people to gain mastery of series of interactive games and activities to reinforce skill tasks and learn different skills. When people feel that understanding, and a home challenge module to encourage they have skill or expertise at doing something, they home-based exposure (Table 1). Other skill-building activities will be more likely to continue doing it. Opportunities such as viewing or practicing with a deep breathing techniques to learn different skills, or be optimally challenged, can video, listening or practicing with a progressive muscle also improve a person’s level of competency [32]. relaxation audio file, or practicing a weekly task adapted from ii. Autonomy: refers to the need to feel in control when the Coping Cat workbook were provided. The number and types performing activities or tasks. The core concept of of skill-builder modules can be adjusted in accordance with the autonomy is freedom. Allowing individuals freedom children’s progress during CBT treatment. in choosing has been shown to improve autonomy and, consequently, their intrinsic motivation [32]. Implementation of Gamification iii. Relatedness or connection: refers to the need to feel Gamification aims to increase people’s engagements in real life connected to others. People tend to internalize and activities and encourage specific human behaviors. To some accept values and practices from those to whom they extent, the concept is already being used in manual-based CBT feel connected and from contexts in which they treatment such as the Coping Cat program [25]. During weekly experience a sense of belonging. Providing a possibility sessions, eg, therapists acknowledge or praise children’s efforts of social connectedness that conveys security can to engage in exposures challenges (eg, talking with 5 people) strengthen intrinsic motivation [33]. by rewarding them with collectible cards (eg, baseball card), stickers, or small toys. Although interest plays a central role in intrinsic motivation, it is not central to all motivated behavior. People often Recent advances in interactive mHealth technologies allow engage in instrumental activities for some desired outcome gamification concepts to be layered on top of activities provided not related to the activity itself (being extrinsically by mobile apps. “Swarm” app, eg, rewards its users for checking motivated). External rewards such as points, money, gift into a new place by giving digital coins, badges, stickers, and cards, toys, or something tangible can motivate people to statuses. These game mechanics serve dual functions—helping complete tasks. For gamification to truly motivate people, users learn to use the app and making a real-world experience it has to target correct and intrinsically motivated activities, more engaging. Digital coins and badges give the users a sense as well as provide external rewards for completing the of accomplishment, whereas status changes such as activities [34]. When working with children, extrinsic “mayorships” allow users to compete with their friends. rewards have been found to be an appropriate form of In this project, the system was gamified so as to drive children’s motivation [35]. Table 2 shows intrinsic and extrinsic engagement in completing their weekly skill-builder modules motivators that were added to the target activities. via an iterative process consisting of four steps. These steps are Apply game design elements to improve user experience: as follows: key elements of gamification are applied to make activities feel more “playful.” Table 3 shows the game design Identify the end goals: identify the desired goals (ie, desired elements that have been implemented. Furthermore, to human behaviors). When defining goals, the contexts of identify the key elements, we can view game design implementation (eg, education and health) and the needs elements as a hierarchy that contains components, or requirements imposed by stakeholders (eg, a policy of mechanics, and dynamics [36]. “Components” represent screen time reduction for children and smartphone use in the specific forms of mechanics and dynamics. Each class) must be considered [29]. Ideally, the goals should be component is tied to one or more higher-level elements. specific (clear and well-defined), measurable, attainable, “Mechanics” refers to a distinct set of rules or basic and intended to support and enhance the existing context. processes that generate user engagement and drive the In this project, the goal was to maintain participants’ action forward. “Dynamics” represents the big-picture therapeutic commitment or motivation in completing aspects of the gamified system that are indirectly managed between-sessions skill-builder activities. by the system. Initially, actions that need monitoring and rewarding are defined. Then, points, badges, and http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al achievements (ie, trophies and stars) are utilized to reward suggestions can capture perceptions and attitudes toward users when performing an action or a collection of actions. gamified apps. Points, levels, badges, and achievements represent the Participants components section of the pyramidal hierarchical structure. A total of 35 participants (aged 9-14 years; mean=11.19) met To generate engagement, challenges and feedback the criteria for the fifth edition of the Diagnostic and Statistical representing the mechanics section are added. After Manual of Mental Disorders (DSM-V) diagnosis of generalized completing a challenge, the user can collect rewards (ie, anxiety disorder, social anxiety disorder, and/or separation tangible payoffs as extrinsic motivators). Ultimately, the anxiety disorder. These diagnoses are common in children, dynamics provided by the game element hierarchy system frequently cooccur, have a similar presentation, and respond to represents the relationship between tangible payoffs and the same treatment approaches [37-39]. A lower age limit of 9 the number of points collected (bigger prizes require one years and an upper limit of 14 years were chosen based on the to get a higher number of points). reading level requirements for the app and the Evaluate effectiveness: depending on the goals defined in age-appropriateness of the materials, respectively. the initial step, gathering quantitative or qualitative data can assess the effectiveness of gamification. Quantitative The participants included 5 participants enrolled in a beta testing data that includes engagement (time spent using the app, phase and 30 participants enrolled in an open trial phase who the number of digital points collected) and retention (the completed treatment. The participants who enrolled in the beta number of features completed between sessions) can be testing phase received similar treatment to those who enrolled used to infer user behavior directly. Qualitative data such in the open trial phase. as user feedback, comments, concerns, frustrations, and Table 1. Skill-builder modules. Module Session Description Skills coach 1, 2, 3, 4, 5, 6, 7 Guide the participant through developing a FEAR plan for a current or recent in vivo anxious experience. a a a a What’s the feeling? (game) Ask the participant to identify emotional and somatic symptoms from various scenarios (in- 1, 2, 3, 4 , 5 , 6 , 7 cluding anxiety, physical pain, and hunger). a a a a a a Chillax View or practice with a video demonstrating deep breathing techniques. 1, 2 , 3 , 4 , 5 , 6 , 7 Listen or practice with an mp3 audio file for progressive muscle relaxation. Thought-buster (game) Ask the participant to identify anxious vs nonanxious self-talk or coping vs noncoping self- 2, 3 , 4, 5, 6, 7 talk. Thought-swapper (game) 3, 4, 5, 6, 7 Ask the participant to identify coping self-talk that works best in a given situation. Problem-solver (game) 3, 4, 5, 6, 7 Generate and evaluate potential solutions to hypothetical problems. Challenger 4, 5, 6, 7 Therapist selects personally relevant home challenges from a menu on the portal; patient is prompted to develop a FEAR plan and complete these challenges via app. Show that I can 1, 2, 3, 4, 5, 6, 7 Therapist selects weekly task (adapted from the Coping Cat workbook) from a menu on the portal; patient is prompted to complete the task via app. Optional. Table 2. Intrinsic and extrinsic motivators in target activities. Activities Intrinsic motivators Extrinsic motivators Completing interactive skill-building modules Specific modules are assigned for a particular session. As Tangible prizes (ie, accessories and (“What’s the feeling?”, Thought-buster, the session progresses, different modules with different makeup, small toys and games, and Thought-swapper, Problem-solver) challenges will be assigned (competence) gift cards for older teens) Each module can be initiated independently (autonomy) Completing skills coach As the session progresses, children are asked to come up with their own coping strategies instead of choosing from a provided checklist (competence and autonomy) Completing at-home challenges (Challenger), At-home challenges are discussed with the therapist in face- Chillax, and Show that I can task to-face sessions. Children can choose which challenges they want to complete (competence and autonomy). Sending or replying to messages Children can send messages to their therapist to ask therapeu- Attention, praise tic questions (relatedness or connection) http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Table 3. Actions, components, and mechanics. Actions Components Mechanics Initiate and complete skill-builder modules when One point toward the target number of points Collect a certain number of points. Therapists will requested to do so by app alarm (cumulative) assign the target points needed to redeem a selected prize. A collection of stars and a trophy will be Initiate and complete skill-builder modules from Two points toward the target number of points displayed on the home screen. A progress bar and within the app (on one’s own initiative). (cumulative) badges are displayed after the completion of actions. Complete all required modules for a particular One star Collect one star for each session. session. Complete all required modules for sessions 1, Silver trophy Collect a silver trophy. 2, and 3. Complete all required modules for sessions 4, Gold trophy Collect a gold trophy. 5, 6, and 7. information is then pushed to the app. To provide motivation Procedures and encouragement to the young patient, the therapist integrates After completing a phone screen, potential participants immediate rewards (ie, points) into the treatment by managing completed a clinical intake interview. To establish anxiety and these rewards directly from the portal. To support exclusionary diagnoses, the Kiddie-Schedule for Affective clinician-patient interaction, the therapist uses the portal to send Disorders and Schizophrenia for School-Aged Children-Present or reply to messages to or from patients between sessions. If and Lifetime version [40] for DSM-V was used. Participants required, the therapist may also activate the location-aware meeting study criteria were scheduled for a CBT pretest a week feature of the app by entering the address of the before the first therapy session to assess their pretreatment anxiety-provoking location after discussing it with the patient. understanding of CBT skills. Each child and a parent or guardian In this case, the address is geocoded into a latitude or longitude attended an orientation before the first therapy session to learn format by the portal and then sent to the app. how to use the smartphone app. Here, the children were provided Measures with an Android smartphone for the duration of the study. User Engagement The children were treated using the brief Coping Cat manual and workbook [41,42], implemented over the course of 8 User engagement was defined as an indicator of the extent to sessions. The treatment includes two key components: (1) CBT which children interact with the app. User engagement data was skills training, including emotion identification and labeling, reported using indications such as how much time the children cognitive reframing, and problem solving and (2) CBT skills spent on the app and the total number of app use during practice through graded exposure to feared stimuli. It should treatment. be noted that breathing or muscle relaxation is not formally