Introduction
Anxiety disorders are the most common mental health disorders in childhood, affecting up to 22% of children (Beesdo et al.
2009). A much larger proportion of youth experience subclinical levels of anxiety with prevalence rates up to 49% (Muris et al.
2000a). These anxiety symptoms commence in childhood and show a chronic and disabling course, especially for individuals showing higher severity and persistence of anxiety symptoms (Asselmann and Beesdo-Baum
2015). Left untreated, anxiety symptoms are associated with a lower general quality of life (Ramsawh and Chavira
2016), worse school performance (Owens et al.
2012), and substance use (Pardee et al.
2014). Effective anxiety prevention programs delivered during childhood, before full-blown anxiety disorders develop, are urgently needed.
Preventing Anxiety Problems
Many anxiety prevention programs are based on cognitive-behavioral therapy (CBT), the first-line treatment of choice for anxiety disorders (James et al.
2015). In CBT, youth are taught to recognize feelings related to anxiety (i.e., emotions and bodily sensations), to identify and challenge anxious self-talk, to develop coping skills, and to evaluate and reward skill use. In addition, youth are exposed to threatening situations and taught to use relaxation techniques in the face of these threats, a key element of CBT (Kendall and Hedtke
2006). Various recent meta-analyses show that anxiety prevention programs that target youth with some degree of risk (i.e., selective or indicated) result in small (e.g., Stockings et al.
2016) to moderate (Mychailyszyn et al.
2012) effect sizes.
Outside of research contexts, however, the majority of children who could benefit from these prevention efforts do not seek help (Salloum et al.
2016) and those who do often dropout of service prematurely (de Haan et al.
2013). Stigma associated with mental health care is a major barrier to delivering conventional treatments (Salloum et al.
2016). Children do not want to be identified as mentally ill and parents fear being blamed for their children’s problems, further preventing children and parents from seeking the help they need (Mukolo and Heflinger
2011). In addition, some families may not be able to afford mental health services (Salloum et al.
2016) or simply have difficulties reaching services due to difficulties in transportation (Green et al.
2012). Thus, pragmatic reasons often hamper the accessibility of conventional prevention programs. Additionally, high dropout rates are a major threat to the effectiveness of conventional (CBT) programs (de Haan et al.
2013), possibly because the programs are not appealing and engaging to children (World Health Organization
2012). These barriers call for a reconsideration of our current group-based and clinical expert-led delivery models of prevention programs (e.g., Kazdin
2015).
Applied Games for Mental Health
Recently, applied games have received increasing attention as a viable and cost-effective alternative delivery model for prevention efforts (Kazdin
2015). The promise of applied games lies in the intrinsically motivating features of games, their high accessibility, reach, scalability, affordability, and convenience (e.g., Granic et al.
2014). Despite these potential advantages of applied games, reliable outcome evidence from rigorous research designs is needed before these games can be considered evidence-based alternative interventions. Very few studies have tested the effects of applied games according to rigorous scientific standards.
Studies investigating applied games for anxiety that have used randomized controlled trials (RCTs) have shown promising results.
Dojo, an emotion management video game that helps youth recognize and control their physiological and emotional arousal, has been found to significantly decrease anxiety symptoms in youth with elevated levels of anxiety (i.e., indicated prevention; Scholten et al.
2016).
MindLight is another applied game specifically designed for children with elevated levels of anxiety. The game uses several evidence-based techniques including neurofeedback (Price and Budzynski
2009), exposure training (Kendall et al.
2005), and attention bias modification (Bar-Haim et al.
2011) which are embedded in a horror-themed survival game that trains children to cope with their anxiety. An initial indicated prevention RCT showed significant improvements in anxiety symptoms after game play and at 3-month follow-up (Schoneveld et al.
2016). However, both the
Dojo and the
MindLight trials employed alternative, commercial games as their control condition. The more rigorous test for the effectiveness of these applied games is to demonstrate non-inferiority (i.e., equal efficacy) to the effective gold standard in anxiety prevention: CBT. To date, there are no direct comparisons of applied games for children with elevated levels of anxiety and CBT (Fleming et al.
2017); the current study was designed to fill this gap.
Current Study
We ran a two-armed randomized controlled non-inferiority trial (Piaggio et al.
2012) comparing
MindLight to CBT within an indicated prevention context. The aim of the current study was to determine whether
MindLight was as effective as CBT for children with elevated anxiety symptoms. We choose
MindLight over
Dojo, because anxiety symptoms are most prevalent in childhood and
MindLight is, in contrast to
Dojo, designed for children. Based on previous indicated prevention RCTs with
MindLight (Schoneveld et al.
2016) and CBT (van Starrenburg et al.
2017), our primary hypothesis was that children with elevated anxiety symptoms in the
MindLight condition would show comparable decreases in anxiety symptoms as children in the CBT condition. Further, we aimed to test the effectiveness of the design of the game beyond its impact on anxiety symptoms. Specifically, based on evidence-based exposure principles (Kendall et al.