App Retention taught in the brief version. As part of the treatment, the children App retention was defined as the extent to which children retain were asked to complete homework assignments using the app their willingness in completing skill-builder modules between at home. These assignments consisted of specific modules sessions. Retention data was reported using the app use between delineated at the end of each session. Treatment was delivered sessions. by a master or doctoral level therapist trained in CBT for child anxiety. Statistical Analyses As part of the treatment, the therapist was required to complete A Mann-Whitney U test was conducted to test whether the several tasks via the clinician portal, which is accessible from gamified system has a higher user engagement rate than the a computer or a tablet (see Table 4). At the beginning of each existing version of SmartCAT. A Cronbach alpha level of .10 session, the therapist, in conjunction with the patient, uses the was used for the test because of the exploratory nature of the portal to review the data for the skills coach and other modules study [43]. The Mann-Whitney U test was preferred because of from the past week. On the basis of the subsequent discussion an expected nonnormality of the data given the small sample and level of patient improvement, the therapist selects germane size and possible extreme outliers among participants [44]. modules and sets time ranges for the following week. This http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Table 4. Portal tasks a therapist was required to complete. Tasks Start of session End of session Between sessions Enter custom locations and times ✓ Select modules for upcoming week ✓ Review skills coach or other module data from the week with child ✓ Set target points for the following weeks ✓ Send or receive messages ✓ Game- or Multimedia-Based Coping Skills Learning Results The following minigames (see Figure 1, line 3) were developed to provide anxious children more interactive ways to learn Gamified Mobile Health System (SmartCAT 2.0) for important CBT skills such as emotion and somatic symptoms Childhood Anxiety identification, cognitive restructuring, and problem solving. The app was developed using an Androidsoftw   are development kit (SDK). To accommodate new features (ie, low-power “What’s the feeling?” (Emotion and Somatic Symptoms location monitoring and improved user interface), Android SDK Identification Skills) version 4.2 or above was used. The minigames were developed Some anxious children are insufficiently skilled in recognizing using Unity, a cross-platform game engine developed by Unity somatic cues associated with different feelings (eg, anxiety, Technologies. Unity allows the games to be run on top of anger, boredom, and sadness) [46]. The first thing that the Android or iPhone operating system (iOS, Apple Inc) devices. children learn in therapy sessions is how to identify their The following key components of the system were implemented individual physiological or bodily reactions to anxiety, or more during the iterative system development process. specifically, their own physiological reactions toward anxiety-provoking situations. During the session, the children Reminder are shown how physical reactions provide cues associated with The reminder (Figure 1, line 1) is designed to cue the anxious anxiety but are also provided with suggestions on how to help child toward initiating a skill-builder activity for the day. The their body relax. Moreover, the children learn how to identify app automatically wakes the device, shows a notification dialog, and classify what emotions a person is most likely experiencing and then plays a distinct sound to get the child’s attention. The based on contextual information (eg, scenarios). The “What’s dialog contains a customized message, a snooze button, and a the feeling?” module translates the learning process by asking shortcut button for initiating the module of the day. If the time the child to identify emotional and somatic symptoms from is inconvenient, the child can choose to reschedule the reminder various scenarios. later (ie, 30 min, 1 hour, and 2 hours) up to a maximum of three “Thought-Buster” (Cognitive Restructuring Skills) times. To increase the effectiveness of the reminders, the child is also allowed to set their own preprogrammed reminders after Clinical levels of anxiety can come from irrational or completing a skill-builder activity. maladaptive thoughts, beliefs, or self-talk. In therapy sessions, the therapist teaches anxious children cognitive reframing To complement time-based reminders, we also provide techniques to modify the maladaptive nature of their self-talk. location-aware reminders using geofencing. Geofencing enables This requires the children to first recognize their self-talk. The automatic detection of mobile objects as they enter or exit a “Thought-buster” module helps the child in classifying self-talk geofence, which is a virtual boundary for a real-world area [45]. as either anxious or nonanxious. Self-talk in the app is presented These alert the child, as he or she enter locations that will cause as balloons that can be popped by tapping the screen and are him or her anxiety, to appropriately deal with the situation. randomized between screens. The reminders are integrated into a weekly plan for each child “Thought-Swapper” (Cognitive Restructuring Skills) that is pushed to the child’s app. As shown in Figure 1 (line 2), Rational analysis of thoughts followed by a generation of coping the plan represents a calendar event consisting of four parts: thoughts marks another important task in cognitive restructuring Notes: an instructional message that will be shown on the processes. The “Thought-swapper” module guides the child in message part of the app’s notification dialog conducting rational analysis of a thought based on a hypothetical Time: the length of the event and the 2-hour window (ie, situation. For each hypothetical situation, an anxious thought 4-6 PM, 5-7 PM, 6-8 PM, and 7-9 PM) of the day that a presents in a thought bubble on top of the character. For each notification should pop up, situation, the child needs to either counter the initial thought or Session: each session is associated with a different set of intensify it. This way, the child can experiment and learn what skill-builder modules coping thoughts will work best in a given situation and foster Optional module: an indicator to include additional an understanding that thoughts can influence emotions. skill-builder modules. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al of, evaluate all of the options, and pick one or two best solutions. Problem-Solver (Problem-Solving Skills) To familiarize the child with these four steps, the module Anxious children often present with problems they wish to imitates an SMS text message (short message service, SMS) resolve. The strategies (eg, avoidance and escape) these children conversation between the child and his or her virtual friend who have used to resolve problems in the past is often not an is experiencing a hypothetical problem from his or her effective strategy for future difficulties. For example, anxious hypothetical life (eg, performing at the talent show after school children might not leave their home to avoid panicky feelings. or going to a friend’s sleepover). Here the child must help his Although avoidance might be effective in reducing anxious or her virtual friend solve the problem randomly generated each distress in the short term, it is an ineffective strategy for dealing time the module is initiated. with future uncomfortable thoughts and feelings. During a face-to-face session, a CBT therapist leads the child through To complement the games, we have included the “Chillax” the steps in the problem-solving process. module (see Figure 1, line 4) that contains a video recording of deep breathing exercises, as well as an audio recording for The “Problem-solver” module provides an interactive way for relaxation. These multimedia files are accessible by initiating the child to practice the four steps of problem solving: define the Chillax module—which is part of session-specific the problem, come up with as many solutions as you can think skill-builder modules—or by accessing the Media Library. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Figure 1. SmartCAT reminders, weekly plan, minigames, and Chillax module screen. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Skills Coach: Step-Based Plan for Dealing With Anxiety Therapist-Patient Interaction The “skills coach” module (Figure 2, line 1) provides a series To support therapist-patient interaction, we developed a secure of questions that guide the child in developing a FEAR plan for messaging interface (Figure 3, line 1). Using this interface, the a current or recent in vivo experience of anxiety. To reduce the child can compose a message on the phone, and that message child’s burden, checklists are provided. These checklists include will be sent to the portal rather than the therapist’s private phone. common responses to items (ie, typical negative scenarios, The therapist may view these messages and/or send the child a automatic thoughts, and coping thoughts) that were generated message at any time using the portal. Incoming or outgoing based on the therapists’ input. As the session advances, the messages from or to the therapist were encrypted and stored in prepopulated responses from the checklist are replaced by text the phone’s local storage using Advanced Encryption Standard responses that encourage the child to generate his or her own with a 256-bit key. During transmission, these messages were response. FEAR plans are sent to the portal and stored locally encrypted using Rivest-Shamir-Adleman algorithm with a on the app for later use when the patient is feeling anxious. 2048-bit key to prevent man-in-the-middle attacks. The portal is secure, protected by a corporate firewall. As illustrated in Figure 2, line 1 (right-hand screen), the therapist can review FEAR plans created using the skills coach. The Reinforcement Through Gamification FEAR plans can be ordered by importance (set by the child Skill-builder modules can be activated during instances of acute using the app before FEAR plan submission), session, or anxiety by launching the app. From the app’s home screen submission date. The FEAR plans that need to be discussed (Figure 3, line 2), the child can initiate the skill-builder activities with the child have the title appearing over a yellow background. that they find most useful. Each time they complete any of the skill-builder modules, digital points are awarded. The target Exposure Tasks points are associated with a prize that the child can choose and The therapist activates the “Challenger” module (see Figure 2, are then assigned by the therapist using the portal. Depending line 2) from the portal during session four or beyond. This on the target, the points can be redeemed for the desired prize module provides a list of in vivo exposure tasks prepared by every two or three sessions. If the child acquires digital points the therapist and the child during face-to-face sessions. For each beyond the target, however, the remaining digital points will exposure task, the child must describe how each task should be carry over to the following session. A star will be awarded when conducted in the “real world situation” and/or provide a all of the week’s skill-builder modules are completed. A photograph showing that he or she completed this task. The maximum number of seven stars can be awarded. To maintain child’s response will be sent to the portal for the therapist to patient motivation during treatment, the child is challenged to see. get a silver trophy for collecting three stars and a gold trophy for collecting the remaining four stars. Figure 2. Skills Coach and Challenger module screen. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Figure 3. SmartCAT secure messaging system, app and portal home screen, and Show that I can module screen. and Challenger) entries, managing treatment regimens and Usage Monitoring reminders, sending or replying to secure messages, managing The portal allows therapists to monitor patients’ progress, as geofences, and digital points. A usage summary contains well as access their skills coach, Show that I can, and Challenger information on the type of trophy and the number of stars entries. The home screen of the portal can be seen illustrated in collected by each patient. Therapists can also track how far each Figure 3 (line 2; right-hand screen). After successful login, patient is from the target points and the number and type of therapists can view a list of their patients and a summary of skill-builder modules that have been completed. each patient’s progress. The list provides information about We have also included the Show that I can module (Figure 3, each patient’s smartphone connectivity—a green mark indicating line 3) that contains session-specific assignments adapted from that a patient’s phone is currently connected and a grey mark the Coping Cat workbook. This can be activated by therapists indicating no connection. An action button, next to the who are utilizing the Coping Cat workbook to provide additional connectivity status, initiates patient-related actions such as practice with the skills learned in session that week. reviewing skill-builder module (skills coach, Show that I can, http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Table 5 presents the summary of user engagement and retention Usage of the Gamified SmartCAT System (SmartCAT of the existing and gamified versions, respectively. A two-tailed 2.0) Mann-Whitney U test (Cronbach alpha=.10) indicated that the The child usage data revealed that the app was used frequently children were using SmartCAT 2.0 more frequently (median during treatment. On average, each child spent 35.59 min on 68.00) than SmartCAT 1.0 (median 37.00, U=76.00, P<.01), the app (SD 64.18) completing 13.00 skill-builder modules per with a large effect size, Cohen r=.56. The test also indicated session (SD 12.61), suggesting high motivation during treatment. that the children spent longer using SmartCAT 2.0 (median Figure 4 shows the app retention of SmartCAT 1.0 compared 173.15) than SmartCAT 1.0 (median 120.73, U=173.00, P=.06), with that of SmartCAT 2.0. The Y scale represents the app use. with a medium effect size, Cohen r=.27. The average is represented by the wide horizontal line on each box plot. The median is represented by the short line. App use The children were using different sets of skill-builder modules above 60 modules was considered an outlier and was not between sessions, suggesting their willingness to learn a varying included. Although SmartCAT 2.0 was used more often than set of skills. As illustrated in Figure 5, the interactive SmartCAT 1.0 between sessions, the pattern of use between the skill-builder modules were completed more frequently than the two systems was arguably consistent. In other words, both other modules between sessions. This suggests that the systems were highly utilized earlier in the session but then participants were more motivated and likely to engage in leveled off toward the end. learning CBT skills using an interactive and fun learning environment such as games. Figure 4. SmartCAT 1.0 vs. SmartCAT 2.0 usage frequency. Usage data were collected after Session 1 and calculated at the end of Session 8. Table 5. User engagement and app retention by system. System Number of participants Engagement (across duration of treatment) App retention Time spent in minutes (SD) App use (SD) App use per session (SD) SmartCAT 1.0 15 135.08 (56.48) 36.13 (13.54) 5.16 (3.03) SmartCAT 2.0 35 248.02 (327.41) 90.40 (69.33) 13.00 (12.61) http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Figure 5. SmartCAT 2.0 module usage between sessions. Although effective, the effects of gamification were not Discussion uniformly experienced by all participants. During the clinical trial, one participant did not use the app often, completing only Principal Findings 12 skill-builder modules throughout treatment. This participant Participants were satisfied with the visual appearance of the was not motivated to use the app and was diagnosed and referred app, comfortable using the app, and making the app part of their for depression treatment at posttreatment. This suggests that daily routine. They stated that the app was easy to use and found symptoms of depression may interfere with engagement. Six it helpful when they were experiencing anxiety, as illustrated patients used the app more often—but less than an average of in the following quotes: seven times—between sessions (<49 times across duration of treatment). This suggests that the implementation of It is amazing, it can really help you. [Patient 1216] gamification does not always lead to significant increases in I thought the app helped me out a lot. It was like user engagement and app retention. As previous studies on therapist on a phone. [Patient 1240] player motivation suggest, intrinsic and extrinsic motivators Was very easy to use and learn. Keep up the good can differently influence the way people interact with game-like work! [Patient 1302] systems [47,48]. Thus, user experience created by gamification The app was very easy to use and wasn’t confusing is likely to differ [49]. at all. [Patient 1309] Limitations On average, the app was used twice a day. The therapists could The project was implemented in an uncontrolled clinical trial track participants’ weekly progress and could provide written involving a small number of patients, which must be taken into reinforcements when required using the portal. The result of account in interpreting the results. The usage patterns observed the implementation indicates that the gamified SmartCAT at posttreatment may not reflect realistic usage patterns, as the system has been used as expected and suggests that the inclusion patients who already have iPhones were not able to use the of gamification can effectively increase user engagement and system on their own smartphones. retention. Acknowledgments This project was funded in part by the National Institute of Mental Health (NIMH) grant #R34MH102666 (PI JS). GP and BP are also funded through the RERC on ICT “From Cloud to Smartphone—Accessible and Empowering ICT,” grants #90RE5018 and #90DP0064 from the National Institute for Disability, Independent Living, and Rehabilitation Research (NIDILRR). The authors would like to thank Marcie L Walker and Han-Tsung (Marcus) Min from the Department of Psychology, University of Pittsburgh, for their help with project and data management. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Conflicts of Interest JS, BP, GP, and OL are the inventors of the SmartCAT mHealth system. JL is also the Chief Executive Officer (CEO) of Playpower Labs, Inc, which provided design and development services for SmartCAT games. He has no further ownership of the games or financial interest in the outcomes. PCK receives royalties from the sales of materials related to the treatment of anxiety in youth. References 1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol 1996 Apr;64(2):333-342. [Medline: 8871418] 2. Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol 1998 Dec;27(4):459-468. [doi: 10.1207/s15374424jccp2704_10] [Medline: 9866083] 3. Beidel DC, Turner SM, Morris TL. Behavioral treatment of childhood social phobia. J Consult Clin Psychol 2000 Dec;68(6):1072-1080. [Medline: 11142541] 4. Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, Southam-Gerow M, Henin A, Warman M. Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 1997 Jun;65(3):366-380. [Medline: 9170760] 5. Kendall PC, Hudson JL, Gosch E, Flannery-Schroeder E, Suveg C. Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol 2008 Apr;76(2):282-297. [doi: 10.1037/0022-006X.76.2.282] [Medline: 18377124] 6. Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Lumpkin PW, Carmichael DH. Treating anxiety disorders in children with group cognitive-behaviorial therapy: a randomized clinical trial. J Consult Clin Psychol 1999 Dec;67(6):995-1003. [Medline: 10596522] 7. Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008 Dec 25;359(26):2753-2766 [FREE Full text] [doi: 10.1056/NEJMoa0804633] [Medline: 18974308] 8. James A, Soler A, Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2005 Oct 19(4):CD004690. [doi: 10.1002/14651858.CD004690.pub2] [Medline: 16235374] 9. Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy. Cogn Behav Ther 2013;42(3):171-179. [doi: 10.1080/16506073.2013.763286] [Medline: 23419077] 10. Neimeyer RA, Kazantzis N, Kassler DM, Baker KD, Fletcher R. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. Cogn Behav Ther 2008;37(4):199-215. [doi: 10.1080/16506070801981240] [Medline: 18608311] 11. Rees CS, McEvoy P, Nathan PR. Relationship between homework completion and outcome in cognitive behaviour therapy. Cogn Behav Ther 2005;34(4):242-247. [doi: 10.1080/16506070510011548] [Medline: 16319035] 12. Kazantzis N, Deane F, Ronan K. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Clin Psychol Sci Pract 2006;7(2):202. [doi: 10.1093/clipsy.7.2.189] 13. Peris T, Compton S, Kendall P, Birmaher B, Sherrill J, March J, et al. Trajectories of change in youth anxiety during cognitive-behavior therapy. J Consult Clin Psychol 2015 Apr;83(2):239-252 [FREE Full text] [doi: 10.1037/a0038402] [Medline: 25486372] 14. Hudson JL, Kendall PC. Showing you can do it: homework in therapy for children and adolescents with anxiety disorders. J Clin Psychol 2002 May;58(5):525-534. [doi: 10.1002/jclp.10030] [Medline: 11967878] 15. Houlding C, Schmidt F, Walker D. Youth therapist strategies to enhance client homework completion. Child Adolesc Ment Health 2010;15(2):109. [doi: 10.1111/j.1475-3588.2009.00533.x] 16. Cummings C, Kazantzis N, Kendall P. Facilitating Homework and Generalization of Skills to the Real World. In: Evidence‐Based CBT for Anxiety and Depression in Children and Adolescents: A Competencies‐Based Approach, 1. Hoboken, New Jersey: John Wiley & Sons; 2014. 17. Heron KE, Smyth JM. Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol 2010 Feb;15(Pt 1):1-39 [FREE Full text] [doi: 10.1348/135910709X466063] [Medline: 19646331] 18. Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res 2012;14(3):e70 [FREE Full text] [doi: 10.2196/jmir.2058] [Medline: 22564332] 19. Deterding S, Sicart M, Nacke L, O'Hara K, Dixon D. Gamification. using game-design elements in non-gaming contexts. New York, New York, USA: ACM Press; 2011 Presented at: The ACM CHI Conference on Human Factors in Computing Systems; May 7-12, 2011; Vancouver, BC p. 2425-2428. [doi: 10.1145/1979742.1979575] 20. Brewer R, Anthony L, Brown Q, Irwin G, Nias J, Tate B. Using gamification to motivate children to complete empirical studies in lab environments. New York, New York, USA: ACM Press; 2013 Presented at: The 12th International Conference on Interaction Design and Children; June 24-27, 2013; New York, NY, USA p. 388-391. [doi: 10.1145/2485760.2485816] http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al 21. Pramana G, Parmanto B, Kendall PC, Silk JS. The SmartCAT: an m-health platform for ecological momentary intervention in child anxiety treatment. Telemed J E Health 2014 May;20(5):419-427 [FREE Full text] [doi: 10.1089/tmj.2013.0214] [Medline: 24579913] 22. Barendregt W, Bekker M, Bouwhuis D, Baauw E. Identifying usability and fun problems in a computer game during first use and after some practice. Int J Hum Comput Stud 2006 Sep;64(9):830-846. [doi: 10.1016/j.ijhcs.2006.03.004] 23. Leventhal H, Cameron L. Behavioral theories and the problem of compliance. Patient Educ Couns 1987 Oct;10(2):117-138. [doi: 10.1016/0738-3991(87)90093-0] 24. Rankin Y, McNeal M, Shute M, Gooch B. User centered game design. New York, New York, USA: ACM Press; 2008 Presented at: Sandbox '08 Proceedings of the 2008 ACM SIGGRAPH symposium on Video games; August 09 - 10, 2008; Los Angeles, CA, USA p. 43-49. [doi: 10.1145/1401843.1401851] 25. Kendall P, Hedtke K. Coping Cat Workbook. 2nd ed. Ardmore, PA: Workbook Publishing; 2006. 