2005), we tested whether the game elicited the feelings of anxiety that it was designed to trigger, in order for exposure techniques to be relevant. We also examined the game’s motivating properties and appeal to children. Our secondary hypothesis was that children would rate
MindLight as more appealing compared to CBT but equally anxiety inducing.
Discussion
The current study represents one of the first of a handful of RCTs on applied games for children’s mental health. To date, there have been no other direct comparisons between applied games for anxious children and the CBT gold standard intervention. We aimed to fill this gap by conducting a non-inferiority randomized controlled trial testing equal efficacy of the applied game
MindLight and CBT. As predicted, results indicated that
MindLight is as effective as CBT in the prevention of anxiety. The CI approach showed affirmatively that
MindLight was non-inferior to CBT over the course of the study for total anxiety symptoms reported by children and parents.
MindLight showed a larger decrease in child reported personalized anxiety symptoms at post-test and 6-month FU. LGCM analyses demonstrated that children who played
MindLight showed the same significant decrease in anxiety symptoms compared to those who received CBT. Three- and 6-month follow-up assessments indicated that improvements were sustained based on both child and parent reports of anxiety measures. Moderation analyses showed that improvements were sustained to a somewhat lesser extent for children who were in the
MindLight condition and had the highest amount of weekly game time. A possible explanation for this might be that these children were less engaged than the other children were, because
MindLight might have been different than the games they normally play and therefore the effect of
MindLight might be smaller (Glenn et al.
2013). Taken together, these results show that
MindLight is an effective anxiety prevention program for at-risk children.
In trials assessing non-inferiority, it is essential that the effect of the gold standard—in this case CBT—is comparable to previous trials. Accordingly, in the current study, the CBT condition yielded effects in line with a previous indicated prevention trial (van Starrenburg et al.
2017). Furthermore, efficacy results for
MindLight were comparable to those of an initial RCT (Schoneveld et al.
2016). Importantly, both
MindLight and CBT demonstrated medium within group effect sizes, which corresponds or exceeds effect sizes reported in recent meta-analyses (e.g., Mychailyszyn et al.
2012).
Current results counter a main concern about applied games: that the acquired skills learned through playing a game may not transfer to children’s everyday lives (Girard et al.
2013). First, the measures we used focused on reports of functioning in real-life situations and not on
MindLight or CBT specifically. For example, statements on self- and parent reports were “I [my son/daughter] am afraid in the dark” and “I [my son/daughter] worry what other people think of me.” Thus, children and parent reports that the anxiety-regulation skill children learned in
MindLight are not restricted to the game context, but seem to transfer to children’s everyday lives. Second, the fact that not only the children themselves but also their parents reported anxiety decreases and that these improvements were maintained up to 6 months imply transference. This finding moves the applied games field forward as most studies focus only on immediate or short-term improvement. Moreover, the exposure training that is embedded in
MindLight resembles the more transdiagnostic technique of interoceptive exposure, in which people are exposed to, and made aware of, the physical sensations of anxiety rather than specifying particular anxiety-inducing situations. It seems that children in the
MindLight group may have learned to regulate their physiological arousal generally and appear to use this skill in their daily lives.
As outlined above, stigma, accessibility, and non-motivating programs prevent children and parents from seeking help or cause them to drop out of conventional prevention programs. In the current study, dropout rates did not differ between the programs. They were equally low in MindLight and CBT, because the supervisors (Masters students and psychologists) worked hard to keep attrition in both groups as low as possible. However, in the context of “real world,” implementation where games like MindLight could be accessible not only during research protocols but also at home; it may still be that applied games are less likely to show high attrition rates. In addition, when looking into the reasons why children did not want to continue the allocated program, differences between MindLight and CBT appeared. Parents of children who dropped out of the CBT program expressed that it took too much time, a reason not mentioned by parents of children who discontinued MindLight. This highlights possibly a relative advantage of MindLight beyond the first-line treatment of choice for anxiety disorders (CBT): less children might drop out of the program because of time investment issues.
Children’s Program Ratings
The second aim of the study was to test the emotion-inducing and motivational features of
MindLight. An important finding was that children rated
MindLight equally anxiety inducing as CBT. Both programs were rated as anxiety evoking (well above the middle of the scale), which is a prerequisite for children to be able to practice their emotion-regulation skills and for exposure techniques to work. In addition,
MindLight was rated as equally difficult as CBT. When a game is too difficult, children often experience performance anxiety and give up easily. In contrast, when a game is too easy, children become bored and may lose interest quickly (Nakamura and Csikszentmihalyi
2002). Overall, children rated the difficulty level somewhere in the middle of the scale, suggesting that
MindLight (and CBT) hit the “sweet spot” of challenge and learning.
Contrary to expectations, children found
MindLight as appealing as CBT. Both were rated as moderately appealing for themselves and others. It may be that children liked CBT because they got personal attention and it was delivered in a group setting with like-minded peers. In
MindLight, children were asked to play on their own, at their own pace. This lack of social connection may have made
MindLight less fun. Given that the majority of gaming is now social (Lenhart et al.