26. Podell J, Mychailyszyn M, Edmunds J, Puleo C, Kendall P. The Coping Cat Program for anxious youth: the FEAR plan comes to life. Cogn Behav Pract 2010 May;17(2):132-141. [doi: 10.1016/j.cbpra.2009.11.001] 27. Peterman J, Read K, Wei C, Kendall P. The art of exposure: putting science into practice. Cogn Behav Pract 2015 Aug;22(3):379-392. [doi: 10.1016/j.cbpra.2014.02.003] 28. Kendall P, Barmish A. Show-That-I-Can (Homework) in cognitive-behavioral therapy for anxious youth: individualizing homework for Robert. Cogn Behav Pract 2007 Aug;14(3):289-296. [doi: 10.1016/j.cbpra.2006.04.022] 29. Richards C, Thompson C, Graham N. Beyond designing for motivation: the importance of context in gamification. New York, New York, USA: ACM Press; 2014 Presented at: CHI PLAY '14 Proceedings of the first ACM SIGCHI annual symposium on Computer-human interaction in play; October 19 - 21, 2014; Toronto, Ontario, Canada p. 217-226. [doi: 10.1145/2658537.2658683] 30. Deci EL. The relation of interest to the motivation of behavior: a self-determination theory perspective. In: Renninger KA, Hidi S, Krapp A, editors. The Role of interest in Learning and Development. New York, NY: Lawrence Erlbaum Associates, Inc; 1992:43-70. 31. Ryan RM, Deci EL. Intrinsic and extrinsic motivations: classic definitions and new directions. Contemp Educ Psychol 2000 Jan;25(1):54-67. [doi: 10.1006/ceps.1999.1020] [Medline: 10620381] 32. Ryan R, Rigby C, Przybylski A. The motivational pull of video games: a self-determination theory approach. Motiv Emot 2006 Nov 29;30(4):344-360. [doi: 10.1007/s11031-006-9051-8] 33. Deci E, Ryan R. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychol Inq 2000 Oct;11(4):227-268. [doi: 10.1207/S15327965PLI1104_01] 34. Kappen D, Nacke L. The kaleidoscope of effective gamification. New York, New York, USA: ACM Press; 2013 Presented at: Gamification '13 Proceedings of the First International Conference on Gameful Design, Research, and Applications; October 02 - 04, 2013; Toronto, Ontario, Canada p. 119-122. [doi: 10.1145/2583008.2583029] 35. Williams R, Stockdale S. Classroom motivation strategies for prospective teachers. Teach Educ 2004 Mar;39(3):212-230. [doi: 10.1080/08878730409555342] 36. Werbach K, Hunter D. For the Win: How game thinking can revolutionize your business. Philadelphia: Wharton Digital Press; 2012. 37. Collins KA, Westra HA, Dozois DJ, Burns DD. Gaps in accessing treatment for anxiety and depression: challenges for the delivery of care. Clin Psychol Rev 2004 Sep;24(5):583-616. [doi: 10.1016/j.cpr.2004.06.001] [Medline: 15325746] 38. Albano A, Chorpita B, Barlow D. Childhood Anxiety Disorders. In: Mash EJ, Barkley RA, editors. Child Psychopathology. New York: The Guilford Press; 2003:279-329. 39. Lahey BB, Rathouz PJ, Van Hulle C, Urbano RC, Krueger RF, Applegate B, et al. Testing structural models of DSM-IV symptoms of common forms of child and adolescent psychopathology. J Abnorm Child Psychol 2008 Feb;36(2):187-206. [doi: 10.1007/s10802-007-9169-5] [Medline: 17912624] 40. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 1997 Jul;36(7):980-988. [doi: 10.1097/00004583-199707000-00021] [Medline: 9204677] 41. Kendall P, Beidas R, Mauro C. Brief Coping Cat: The 8-session Coping Cat workbook. Ardmore, PA: Workbook Publishing; 42. Kendall P, Crawley S, Benjamin C, Mauro C. Brief Coping Cat: The 8-session therapist manual. Ardmore, PA: Workbook Publishing; 2013. 43. Schumm W, Pratt K, Hartenstein J, Jenkins B, Johnson G. Determining statistical significance (alpha) and reporting statistical trends: controversies, issues, and facts. Compr Psychol 2013 Jan;2(1):Article 10. [doi: 10.2466/03.CP.2.10] 44. Sainani KL. Dealing with non-normal data. PM R 2012 Dec;4(12):1001-1005. [doi: 10.1016/j.pmrj.2012.10.013] [Medline: 23245662] 45. Namiot D, Sneps-Sneppe M. Geofence and Network Proximity. In: Balandin S, Andreev S, Koucheryavy Y, editors. Internet of Things, Smart Spaces, and Next Generation Networks and Systems. Berlin, Heidelberg: Springer Berlin Heidelberg; 2013:117-127. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al 46. Gosch E, Flannery-Schroeder E, Mauro C, Compton S. Principles of cognitive-behavioral therapy for anxiety disorders in children. J Cogn Psychother 2006 Sep 01;20(3):247-262. [doi: 10.1891/jcop.20.3.247] 47. Yee N. Motivations for play in online games. Cyberpsychol Behav 2006 Dec;9(6):772-775. [doi: 10.1089/cpb.2006.9.772] [Medline: 17201605] 48. Bostan B. silentblade. 2009 Jun 01. Player motivations: A psychological perspective URL: http://www.silentblade.com/ presentations/BBostan-2008-2.pdf [accessed 2018-05-03] [WebCite Cache ID 6z8YFqgrY] 49. Huotari K, Hamari J. Defining Gamification - A Service Marketing Perspective. New York, New York, USA: ACM Press; 2012 Presented at: MindTrek '12 Proceeding of the 16th International Academic MindTrek Conference; October 03 - 05, 2012; Tampere, Finland p. 17-22. [doi: 10.1145/2393132.2393137] Abbreviations BCBT: brief cognitive behavioral therapy CBT: cognitive behavioral therapy EMI: ecological momentary intervention mHealth: mobile health SDK: software development kit UCD: user-centered design Edited by G Eysenbach; submitted 05.09.17; peer-reviewed by A AlMarshedi, P Lindner; comments to author 03.12.17; revised version received 03.03.18; accepted 14.03.18; published 10.05.18 Please cite as: Pramana G, Parmanto B, Lomas J, Lindhiem O, Kendall PC, Silk J Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial JMIR Serious Games 2018;6(2):e9 URL: http://games.jmir.org/2018/2/e9/ doi: 10.2196/games.8902 PMID: 29748165 ©Gede Pramana, Bambang Parmanto, James Lomas, Oliver Lindhiem, Philip C Kendall, Jennifer Silk. Originally published in JMIR Serious Games (http://games.jmir.org), 10.05.2018. 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/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 16 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial

Download PDF
16 pages

Loading next page...
 
/lp/jmir-publications/using-mobile-health-gamification-to-facilitate-cognitive-behavioral-pDYuezsumW
Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/games.8902
Publisher site
See Article on Publisher Site

Abstract

Background: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment. (JMIR Serious Games 2018;6(2):e9) doi: 10.2196/games.8902 KEYWORDS gamification; mobile health; ecological momentary intervention; cognitive behavioral therapy; child anxiety treatment; SmartCAT; childhood anxiety disorders elements to engage people in nongame contexts [19]. Among Introduction children, the use of gamification is particularly effective in addressing the problem of lack of motivation [20]. When Background integrated with mHealth apps, gamification can potentially make The results of multiple independent randomized clinical trials tedious activities on mHealth apps more engaging to children, provide evidence that cognitive behavioral therapy (CBT) is an thus increasing their motivation to use them. efficacious treatment for childhood anxiety [1-7]. CBT typically Goal of This Project requires 10 to 20 weeks of weekly sessions with a CBT therapist [8] and emphasizes the importance of CBT skills rehearsal, The purpose of this project was multifaceted. First, we exposure tasks, and practice beyond office visits (homework) redesigned our existing mHealth system, titled [9-13]. Markedly, about 40% of anxious children receiving CBT “Smartphone-enhanced Child Anxiety Treatment” (SmartCAT), treatment show little recovery from primary anxiety diagnoses, consisting of a smartphone app (SmartCAT app), a therapist despite evidence suggesting CBT is an efficacious treatment portal (SmartCAT portal), and a two-way communication [8]. One possibility is that treatment requires a willingness to connecting them [21]. This redesign included gamification learn and practice CBT skills beyond therapy sessions. techniques as well as a number of interactive skill-builder modules to increase user engagement or retention and facilitate Although homework is routinely assigned, many anxious learning. Second, we evaluated the utility of the redesigned children struggle with homework completion [14] possibly SmartCAT as an adjunctive component to CBT treatment in an because of a lack of therapeutic commitment or motivation [15]. open clinical trial. User engagement data (ie, time spent on app Unlike adults who are often self-referred, children are usually and app use) and the app retention (app use per session) at brought to therapy by their parents or caregivers. As a result, posttreatment were used to assess the utility. Finally, the these children are not always considered to be “voluntary effectiveness of gamification was evaluated by comparing user participants” in therapy and may view homework as unfavorable engagement data with the previous version of SmartCAT [16]. Therapists note that other noncompliance factors include without gamification. forgetfulness and lack of understanding of CBT skills [14]. Overcoming Barriers to Home-Based Skills Practice Methods for Children User-Centered Design Mobile health (mHealth) technologies present potential solutions A user-centered design (UCD) approach was used to gather to overcoming barriers to fostering home-based skills practice requirements and iteratively design the system, leveraging the for children. First, the “always-carried” and “always-on” nature SmartCAT 1.0 system that had been previously pilot-tested of smartphones creates an opportunity to deliver CBT [21]. In this version, the app notifies patients to initiate a “skills interventions to children in natural settings during their everyday coach” module, which then cues patients to complete a series lives, an approach referred to as “ecological momentary of questions about recent emotional events and to apply skills intervention” (EMI) [17]. EMIs can provide skills coaching to learned in therapy toward coping with that event. Throughout anxious children in the real world outside of sessions, when it this study, the skills coach was scheduled from the portal by is most needed. Anxious children can also access training the therapist to launch automatically once per day (either at a materials in situ at their convenience throughout the day. fixed or random time depending on patients’ desire) and be Second, the increased processing and sensing capability of completed more frequently if desired by the patient. It could smartphones allows for more sophisticated, interactive, and also be activated at “opportune” moments when patients were engaging health intervention apps. This provides an opportunity experiencing acute anxiety. After completing a skills coach for developers to make context-aware mHealth apps that can entry, patients were rewarded with digital points that could be automatically detect when and where children require skills “cashed in” for a prize. coaching during real-world emotional situations. Although the skills coach in SmartCAT 1.0 was actively used, Despite this potential, the repetitive tasks (eg, self-monitoring averaging 5.36 times per session, children and therapists and self-management) that characterize most mHealth apps can suggested several potential improvements including developing be exhausting and may lack intrinsic rewards [18]. An more interactive and fun ways for the children to learn and alternative to traditional mHealth apps is the use of gamification, practice CBT skills in daily life and also improving rewards to one of many persuasive approaches that uses game design http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al increase the rates of CBT skills practice. On the basis of this used as an appropriate way to provide an interactive yet feedback, we redesigned and developed a new system using the fun learning environment beyond the weekly in-person iterative, user-centered approach described below. sessions. Ultimately, game-based learning provides a type of game play that has well-defined learning outcomes. The SmartCAT addresses barriers to home-based skills practice Moreover, research suggests that games can effectively for children by (1) Providing automatic cues to children to model the learning process in that games require players to practice skills at prescribed times and places, even when they be active and to provide immediate feedback as a result of forget to initiate skills practice on their own; (2) Motivating players’ decisions during game play [24]. To facilitate the children to practice skills; and (3) Providing interactive ways learning of coping skills, several CBT components—such to learn the skills and offering in situ learning exercises to as emotion and somatic symptoms identification, cognitive increase understanding of skills as well as daily personalized restructuring, and problem solving—were translated into home-based exposures. To achieve this goal, a UCD approach game formats. Audio or video recording were also used to was used to identify key components of the system by involving improve such coping exercises such as deep breathing or CBT therapists and children in the process. Because it relaxation.ing, and problem-solving was translated into emphasizes user perspective or context, UCD is an appropriate game format.nts such as emotion and somatic symptoms method for achieving a balance between fun and function (in identification, cognitive rest formal terms, between the internal goal of the system and the Step-based plan for dealing with anxiety: the “Coping Cat” treatment goal of improving skills understanding) [22]. program is a structured CBT program that was developed The UCD process was conducted in three steps. The initial step at Temple University’s Child and Adolescent Anxiety of this UCD process was the development of design principles Disorders Clinic [25,26]. Notably, CBT skills training is based on user information captured and interpreted by therapists one of the two key components of the Coping Cat program. that deliver CBT to anxious children. The therapists served as Here, anxious children learn several basic skills that are the interface between the users (ie, anxious children) and the then integrated into a plan for dealing with anxiety called designer or software developer. Meetings with therapists were the FEAR plan. The FEAR plan comprises four concepts conducted to brainstorm and identify design ideas and criteria. addressed in the following, easily remembered anagram: Such ideas as including interactive features, treatment (1) Feeling frightened? This step aims to increase awareness engagement and adherence, and educational content were of physical symptoms of anxiety; (2) Expecting bad things addressed. These design ideas and criteria were then translated to happen? Here, the focus is on recognizing anxious into design principles, which were in turn used to evaluate the self-talk; (3) Attitudes and actions that will help. In this system. The results from the design principles development step step, participants develop behavior and coping talk to use provided general guidelines for implementation by software when anxious; and (4) Results and rewards. This final step developers for the iterative system development step. comprises a self-evaluation and administration of reward Continuous input or feedback was provided by two therapists for effort. during the system development process. A formative usability Exposure tasks: another important component of CBT is study involving the children in the study was conducted skills practice, which involves having the children following the system development process to collect feedback experience anxious distress in real anxiety-provoking and discover usability problems. Revisions were made before situations. Exposure tasks tailored to the children’s fears the system was implemented as part of the clinical trial. are conducted once the children demonstrate an understanding of the concept within the FEAR plan (based The initial UCD process revealed a conceptual model for the on the therapist’s clinical judgment). To facilitate exposure system that includes seven key components. By implementing task practice, a list of in vivo tasks that the children need these components in the system, CBT treatment outcomes can to conduct were included. The therapist collaborates with hopefully be improved. The individual and specific components the children to prepare the list [27]. of the system are outlined as follows: Therapist-patient interaction: to support therapist-patient Reminder: home-based skills practice is often less impactful interaction beyond office visits, a Health Insurance because of children forgetting to practice CBT skills beyond Portability and Accountability Act–compliant messaging the clinic. According to behavioral learning theory, behavior system is required. Using this feature, a participant can depends on internal (thoughts) or external (environmental) compose a message on his or her phone, and the message stimuli or cues [23]. This means that noncompliant will be sent to a Web-based portal rather than the therapist’s behaviors such as not remembering to practice CBT skills private phone. This protects the private space of the can be modified by introducing repetition of external stimuli clinician and allows the communication to be part of the or cues such as reminders. treatment record. 2. 6. Game- or multimedia-based coping skills learning: CBT Reinforcement through gamification: one way to improve for anxious children aims at reducing anxiety and preventing homework compliance is by providing positive relapse. As CBT is a skills-based treatment, much of the reinforcement in the form of rewards (eg, small toys, work associated with treatment involves teaching children accessories or makeup, and gift cards) for completing new behaviors, concrete problem-solving skills, and homework [16,28]. In many manual-based CBT treatment strategies for challenging anxious thoughts and beliefs. To (eg, the Coping Cat program), therapists acknowledge or improve the learning process, game-based learning can be praise participants’ efforts to engage in exposure challenges http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al (eg, talking with 5 people) by rewarding them with Determine interesting activities to move patients toward collectible cards (eg, baseball card), stickers, or small toys. the end goals: identify activities that are aligned with the Gamification techniques, which add gameful (rule-based goals. The activities should also capture the interest of the and goal-oriented) experience, can provide positive person. From a self-determination theory perspective, reinforcement to anxious children by rewarding their efforts interest can be defined as an affect that occurs in the in completing homework. interaction between a person and an activity [ 30]. Interest Usage monitoring: as part of clinician-directed CBT organizes people’s attention and activity. When people treatment, the therapists are required to monitor a experience interest (being intrinsically motivated), the participant’s adherence to treatment regimens and activities. energy necessary for action is readily available because The therapist can then use the monitoring data to determine they are rewarded with spontaneous affective or cognitive the treatment regimen for the upcoming week. experiences accompanying their behavior. Ryan and Deci [31] explain that intrinsic motivation can be maintained by The CBT components of the model were translated into several satisfying three psychological needs: skill-builder modules that include an in vivo skills coach, a i. Competence: the need of people to gain mastery of series of interactive games and activities to reinforce skill tasks and learn different skills. When people feel that understanding, and a home challenge module to encourage they have skill or expertise at doing something, they home-based exposure (Table 1). Other skill-building activities will be more likely to continue doing it. Opportunities such as viewing or practicing with a deep breathing techniques to learn different skills, or be optimally challenged, can video, listening or practicing with a progressive muscle also improve a person’s level of competency [32]. relaxation audio file, or practicing a weekly task adapted from ii. Autonomy: refers to the need to feel in control when the Coping Cat workbook were provided. The number and types performing activities or tasks. The core concept of of skill-builder modules can be adjusted in accordance with the autonomy is freedom. Allowing individuals freedom children’s progress during CBT treatment. in choosing has been shown to improve autonomy and, consequently, their intrinsic motivation [32]. Implementation of Gamification iii. Relatedness or connection: refers to the need to feel Gamification aims to increase people’s engagements in real life connected to others. People tend to internalize and activities and encourage specific human behaviors. To some accept values and practices from those to whom they extent, the concept is already being used in manual-based CBT feel connected and from contexts in which they treatment such as the Coping Cat program [25]. During weekly experience a sense of belonging. Providing a possibility sessions, eg, therapists acknowledge or praise children’s efforts of social connectedness that conveys security can to engage in exposures challenges (eg, talking with 5 people) strengthen intrinsic motivation [33]. by rewarding them with collectible cards (eg, baseball card), stickers, or small toys. Although interest plays a central role in intrinsic motivation, it is not central to all motivated behavior. People often Recent advances in interactive mHealth technologies allow engage in instrumental activities for some desired outcome gamification concepts to be layered on top of activities provided not related to the activity itself (being extrinsically by mobile apps. “Swarm” app, eg, rewards its users for checking motivated). External rewards such as points, money, gift into a new place by giving digital coins, badges, stickers, and cards, toys, or something tangible can motivate people to statuses. These game mechanics serve dual functions—helping complete tasks. For gamification to truly motivate people, users learn to use the app and making a real-world experience it has to target correct and intrinsically motivated activities, more engaging. Digital coins and badges give the users a sense as well as provide external rewards for completing the of accomplishment, whereas status changes such as activities [34]. When working with children, extrinsic “mayorships” allow users to compete with their friends. rewards have been found to be an appropriate form of In this project, the system was gamified so as to drive children’s motivation [35]. Table 2 shows intrinsic and extrinsic engagement in completing their weekly skill-builder modules motivators that were added to the target activities. via an iterative process consisting of four steps. These steps are Apply game design elements to improve user experience: as follows: key elements of gamification are applied to make activities feel more “playful.” Table 3 shows the game design Identify the end goals: identify the desired goals (ie, desired elements that have been implemented. Furthermore, to human behaviors). When defining goals, the contexts of identify the key elements, we can view game design implementation (eg, education and health) and the needs elements as a hierarchy that contains components, or requirements imposed by stakeholders (eg, a policy of mechanics, and dynamics [36]. “Components” represent screen time reduction for children and smartphone use in the specific forms of mechanics and dynamics. Each class) must be considered [29]. Ideally, the goals should be component is tied to one or more higher-level elements. specific (clear and well-defined), measurable, attainable, “Mechanics” refers to a distinct set of rules or basic and intended to support and enhance the existing context. processes that generate user engagement and drive the In this project, the goal was to maintain participants’ action forward. “Dynamics” represents the big-picture therapeutic commitment or motivation in completing aspects of the gamified system that are indirectly managed between-sessions skill-builder activities. by the system. Initially, actions that need monitoring and rewarding are defined. Then, points, badges, and http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al achievements (ie, trophies and stars) are utilized to reward suggestions can capture perceptions and attitudes toward users when performing an action or a collection of actions. gamified apps. Points, levels, badges, and achievements represent the Participants components section of the pyramidal hierarchical structure. A total of 35 participants (aged 9-14 years; mean=11.19) met To generate engagement, challenges and feedback the criteria for the fifth edition of the Diagnostic and Statistical representing the mechanics section are added. After Manual of Mental Disorders (DSM-V) diagnosis of generalized completing a challenge, the user can collect rewards (ie, anxiety disorder, social anxiety disorder, and/or separation tangible payoffs as extrinsic motivators). Ultimately, the anxiety disorder. These diagnoses are common in children, dynamics provided by the game element hierarchy system frequently cooccur, have a similar presentation, and respond to represents the relationship between tangible payoffs and the same treatment approaches [37-39]. A lower age limit of 9 the number of points collected (bigger prizes require one years and an upper limit of 14 years were chosen based on the to get a higher number of points). reading level requirements for the app and the Evaluate effectiveness: depending on the goals defined in age-appropriateness of the materials, respectively. the initial step, gathering quantitative or qualitative data can assess the effectiveness of gamification. Quantitative The participants included 5 participants enrolled in a beta testing data that includes engagement (time spent using the app, phase and 30 participants enrolled in an open trial phase who the number of digital points collected) and retention (the completed treatment. The participants who enrolled in the beta number of features completed between sessions) can be testing phase received similar treatment to those who enrolled used to infer user behavior directly. Qualitative data such in the open trial phase. as user feedback, comments, concerns, frustrations, and Table 1. Skill-builder modules. Module Session Description Skills coach 1, 2, 3, 4, 5, 6, 7 Guide the participant through developing a FEAR plan for a current or recent in vivo anxious experience. a a a a What’s the feeling? (game) Ask the participant to identify emotional and somatic symptoms from various scenarios (in- 1, 2, 3, 4 , 5 , 6 , 7 cluding anxiety, physical pain, and hunger). a a a a a a Chillax View or practice with a video demonstrating deep breathing techniques. 