2008), the constrained and individual nature of their game play might have impeded their feelings of autonomy and relatedness and consequently their motivation to play (Ryan and Deci
2000).
Lastly, children rated CBT as more relevant to their daily life than MindLight. In CBT, children created their own personal anxiety hierarchy, based on which they chose exercises to practice regulating their anxiety. Children were explicitly told to think about what they do in the CBT sessions, practice the skills through homework assignments in their everyday life, and reflect on those “real-life” practice sessions. MindLight, on the other hand, has no such meta-cognitive exercises. The game does not explicitly, and regularly, remind children to practice the skills they learn in the game in their everyday experiences. This was an explicit design decision, aimed to decrease the didactic nature that often significantly diminishes the “fun factor” of most “serious games.” However, as a result, children may have rated MindLight as less relevant. It is important to note, however, that MindLight was still considered modestly relevant; the children did not rate the game as irrelevant. More critically, our results suggest that this meta-cognizing and explicit didactic exercises that ask children to take what they learn in a training session and apply it to “real life” may not be necessary to produce similar positive improvements as CBT.
Limitations and Future Directions
Expectations about intervention effects are an important source of potential bias. To equalize expectations across conditions, children and parents were told that both programs were aimed at teaching coping skills in stressful situations. This framing, however, could have primed them to believe that the programs could improve children’s anxiety and hence biased their reports. Future studies could use, in addition to multiple informants, diverse types of measures to assess whether children change in the way they behaviorally cope with, and physiologically regulate, their anxiety.
A clear strength of the current study was the inclusion of a gold-standard active control condition instead of a no-contact or wait-list control group. RCTs are designed to test whether a certain intervention is effective, but they do not inform us about the mechanisms by which the intervention works. An important future step in this line of research is to examine underlying mechanisms by which games like
MindLight might impact anxiety outcomes. Questions about mechanisms of change could be addressed in dismantling studies (Bell et al.
2013) in which one component of
MindLight (e.g., neurofeedback, exposure, or attention-bias modification) is removed and the full version is compared to the dismantled version. Despite the call for dismantling studies for over two decades (Kendall et al.
1997) and their feasibility for childhood anxiety interventions (Whiteside et al.
2015), no studies have been conducted in which the full version of an anxiety prevention program is compared with a version missing one or select few components. Games provide a particularly promising avenue for this precise type of research, given their inherent modularity (Granic et al.
2014).
We are strongly encouraged by the findings of the current trial. However, we see this study not as the end of a develop and evaluation process, but the beginning of a promising and challenging approach. As part of that beginning, it is critical to note that most applied games and digital interventions that are developed and tested in a research setting stay in the scientific community, belying the main purpose of their development in the first place: large, scalable impact at low cost (Hollis et al.
2017). One of the reasons for the lack of implementation success might be absence of a systematic strategy for effective dissemination of evidence-based applied games (Gehring et al.
2017). Our Games for Emotional and Mental Health (GEMH) lab is at the early stages of building this strategic framework which includes (a) a replicable methodology by which games for mental health can be co-developed with partners in diverse disciplines including design, engineering and art; (b) an index of resources essential for not only successful development, but also dissemination and/or commercialization and the digital infrastructure required to maintain these interventions; and (c) a set of rationale for applying diverse research approaches (e.g., playtesting, user research, RCTs, experimental designs, qualitative interviews) that test not just for game design elements, outcomes and mechanisms, but also track the success of commercial uptake and other dissemination markers (
www.gemhlab.com).
Ultimately, it may not be necessary to compete with the best commercial AAA games on the market to have an impact on young people’s mental health with applied games. Applied games can co-exist with purely education-focused games, just as documentaries co-exist with Hollywood blockbusters, each appealing to individuals for different, and some overlapping, reasons. What does seem to be necessary, however, is for youth to be part of the design and development process so that our games are relevant, appealing, and optimally engaging to their target audience, increasing the probability that they will also be shared with family and friends. Finally, it may be important for scientists to take a more proactive role in engaging commercial industry and making the case for the financial, as well as health, benefits of providing beautiful, entertaining, and scientifically validated mental health tools.
Conclusion
The current study adds to the growing research on applied games for mental health and shows that these games hold potential as alternative delivery models of therapeutic techniques in mental health prevention. In this non-inferiority RCT, the applied game MindLight was shown to be as effective as conventional CBT in reducing child- and parent-reported anxiety levels in 8- to 12-year-old at-risk children. These improvements were maintained at 3- and 6-month follow-ups. Furthermore, MindLight and CBT were rated equally anxiety inducing, difficult, and appealing. Given that there are no clinicians or teachers involved and overhead costs associated with the game are non-existent, MindLight seems a more cost-effective alternative than traditional anxiety intervention and prevention programs. In terms of school programs, applied games, and MindLight specifically, can easily be added to the toolbox of effective prevention approaches already in place in these contexts. Children with concerns about their own capacities to cope with anxiety may be provided with the choice of the delivery model (games or group face-to-face programs), potentially decreasing stigma, increasing their motivation to participate, and ultimately improving mental health outcomes across a broader range of children.