1, 2 , 3 , 4 , 5 , 6 , 7 Listen or practice with an mp3 audio file for progressive muscle relaxation. Thought-buster (game) Ask the participant to identify anxious vs nonanxious self-talk or coping vs noncoping self- 2, 3 , 4, 5, 6, 7 talk. Thought-swapper (game) 3, 4, 5, 6, 7 Ask the participant to identify coping self-talk that works best in a given situation. Problem-solver (game) 3, 4, 5, 6, 7 Generate and evaluate potential solutions to hypothetical problems. Challenger 4, 5, 6, 7 Therapist selects personally relevant home challenges from a menu on the portal; patient is prompted to develop a FEAR plan and complete these challenges via app. Show that I can 1, 2, 3, 4, 5, 6, 7 Therapist selects weekly task (adapted from the Coping Cat workbook) from a menu on the portal; patient is prompted to complete the task via app. Optional. Table 2. Intrinsic and extrinsic motivators in target activities. Activities Intrinsic motivators Extrinsic motivators Completing interactive skill-building modules Specific modules are assigned for a particular session. As Tangible prizes (ie, accessories and (“What’s the feeling?”, Thought-buster, the session progresses, different modules with different makeup, small toys and games, and Thought-swapper, Problem-solver) challenges will be assigned (competence) gift cards for older teens) Each module can be initiated independently (autonomy) Completing skills coach As the session progresses, children are asked to come up with their own coping strategies instead of choosing from a provided checklist (competence and autonomy) Completing at-home challenges (Challenger), At-home challenges are discussed with the therapist in face- Chillax, and Show that I can task to-face sessions. Children can choose which challenges they want to complete (competence and autonomy). Sending or replying to messages Children can send messages to their therapist to ask therapeu- Attention, praise tic questions (relatedness or connection) http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Table 3. Actions, components, and mechanics. Actions Components Mechanics Initiate and complete skill-builder modules when One point toward the target number of points Collect a certain number of points. Therapists will requested to do so by app alarm (cumulative) assign the target points needed to redeem a selected prize. A collection of stars and a trophy will be Initiate and complete skill-builder modules from Two points toward the target number of points displayed on the home screen. A progress bar and within the app (on one’s own initiative). (cumulative) badges are displayed after the completion of actions. Complete all required modules for a particular One star Collect one star for each session. session. Complete all required modules for sessions 1, Silver trophy Collect a silver trophy. 2, and 3. Complete all required modules for sessions 4, Gold trophy Collect a gold trophy. 5, 6, and 7. information is then pushed to the app. To provide motivation Procedures and encouragement to the young patient, the therapist integrates After completing a phone screen, potential participants immediate rewards (ie, points) into the treatment by managing completed a clinical intake interview. To establish anxiety and these rewards directly from the portal. To support exclusionary diagnoses, the Kiddie-Schedule for Affective clinician-patient interaction, the therapist uses the portal to send Disorders and Schizophrenia for School-Aged Children-Present or reply to messages to or from patients between sessions. If and Lifetime version [40] for DSM-V was used. Participants required, the therapist may also activate the location-aware meeting study criteria were scheduled for a CBT pretest a week feature of the app by entering the address of the before the first therapy session to assess their pretreatment anxiety-provoking location after discussing it with the patient. understanding of CBT skills. Each child and a parent or guardian In this case, the address is geocoded into a latitude or longitude attended an orientation before the first therapy session to learn format by the portal and then sent to the app. how to use the smartphone app. Here, the children were provided Measures with an Android smartphone for the duration of the study. User Engagement The children were treated using the brief Coping Cat manual and workbook [41,42], implemented over the course of 8 User engagement was defined as an indicator of the extent to sessions. The treatment includes two key components: (1) CBT which children interact with the app. User engagement data was skills training, including emotion identification and labeling, reported using indications such as how much time the children cognitive reframing, and problem solving and (2) CBT skills spent on the app and the total number of app use during practice through graded exposure to feared stimuli. It should treatment. be noted that breathing or muscle relaxation is not formally App Retention taught in the brief version. As part of the treatment, the children App retention was defined as the extent to which children retain were asked to complete homework assignments using the app their willingness in completing skill-builder modules between at home. These assignments consisted of specific modules sessions. Retention data was reported using the app use between delineated at the end of each session. Treatment was delivered sessions. by a master or doctoral level therapist trained in CBT for child anxiety. Statistical Analyses As part of the treatment, the therapist was required to complete A Mann-Whitney U test was conducted to test whether the several tasks via the clinician portal, which is accessible from gamified system has a higher user engagement rate than the a computer or a tablet (see Table 4). At the beginning of each existing version of SmartCAT. A Cronbach alpha level of .10 session, the therapist, in conjunction with the patient, uses the was used for the test because of the exploratory nature of the portal to review the data for the skills coach and other modules study [43]. The Mann-Whitney U test was preferred because of from the past week. On the basis of the subsequent discussion an expected nonnormality of the data given the small sample and level of patient improvement, the therapist selects germane size and possible extreme outliers among participants [44]. modules and sets time ranges for the following week. This http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Table 4. Portal tasks a therapist was required to complete. Tasks Start of session End of session Between sessions Enter custom locations and times ✓ Select modules for upcoming week ✓ Review skills coach or other module data from the week with child ✓ Set target points for the following weeks ✓ Send or receive messages ✓ Game- or Multimedia-Based Coping Skills Learning Results The following minigames (see Figure 1, line 3) were developed to provide anxious children more interactive ways to learn Gamified Mobile Health System (SmartCAT 2.0) for important CBT skills such as emotion and somatic symptoms Childhood Anxiety identification, cognitive restructuring, and problem solving. The app was developed using an Androidsoftw   are development kit (SDK). To accommodate new features (ie, low-power “What’s the feeling?” (Emotion and Somatic Symptoms location monitoring and improved user interface), Android SDK Identification Skills) version 4.2 or above was used. The minigames were developed Some anxious children are insufficiently skilled in recognizing using Unity, a cross-platform game engine developed by Unity somatic cues associated with different feelings (eg, anxiety, Technologies. Unity allows the games to be run on top of anger, boredom, and sadness) [46]. The first thing that the Android or iPhone operating system (iOS, Apple Inc) devices. children learn in therapy sessions is how to identify their The following key components of the system were implemented individual physiological or bodily reactions to anxiety, or more during the iterative system development process. specifically, their own physiological reactions toward anxiety-provoking situations. During the session, the children Reminder are shown how physical reactions provide cues associated with The reminder (Figure 1, line 1) is designed to cue the anxious anxiety but are also provided with suggestions on how to help child toward initiating a skill-builder activity for the day. The their body relax. Moreover, the children learn how to identify app automatically wakes the device, shows a notification dialog, and classify what emotions a person is most likely experiencing and then plays a distinct sound to get the child’s attention. The based on contextual information (eg, scenarios). The “What’s dialog contains a customized message, a snooze button, and a the feeling?” module translates the learning process by asking shortcut button for initiating the module of the day. If the time the child to identify emotional and somatic symptoms from is inconvenient, the child can choose to reschedule the reminder various scenarios. later (ie, 30 min, 1 hour, and 2 hours) up to a maximum of three “Thought-Buster” (Cognitive Restructuring Skills) times. To increase the effectiveness of the reminders, the child is also allowed to set their own preprogrammed reminders after Clinical levels of anxiety can come from irrational or completing a skill-builder activity. maladaptive thoughts, beliefs, or self-talk. In therapy sessions, the therapist teaches anxious children cognitive reframing To complement time-based reminders, we also provide techniques to modify the maladaptive nature of their self-talk. location-aware reminders using geofencing. Geofencing enables This requires the children to first recognize their self-talk. The automatic detection of mobile objects as they enter or exit a “Thought-buster” module helps the child in classifying self-talk geofence, which is a virtual boundary for a real-world area [45]. as either anxious or nonanxious. Self-talk in the app is presented These alert the child, as he or she enter locations that will cause as balloons that can be popped by tapping the screen and are him or her anxiety, to appropriately deal with the situation. randomized between screens. The reminders are integrated into a weekly plan for each child “Thought-Swapper” (Cognitive Restructuring Skills) that is pushed to the child’s app. As shown in Figure 1 (line 2), Rational analysis of thoughts followed by a generation of coping the plan represents a calendar event consisting of four parts: thoughts marks another important task in cognitive restructuring Notes: an instructional message that will be shown on the processes. The “Thought-swapper” module guides the child in message part of the app’s notification dialog conducting rational analysis of a thought based on a hypothetical Time: the length of the event and the 2-hour window (ie, situation. For each hypothetical situation, an anxious thought 4-6 PM, 5-7 PM, 6-8 PM, and 7-9 PM) of the day that a presents in a thought bubble on top of the character. For each notification should pop up, situation, the child needs to either counter the initial thought or Session: each session is associated with a different set of intensify it. This way, the child can experiment and learn what skill-builder modules coping thoughts will work best in a given situation and foster Optional module: an indicator to include additional an understanding that thoughts can influence emotions. skill-builder modules. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al of, evaluate all of the options, and pick one or two best solutions. Problem-Solver (Problem-Solving Skills) To familiarize the child with these four steps, the module Anxious children often present with problems they wish to imitates an SMS text message (short message service, SMS) resolve. The strategies (eg, avoidance and escape) these children conversation between the child and his or her virtual friend who have used to resolve problems in the past is often not an is experiencing a hypothetical problem from his or her effective strategy for future difficulties. For example, anxious hypothetical life (eg, performing at the talent show after school children might not leave their home to avoid panicky feelings. or going to a friend’s sleepover). Here the child must help his Although avoidance might be effective in reducing anxious or her virtual friend solve the problem randomly generated each distress in the short term, it is an ineffective strategy for dealing time the module is initiated. with future uncomfortable thoughts and feelings. During a face-to-face session, a CBT therapist leads the child through To complement the games, we have included the “Chillax” the steps in the problem-solving process. module (see Figure 1, line 4) that contains a video recording of deep breathing exercises, as well as an audio recording for The “Problem-solver” module provides an interactive way for relaxation. These multimedia files are accessible by initiating the child to practice the four steps of problem solving: define the Chillax module—which is part of session-specific the problem, come up with as many solutions as you can think skill-builder modules—or by accessing the Media Library. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Figure 1. SmartCAT reminders, weekly plan, minigames, and Chillax module screen. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Skills Coach: Step-Based Plan for Dealing With Anxiety Therapist-Patient Interaction The “skills coach” module (Figure 2, line 1) provides a series To support therapist-patient interaction, we developed a secure of questions that guide the child in developing a FEAR plan for messaging interface (Figure 3, line 1). Using this interface, the a current or recent in vivo experience of anxiety. To reduce the child can compose a message on the phone, and that message child’s burden, checklists are provided. These checklists include will be sent to the portal rather than the therapist’s private phone. common responses to items (ie, typical negative scenarios, The therapist may view these messages and/or send the child a automatic thoughts, and coping thoughts) that were generated message at any time using the portal. Incoming or outgoing based on the therapists’ input. As the session advances, the messages from or to the therapist were encrypted and stored in prepopulated responses from the checklist are replaced by text the phone’s local storage using Advanced Encryption Standard responses that encourage the child to generate his or her own with a 256-bit key. During transmission, these messages were response. FEAR plans are sent to the portal and stored locally encrypted using Rivest-Shamir-Adleman algorithm with a on the app for later use when the patient is feeling anxious. 2048-bit key to prevent man-in-the-middle attacks. The portal is secure, protected by a corporate firewall. As illustrated in Figure 2, line 1 (right-hand screen), the therapist can review FEAR plans created using the skills coach. The Reinforcement Through Gamification FEAR plans can be ordered by importance (set by the child Skill-builder modules can be activated during instances of acute using the app before FEAR plan submission), session, or anxiety by launching the app. From the app’s home screen submission date. The FEAR plans that need to be discussed (Figure 3, line 2), the child can initiate the skill-builder activities with the child have the title appearing over a yellow background. that they find most useful. Each time they complete any of the skill-builder modules, digital points are awarded. The target Exposure Tasks points are associated with a prize that the child can choose and The therapist activates the “Challenger” module (see Figure 2, are then assigned by the therapist using the portal. Depending line 2) from the portal during session four or beyond. This on the target, the points can be redeemed for the desired prize module provides a list of in vivo exposure tasks prepared by every two or three sessions. If the child acquires digital points the therapist and the child during face-to-face sessions. For each beyond the target, however, the remaining digital points will exposure task, the child must describe how each task should be carry over to the following session. A star will be awarded when conducted in the “real world situation” and/or provide a all of the week’s skill-builder modules are completed. A photograph showing that he or she completed this task. The maximum number of seven stars can be awarded. To maintain child’s response will be sent to the portal for the therapist to patient motivation during treatment, the child is challenged to see. get a silver trophy for collecting three stars and a gold trophy for collecting the remaining four stars. Figure 2. Skills Coach and Challenger module screen. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Figure 3. SmartCAT secure messaging system, app and portal home screen, and Show that I can module screen. and Challenger) entries, managing treatment regimens and Usage Monitoring reminders, sending or replying to secure messages, managing The portal allows therapists to monitor patients’ progress, as geofences, and digital points. A usage summary contains well as access their skills coach, Show that I can, and Challenger information on the type of trophy and the number of stars entries. The home screen of the portal can be seen illustrated in collected by each patient. Therapists can also track how far each Figure 3 (line 2; right-hand screen). After successful login, patient is from the target points and the number and type of therapists can view a list of their patients and a summary of skill-builder modules that have been completed. each patient’s progress. The list provides information about We have also included the Show that I can module (Figure 3, each patient’s smartphone connectivity—a green mark indicating line 3) that contains session-specific assignments adapted from that a patient’s phone is currently connected and a grey mark the Coping Cat workbook. This can be activated by therapists indicating no connection. An action button, next to the who are utilizing the Coping Cat workbook to provide additional connectivity status, initiates patient-related actions such as practice with the skills learned in session that week. reviewing skill-builder module (skills coach, Show that I can, http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Table 5 presents the summary of user engagement and retention Usage of the Gamified SmartCAT System (SmartCAT of the existing and gamified versions, respectively. A two-tailed 2.0) Mann-Whitney U test (Cronbach alpha=.10) indicated that the The child usage data revealed that the app was used frequently children were using SmartCAT 2.0 more frequently (median during treatment. On average, each child spent 35.59 min on 68.00) than SmartCAT 1.0 (median 37.00, U=76.00, P<.01), the app (SD 64.18) completing 13.00 skill-builder modules per with a large effect size, Cohen r=.56. The test also indicated session (SD 12.61), suggesting high motivation during treatment. that the children spent longer using SmartCAT 2.0 (median Figure 4 shows the app retention of SmartCAT 1.0 compared 173.15) than SmartCAT 1.0 (median 120.73, U=173.00, P=.06), with that of SmartCAT 2.0. The Y scale represents the app use. with a medium effect size, Cohen r=.27. The average is represented by the wide horizontal line on each box plot. The median is represented by the short line. App use The children were using different sets of skill-builder modules above 60 modules was considered an outlier and was not between sessions, suggesting their willingness to learn a varying included. Although SmartCAT 2.0 was used more often than set of skills. As illustrated in Figure 5, the interactive SmartCAT 1.0 between sessions, the pattern of use between the skill-builder modules were completed more frequently than the two systems was arguably consistent. In other words, both other modules between sessions. This suggests that the systems were highly utilized earlier in the session but then participants were more motivated and likely to engage in leveled off toward the end. learning CBT skills using an interactive and fun learning environment such as games. Figure 4. SmartCAT 1.0 vs. SmartCAT 2.0 usage frequency. Usage data were collected after Session 1 and calculated at the end of Session 8. Table 5. User engagement and app retention by system. System Number of participants Engagement (across duration of treatment) App retention Time spent in minutes (SD) App use (SD) App use per session (SD) SmartCAT 1.0 15 135.08 (56.48) 36.13 (13.54) 5.16 (3.03) SmartCAT 2.0 35 248.02 (327.41) 90.40 (69.33) 13.00 (12.61) http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Figure 5. SmartCAT 2.0 module usage between sessions. Although effective, the effects of gamification were not Discussion uniformly experienced by all participants. During the clinical trial, one participant did not use the app often, completing only Principal Findings 12 skill-builder modules throughout treatment. This participant Participants were satisfied with the visual appearance of the was not motivated to use the app and was diagnosed and referred app, comfortable using the app, and making the app part of their for depression treatment at posttreatment. This suggests that daily routine. They stated that the app was easy to use and found symptoms of depression may interfere with engagement. Six it helpful when they were experiencing anxiety, as illustrated patients used the app more often—but less than an average of in the following quotes: seven times—between sessions (<49 times across duration of treatment). This suggests that the implementation of It is amazing, it can really help you. [Patient 1216] gamification does not always lead to significant increases in I thought the app helped me out a lot. It was like user engagement and app retention. As previous studies on therapist on a phone. [Patient 1240] player motivation suggest, intrinsic and extrinsic motivators Was very easy to use and learn. Keep up the good can differently influence the way people interact with game-like work! [Patient 1302] systems [47,48]. Thus, user experience created by gamification The app was very easy to use and wasn’t confusing is likely to differ [49]. at all. [Patient 1309] Limitations On average, the app was used twice a day. The therapists could The project was implemented in an uncontrolled clinical trial track participants’ weekly progress and could provide written involving a small number of patients, which must be taken into reinforcements when required using the portal. The result of account in interpreting the results. The usage patterns observed the implementation indicates that the gamified SmartCAT at posttreatment may not reflect realistic usage patterns, as the system has been used as expected and suggests that the inclusion patients who already have iPhones were not able to use the of gamification can effectively increase user engagement and system on their own smartphones. retention. Acknowledgments This project was funded in part by the National Institute of Mental Health (NIMH) grant #R34MH102666 (PI JS). GP and BP are also funded through the RERC on ICT “From Cloud to Smartphone—Accessible and Empowering ICT,” grants #90RE5018 and #90DP0064 from the National Institute for Disability, Independent Living, and Rehabilitation Research (NIDILRR). The authors would like to thank Marcie L Walker and Han-Tsung (Marcus) Min from the Department of Psychology, University of Pittsburgh, for their help with project and data management. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al Conflicts of Interest JS, BP, GP, and OL are the inventors of the SmartCAT mHealth system. JL is also the Chief Executive Officer (CEO) of Playpower Labs, Inc, which provided design and development services for SmartCAT games. He has no further ownership of the games or financial interest in the outcomes. PCK receives royalties from the sales of materials related to the treatment of anxiety in youth. References 1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol 1996 Apr;64(2):333-342. [Medline: 8871418] 2. Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol 1998 Dec;27(4):459-468. [doi: 10.1207/s15374424jccp2704_10] [Medline: 9866083] 3. Beidel DC, Turner SM, Morris TL. Behavioral treatment of childhood social phobia. J Consult Clin Psychol 2000 Dec;68(6):1072-1080. [Medline: 11142541] 4. Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, Southam-Gerow M, Henin A, Warman M. Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 1997 Jun;65(3):366-380. [Medline: 9170760] 5. Kendall PC, Hudson JL, Gosch E, Flannery-Schroeder E, Suveg C. Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol 2008 Apr;76(2):282-297. [doi: 10.1037/0022-006X.76.2.282] [Medline: 18377124] 6. Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Lumpkin PW, Carmichael DH. Treating anxiety disorders in children with group cognitive-behaviorial therapy: a randomized clinical trial. J Consult Clin Psychol 1999 Dec;67(6):995-1003. [Medline: 10596522] 7. Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008 Dec 25;359(26):2753-2766 [FREE Full text] [doi: 10.1056/NEJMoa0804633] [Medline: 18974308] 8. James A, Soler A, Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2005 Oct 19(4):CD004690. [doi: 10.1002/14651858.CD004690.pub2] [Medline: 16235374] 9. Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy. Cogn Behav Ther 2013;42(3):171-179. [doi: 10.1080/16506073.2013.763286] [Medline: 23419077] 10. Neimeyer RA, Kazantzis N, Kassler DM, Baker KD, Fletcher R. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. Cogn Behav Ther 2008;37(4):199-215. [doi: 10.1080/16506070801981240] [Medline: 18608311] 11. Rees CS, McEvoy P, Nathan PR. Relationship between homework completion and outcome in cognitive behaviour therapy. Cogn Behav Ther 2005;34(4):242-247. [doi: 10.1080/16506070510011548] [Medline: 16319035] 12. Kazantzis N, Deane F, Ronan K. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Clin Psychol Sci Pract 2006;7(2):202. [doi: 10.1093/clipsy.7.2.189] 13. Peris T, Compton S, Kendall P, Birmaher B, Sherrill J, March J, et al. Trajectories of change in youth anxiety during cognitive-behavior therapy. J Consult Clin Psychol 2015 Apr;83(2):239-252 [FREE Full text] [doi: 10.1037/a0038402] [Medline: 25486372] 14. Hudson JL, Kendall PC. Showing you can do it: homework in therapy for children and adolescents with anxiety disorders. J Clin Psychol 2002 May;58(5):525-534. [doi: 10.1002/jclp.10030] [Medline: 11967878] 15. Houlding C, Schmidt F, Walker D. Youth therapist strategies to enhance client homework completion. Child Adolesc Ment Health 2010;15(2):109. [doi: 10.1111/j.1475-3588.2009.00533.x] 16. Cummings C, Kazantzis N, Kendall P. Facilitating Homework and Generalization of Skills to the Real World. In: Evidence‐Based CBT for Anxiety and Depression in Children and Adolescents: A Competencies‐Based Approach, 1. Hoboken, New Jersey: John Wiley & Sons; 2014. 17. Heron KE, Smyth JM. Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol 2010 Feb;15(Pt 1):1-39 [FREE Full text] [doi: 10.1348/135910709X466063] [Medline: 19646331] 18. Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res 2012;14(3):e70 [FREE Full text] [doi: 10.2196/jmir.2058] [Medline: 22564332] 19. Deterding S, Sicart M, Nacke L, O'Hara K, Dixon D. Gamification. using game-design elements in non-gaming contexts. New York, New York, USA: ACM Press; 2011 Presented at: The ACM CHI Conference on Human Factors in Computing Systems; May 7-12, 2011; Vancouver, BC p. 2425-2428. [doi: 10.1145/1979742.1979575] 20. Brewer R, Anthony L, Brown Q, Irwin G, Nias J, Tate B. Using gamification to motivate children to complete empirical studies in lab environments. New York, New York, USA: ACM Press; 2013 Presented at: The 12th International Conference on Interaction Design and Children; June 24-27, 2013; New York, NY, USA p. 388-391. [doi: 10.1145/2485760.2485816] http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al 21. Pramana G, Parmanto B, Kendall PC, Silk JS. The SmartCAT: an m-health platform for ecological momentary intervention in child anxiety treatment. Telemed J E Health 2014 May;20(5):419-427 [FREE Full text] [doi: 10.1089/tmj.2013.0214] [Medline: 24579913] 22. Barendregt W, Bekker M, Bouwhuis D, Baauw E. Identifying usability and fun problems in a computer game during first use and after some practice. Int J Hum Comput Stud 2006 Sep;64(9):830-846. [doi: 10.1016/j.ijhcs.2006.03.004] 23. Leventhal H, Cameron L. Behavioral theories and the problem of compliance. Patient Educ Couns 1987 Oct;10(2):117-138. [doi: 10.1016/0738-3991(87)90093-0] 24. Rankin Y, McNeal M, Shute M, Gooch B. User centered game design. New York, New York, USA: ACM Press; 2008 Presented at: Sandbox '08 Proceedings of the 2008 ACM SIGGRAPH symposium on Video games; August 09 - 10, 2008; Los Angeles, CA, USA p. 43-49. [doi: 10.1145/1401843.1401851] 25. Kendall P, Hedtke K. Coping Cat Workbook. 2nd ed. Ardmore, PA: Workbook Publishing; 2006. 26. Podell J, Mychailyszyn M, Edmunds J, Puleo C, Kendall P. The Coping Cat Program for anxious youth: the FEAR plan comes to life. Cogn Behav Pract 2010 May;17(2):132-141. [doi: 10.1016/j.cbpra.2009.11.001] 27. Peterman J, Read K, Wei C, Kendall P. The art of exposure: putting science into practice. Cogn Behav Pract 2015 Aug;22(3):379-392. [doi: 10.1016/j.cbpra.2014.02.003] 28. Kendall P, Barmish A. Show-That-I-Can (Homework) in cognitive-behavioral therapy for anxious youth: individualizing homework for Robert. Cogn Behav Pract 2007 Aug;14(3):289-296. [doi: 10.1016/j.cbpra.2006.04.022] 29. Richards C, Thompson C, Graham N. Beyond designing for motivation: the importance of context in gamification. New York, New York, USA: ACM Press; 2014 Presented at: CHI PLAY '14 Proceedings of the first ACM SIGCHI annual symposium on Computer-human interaction in play; October 19 - 21, 2014; Toronto, Ontario, Canada p. 217-226. [doi: 10.1145/2658537.2658683] 30. Deci EL. The relation of interest to the motivation of behavior: a self-determination theory perspective. In: Renninger KA, Hidi S, Krapp A, editors. The Role of interest in Learning and Development. New York, NY: Lawrence Erlbaum Associates, Inc; 1992:43-70. 31. Ryan RM, Deci EL. Intrinsic and extrinsic motivations: classic definitions and new directions. Contemp Educ Psychol 2000 Jan;25(1):54-67. [doi: 10.1006/ceps.1999.1020] [Medline: 10620381] 32. Ryan R, Rigby C, Przybylski A. The motivational pull of video games: a self-determination theory approach. Motiv Emot 2006 Nov 29;30(4):344-360. [doi: 10.1007/s11031-006-9051-8] 33. Deci E, Ryan R. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychol Inq 2000 Oct;11(4):227-268. [doi: 10.1207/S15327965PLI1104_01] 34. Kappen D, Nacke L. The kaleidoscope of effective gamification. New York, New York, USA: ACM Press; 2013 Presented at: Gamification '13 Proceedings of the First International Conference on Gameful Design, Research, and Applications; October 02 - 04, 2013; Toronto, Ontario, Canada p. 119-122. [doi: 10.1145/2583008.2583029] 35. Williams R, Stockdale S. Classroom motivation strategies for prospective teachers. Teach Educ 2004 Mar;39(3):212-230. [doi: 10.1080/08878730409555342] 36. Werbach K, Hunter D. For the Win: How game thinking can revolutionize your business. Philadelphia: Wharton Digital Press; 2012. 37. Collins KA, Westra HA, Dozois DJ, Burns DD. Gaps in accessing treatment for anxiety and depression: challenges for the delivery of care. Clin Psychol Rev 2004 Sep;24(5):583-616. [doi: 10.1016/j.cpr.2004.06.001] [Medline: 15325746] 38. Albano A, Chorpita B, Barlow D. Childhood Anxiety Disorders. In: Mash EJ, Barkley RA, editors. Child Psychopathology. New York: The Guilford Press; 2003:279-329. 39. Lahey BB, Rathouz PJ, Van Hulle C, Urbano RC, Krueger RF, Applegate B, et al. Testing structural models of DSM-IV symptoms of common forms of child and adolescent psychopathology. J Abnorm Child Psychol 2008 Feb;36(2):187-206. [doi: 10.1007/s10802-007-9169-5] [Medline: 17912624] 40. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 1997 Jul;36(7):980-988. [doi: 10.1097/00004583-199707000-00021] [Medline: 9204677] 41. Kendall P, Beidas R, Mauro C. Brief Coping Cat: The 8-session Coping Cat workbook. Ardmore, PA: Workbook Publishing; 42. Kendall P, Crawley S, Benjamin C, Mauro C. Brief Coping Cat: The 8-session therapist manual. Ardmore, PA: Workbook Publishing; 2013. 43. Schumm W, Pratt K, Hartenstein J, Jenkins B, Johnson G. Determining statistical significance (alpha) and reporting statistical trends: controversies, issues, and facts. Compr Psychol 2013 Jan;2(1):Article 10. [doi: 10.2466/03.CP.2.10] 44. Sainani KL. Dealing with non-normal data. PM R 2012 Dec;4(12):1001-1005. [doi: 10.1016/j.pmrj.2012.10.013] [Medline: 23245662] 45. Namiot D, Sneps-Sneppe M. Geofence and Network Proximity. In: Balandin S, Andreev S, Koucheryavy Y, editors. Internet of Things, Smart Spaces, and Next Generation Networks and Systems. Berlin, Heidelberg: Springer Berlin Heidelberg; 2013:117-127. http://games.jmir.org/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Pramana et al 46. Gosch E, Flannery-Schroeder E, Mauro C, Compton S. Principles of cognitive-behavioral therapy for anxiety disorders in children. J Cogn Psychother 2006 Sep 01;20(3):247-262. [doi: 10.1891/jcop.20.3.247] 47. Yee N. Motivations for play in online games. Cyberpsychol Behav 2006 Dec;9(6):772-775. [doi: 10.1089/cpb.2006.9.772] [Medline: 17201605] 48. Bostan B. silentblade. 2009 Jun 01. Player motivations: A psychological perspective URL: http://www.silentblade.com/ presentations/BBostan-2008-2.pdf [accessed 2018-05-03] [WebCite Cache ID 6z8YFqgrY] 49. Huotari K, Hamari J. Defining Gamification - A Service Marketing Perspective. New York, New York, USA: ACM Press; 2012 Presented at: MindTrek '12 Proceeding of the 16th International Academic MindTrek Conference; October 03 - 05, 2012; Tampere, Finland p. 17-22. [doi: 10.1145/2393132.2393137] Abbreviations BCBT: brief cognitive behavioral therapy CBT: cognitive behavioral therapy EMI: ecological momentary intervention mHealth: mobile health SDK: software development kit UCD: user-centered design Edited by G Eysenbach; submitted 05.09.17; peer-reviewed by A AlMarshedi, P Lindner; comments to author 03.12.17; revised version received 03.03.18; accepted 14.03.18; published 10.05.18 Please cite as: Pramana G, Parmanto B, Lomas J, Lindhiem O, Kendall PC, Silk J Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial JMIR Serious Games 2018;6(2):e9 URL: http://games.jmir.org/2018/2/e9/ doi: 10.2196/games.8902 PMID: 29748165 ©Gede Pramana, Bambang Parmanto, James Lomas, Oliver Lindhiem, Philip C Kendall, Jennifer Silk. Originally published in JMIR Serious Games (http://games.jmir.org), 10.05.2018. 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/2018/2/e9/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e9 | p. 16 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious Games – JMIR Publications

Published: May 10, 2018

Keywords: gamification; mobile health; ecological momentary intervention; cognitive behavioral therapy; child anxiety treatment; SmartCAT; childhood anxiety disorders

There are no references for this article.